Your two jobs on the floor are protecting the access and keeping fluid volume in range. Everything below serves those priorities.
Nursing Care Plans and Management
Nursing Problem Priorities
- Preventing infection
- Managing fluid volume
Nursing Assessment
Assess for the following subjective and objective data:
- Weakness, dizziness, restlessness, changes in mentation
- Hypotension or hypertension
- Concentrated urine or decreased urine output
- Dry mucous membranes, decreased skin turgor
- Weak pulse, tachycardia
- Weight gain, edema
- Shortness of breath (orthopnea, dyspnea, increased respiratory rate)
- Adventitious breath sounds (rales or crackles), pleural effusion
- Hypernatremia
- Decreased hemoglobin or hematocrit
- Increased central venous pressure, jugular vein distention
Assess for factors related to the cause of hemodialysis:
- Clotting, hemorrhage from accidental disconnection, infection
- Ultrafiltration, fluid restrictions
- Actual blood loss (systemic heparinization or shunt disconnection)
- Rapid or excessive fluid intake: IV, blood, plasma expanders, saline given to support BP during dialysis
Nursing Goals
- Maintain patent vascular access.
- Stay free of infection.
- Maintain fluid balance, shown by stable weight and vital signs, good skin turgor, moist mucous membranes, and no bleeding.
- Hold "dry weight" within the patient's normal range.
- Stay free of edema.
- Keep breath sounds clear and serum sodium within normal limits.
Nursing Interventions and Actions
1. Protecting the Access and Preventing Injury
The access is the patient's lifeline, and it is the thing most likely to fail. Infection, bleeding, and clotting all start here, and dialysis itself adds hypotension, cramping, and dizziness that raise fall risk. Check the access every shift and teach the patient to protect it.
1. Check internal AV shunt patency frequently.
- 1.1. Palpate for a distal thrill. The thrill comes from high-pressure arterial blood entering the low-pressure venous system. It should be palpable above the venous exit site.
- 1.2. Auscultate for a bruit. The bruit should be audible by stethoscope, though it may be faint. Its absence signals trouble.
- 1.3. Note the color of the blood and any separation of cells and serum. A shift from uniform medium red to dark purplish red means sluggish flow or early clotting. Separation in the tubing means clotting. Very dark reddish-black blood next to clear yellow fluid means a full clot.
- 1.4. Palpate the skin around the shunt for warmth. Diminished flow makes the shunt feel cool.
2. Evaluate reports of pain, numbness, or tingling, and note swelling distal to the access. These point to inadequate blood supply.
3. Assess the skin around the access for redness, swelling, warmth, exudate, and tenderness. Local infection here can progress to sepsis.
4. Monitor temperature. Note fever, chills, and hypotension. These signal infection or sepsis and need prompt intervention.
5. Monitor PT and activated partial thromboplastin time (aPTT) as appropriate. Shows coagulation status and guides treatment.
6. Culture the site and draw blood samples as indicated. Identifies pathogens.
7. Notify the physician or start a declotting procedure at any sign of lost shunt patency. Fast intervention can save the access, but declotting must be done by experienced staff.
8. Avoid trauma to the shunt. Handle tubing gently, keep the cannula aligned, and limit activity of the extremity. Do not take BP or draw blood from the shunt arm. Tell the patient not to sleep on the shunt side or carry packages, books, or purses on that arm. This cuts the risk of clotting and disconnection.
9. Keep two cannula clamps on the shunt dressing and a tourniquet within reach. If the cannulas separate, clamp the arterial cannula first, then the venous. If the tubing comes out of the vessel, clamp the cannula still in place and apply direct pressure to the bleeding site. Place a tourniquet above the site or inflate a BP cuff just above the patient's systolic pressure. This prevents massive blood loss while you wait for help.
10. Avoid contaminating the access site. Use aseptic technique and a mask for shunt care, dressing changes, and starting or completing dialysis.
11. Administer medications as indicated:
- 11.1. Heparin (low-dose). Infused on the arterial side of the filter to prevent clotting in the filter without systemic effects.
- 11.2. Antibiotics (systemic or topical). Prompt treatment can save the access and prevent sepsis.
2. Preventing Hypovolemia
Fluid restrictions, blood loss, and ultrafiltration can drop volume fast. Pull off too much fluid, or lose blood through the access, and the patient bottoms out. Watch weight and pressure closely around each run.
1. Measure all sources of I&O. Have the patient keep a diary. Helps evaluate fluid status against weight. Urine output is an unreliable measure of renal function in dialysis patients; some put out water with little toxin clearance, others are oliguric or anuric.
2. Weigh daily, before and after dialysis. Weight loss over a measured time reflects ultrafiltration and fluid removal.
3. Monitor BP, pulse, and hemodynamic pressures during dialysis. Hypotension, tachycardia, and falling pressures point to volume depletion.
4. Assess for oozing or frank bleeding at the access, mucous membranes, incisions, or wounds. Hematest stools and gastric drainage. Systemic heparinization raises clotting times and puts the patient at risk for bleeding, especially in the first 4 hours after the procedure.
5. Monitor labs as indicated:
- 5.1. Hb/Hct. May drop from anemia, hemodilution, or actual blood loss.
- 5.2. Serum electrolytes and pH. Imbalances may need a change in dialysate or supplemental replacement.
- 5.3. Clotting times (PT/aPTT) and platelet count. Heparin in the lines and hemofilter alters coagulation and can drive active bleeding.
6. Note whether diuretics or antihypertensives are to be held. Dialysis amplifies their hypotensive effect.
7. Verify continuity of the shunt or access catheter. A disconnected shunt or open access permits exsanguination.
8. Apply the external shunt dressing and permit no puncture of the shunt. Reduces stress on the insertion site and prevents dislodgement and bleeding.
9. Place the patient supine or in Trendelenburg as needed. If hypotension occurs, these positions maximize venous return.
10. Administer IV solutions (normal saline) or volume expanders (albumin) during dialysis as indicated. Saline or dextrose solutions, electrolytes, and NaHCO3 may be infused on the venous side of a continuous arteriovenous (CAV) hemofilter when high ultrafiltration rates are used. Volume expanders may be needed during or after dialysis if marked hypotension occurs.
11. Administer blood or PRBCs if needed. Mechanical hemolysis, hemorrhagic losses, and decreased RBC production can cause progressive anemia.
12. Reduce the ultrafiltration rate during dialysis as indicated. Removes less water and may correct hypotension or hypovolemia.
13. Administer protamine sulfate as appropriate. May be needed to normalize clotting times or if heparin rebound occurs, up to 16 hours after hemodialysis.
3. Preventing Hypervolemia
Between runs, fluid and waste build back up. If the kidneys can't clear it and the patient overdrinks, volume overload follows fast. Track weight, pressure, and lung sounds, and set the dialysis prescription to pull the right amount.
1. Measure all sources of I&O and weigh routinely. Weight gain between treatments should not exceed 0.5 kg/day.
2. Monitor BP and pulse. Hypertension and tachycardia between runs can mean fluid overload or heart failure.
3. Note peripheral or sacral edema, rales, dyspnea, orthopnea, distended neck veins, and ECG changes of ventricular hypertrophy. Overload from inefficient dialysis or repeated hypervolemia can cause or worsen heart failure.
4. Note changes in mentation. Overload can drive cerebral edema (disequilibrium syndrome).
5. Monitor serum sodium and restrict sodium intake as indicated. High sodium drives fluid overload, edema, hypertension, and cardiac complications.
6. Restrict PO and IV fluids as indicated, spacing allowed fluids across 24 hours. Hemodialysis is intermittent, so fluid builds between runs. Spacing fluids also eases thirst.
7. Teach the patient and family the signs of fluid overload. Swelling in the feet, ankles, wrists, and face, shortness of breath, abdominal bloating, needing to sleep sitting up, rapid weight gain, and headache all point to retention.
8. Review dietary restrictions. Patients are often on a restricted sodium, potassium, and phosphorus diet, with limits on fruits, vegetables, nuts, legumes, dairy, and whole grains.
9. Administer diuretics as ordered. They cut sodium reabsorption in the renal tubules, increasing urinary sodium and water excretion.
Frequently Asked Questions
How often and how long is hemodialysis? A standard schedule is 3 times a week, with each session running about 3 to 4 hours (NIDDK). It can be done in a hospital, an outpatient center, or at home, and the prescription is set to pull off the right amount of fluid and waste built up between runs.
Why can't you take blood pressure or draw blood from the access arm? The arteriovenous fistula or graft is the patient's lifeline, and pressure on it raises the risk of clotting and access failure. Teach the patient not to sleep on that side and not to carry packages, books, or a purse on that arm.
How do you tell whether a fistula or graft is still working? Palpate for a thrill (a buzzing vibration) and auscultate for a bruit (a whooshing sound) over the access. Both should be present. A thrill or bruit that disappears, blood that turns dark or separates in the tubing, or a cool, painful access all signal clotting and need fast intervention.
How much weight gain between treatments is acceptable? Weight gain between treatments should generally stay at or below about 0.5 kg per day. Larger gains point to fluid retention and raise the risk of hypertension, pulmonary congestion, and strain on the heart.
Why is bleeding a risk right after dialysis? Patients are given heparin during the run to keep the blood from clotting in the filter, which prolongs clotting times for several hours afterward. Watch for oozing at the access, mucous membranes, and incisions, especially in the first 4 hours, and protamine sulfate may be ordered if heparin rebound occurs (up to about 16 hours later).
What do you do if the access cannulas separate or bleed? Keep two clamps and a tourniquet within reach. If the cannulas separate, clamp the arterial side first, then the venous. If tubing pulls out of the vessel, clamp what remains, apply direct pressure, and place a tourniquet or an inflated blood pressure cuff just above the site while you call for help.