Hemodialysis and 3 Nursing Care Plans for Hemodialysis.

Hemodialysis and 3 Nursing Care Plans for Hemodialysis.

This study guide is about hemodialysis and 3 nursing care plans for hemodialysis. Use it to create educational nursing care plans for hemodialysis.

Hemodialysis

What is hemodialysis?

Hemodialysis and 3 Nursing Care Plans for Hemodialysis.
Hemodialysis

Hemodialysis is a procedure that separates solutes by differential diffusion through a cellophane membrane placed between the blood and dialysate solution, in an external receptacle. In hemodialysis, a machine filters wastes, salts, and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately. Hemodialysis (he-moe-die-AL-uh-sis) is one way to treat advanced kidney failure and can help you carry on an active life despite failing kidneys.

With hemodialysis, you’ll need to:

  • Follow a strict treatment schedule
  • Take medications regularly
  • Make changes in your diet

Hemodialysis is a serious responsibility, but you don’t have to shoulder it alone. You’ll work closely with your health care team, including a kidney specialist and other professionals with experience managing hemodialysis. You may be able to do hemodialysis at home.

How do kidneys work?

Why is hemodialysis done?

Your doctor will help determine when you should start hemodialysis based on several factors, including your:

  • Overall health
  • Kidney function
  • Signs and symptoms
  • Quality of life
  • Personal preferences

You might notice signs and symptoms of kidney failure (uremia), such as nausea, vomiting, swelling or fatigue. Your doctor uses your estimated glomerular filtration rate (eGFR) to measure your level of kidney function. Your eGFR is calculated using your blood creatinine test results, sex, age and other factors. A normal value varies with age. This measure of your kidney function can help to plan your treatment, including when to start hemodialysis.

Hemodialysis can help your body control blood pressure and maintain the proper balance of fluid and various minerals — such as potassium and sodium — in your body. Normally, hemodialysis begins well before your kidneys have shut down to the point of causing life-threatening complications.

Common causes of kidney failure include:

  • Diabetes
  • High blood pressure (hypertension)
  • Kidney inflammation (glomerulonephritis)
  • Kidney cysts (polycystic kidney disease)
  • Inherited kidney diseases
  • Long-term use of nonsteroidal anti-inflammatory drugs or other medications that could harm the kidneys

However, your kidneys may shut down suddenly (acute kidney injury) after a severe illness, complicated surgery, heart attack or other serious problem. Certain medications also can cause kidney injury.

Some people with severe long-standing (chronic) kidney failure may decide against starting dialysis and opt for a different path. Instead, they may choose maximal medical therapy, also called maximum conservative management or palliative care. This therapy involves active management of complications of advanced chronic kidney disease, such as fluid overload, high blood pressure and anemia, with a focus on supportive management of symptoms that affect quality of life.

Other people may be candidates for a preemptive kidney transplant, instead of starting on dialysis. Ask your health care team for more information about your options. This is an individualized decision because benefits of dialysis may vary, depending on your particular health issues.

What are the risks of hemodialysis?

Hemodialysis and 3 Nursing Care Plans for Hemodialysis.
Risks of hemodialysis

Most people who require hemodialysis have a variety of health problems. Hemodialysis prolongs life for many people, but life expectancy for people who need it is still less than that of the general population.

While hemodialysis treatment can be efficient at replacing some lost kidney function, you may experience some of the related conditions listed below, although not everyone experiences all of these issues. Your dialysis team can help you deal with them.

  • Low blood pressure (hypotension). A drop in blood pressure is a common side effect of hemodialysis. Low blood pressure may be accompanied by shortness of breath, abdominal cramps, muscle cramps, nausea or vomiting.
  • Muscle cramps. Although the cause is not clear, muscle cramps during hemodialysis are common. Sometimes the cramps can be eased by adjusting the hemodialysis prescription. Adjusting fluid and sodium intake between hemodialysis treatments also may help prevent symptoms during treatments.
  • Itching. Many people who undergo hemodialysis have itchy skin, which is often worse during or just after the procedure.
  • Sleep problems. People receiving hemodialysis often have trouble sleeping, sometimes because of breaks in breathing during sleep (sleep apnea) or because of aching, uncomfortable or restless legs.
  • Anemia. Not having enough red blood cells in your blood (anemia) is a common complication of kidney failure and hemodialysis. Failing kidneys reduce the production of a hormone called erythropoietin (uh-rith-roe-POI-uh-tin), which stimulates the formation of red blood cells. Diet restrictions, poor absorption of iron, frequent blood tests, or removal of iron and vitamins by hemodialysis also can contribute to anemia.
  • Bone diseases. If your damaged kidneys are no longer able to process vitamin D, which helps you absorb calcium, your bones may weaken. In addition, overproduction of parathyroid hormone — a common complication of kidney failure — can release calcium from your bones. Hemodialysis may make these conditions worse by removing too much or too little calcium.
  • High blood pressure (hypertension). If you consume too much salt or drink too much fluid, your high blood pressure is likely to get worse and lead to heart problems or strokes.
  • Fluid overload. Since fluid is removed from your body during hemodialysis, drinking more fluids than recommended between hemodialysis treatments may cause life-threatening complications, such as heart failure or fluid accumulation in your lungs (pulmonary edema).
  • Inflammation of the membrane surrounding the heart (pericarditis). Insufficient hemodialysis can lead to inflammation of the membrane surrounding your heart, which can interfere with your heart’s ability to pump blood to the rest of your body.
  • High potassium levels (hyperkalemia) or low potassium levels (hypokalemia). Hemodialysis removes extra potassium, which is a mineral that is normally removed from your body by your kidneys. If too much or too little potassium is removed during dialysis, your heart may beat irregularly or stop.
  • Access site complications. Potentially dangerous complications ― such as infection, narrowing or ballooning of the blood vessel wall (aneurysm), or blockage ― can impact the quality of your hemodialysis. Follow your dialysis team’s instructions on how to check for changes in your access site that may indicate a problem.
  • Amyloidosis. Dialysis-related amyloidosis (am-uh-loi-DO-sis) develops when proteins in blood are deposited on joints and tendons, causing pain, stiffness and fluid in the joints. The condition is more common in people who have undergone hemodialysis for several years.
  • Depression. Changes in mood are common in people with kidney failure. If you experience depression or anxiety after starting hemodialysis, talk with your health care team about effective treatment options.

How do you prepare for hemodialysis?

Preparation for hemodialysis starts several weeks to months before your first procedure. To allow for easy access to your bloodstream, a surgeon will create vascular access. The access provides a mechanism for a small amount of blood to be safely removed from your circulation and then returned to you in order for the hemodialysis process to work. The surgical access needs time to heal before you begin hemodialysis treatments.

There are three types of accesses:

  • Arteriovenous (AV) fistula. A surgically created AV fistula is a connection between an artery and a vein, usually, in the arm, you use less often. This is the preferred type of access because of effectiveness and safety.
  • AV graft. If your blood vessels are too small to form an AV fistula, the surgeon may instead create a path between an artery and a vein using a flexible, synthetic tube called a graft.
  • Central venous catheter. If you need emergency hemodialysis, a plastic tube (catheter) may be inserted into a large vein in your neck. The catheter is temporary.

It’s extremely important to take care of your access site to reduce the possibility of infection and other complications. Follow your health care team’s instructions about caring for your access site.

What is the procedure of conducting hemodialysis?

During treatments, you sit or recline in a chair while your blood flows through the dialyzer ― a filter that acts as an artificial kidney to clean your blood. You can use the time to watch TV or a movie, read, nap, or perhaps talk to your “neighbors” at the center. If you receive hemodialysis at night, you can sleep during the procedure.

  • Preparation. Your weight, blood pressure, pulse and temperature are checked. The skin covering your access site — the point where blood leaves and then reenters your body during treatment — is cleansed.
  • Starting. During hemodialysis, two needles are inserted into your arm through the access site and taped in place to remain secure. Each needle is attached to a flexible plastic tube that connects to a dialyzer. Through one tube, the dialyzer filters your blood a few ounces at a time, allowing wastes and extra fluids to pass from your blood into a cleansing fluid called dialysate. The filtered blood returns to your body through the second tube.
  • Symptoms. You may experience nausea and abdominal cramps as excess fluid is pulled from your body — especially if you have gained a significant amount of fluid in between dialysis sessions. If you’re uncomfortable during the procedure, ask your care team about minimizing side effects by such measures as adjusting the speed of your hemodialysis, your medication or your hemodialysis fluids.
  • Monitoring. Because blood pressure and heart rate can fluctuate as excess fluid is drawn from your body, your blood pressure and heart rate will be checked several times during each treatment.
  • Finishing. When hemodialysis is completed, the needles are removed from your access site and a pressure dressing is applied to the site to prevent bleeding. Your weight may be recorded again. Then you’re free to go about your usual activities until your next session.

What are the goals of hemodialysis?

If you had a sudden (acute) kidney injury, you may need hemodialysis only for a short time until your kidneys recover. If you had reduced kidney function before a sudden injury to your kidneys, the chances of full recovery back to independence from hemodialysis are lessened.

Although in-center, three-times-a-week hemodialysis is more common, some research suggests that home dialysis is linked to:

  • Better quality of life
  • Increased well-being
  • Reduced symptoms and less cramping, headaches and nausea
  • Improved sleeping patterns and energy level

Your hemodialysis care team monitors your treatment to make sure you’re getting the right amount of hemodialysis to remove enough wastes from your blood. Your weight and blood pressure are monitored very closely before, during and after your treatment. About once a month, you’ll receive these tests:

  • Blood tests to measure urea reduction ratio (URR) and total urea clearance (Kt/V) to see how well your hemodialysis is removing waste from your body
  • Blood chemistry evaluation and assessment of blood counts
  • Measurements of the flow of blood through your access site during hemodialysis

Your care team may adjust your hemodialysis intensity and frequency based, in part, on test results.

3 Nursing Care Plans for Hemodialysis

Hemodialysis and 3 Nursing Care Plans for Hemodialysis.
3 Nursing Care Plans for Hemodialysis.

Nursing care planning and goals for patients who are undergoing hemodialysis include monitoring of the AV shunt patency during the process, preventing risk for injury, monitoring fluid status, and providing information.

1. Risk for Injury

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

  • Maintain patent vascular access.
  • Be free of infection.
Nursing Interventions Rationale
Monitor internal AV shunt patency at frequent intervals:
  • Palpate for the 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.
  • 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.
  • 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.
  • Palpate skin around shunt for warmth.
Diminished blood flow results in “coolness” of the shunt.
Notify physician and/or initiate declotting procedure if there is evidence of loss of shunt patency. Rapid intervention may save access; however, declotting must be done by experienced personnel.
Evaluate reports of pain, numbness, or tingling; note extremity swelling distal to access. May indicate inadequate blood supply.
Avoid trauma to shunt. Handle tubing gently, maintain cannula alignment. The limit activity of extremity. Avoid taking BP or drawing blood samples in the shunt extremity. Instruct patient not to sleep on the side with shunt or carry packages, books, purse on the affected extremity. Decreases risk of clotting and disconnection.
Attach two cannula clamps to 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.
Assess skin around vascular access, noting redness, swelling, local warmth, exudate, tenderness. Signs of local infection, which can progress to sepsis if untreated.
Avoid contamination of access site. Use 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.
Monitor temperature. Note the presence of fever, chills, hypotension. Signs of infection or sepsis requiring prompt medical intervention.
Culture the site and obtain blood samples as indicated. Determines presence of pathogens.
Monitor PT, activate partial thromboplastin time (aPTT) as appropriate. Provides information about coagulation status, identifies treatment needs, and evaluates effectiveness.
Administer medications as indicated: 
  • Heparin (low-dose)
Infused on the arterial side of the filter to prevent clotting in the filter without systemic side effects.
  • Antibiotics (systemic and/or topical)
Prompt treatment of infection may save access, prevent sepsis.

2. Deficient Fluid Volume

Nursing Diagnosis

  • Deficient Fluid Volume

Risk factors may include

  • Ultrafiltration
  • Fluid restrictions
  • Actual blood loss (systemic heparinization or disconnection of the shunt)

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

  • Maintain fluid balance as evidenced by stable/appropriate weight and vital signs, good skin turgor, moist mucous membranes, absence of bleeding.
Nursing Interventions Rationale
Measure all sources of I&O. Have the patient keep a diary. Aids in evaluating the 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.
Weigh daily before and after dialysis. Weight loss over precisely measured time is a measure of ultrafiltration and fluid removal.
Monitor BP, pulse, and hemodynamic pressures if available during dialysis. Hypotension, tachycardia, falling hemodynamic pressures suggest volume depletion.
Note whether diuretics and/or antihypertensives are to be withheld. Dialysis potentiates the hypotensive effects of these drugs that have been administered.
Verify continuity of shunt and/or access catheter. Disconnected shunt or open access permits exsanguination.
Apply external shunt dressing. Permit no puncture of the shunt. Minimizes stress on cannula insertion site to reduce inadvertent dislodgement and bleeding from site.
Place the patient in a supine or Trendelenburg position as necessary. If hypotension occurs, these positions can maximize venous return.
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 patients at risk for bleeding, especially during the first 4 hr after the procedure.
Monitor laboratory studies as indicated:
  • Hb/Hct
May be reduced because of anemia, hemodilution, or actual blood loss.
  • Serum electrolytes and pH
Imbalances may require changes in the dialysate solution or supplemental replacement to achieve balance.
  • Clotting times: PT/aPTT, and platelet count
The use of heparin to prevent clotting in bloodlines and hemofilter alters coagulation and potentiates active bleeding.
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.
Blood/PRCs if needed. Destruction of RBCs (hemolysis) by mechanical dialysis, hemorrhagic losses, decreased RBC production may result in profound or progressive anemia requiring corrective action.
Reduce the rate of ultrafiltration during dialysis as indicated Reduces the amount of water being removed and may correct hypotension or hypovolemia.
Administer protamine sulfate as appropriate. It may be needed to return clotting times to normal or if heparin rebound occurs (up to 16 hr after hemodialysis).

3. Excess Fluid Volume

Nursing Diagnosis

  • Excess Fluid Volume

Risk factors may include

  • Rapid/excessive fluid intake: IV, blood, plasma expanders, saline given to support BP during dialysis

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

  • Maintain “dry weight” within patient’s normal range
  • Be free of edema
  • Have clear breath sounds and serum sodium levels within normal limits.
Nursing Interventions Rationale
Measure all sources of I&O. Weigh routinely. Aids in evaluating the fluid status, especially when compared with weight. Weight gain between treatments should not exceed 0.5 kg/day.
Monitor BP, pulse. Hypertension and tachycardia between hemodialysis runs may result from fluid overload and/or HF.
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.
Note changes in mentation. Fluid overload or hypervolemia may potentiate cerebral edema (disequilibrium syndrome).
Monitor serum sodium levels. Restrict sodium intake as indicated. High sodium levels are associated with fluid overload, edema, hypertension, and cardiac complications.
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.

 

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