Dialysis Day: Tips for Critical Care Nurses Caring for Hemodialysis Patients

Hemodialysis treatments clean the blood and remove extra fluid from the body when the kidneys are not functioning well. As an ICU nurse, you will likely care for patients who are new to hemodialysis or have been receiving it already prior to this hospital admission. On the day that dialysis is scheduled, "dialysis day", the acute dialysis nurse will arrive and provide the hemodialysis treatment to your shared patient. Treatments typically last 3-4 hours. The treatment is delivered either through a hemodialysis catheter or by inserting needles into an arteriovenous fistula or graft. Here are several tips for how to provide the best care for your patient before, during, and after the hemodialysis treatment.

Before Dialysis

Scheduling: Are any other procedures scheduled today?

If your patient is scheduled for any other procedures or imaging in addition to dialysis, it is helpful to call the on-call acute dialysis nurse to help coordinate the timing of their treatment. It is especially important to keep in mind the type of procedure or imaging that is scheduled. For example, if a patient is scheduled for a CT scan with contrast, they will typically need to have dialysis after the CT scan in order to clean the contrast from their blood because the kidneys are unable to clean the blood.  If you are uncertain whether dialysis should be scheduled before or after a procedure, you can call the on-call dialysis nurse to discuss this. If they have questions, they will call the nephrologist.

Medications

Are there scheduled antibiotics or blood pressure medications? It is important to review a patient's medications before they receive dialysis. Because dialysis cleans the blood, it can also clean out, or "dialyze out,” any medications that the patient takes before or during the treatment. There are many medications that are dialyzed, but there are generally two main medications to consider holding before dialysis: antibiotics and antihypertensive medications.

• Antibiotics: Most antibiotics are dialyzed out of the blood and are not recommended to be given right before or during treatment.
• Antihypertensive medications: Most blood pressure medications are also dialyzed out of the blood. The second reason why antihypertensives are often held before and during dialysis is that the patient's blood pressure must be high enough to tolerate fluid being removed from the blood.

*If you are considering holding a scheduled medication before or during dialysis, you will need to receive an order from the prescribing provider in order to hold the medication.  

During Dialysis

Monitor blood pressure

Hemodialysis treatments can cause hypotension due to fluid removal. If the patient's blood pressure is low, the acute dialysis nurse can adjust how much fluid is being removed. Sometimes fluid removal is such a priority that the nephrologist and ICU doctors prefer to start a pressor medication in order to increase the patient's blood pressure and enable fluid to be removed. If a pressor is started, you will be responsible for titrating the medication and will be working closely with the dialysis nurse as they perform the dialysis treatment.

Assist with patient comfort

The hemodialysis treatment itself does not usually cause pain, but it can be uncomfortable for the patient to lay in bed for 3-4 hours. As the ICU nurse, you can help by repositioning the patient and by giving scheduled or as-needed pain medications if indicated.

After Dialysis

Care for the patient's access

If the patient has an arteriovenous fistula or graft for dialysis, a bandage will be placed on the sites where the needles were removed. This bandage should be removed after 4-6 hours to prevent infection. If the patient has a hemodialysis catheter, the dialysis nurse will instill either heparin or citrate into the catheter to prevent clots from forming inside and place caps on the end of the catheter. The dressing on the catheter site will typically be changed by the dialysis nurses, but you can notify them if it looks like the dressing is soiled and needs to be changed.

Receive report

When dialysis is completed, the acute dialysis nurse will report to you how much fluid was removed during the treatment and the final blood pressure reading.

Anticipate patient fatigue

Hemodialysis is a necessary, life-saving treatment for patients with kidney failure, but it can cause extreme fatigue. Many patients report feeling tired after dialysis day. Your patients need several hours of rest before they have enough energy to participate in other activities, such as physical therapy.

References/Resources

Be Aware – Medications NOT to Take Before Dialysis

Guidelines for Managing Hospitalized Hemodialysis Patients