Hemodialysis separates solutes by differential diffusion through a cellophane membrane placed between the blood and dialysate solution, in an external receptacle. Blood is shunted through an artificial kidney (dialyzer) for the removal of excess fluid and toxins and then returned to the venous circulation. Because the blood must actually pass out of the body into a dialysis machine, hemodialysis requires an access route to the blood supply by an arteriovenous fistula or cannula or by a bovine or synthetic graft. Hemodialysis is a fast and efficient method of removing urea and other toxic products. It is usually performed three times per week for four hours and can be done in a hospital, outpatient dialysis center, or at home.
Nursing care planning and goals for patients who are undergoing hemodialysis include monitoring of the AV shunt patency during the process, preventing risk for injury, monitoring fluid status, and providing information.
Risk for Injury
Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.
Risk factors may include
Possibly evidenced by
- Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
- Maintain patent vascular access.
- Be free of infection.
|Monitor internal AV shunt patency at frequent intervals:|
|Thrill is caused by turbulence of high-pressure arterial blood flow entering low-pressure venous system and should be palpable above venous exit site.|
|Bruit is the sound caused by the turbulence of arterial blood entering venous system and should be audible by stethoscope, although may be very faint.|
|Change of color from uniform medium red to dark purplish red suggests sluggish blood flow and/or early clotting. Separation in tubing is indicative of clotting. Very dark reddish-black blood next to clear yellow fluid indicates full clot formation.|
|Diminished blood flow results in “coolness” of shunt.|
|Notify physician and/or initiate declotting procedure if there is evidence of loss of shunt patency.||Rapid intervention may save access; however, declotting must be done by experienced personnel.|
|Evaluate reports of pain, numbness or tingling; note extremity swelling distal to access.||May indicate inadequate blood supply.|
|Avoid trauma to shunt. Handle tubing gently, maintain cannula alignment. Limit activity of extremity. Avoid taking BP or drawing blood samples in shunt extremity. Instruct patient not to sleep on side with shunt or carry packages, books, purse on affected extremity.||Decreases risk of clotting and disconnection.|
|Attach two cannula clamps to shunt dressing. Have tourniquet available. If cannulas separate, clamp the arterial cannula first, then the venous. If tubing comes out of vessel, clamp cannula that is still in place and apply direct pressure to bleeding site. Place tourniquet above site or inflate BP cuff to pressure just above patient’s systolic BP.||Prevents massive blood loss while awaiting medical assistance if cannula separates or shunt is dislodged.|
|Assess skin around vascular access, noting redness, swelling, local warmth, exudate, tenderness.||Signs of local infection, which can progress to sepsis if untreated.|
|Avoid contamination of access site. Use aseptic technique and masks when giving shunt care, applying or changing dressings, and when starting or completing dialysis process.||Prevents introduction of organisms that can cause infection.|
|Monitor temperature. Note presence of fever, chills, hypotension.||Signs of infection or sepsis requiring prompt medical intervention.|
|Culture the site and obtain blood samples as indicated.||Determines presence of pathogens.|
|Monitor PT, activated partial thromboplastin time (aPTT) as appropriate.||Provides information about coagulation status, identifies treatment needs, and evaluates effectiveness.|
|Administer medications as indicated:|
|Infused on arterial side of filter to prevent clotting in the filter without systemic side effects.|
|Prompt treatment of infection may save access, prevent sepsis.|
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