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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 Plans
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.
Here are three (3) nursing care plans (NCP) and nursing diagnosis for hemodialysis:
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Risk for Injury
Nursing Diagnosis
- Risk for Injury
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.
Desired Outcomes
- Maintain patent vascular access.
- Be free of infection.
| Nursing Interventions | Rationale |
|---|---|
| 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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Recommended Resources
Recommended nursing diagnosis and nursing care plan books and resources.
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- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use. - Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively. - NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales. - Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates. - Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing. - Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans. - Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you. - Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023. - All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
See also
Other recommended site resources for this nursing care plan:
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- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch. - Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other care plans and nursing diagnoses related to reproductive and urinary system disorders:
- Acute Glomerulonephritis | 4 Care Plans
- Acute Renal Failure | 6 Care Plans
- Benign Prostatic Hyperplasia (BPH) | 5 Care Plans
- Chronic Renal Failure | 11 Care Plans
- Hemodialysis | 3 Care Plans
- Hysterectomy (TAHBSO) | 6 Care Plans
- Mastectomy | 14+ Care Plans
- Menopause | 6 Care Plans
- Nephrotic Syndrome | 5 Care Plans
- Peritoneal Dialysis | 6 Care Plans
- Prostatectomy | 6 Care Plans
- Urolithiasis (Renal Calculi) | 4 Care Plans
- Urinary Tract Infection | 4 Care Plans
- Vesicoureteral Reflux (VUR) | 5 Care Plans
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very good information
Awesome information
For deficient fluid volume shouldn’t there be AEB since it is not a “risk for”?
Hey Sam, that diagnosis should be Risk for Deficient Fluid Volume.