2. Anticoagulant : prescribed type and dosage of heparin.

3. Infection control : aseptic technique

B. Intra-dialytic monitoring :

1. BP, P, CVP & respiration hourly or p.r.n.

2. Clotting time

3. Patient's general condition e.g. level of consciousness, skin colour, S/S of

acute complications of haemodilaysis.

4. Check and monitor the dialysis machine, heparinization and UF rate.

5. Observe and monitor the extracorporeal circuit for any clotting.

6. Termination of haemodialysis : according to the prescription unless encounter an emergency needs.

7. Remove the fistula needle and apply direct pressure to the needle site or

proper care of dual lumen catheter according to the practice of the unit.

C. Post dialysis assessment :

1. Vital signs.

2. Body weight

3. Amount of saline required to support the haemodynamic stability and rinse back of the blood.

4. Vascular access : patency, infection

5. Estimate any blood loss e.g. rupture or clotted dialyser.

6. Amount of heparin infused.

7. Any complications related to haemodialysis.

8. Planning of :

- Date of next dialysis.

- Advice on care of vascular access, dietary & fluid restriction, medication compliance.

D. Post dialysis care of machine : thermal or chemical disinfection procedure.

 I. Problem : Potential grieving related to loss of kidney function and change of life-style

1. as evidenced by non-compliance to treatment and depression.

Goal : Patient will show progression through the grieving process before discharge

as evidenced by patient's behaviour and verbalization.

Nursing interventions:

1. Observe for emotional and behavioral signs of grieving.

2. Counseling the patient and encourage the patient to express her feeling.

Provide adequate and necessary information to the patient / family.

3. Help patient to explore strength and resources to cope with the changes of life- style.

4. Introduce peer group to the patient so that he / she can share their feelings.

5. Establish a good rapport with the patient / family.

Goal : Patient has no evidence of hypotension during haemodialysis.

Nursing interventions:

1. Assess patient's body weight before dialysis.

2. Set an accurate UF rate or TMP.

3. Educate the patient on fluid and dietary restriction.

4. Develop strategy to prevent the patient suffering from hypotension during dialysis.

5. Nursing actions when patient develop hypotension :

- Immediate place the patient in the Trendenleburg position.

- Administer a bolus of N.S. rapidly (100 ml or more)

- Reduce the UF rate

- Administer prescribed albumin solution in severe hypotension episode.

- Monitor patient's vital signs and act accordingly.

- Terminate the haemodialysis therapy before scheduled time if necessary.

Goal : Patient will not experience muscle cramps during and after haemoidalysis.

Nursing interventions : Check the correct conductivity of the dialysate before initiation of

Haemodialysis.

Nursing actions when patient has muscle cramps :

- Administration of hypertonic solution e.g. 5.85% NaCl can be given in acute management

of muscle cramps.

- Check and monitor the conductivity of the dialysate.

- Encourage the patient to apply imagery and relaxation exercise.

- Application of warm compass to local area.

- Message the local area with analgesic balm.

IV. Problem: Potential Gastro-intestinal complications e.g. nausea and vomiting as related to

Goal : Patient will not exhibit nausea and vomiting during haemodialysis.

Nursing interventions:

1. Treat any associated hypotension. accordingly.

2. Reduce the blood flow rate & the duration of haemodialysis to decrease the

efficiency of solute removal and pH change.

3. Use a small surface area dialyser for the first session of haemodialysis.

4. Maintain personal hygiene after vomiting.

 

V. Problem : Headache

Goal : Patient verbalize she / he does not experience headache during haemodialysis.

Nursing interventions:

1. Monitor patient's blood pressure.

2. Administer prescribed paracetamol.

VI. Problem : Potential complications related to haemodialysis with the evidence of

Chest pain, back pain, arrhythmia, cardiac temponade

Goal : Patient will show no sign of adverse effect of haemodialysis such as arrhythmia as

evidenced by : - regular apical pulse at 60-100 / min.

- equal apical and radial pulse.

- absence of syncope and palpitation

- ECG reading shows normal sinus rhythm.

Nursing interventions:

1. Report to physician and administration of medications may be required.

2. Initiate continuous cardiac monitoring if not already being done.

3. Reduce the blood flow rate.

4. Administer Oxygen therapy as ordered.

5. Terminate the haemodialysis in emergency incident.

VII. Problem : Potential for dialysis related complication of first-use syndrome

as evidenced by Chest pain, nausea, arrhythmia etc.

Goal : Patient will show no sign of adverse reaction during haemoidalysis.

Nursing interventions:

1. Proper and adequate priming of dialyser.

2. Observe for any sign of first-use syndrome.

Nursing actions in the occurrence of first-use syndrome :

1. Stop the dialysis immediately.

2. Clamp and disconnect the bloodlines from the patient. Discard the dialyser and blood lines without returning blood to the patient.

3. Keep the vascular access patent for administration of drugs e.g. steroids,

4. Administer Oxygen therapy to the patient.

5. Perform active cardiac pulmonary resuscitation if patient develops cardiac arrest

6. Reassure and give psychological support to the patient.

7. Report to the doctor. Use the dialyser with gamma-irradiation sterilization is

recommended.

VIII. Problem : Haemolysis related to :

- overheated dialysis solution.

- Hypotonic dialysis solution.

- contaminated dialysis solution.

- formaline reaction.

With the evidence of red ink like blood, low blood pressure, nausea and yawning,

tightness of chest, shortness of breath, pallor, arrthymias.

Goal : There is no evidence of haemolyiss during dialysis treatment.

Nursing interventions:

1. Stop the blood pump immediately.

2. Clamp and disconnect the bloodlines from the patient. Discard the dialyser and blood

lines without rinseback to the patient.

3. Observe the vital signs.

4. Cross match and transfuse the blood if required.

5. Investigate and identify the cause of haemolysis and preventive measures should be

taken.

6. Reassure the patient.

IX. Problem : Febrile reaction related to :

' - Bacteraemia e.g. infected shunt, chest infection or UTI

- local site of vascular access infection.

- contaminated equipment.

Goal : Patient's body temperature shows normal during and after haemodialysis.

Nursing interventions:

1. Observe the body temperature e.g. Q1H

2. Maintain aseptic technique during the whole haemodialysis procedure.

2. Disinfect the equipment adequately and properly, especially water purification

system.

4. Monitor the patient for presence of chills and rigor during dialysis.

Nursing actions in case of pyrexia occurs :

1. Identify the cause.

2. Send blood, water sample and dialysate sample for culture.

3. If suspected pyogenic reaction, rinseback the dialyser with normal saline and restart

4. Discard the blood of the extracorporeal circuit if condition is critical.

5. Administration prescribed antibiotics.

6. Administer prescribed paracetamol to lower the body temperature.

X. Problem : Less common but serious complications.

Air embolism related to:

1. air leakage into the pump segment

2. air entering to the extracorporeal circuit due to line separation

3. running of air during washback ( air rinse back procedure)

4. failure of air bubble detector.

Goal: Patient will not suffer from air embolism during and after haemodialysis.

Nursing interventions:

1. Monitor for and report any sign of air embolism. e.g. cyanosis, weak rapid pulse

2. Clamp the I.V. Bottle before empty.

3. Maintain tight connections.

Implement measures once air embolism occurs:

1. Stop the blood pump immediately and clamp the venous bloodlines.

2. Discontinue dialysis disconnecting the patient from the extracorporeal circuit.

3. Place the patient in head-low and right side up position. (this keeps air in right side of the heart , allowing pulmonary artery to absorb the bubbles.)

4. Administer oxygen therapy 100%.

5. Call for urgent medical assistance.

6. Arrange urgent portable X-ray chest.

7. Continuous monitoring patient's neurological, cardiac and respiratory condition.

8. Arrange de-compression treatment or intra-cardiac air aspiration if necessary.

9. Give psychological care and reassurance to the patient.

11. Problem : Potential complication of haemodialysis of cardiac arrest related to severe

Goal : Patient shows no evidence of cardiac arrest during haemodilaysis.

Nursing interventions:

1. Frequent monitoring of patient's vital signs and general condition.

2. Termination of dialysis and return blood to the patient immediately.
3. Maintain the vascular access patent for administration of cardiac stimulative medication

intravenously.

4. Provide active cardiac pulmonary resuscitation.

I. Problem : Potential technical complications of coagulation of extracorporeal circuit Clotted dialyser related to :

- inadequate heparinization .

- inadequate blood flow through the dialyser.

- dirty dialyser or air locked.

- patient with thrombotic tendency.

- low temperature of the dialysate.

- heparin line clamped or heparin pump out of order.

With the evidence of :

- fibrin deposition in venous and arterial chambers.

- elevated venous pressure.

- blood in the extracorporeal circuit is dark red in colour.

Goal : There is no signs of blood clotted in the extracorporeal circuit.

1. Prime the dialyser properly.

2. Monitor of ACT and heparin infusion frequently.

3. Administer adequate and accurate amount of heparin.

4. Check and analyze the WBAPTT report and readjust the amount of heparin accordingly.

2. Monitor the extracorporeal circuit for the presence of 'fibrin ring' in the 'A' & 'V'

6. Check the colour of the extracorporeal circuit.

7. Monitor for any signs of elevated 'V' pressure.

8. Return as much blood as possible to the patient in case of massive coagulation.

Then prepare another new set of dialyser and bloodlines. Resume the therapy.

9. Cross-match and transfuse blood product as prescribed.

II. Problem : Sucking (inadequate arterial flow)

Causes:

1. Poor needling technique.

2. Kicking or clamping of arterial blood lines.

3. Failed vascular access.

4. Clotted vascular access e.g. A-V fistula, A-V shunt, or Dual lumen catheter.

1. Assess the circuit for the followings frequently :

- jerking of arterial line

- emptying or collapse of arterial chamber

- low arterial pressure

- discomfort at the puncture site.

2. If sucking occurs:

- stop / slow down the blood pump immediately.

- identify the cause and correct it accordingly.

- build up the pump speed gradually.

- repositioning of the catheter is necessary.

- Watch for any air turbulence within the dialyser.

III. Problem : High venous pressure

Causes : a. Abrupt - kicking or clamping of venous line

b. Gradual - venospams

- venous needle packed with clots or out of vein.

Interventions:

1. Careful handling of 'A' & 'V' bloodlines.

2. Monitor the patient for any signs of hypotension (venospasm)

3. Implement measures if it occurs : - stop / slow down the blood pump .

- identify the cause.

- if needle out of vein :

- recirculate the extracorporeal circuit.

- flush 'A' catheter with saline.

- prepare another new 'V' vascular access.

- resume the haemodialysis as scheduled.

IV. Problem : Low venous pressure

Causes:

1. Sucking (secondary to inadequate arterial blood flow).

2. Blockage in the pressure transducer

3. Separation of blood lines.

Interventions:

1. Check for any blockage of pressure transducer, separation of bloodlines.

2. For separation of venous blood lines:

- stop the blood pump immediately.

- clamp the blood lines and the cannula catheter.

- reconnect the catheter and blood lines after disinfection.

- release the clamps and restart haemodialysis as scheduled.

V. Problem : Blood leakage ( rupture of the membrane of the dialyser )

Causes :

1. Improper priming of dialyser

2. Faulty or damage of dialyser.

3. Transmembrane pressure is too high that beyond the recommended limit.

Types : 1. False blood leak - air bubble in dialyser

- dirty lens of photo cell

2. True blood leak - minor

- major

Interventions:

1. Test the extracorporeal circuit for any leakage with recommended pressure.

2. Avoid too high UF rate / TMP.

3. Careful handling of dialyser.

4. Implement measures if blood leakage occurs :

- Use Serim Blood leak Test strips to test the dialysate for the presence of blood.

- Centrifuge dialysate specimen for the presence of RBC.

• Check the colour of dialysate. If pink in colour, it indicates the occurrences of

- Stop the blood pump.

- Return the blood in the 'A' blood lines to the patient.

Discard the rest of the extracorporeal circuit.

- Prepare a new dialyser for and blood lines for re-connection.

- Cross match packed cells and transfuse as prescribed.

Causes: 1. Restless patient.

2. Ill fitting of blood lines to the catheter of the access.

Interventions:

1. Monitor 'A' & 'V' pressure frequently.

2. Tape the needles and bloodlines properly and securely.

3. Maintain tight connection site.

4. Implement measures if line separation occurs:

- Stop the blood pump.

- Clamp the bloodlines and catheter to avoid excessive blood loss.

- Watch out any air in the bloodline.

- Avoid air goes into the patient or dialyser by trapping the air in the 'V' chamber.

N.B.: Severity of the condition depends on when you discover the incident.

VII. Problem : Formalin / Sterilant reaction

Causes:

1. Inadequate rinsing of sterilant from the machine.

2. Inadequate rinsing of Sterilant from the extracorporeal circuit (reused dialyser or

bloodlines) .

Interventions:

1. Test the reused extracorporeal circuit for any residual sterilant before use.

2. Observe the patient for any sign of sterilant reaction:

- tightness of throat

- palpitation

- chest discomfort , difficult in breathing.

- hotness

- burning sensation and pain over the site of the vascular access.

3. Implement measures if sterilant reaction occurs :

For mild sterilant reaction :

- Disconnect the patient from the extracorporeal circuit.

- Self recirculate the extracorporeal circuit for 20-30 minutes.

- Infused normal saline through the side arm into the extracorporeal circuit.

- Adjust the TMP to 200-250 mm Hg during recirculation.

- Keep the blood flow rate at 200 ml / minute.

- Keep the vascular access patent with heparinized saline / saline.

- Resume the dialysis and observe patient's condition. 

VIII. Problem : Interruption of electrical supply

Causes :

1. Loosened power plugs.

2. Machine breakdown e.g. fuses.

3. No electrical supply.

Goal : Ensure no interruption of electricity during haemodialysis.