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
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.