Haemodialysis access and its non-negotiable rules
An arteriovenous fistula is a surgically created connection between an artery and a vein, usually in the forearm, that needs six weeks to several months to mature before use. An arteriovenous graft uses synthetic material and can be used sooner but clots and becomes infected more readily. A temporary dialysis catheter is used when access is needed immediately and carries the highest infection risk.
Assessment is simple and heavily tested: auscultate for a bruit and palpate for a thrill at least every shift and before each treatment. Loss of the bruit or thrill, coolness, pallor, numbness or a pulseless extremity signals clotting or steal syndrome and requires immediate provider notification. Distal pulses, capillary refill and sensation are checked because arterial diversion can leave the hand ischaemic.
The protection rules apply to the entire access extremity. No blood pressure cuff, no venipuncture, no intravenous line, no injections, no tight clothing or jewellery, no sleeping on that arm and no carrying heavy objects with it. Clients are taught to check the thrill themselves daily and to report bleeding, swelling, pain or absence of the buzzing sensation.
- •Palpate the thrill and auscultate the bruit every shift
- •Place a limb-alert sign above the bed
- •Hold antihypertensives before treatment as ordered to prevent hypotension
- •Weigh the client before and after every session
- •Assess the access site for bleeding after needle removal
- •Report absent thrill, coldness, numbness or new pain immediately
During and after haemodialysis
Complications during treatment are mostly haemodynamic. Hypotension is the most frequent, caused by rapid fluid removal, and is treated by slowing ultrafiltration, lowering the head of the bed and giving normal saline as ordered. Muscle cramps, nausea, chest pain and dysrhythmias from rapid electrolyte shifts may also occur, and heparin used in the circuit increases bleeding risk.
Disequilibrium syndrome develops when urea is cleared from blood faster than from the brain, drawing water into cerebral tissue. It typically appears in a new dialysis client during or shortly after the first sessions with headache, nausea, vomiting, restlessness, confusion, altered level of consciousness and, in severe cases, seizures. Management is to slow or stop dialysis and notify the provider; prevention is achieved by shorter, slower initial treatments.
After treatment, the nurse assesses weight loss against the target, blood pressure trends including orthostatic values, the access site for bleeding or haematoma, and the client for fatigue, dizziness and headache. Medications held before dialysis are given afterwards, and laboratory values including potassium, phosphate, haemoglobin and calcium are reviewed. Bleeding precautions apply for several hours because of the heparin.
| Complication | Signs | Nursing response |
|---|---|---|
| Hypotension | Dizziness, pallor, low blood pressure | Slow ultrafiltration, lower head, saline bolus per order |
| Disequilibrium syndrome | Headache, confusion, seizure | Slow or stop dialysis, notify provider |
| Clotted access | No thrill or bruit | Notify provider immediately; do not use the access |
| Access bleeding | Oozing after needle removal | Firm pressure without occluding the thrill |
| Infection | Fever, redness, drainage at site | Cultures, notify provider, aseptic technique |
Peritoneal dialysis: exchanges, outflow and peritonitis
Peritoneal dialysis uses the peritoneum as the semipermeable membrane. Each exchange has three phases: inflow of warmed dialysate over about ten minutes, dwell for the prescribed time during which diffusion and osmosis occur, and drain by gravity over roughly twenty minutes. Dialysate is warmed with a dry heating pad, never in a microwave, because uneven heating causes abdominal pain and tissue injury.
Outflow problems are common exam items. If drainage is slow or incomplete, the nurse first checks the tubing for kinks and closed clamps, ensures the drainage bag is below the abdomen, reposition the client from side to side, and encourages ambulation if permitted. Constipation is a frequent and under-recognized cause, so a stool softener may be indicated. Only after these steps does the situation warrant provider notification.
Peritonitis is the major complication and the most tested. The hallmark is cloudy effluent, accompanied by abdominal pain, rebound tenderness, fever, nausea and an elevated white cell count in the drained fluid. The effluent is sent for cell count, Gram stain and culture, and antibiotics are usually added to the dialysate. Prevention is strict aseptic technique at every connection, hand hygiene, mask use during exchanges and daily exit-site care.
- •Warm dialysate with a dry heat source only
- •Record inflow and outflow volumes and the running balance
- •Outflow less than inflow means fluid retention — assess and report a trend
- •Cloudy effluent equals suspected peritonitis: culture and notify
- •Weigh daily after a drain, at the same time and in similar clothing
- •Monitor glucose, since dialysate glucose is absorbed
Diet, medications and living with dialysis
Nutrition for the client on haemodialysis restricts sodium, potassium, phosphorus and fluid while providing generous high-biological-value protein, because protein is lost across the membrane. Fluid allowance is typically the previous day's urine output plus about five hundred to a thousand millilitres, and interdialytic weight gain is kept modest. Peritoneal dialysis is more liberal with potassium and fluid but requires even more protein because more is lost in the effluent.
Medications cluster into predictable groups: phosphate binders taken with meals to bind dietary phosphorus, calcium and active vitamin D for bone health, erythropoiesis-stimulating agents with iron for anaemia, and antihypertensives that are often held before treatment. Water-soluble vitamins are replaced because they are dialyzed out. Nephrotoxic drugs, magnesium-containing antacids and potassium-based salt substitutes are avoided.
Psychosocial content is fair game. Chronic dialysis affects employment, sexuality, body image and independence, and clients face lifelong scheduling demands. Correct answers acknowledge the loss, encourage the client to participate in care decisions, involve family and social work, and refer to peer support rather than offering false reassurance.