Haemodialysis Nursing Care Plan
Nursing Diagnosis
▪ Injury, risk for [loss of vascular access]
Risk factors may include
▪ Clotting
▪ Haemorrhage 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
Monitor internal AV shunt patency at frequent intervals:
▪ Palpate for distal thrill.
▪ Rationale: Thrill is caused by turbulence of high-pressure arterial
blood flow entering low-pressure venous system and should be
palpable above venous exit site.
▪ Auscultate for a bruit.
▪ Rationale: Bruit is the sound caused by the turbulence of arterial
blood entering venous system and should be audible by stethoscope,
although may be very faint.
▪ Note colour of blood and/or obvious separation of cells and serum.
▪ Rationale: Change of colour from uniform medium red to dark
purplish red suggests sluggish blood flow and/or early clotting.
Separation in 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.
▪ Rationale: Diminished blood flow results in “coolness” of shunt.
▪ Notify physician and/or initiate DE clotting procedure if there is evidence
of loss of shunt patency.
, ▪ Rationale: Rapid intervention may save access; however, DE clotting
must be done by experienced personnel.
▪ Evaluate reports of pain, numbness or tingling; note extremity swelling
distal to access.
▪ Rationale: May indicate inadequate blood supply.
▪ Avoid trauma to shunt. Handle tubing gently, maintain cannula alignment.
Limit activity of extremity. Avoid taking BP or drawing blood samples in
shunt extremity. Instruct patient not to sleep on side with shunt or carry
packages, books, purse on affected extremity.
▪ Rationale: Decreases risk of clotting and disconnection.
▪ Attach two cannula clamps to shunt dressing. Have tourniquet available.
If cannulas separate, clamp the arterial cannula first, then the venous. If
tubing comes out of vessel, clamp cannula that is still in place and apply
direct pressure to bleeding site. Place tourniquet above site or inflate BP
cuff to pressure just above patient’s systolic BP.
▪ Rationale: Prevents massive blood loss while awaiting medical
assistance if cannula separates or shunt is dislodged.
▪ Assess skin around vascular access, noting redness, swelling, local
warmth, exudate, tenderness.
▪ Rationale: 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 dialysis process.
▪ Rationale: Prevents introduction of organisms that can cause
infection.
▪ Monitor temperature. Note presence of fever, chills, hypotension.
▪ Rationale: Signs of infection or sepsis requiring prompt medical
intervention.
▪ Culture the site and obtain blood samples as indicated.
▪ Rationale: Determines presence of pathogens.
▪ Monitor PT, activated partial thromboplastin time (aPTT) as appropriate.
▪ Rationale: Provides information about coagulation status, identifies
treatment needs, and evaluates effectiveness.
Administer medications as indicated:
▪ Heparin (low-dose);
▪ Rationale: Infused on arterial side of filter to prevent clotting in the
filter without systemic side effects.
Nursing Diagnosis
▪ Injury, risk for [loss of vascular access]
Risk factors may include
▪ Clotting
▪ Haemorrhage 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
Monitor internal AV shunt patency at frequent intervals:
▪ Palpate for distal thrill.
▪ Rationale: Thrill is caused by turbulence of high-pressure arterial
blood flow entering low-pressure venous system and should be
palpable above venous exit site.
▪ Auscultate for a bruit.
▪ Rationale: Bruit is the sound caused by the turbulence of arterial
blood entering venous system and should be audible by stethoscope,
although may be very faint.
▪ Note colour of blood and/or obvious separation of cells and serum.
▪ Rationale: Change of colour from uniform medium red to dark
purplish red suggests sluggish blood flow and/or early clotting.
Separation in 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.
▪ Rationale: Diminished blood flow results in “coolness” of shunt.
▪ Notify physician and/or initiate DE clotting procedure if there is evidence
of loss of shunt patency.
, ▪ Rationale: Rapid intervention may save access; however, DE clotting
must be done by experienced personnel.
▪ Evaluate reports of pain, numbness or tingling; note extremity swelling
distal to access.
▪ Rationale: May indicate inadequate blood supply.
▪ Avoid trauma to shunt. Handle tubing gently, maintain cannula alignment.
Limit activity of extremity. Avoid taking BP or drawing blood samples in
shunt extremity. Instruct patient not to sleep on side with shunt or carry
packages, books, purse on affected extremity.
▪ Rationale: Decreases risk of clotting and disconnection.
▪ Attach two cannula clamps to shunt dressing. Have tourniquet available.
If cannulas separate, clamp the arterial cannula first, then the venous. If
tubing comes out of vessel, clamp cannula that is still in place and apply
direct pressure to bleeding site. Place tourniquet above site or inflate BP
cuff to pressure just above patient’s systolic BP.
▪ Rationale: Prevents massive blood loss while awaiting medical
assistance if cannula separates or shunt is dislodged.
▪ Assess skin around vascular access, noting redness, swelling, local
warmth, exudate, tenderness.
▪ Rationale: 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 dialysis process.
▪ Rationale: Prevents introduction of organisms that can cause
infection.
▪ Monitor temperature. Note presence of fever, chills, hypotension.
▪ Rationale: Signs of infection or sepsis requiring prompt medical
intervention.
▪ Culture the site and obtain blood samples as indicated.
▪ Rationale: Determines presence of pathogens.
▪ Monitor PT, activated partial thromboplastin time (aPTT) as appropriate.
▪ Rationale: Provides information about coagulation status, identifies
treatment needs, and evaluates effectiveness.
Administer medications as indicated:
▪ Heparin (low-dose);
▪ Rationale: Infused on arterial side of filter to prevent clotting in the
filter without systemic side effects.
