Dialysis Nursing Care
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Direct answer
Dialysis replaces renal clearance either by pumping blood across an extracorporeal semi-permeable membrane (haemodialysis, typically four hours thrice weekly) or by using the peritoneum as the membrane in continuous ambulatory peritoneal dialysis (CAPD) with four exchanges of two to two and a half litres daily. Haemodialysis nursing protects the arteriovenous fistula — no pressure, cannulation or intravenous lines in that arm, bruit and thrill checked daily — and manages intra-dialytic hypotension and disequilibrium. Peritoneal dialysis nursing is aseptic technique plus early recognition of peritonitis, whose earliest and most reliable sign is cloudy effluent.
What you must remember
- Haemodialysis removes solutes by diffusion down the concentration gradient and water by pressure-driven ultrafiltration; adult extracorporeal blood flow runs around 300 to 400 mL per minute with heparin anticoagulation.
- The arteriovenous fistula is the preferred access and matures over roughly 6 to 8 weeks before first use; grafts and tunnelled catheters serve earlier or failed access.
- Fistula rules: no blood pressure cuff, venepuncture or intravenous cannulation on that arm; check the thrill at the anastomosis and bruit on auscultation daily — loss of both means thrombosis and is an emergency.
- Intra-dialytic hypotension is the commonest complication of a session: nausea, cramps, yawning and fall in pressure with fluid removal — reduce or stop ultrafiltration, give a normal saline bolus and place the head down.
- Dialysis disequilibrium syndrome affects first sessions and very high urea patients: headache, nausea, restlessness and seizures as solutes shift — prevented with shorter, lower-efficiency initial dialyses.
- Between sessions the patient restricts fluid (roughly urine output plus 500 to 1000 mL daily) and potassium; interdialytic weight gain tracks salt and water excess against the target dry weight.
- CAPD uses a Tenckhoff catheter and four exchanges daily; strict asepsis and hand hygiene precede every connection because touch contamination causes most peritonitis.
- Peritonitis diagnosis: cloudy effluent with abdominal pain or fever; confirm with effluent white cell count above 100 per microlitre with neutrophil predominance, before antibiotics are instilled intraperitoneally.
A session and a peritonitis scare
A maintenance patient arrives for her Tuesday session 2.8 kg above dry weight, having attended a wedding. The nurse screens her — weight, temperature, access examination, thrill present — and cannulates the fistula with a rotating-site technique after local anaesthetic. Ninety minutes in, she yawns repeatedly, complains of calf cramps and her pressure falls from 140/85 to 95/60. The response sequence is textbook: stop ultrafiltration first, saline 250 mL bolus, legs raised if tolerated, pressure rechecked every 5 to 10 minutes; the doctor reduces the session's fluid-removal target and re-education on salt follows. Contrast the CAPD patient who phones because his overnight bag looks like cloudy diluted milk without much pain. He is called in the same day: the effluent cell count confirms peritonitis, specimens go for culture before intraperitoneal antibiotics are started per protocol, and the exchange technique is observed step by step — handwashing, mask, cleaning the connecting surfaces, the five-minute drain-fill discipline — because most infections trace to one skipped step. Two settings, one principle: in dialysis, the nurse's eyes (thrill, cloudiness, cramps) outrun every laboratory.
Where students slip
The blood-pressure cuff question is answered wrongly under time pressure: the fistula arm is forbidden for cuffs, needles and infusions — the classic "which arm" MCQ. Students also reorder the hypotension response, reaching for a vasopressor before stopping ultrafiltration and giving saline, and confuse disequilibrium syndrome (early sessions, neurological shift) with routine hypotension. In peritonitis items, abdominal pain is chosen as the earliest sign; the tested answer is cloudy effluent, since pain can be late or mild. Protein requirements are quoted identically for both modalities, forgetting the peritoneal losses that raise CAPD needs.
Frequently asked questions
What must never be done to the fistula arm?
Blood pressure measurement, venepuncture, intravenous cannulation or tight clothing — anything that compresses or punctures the access risks thrombosis and loss.
How is fistula patency checked?
Palpate for the thrill at the anastomosis and auscultate for the bruit daily; absence of both signals thrombosis needing urgent intervention.
What is dialysis disequilibrium syndrome?
Headache, nausea, restlessness and sometimes seizures during early or aggressive dialysis, caused by solute shifts; it is prevented with shorter, gentler initial sessions.
What is the first nursing action for intra-dialytic hypotension?
Stop or reduce ultrafiltration, give an intravenous normal saline bolus and recheck blood pressure, before considering any drug therapy.
What is the earliest sign of CAPD peritonitis?
Cloudiness of the dialysate effluent, with or without pain or fever; effluent is sent for cell count and culture before intraperitoneal antibiotics.
How do protein needs differ between the two modalities?
Haemodialysis patients need about 1 to 1.2 g per kg daily, while peritoneal dialysis patients need 1.2 to 1.5 g per kg to replace protein lost into dialysate.