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Patient assessment and monitoring before, during and immediately after hemodialysis (3.9)

Patient assessment and monitoring before, during and immediately after hemodialysis (3.9) - Policies, Clinical, UWHC Clinical, Department Specific, Hemodialysis

3.9

University of Wisconsin Hospital and Clinics
Inpatient Hemodialysis
Department 55400

TITLE: Patient assessment and
monitoring before, during and
immediately after hemodialysis

POLICY #3.9
REVISED: October 1, 2014
Page 1 of 2
Nurse Manager: Joan Watson, MS, RN
Director: Ann Malec, DNP, RN, NEA-BC
Medical Director: Alex Yevzlin, MD


I. PURPOSE

To establish a standard of care for patient receiving hemodialysis treatment.

II. POLICIES

A. The registered nurse (RN) responsible for the patient’s care will perform a brief pre-
treatment assessment and will review the patient’s electronic medical record for
information necessary to provide care. This information includes but is not limited to:
vital signs, pain assessments, lab values, allergies, medication administration record
(MAR), SBAR hand-off report, and active orders report.
B. Patient and the hemodialysis machine are monitored throughout the dialysis treatment by
an RN or patient care technician (PCT), all observations and/or assessments will be
recorded in the electronic medical record or for Veteran Administration Hospital (VAH)
patients the Hemodialysis (HD) Nurses Notes form.
C. After the hemodialysis treatment is completed the RN responsible for the patient’s care
assesses the patient’s response to treatment and summarizes the hemodialysis treatment
in the hemodialysis department hand-off note.
D. See UWHC Department of Nursing Basic Nursing Procedures for policies related to
nursing care provided to patients during their stay in the Hemodialysis Department.

III. PROCEDURES

A. Pre-treatment assessment
1. The machine set up and anticoagulation (if ordered) are verified against the
physician order. Machine safety checks are verified as performed.
2. Dialysis vascular access is assessed prior to cannulization and/or preparation for
the initiation of dialysis:
i. Hemodialysis catheter assessment includes: dressing type and exit site,
presences of suture/securing device, dressing change (if due), lumen
patency and blood return.
ii. Hemodialysis arteriovenous access assessment includes: auscultation for
bruit, palpation of thrill, presence of incisions, aneurysms, warmth, or
redness. Bandaids/previous needle site dressings if present will be
removed and the exit sites assessed for active bleeding or drainage.

Page 2 of 2
Surgical site wound dressings will be assessed and if needed changed
and/or reinforced.
3. Patient’s weight, vital signs, standing BP (if ambulatory), respiratory status, pain
and edema are assessed to provide a baseline of fluid status and level of comfort
prior to initiating dialysis.
B. During treatment monitoring
1. The patient’s vital signs, responses to treatment and machine parameters
including: blood flow rate, arterial and venous pressure, ultrafiltration rate and
cumulative fluid removed are observed every 15 minutes throughout the
treatment. Optional recordings: transmembrane pressure, relative blood volume.
Vital signs maybe monitored more frequently if the patient’s condition warrants.
2. The extracorporeal circuit is observed every 15 minutes to verify all connections
and clamps are secure, blood lines and chambers are filled, free of leaks and
performing properly.
3. If the patient does not have an anticoagulant ordered the bloodlines, artificial
kidney and chambers may be flushed with normal saline as needed to observe for
the presence of clotting.
4. Patient complaints should be evaluated and referred to the RN or nephrologist, if
necessary.
C. Post treatment
1. The patient’s response to treatment will be assessed. Post treatment vital signs,
fluid removal /gain, medications given during dialysis, if possible a post treatment
weight and standing BP if ambulatory.

IV. DOCUMENTATION
A. Observations and/or assessments are recorded in the electronic medical record in the
corresponding flow sheet rows.
B. Medication administered during dialysis will be recorded on the MAR. Patient responses
to medications are documented in the appropriate flow sheet rows, i.e. pain assessment
and reassessment.
C. See Hemodialysis Departmental policy1.3 Medical Records for Dialysis Services
provided to Middleton’s Memorial Veterans Administration Hospital (VAH) regarding
documentation requirements for VA patients.

VI. RESOURCES

A. Gomez, N. J. (Eds.). (2011). Hemodialysis. Nephrology nursing standards of practice
and guidelines for care (pp.123-144). Pitman, NJ: American Nephrology Nurses'
Association.
B. UWHC Department of Nursing Basic Nursing Procedures



REVIEWED:
JMW6/1/13