3 Hemodialysis Nursing Care Plans

Risk for Injury

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.

Nursing Diagnosis

• Risk for Injury

Risk factors may include

• Clotting
• Hemorrhage related to accidental disconnection
• Infection

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

• The client will maintain patent vascular access.
• The client will be free of infection.

Nursing Assessments and Rationales

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.

Nursing Interventions and Rationales

1. 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.

2. 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.

3. 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.

4. 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.

5. Administer medications as indicated: 

• 5.1. Heparin (low-dose)
  Infused on the arterial side of the filter to prevent clotting in the filter without systemic side effects.

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