3 Hemodialysis Nursing Care Plans

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 and Management
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Nursing Care Plans and Management

The nursing goal for patients who are undergoing hemodialysis includes prevention or minimization of complications, supporting adaptation to change, preventing complications, and providing information on the prognosis and treatment regimen is well understood, and management of pain.

Nursing Problem Priorities

The following are the nursing priorities for patients undergoing hemodialysis:

Preventing infection
Managing fluid volume

Nursing Assessment

Assess for the following subjective and objective data:

Weakness
Dizziness
Hypotension
Concentrated urine/decreased urine output
Dry mucous membranes
Weak pulse/tachycardia
Decreased skin turgor
Weight gain
Shortness of breath (orthopnea, dyspnea, increased respiratory rate)
Adventitious breath sounds (rales or crackles)
Changes in mentation
Hypernatremia
Hypertension
Edema
Pleural effusion
Restlessness
Decreased hemoglobin or hematocrit
Increased central venous pressure
Jugular vein distention
Tachycardia

Assess for factors related to the cause of hemodialysis:

Clotting
Hemorrhage related to accidental disconnection
Infection
Ultrafiltration
Fluid restrictions
Actual blood loss (systemic heparinization or disconnection of the shunt)
Rapid/excessive fluid intake: IV, blood, plasma expanders, saline given to support BP during dialysis

Nursing Diagnosis

Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with hemodialysis based on the nurse’s clinical judgment and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.

Nursing Goals

Goals and expected outcomes may include:

The client will maintain patent vascular access.
The client will be free of infection.
The client will maintain fluid balance as evidenced by stable/appropriate weight and vital signs, good skin turgor, moist mucous membranes, and absence of bleeding.
The client will maintain “dry weight” within the patient’s normal range
The client will be free of edema
The client will have clear breath sounds and serum sodium levels within normal limits.

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients undergoing hemodialysis may include:

1. Promoting Safety and Preventing Injury Risk

Patients undergoing hemodialysis are at risk for injury due to the invasive nature of the procedure and the need for vascular access. There is a risk of infection, bleeding, and clotting associated with the insertion and maintenance of vascular access devices, such as catheters or arteriovenous fistulas. Additionally, hemodialysis can have other complications, such as hypotension, cramping, and dizziness, which can increase the risk of falls or other injuries. Promoting safety and preventing injury risk is important for patients undergoing hemodialysis to ensure their well-being throughout the treatment process. Several measures can be taken to achieve this. First and foremost, healthcare providers should ensure proper training and education for patients regarding their dialysis access and the importance of maintaining its integrity.

1. Monitor internal AV shunt patency at frequent intervals:

1.1. Palpate for a distal thrill.
The thrill is caused by turbulence of high-pressure arterial blood flow entering the low-pressure venous system and should be palpable above the venous exit site.

1.2. Auscultate for a bruit.
Bruit is the sound caused by the turbulence of arterial blood entering the venous system and should be audible by a stethoscope, although may be very faint.

1.3. Note the color of blood and/or obvious separation of cells and serum.
Change of color from uniform medium red to dark purplish red suggests sluggish blood flow and/or early clotting. Separation in the tubing is indicative of clotting. Very dark reddish-black blood next to clear yellow fluid indicates full clot formation.

1.4. Palpate skin around the shunt for warmth.
Diminished blood flow results in the “coolness” of the shunt.

2. Evaluate reports of pain, numbness, or tingling; note extremity swelling distal to access.
This may indicate inadequate blood supply.

3. Assess skin around vascular access, noting redness, swelling, local warmth, exudate, and tenderness.
Signs of local infection, which can progress to sepsis if untreated.

4. Monitor temperature. Note the presence of fever, chills, and hypotension.
Signs of infection or sepsis requiring prompt medical intervention.

5. Monitor PT, and activated partial thromboplastin time (aPTT) as appropriate.
Provides information about coagulation status, identifies treatment needs, and evaluates effectiveness.

6. Culture the site and obtain blood samples as indicated.
Determines the presence of pathogens.\

7. Notify the physician and/or initiate a Declotting procedure if there is evidence of loss of shunt patency.
Rapid intervention may save access; however, Declotting must be done by experienced personnel.

8. Avoid trauma to shunt. Handle tubing gently, and maintain cannula alignment. Limit activity of extremity. Avoid taking BP or drawing blood samples in the shunt extremity. Instruct patient not to sleep on the side with a shunt or carry packages, books, purses on the affected extremity.
Decreases risk of clotting and disconnection.

9. Attach two cannula clamps to the shunt dressing. Have a tourniquet available. If cannulas separate, clamp the arterial cannula first, then the venous. If tubing comes out of the vessel, clamp the cannula that is still in place and apply direct pressure to the 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 the cannula separates or the shunt is dislodged.

10. Avoid contamination of the access site. Use an aseptic technique and masks when giving shunt care, applying or changing dressings, and when starting or completing the dialysis process.
Prevents the introduction of organisms that can cause infection.

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 side effects.

11.2. Antibiotics (systemic and/or topical)
Prompt treatment of infection may save access, and prevent sepsis.

2. Preventing Hypovolemia

Patients undergoing hemodialysis can experience hypovolemia related to fluid restrictions, blood loss, and ultrafiltration. Fluid restrictions are often necessary to prevent excess fluid from building up in the body between dialysis sessions, which can lead to swelling, shortness of breath, and other complications. Blood loss can occur during the insertion and removal of vascular access devices, or due to other factors such as bleeding ulcers or injury. Ultrafiltration, which removes excess fluid from the blood during hemodialysis, can also lead to dehydration if too much fluid is removed or if electrolytes are not properly balanced. Adequate hydration plays a vital role in maintaining blood volume, so patients should be encouraged to adhere to their prescribed fluid intake guidelines.

1. Measure all sources of I&O. Have the patient keep a diary.
Aids in evaluating fluid status, especially when compared with weight. Note: Urine output is an inaccurate evaluation of renal function in dialysis patients. Some individuals have water output with little renal clearance of toxins, whereas others have oliguria or anuria.

2. Weigh daily before and after dialysis.
Weight loss over precisely measured time is a measure of ultrafiltration and fluid removal.

3. Monitor BP, pulse, and hemodynamic pressures if available during dialysis.
Hypotension, tachycardia, falling hemodynamic pressures suggest volume depletion.

4. Assess for oozing or frank bleeding at access site or mucous membranes, incisions or wounds. Hematest and/or guaiac stools, gastric drainage.
Systemic heparinization during dialysis increases clotting times and places patient at risk for bleeding, especially during the first 4 hr after procedure.

5. Monitor laboratory studies as indicated:

5.1. Hb/Hct
May be reduced because of anemia, hemodilution, or actual blood loss.

5.2. Serum electrolytes and pH
Imbalances may require changes in the dialysate solution or supplemental replacement to achieve balance.

5.3. Clotting times: PT/aPTT, and platelet count
The use of heparin to prevent clotting in blood lines and hemofilter alters coagulation and potentiates active bleeding.

6. Note whether diuretics and/or antihypertensives are to be withheld.
Dialysis potentiates hypotensive effects if these drugs have been administered.

7. Verify continuity of shunt and/or access catheter.
Disconnected shunt or open access permits exsanguination.

8. Apply external shunt dressing. Permit no puncture of shunt.
Minimizes stress on cannula insertion site to reduce inadvertent dislodgement and bleeding from site.

9. Place patient in a supine or Trendelenburg’s position as necessary.
If hypotension occurs, these positions can maximize venous return.

10. Administer IV solutions (e.g., normal saline [NS])/volume expanders (e.g., albumin) during dialysis as indicated;
Saline and/or dextrose solutions, electrolytes, and NaHCO₃ may be infused in the venous side of continuous arteriovenous (CAV) hemofilter when high ultrafiltration rates are used for removal of extracellular fluid and toxic solutes. Volume expanders may be required during or following hemodialysis if sudden or marked hypotension occurs.

11. Administer Blood/PRBCs if needed.
Destruction of RBCs (hemolysis) by mechanical dialysis, hemorrhagic losses, decreased RBC production may result in profound or progressive anemia requiring corrective action.

12. Reduce rate of ultrafiltration during dialysis as indicated
Reduces the amount of water being removed and may correct hypotension or hypovolemia.

13. Administer protamine sulfate as appropriate.
May be needed to return clotting times to normal or if heparin rebound occurs (up to 16 hr after hemodialysis).

3. Preventing Hypervolemia

Patients undergoing hemodialysis can experience excess fluid volume due to the accumulation of fluid and waste products in the body between dialysis sessions. Hemodialysis is used to remove excess fluid and waste products from the blood, but if the kidneys are severely damaged, they may not be able to remove enough fluid on their own, leading to fluid overload. In addition, some patients may consume excessive amounts of fluid or have conditions that cause fluid retention, further exacerbating the problem. Regular monitoring of the patient’s weight, blood pressure, and clinical symptoms is crucial to detect early signs of fluid overload. Healthcare providers should closely assess the patient’s pre-dialysis weight and adjust the dialysis prescription accordingly to remove the appropriate amount of fluid.

1. Measure all sources of I&O. Weigh routinely.
Aids in evaluating fluid status, especially when compared with weight. Weight gain between treatments should not exceed 0.5 kg/day.

2. Monitor BP, pulse.
Hypertension and tachycardia between hemodialysis runs may result from fluid overload and/or HF.

3. Note presence of peripheral or sacral edema, respiratory rales, dyspnea, orthopnea, distended neck veins, ECG changes indicative of ventricular hypertrophy.
Fluid volume excess due to inefficient dialysis or repeated hypervolemia between dialysis treatments may cause or exacerbate HF, as indicated by signs and symptoms of respiratory and/or systemic venous congestion.

4. Note changes in mentation.
Fluid overload or hypervolemia may potentiate cerebral edema (disequilibrium syndrome).

5. Monitor serum sodium levels. Restrict sodium intake as indicated.
High sodium levels are associated with fluid overload, edema, hypertension, and cardiac complications.

6. Restrict PO/IV fluid intake as indicated, spacing allowed fluids throughout a 24-hr period.
The intermittent nature of hemodialysis results in fluid retention or overload between procedures and may require fluid restriction. Spacing fluids helps reduce thirst.

7. Teach the patient and family on signs and symptoms of fluid overload.
Swelling in the feet, ankles, wrist, and face (edema), shortness of breath, abdominal bloating, needing to sleep sitting up (orthopnea), rapid weight gain, and headache are signs of fluid retention and overload.

8. Review dietary restrictions.
Patients may be place on a low or restricted sodium, potassium and phosphorous diet. Specifically, patients are instructed to limit the intake fruits, vegetables, nuts, legumes, dairy, and whole grains.

9. Administer diuretics.
Diuretics decrease sodium reabsorption in specific renal tubules, causing in an increase in urinary sodium and water excretion.

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

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Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.

Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
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Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.

Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!

All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.