Nursing Care Plan of Hemodialysis Patients

Objectives:

•To know how the basic nursing care of patients on hemodialysis and peritoneal dialysis.

•To discuss proper care of vascular access.

•To demonstrate PD exit site care.

TYPES OF DIALYSIS

• Hemodialysis – Dialyzer

• Peritoneal dialysis – Peritoneum

Flow Scheme of Hemodialysis

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1. Initial Nursing Assessment of hemodialysis patient

a. Weight

Present weight – dry weight = Target weight loss.

b. Vital signs

1. BP – standing, sitting

2. Cardiac rate and rhythm

3. Pulse rate

4. Respiratory rate

5. Temperature

Nursing Care of patient during the treatment

1. Promote pt comfort Dialysis tx is during the procedure lengthy

A. Provide physical comfort measures.

a. Back care

b. Elevate head of the bed

c. Assist in turning

B. Keep pt. informed of progress and results.

C. Provide diversional activities.

D. Provide care and attention to pt. considering physiological, psychological care, remembering his needs, reactions and concerns.

2. Maintain good outflow of blood.

A. Monitor alarms of the machine.

B. Monitor vital signs. – a drop in blood pressure may indicate rapid fluid loss that may lead to and dehydration.

3. Monitor changes in fluid and electrolyte status , weight changes.

A. Laboratory studies

B. Assess level of responsiveness at the beginning, throughout and at the end of the treatment.

C. Pre and post dialysis weight

4. Monitor for complications

A. Infection – Bacteremia is an unwanted complication

1. Watch for chills/fever – Antibiotics may be given after the treatment.

2. Redness around the access– Request for blood culture

Observe strict aseptic technique!

B. Bleeding

1. Observe site for any blood leaks

2. Monitor vital signs.

3. Monitor for hypertension/ hypotension

C. General Physical Condition

1. Central Nervous System

2. Cardiovascular

3. Respiratory

4. Hematological

5. Dermatological

6. Gastro-intestinal

7. Genito-urinary

Nursing Post- dialysis Care

1. Check for any blood works or medicines to be given before terminating dialysis.

2. Upon removal of fistula needle apply pressure dressing using sterile gauze and wait until the puncture site has clotted.

3. Snugly tape on a new pressure dressing and instruct pt. to remove 4 to five hrs later when possible bleeding may occur.

4. Ask your patient to rest at least 15 minutes and dangle their legs to prevent postural hypotension after dialysis.

5. Reinforce diet and fluid requirements of patient on dialysis.

6. Remind their about next schedule of their dialysis.

7. Weigh patient before they leave the center.

Post Dialysis Nursing Assessment

1. Patient’s weight and weight loss

2. Vital signs e.g. TPR and BP

3. Resolution/improvement of problematic predialysis parameters ( improvement of fluid status )

4. Total of infusion given, both saline and blood

5. Patient’s subjective physical assessment

6. Bleeding status

Management of complications during the treatment

1. Hypotension

Symptoms:

– lightheadedness, dizziness, yawning,

fainting or collapse

Causes:

– Excess ultrafiltration (excess fluid removal)

– Too much blood in the extracorporeal circuit

– Intake of antihypertensive drug an hour

before the treatment.

– External or internal bleeding

– Decrease fluid intake

– Inability to metabolize acetate

Management:

– Increase blood volume with Normal Saline

given bolus initially at 100 cc – maximum of 300 cc.

– Decrease UF rate or 0 UF

– Reevaluate antihypertensive drug

– Use of vassopressor drugs if

hypotension persist.

– Trendelenburg position.

– reduce coil and cuff pressure decrease

blood flow rate.

2. Muscle Cramps

Common causes:

– rapid sodium and water removal during dialysis

– neuromuscular sensitivity secondary to uremia

Possible remedies

– Administer Normal Saline bolus (100cc) or

– NaCl 10 meq per doctors order

– If not relieved quinine sulfate or muscle relaxant is ordered

Note:

The pt blood pressure & weight will indicate whether or not the cramps are a function of excessive Na and water removal. Evidence of severe uremia would indicate that cramps are caused by neuromuscular

3. Air Embolism

Factors:

– use of blood pump

– high negative pressure

– empty bottles connected to bloodline

– defective line and air detector

Symptoms:

– sudden onset of dyspnea

– cough

– cyanosis

– respiratory arrest

– loss of consciousness

Prevention and treatment

– check for defective tubes/air detector

– clamp IV line after administration of NSS

– place patient on his left side with feet higher than head

– administer oxygen in high concentration

– avoid high negative pressure

– assist respiration in case of respiratory arrest

– catheter aspiration of the right side of the heart

4. Disequilibrium syndrome

– headache

– restlessness

– nausea and vomiting

– hypertension/hypotension

– cramps

– convulsions

Causes:

– Reduction of ECF osmolality

– Increased ICF and CSF acidosis

– reduction of oxygen delivery to the tissue

Possible remedies:

– slow infussion of mannitol or hypertonic NaCl

– administer glucose

– administer dilantin prior to dialysis

– reduce duration and flow rate of the first few dialysis.

VASCULAR ACCESS

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Care of Vascular Access: Central Catheters

• Keep the catheter dressing clean and dry.

• Make sure the area of insertion site is clean and change the dressing at each dialysis session.

• Instruct patient on how to change dressings in an emergency .

• Instruct patient not shower or swim; but tell him/her that he/she may take a bath.

• Wear a mask over nose and mouth anytime the catheter is opened to prevent bacteria from entering the catheter and the bloodstream.

• The caps and the clamps of the central catheter should be kept tightly closed when not being used for dialysis.

• Monitor exit site for soreness/ redness.

• Know the Kt/V and URR (urea reduction ratio). Kt/V should be at least 1.2. If URR is used it should be 65% or more. If the numbers are too low, one possible cause may be that the access is not working well.

*** from the National Kidney Foundation, New York, 2007

Care of Vascular Access: AV Fistulas/Grafts

• Keep the access site clean at all times.

• Avoid injections, intravenous (IV) needles or fluids, or taking blood samples in the access site arm.

• Needle insertions for hemodialysis treatments should be rotated.

• Do not take blood pressure or put pressure on the access arm.

• Advise patients to avoid wearing jewelry or tight clothing, sleeping on, or lifting heavy objects with the access arm.

• Check the access arm for adequate circulation.

• Check for signs of infection at the access site.

* Encyclopedia of Nursing and Allied Health

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