28 Care of the patient undergoing hemodialysis
Overview/pathophysiology
Health care setting
Components of hemodialysis
Vascular access:
Nursing diagnosis:
Risk for imbalanced fluid volume
Desired Outcomes: Postdialysis patient is normovolemic as evidenced by stable weight, respiratory rate (RR) 12-20 breaths/min with normal depth and pattern (eupnea), central venous pressure (CVP) 5-12 cm H2O, heart rate (HR) and blood pressure (BP) within patient’s normal range, and absence of abnormal breath sounds and abnormal bleeding. After instruction, patient relates signs and symptoms of fluid volume excess and deficit.
| ASSESSMENT/INTERVENTIONS | RATIONALES |
|---|---|
| Assess for and instruct patient/family to assess for and report edema, hypertension, crackles (rales), tachycardia, distended neck veins, shortness of breath, and increased central venous pressure (CVP). | These are indicators of fluid volume excess. Dependent edema likely will be detected in the legs or feet of patients who are ambulatory, whereas the sacral area will be edematous in those who are on bedrest. Periorbital edema also may result from excessive fluid overload. Jugular veins are likely to be distended with head of bed (HOB) elevated 45 degrees owing to increased intravascular volume. Crackles and shortness of breath can occur as a result of fluid volume overload. Low serum albumin decreases colloid osmotic pressure, allowing fluid to leak into the extravascular space. Low serum albumin also may contribute to generalized edema and pulmonary edema. Hypertension, tachycardia, and increased CVP may result from sodium and fluid retention. |
| After dialysis, assess for and report hypotension, decreased CVP, tachycardia, and complaints of dizziness or lightheadedness. Describe signs and symptoms to patient, and explain importance of reporting them promptly if they occur. | These are indicators of fluid volume deficit, which may result from rapid or excessive fluid losses during dialysis. It should be noted that patients with uremia may not develop compensatory tachycardia owing to autonomic neuropathy, which can occur with uremia. |
| Assess intake and output (I&O) and daily weight as indicators of fluid status. | Intake greater than output and steady weight gain indicate retained fluid. Patient’s weight is an important guideline for determining quantity of fluid to be removed during dialysis. |
| Weigh patient at the same time each day, using same scale and with patient wearing same amount of clothing (or with same items on the bed if using a bed scale). | Weighing patient under the same conditions helps ensure accurate measurement of fluid status. |
| Monitor for postdialysis bleeding (needle sites, incisions). | This bleeding can occur because of use of heparin during dialysis. |
| Alert patient to potential for bleeding from these areas. | If these signs and symptoms occur, patient will be able to report them promptly to staff or health care provider for timely intervention. |
| Do not give intramuscular (IM) injection for at least 1 hr after dialysis. | Avoiding IM injections for this amount of time prevents hematoma formation. |
| Test all stools for presence of blood. Report significant findings. | Gastrointestinal (GI) bleeding is common in patients with renal failure, especially after heparinization. |
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