Nursing Care of
Patient
on Dialysis
“Don’t Worry I‘ll find a
good site soon “
By: Ms. Shanta Peter
• Protocols – in each unit
• In regard to machines – Procedure &
patient care
• Sanitizing machines
• PD cath care/dressing /treatment
• Flushing new PD catheter
• PET
• Peritonitis care
• Investigation protocol
• Vaccination
• Records /Treatment flow sheets
Hemodialysis requires 5 things
1. Access to patient’s circulation (usually via
fistula)
2. Access to a dialysis machine and dialyzer with
a semipermeable membrane
3. The appropriate solution (dialysate bath)
4. Time: 12 hours each week, divided in 3 equal
segments
5. Place: home (if feasible) or a dialysis center
Access to Circulation
Central Venous Catheter
A-V Fistula
A-V Graft
Hemodialysis – Procedure
1. Patient’s circulation is accessed
2. Unless contraindicated, heparin is administered
3. Dialysis solution surrounds the membranes and
flows in the opposite direction
4. Dialysis solution is:
a. Highly purified water
b. Na,K, Ca, Mg, Cl, & Dextrose
c. Either bicarbonate or acetate, to maintain
a proper pH
6. Via the process of diffusion, wastes are removed
in the form of solutes (metabolic wastes, acid-base
components and electrolytes)
7. Solute wastes can be discarded
8. Ultrafiltration removes excess water from the
blood
9. After cleansing, the blood returns to the client
via the access
Complications related to vascular Access in
Hemodialysis
1. Infection
2. Catheter clotting
3. Central venous thrombosis
4. Stenosis or thrombosis
5. Ischemia of the affected limb
6. Development of an aneurysm
Hemodialysis: Nursing considerations
Pre-dialysis care
Assess
• Weight: Determines amount of fluid to be
removed during dialysis
• Vital signs: BP for hypo and hypertension;
temperature for sepsis; respiration for fluid
overload
• Potassium level: Determines potassium level
in dialysate (in the chronic setting, this is done
monthly unless the patient is symptomatic
Review Medications
• Hold drugs that pass through the dialysis
membrane, such as piperacillin, folic acid,
and other water-soluble vitamins.
• Hold antihypertensive drugs, especially if
systolic pressure is below 100, per physician
order
• Review need for blood products
Check access site
• Assess fistula or graft for infection
• Assess circulation in distal portion of
extremity
• Auscultate for bruit
• Palpate for thrill
• No IV or blood draws in that arm
• No BP in arm
During dialysis
Watch for
• Hypotension
• Muscle cramps
• Nausea and vomiting
• Headache
• Itching
• Less commonly: disequilibrium syndrome,
hypersensitivity reaction, arrhythmia, cardiac
tamponade, seizures, air embolism
Post-Dialysis care
• Monitor BP; report hypotension or hypertension
• Watch for bleeding
• Check weight and compare (weight loss should
be close to fluid removal goal set during
treatment)
• Document unusual findings
• Assess access site for bruit, thrill, exudate, signs
of infection, bleeding
• Give missed meds, if indicated
Complications of dialysis
• Infection
• Hernias
• Nutritional Deficiencies
• Low Blood Pressure
• Muscle Cramps
• Clotting Issues
• Movement Issues
• Dry and Itching Skin
Nursing interventions for H D
1. Explain procedure to client
2. Cannulating & connecting to HD machine
3. Monitor hemodynamic status continuously
4. Monitor acid-base balance
5. Monitor electrolytes
6. Insure sterility of system
7. Maintain a closed system
8. Discuss diet and restrictions on:
a. Protein intake
b. Sodium intake
c. Potassium intake
d. Fluid intake
9. Reinforce adjustment to prescribed medications that may
be affected by the process of hemodialysis
10. Monitor for complications of dialysis related to:
a. Arteriosclerotic cardiovascular disease
b. Congestive heart failure
c. Stroke
d. Infection
e. Gastric ulcers
f. Hypertension
g. Calcium deficiencies (bone problems such as
aseptic necrosis of the hip joint)
h. Anemia and fatigue
i. Depression, sexual dysfunction, suicide risk
11 Dry Weight
Peritoneal Dialysis (PD )
Peritoneal dialysis (PD) is not always trouble-free
Patients may experience both psychological and
physical problems like ---------
• Body image -- catheter outside , size and shape
of abdomen
• Fluid overload
• Dehydration
• Discomfort- uncomfortable when fluid in full
or blotted – backache , shoulder pain
• Poor drainage :
a. Constipation b. Catheter displacement
• Leaks
• Hernia
• Tunnel infection( exit site infection)
• Peritonitis
• Back pain
Nursing Care – P.D
• Imbalanced nutrition
• Impaired physical Mobility
• Self-Care Deficit
• Risk for Constipation
• Risk for disturbed Thought Processes
• Anxiety [specify level]
• Fear
• Disturbed Body Image/situational /low Self-Esteem
• Deficient Knowledge regarding condition, prognosis,
treatment, self-care, and discharge needs
Special considerations –
Hospitalized patients (HD,PD)
• Protecting the vascular access
• Precautions during I.V therapy
• Monitoring symptoms of uremia
• Detecting cardiac and respiratory Complications
• Controlling electrolyte levels and Diet
• Managing discomfort and pain
• Monitoring BP
• Preventing infection
• Caring for the catheter site
• Administering medications
• Providing psychological support –pt and family
Special Nursing responsibilities – DIALYSIS
• Thrill /bruit every 8 hrs – Absence—blockage or clotting
• Observe for clotting ( hypotension , application of tourniquet, BP
cuff
• IV therapy precautions – IV fluid – by pump high rate ---> pulm
edema ------Maintain accurate I/O chart
• Accumulation of uremic toxins ----> pericarditis,
Pericardial effusion, tamponade
(Pericaditis --> fever,, Chest pain, low BP during inspiration , rub , Low
voltage ECG
Elect level – S K is more deadly
Blood transfusions –give during HD --->extra K is excreted
• Monitor diet ---
• Discomfort /Pain – adjust the medication
dosage
• skin clean and well moisture – bath oils, cream
lotions reduce itching (nail trimmed )
• BP monitoring - High BP common
• Antihypertensive medications – teach pts
purpose --- side effects
• Withhold antihypertensive medications on
dialysis days --- to prevent hypotension
• Medications : monitor all medications --- avoid
renal toxic drugs
• Preventing infection :- Low WBC , Low RBC ,
impaired platelets count ---> infection and
bleeding ( Pneumonia is common)
• Catheter site care
• Training CAPD --– compliance should be
checked
• Cather care – showing/change dressing and
site care
• Psychological support
• Evaluate life and status – let pt and family
express feelings
Dialysis & Hypotension
• If syst B/P is 100mmHg or below then hypotensive or if
hypertensive and become symptomatic with a drop in B/P.
• If pt is hypotensive but asymptomatic check B/P every 10
minutes do not give fluid replacement.
ETIOLOGY
• It is a consequence of a decrease
• in blood volume resulting in:
• decreased cardiac filling
• reduced cardiac output
• hypotension if compensatory changes do not occur.
CAUSES
• Excessive decrease in blood volume
• Lack of vasoconstriction
• Cardiac factors
Sudden onset and may include:
• Nausea & vomiting
• Weak thready pulse, shallow respiration's
• Light headednesss & fainting
• Yawning, cold-clammy skin
• Decreased mental state
• Irritability, nervousness, stupor
• Malaise, fatigue
MANAGEMENT
• Place in Trendelenberg position
• UF off
• Vital signs
• IV Saline bolus
Do not place in trendelenberg if have just had a
transplant.
• Reduce TMP to -10 but do not turn off
• Switch UFR off if using a fluid control monitor
• Give a 200 ml saline or gelofusine bolus-- repeated at 5
min intervals if pt remains hypotensive.
Max 3 boluses over15 mins or a total of 600 mls.
• If hypotensive but asymptomatic then check B/P every
PREVENTION
• Patient education
• Accurate patient assessment
• Target weight assessment
• Withhold anti-hypertensives
• Dialysate sodium level
DIET –DIALYSIS
• PD get calories from Dextrose in the fluid -PD patients
may eat fewer CHO than hemodialysis patients
• Protein- HD loses 10-12 gms of Aminoacids and PD 5-
15gms of protein per treatment
Also compensate infection inflammation anemia -->so
consume HBV protein (1gm/Kg/day)
• Na – Salt 2gm/day—salt induce thirst – High BP, and
HF
• K- 2mg/day K is more efficiently removed in PD (daily
treatment)
• Phosphorous cause severe bone and heart
problems , itching and tissue calcifications
(800-1000mg/Day)
• Take phosphate binders
• Ca should be more than 2000mg/day. Ca is pulled
out by dialysis lead to serious health problems
• Fluid- if they consume more fluid—use
concentrated dialysate if no urine out put –
consume <than 4C (32)oz) /day include all food if
urinate 4C + same amount of urine
• Consume 20-25 g fiber
• 1.2 g of protein/kg body weight/day for
hemodialysis patients
• 1.3 g of protein/kg body weight/day for
peritoneal dialysis patients
• 35 kcal/kg body weight for patient
less than 60 years of age
• 30 to 35 kcal/kg body weight
For patients 60 years or older
