Lesson 46: Hemodynamics

 Shock

Description
 This life-threatening condition can result in damage to multiple
organs.
 The condition requires immediate medical treatment; it can worsen
rapidly if it goes untreated, resulting in death.
 Shock takes three main forms: hypovolemic, cardiogenic, and
vasogenic.
 Hypovolemic shock is caused by internal or external blood
or fluid loss.
 Cardiogenic shock is associated with cardiac problems; in
this type of shock the heart is unable to pump sufficient
blood for the body’s needs.
 Vasogenic shock results from massive vasodilation;
anaphylactic shock (associated with an allergic reaction),
septic shock (associated with infection), and neurogenic
shock (associated with injury to the neurological system)
are all types of vasogenic shock.
 In the event of shock, the nurse should do the following:
o Elevate the legs
o Notify the health care provider
o Determine and treat the cause of shock
o Administer oxygen, as prescribed
o Monitor level of consciousness
o Monitor vital signs for increased pulse or
decreased blood pressure
o Monitor intake and output
o Assess color, temperature, turgor, and moisture
of the skin and mucous membranes
o Administer IV fluids, blood, and colloid solutions,
as prescribed
 Intraarterial Blood Pressure Monitoring
3) Follow the fourth intercostal space to the side of the
patient's chest.
4) Determine the midway point between anterior and
posterior.
5) Find the intersection between the midway point and the
line from the fourth intercostal space, and mark it with an
X in indelible ink. This is the phlebostatic axis
 Observe the monitor tracing and assess the quality of the tracing.
 Obtain an analog printout or freeze the monitor tracing and measure
the systolic and diastolic pressures at end expiration.
 Record the pressure measurements.
 Take steps to maintain the intraarterial line.
 Immobilize the insertion site.
 Assess the site frequently for signs of leakage and
infection.
 Assess the circulation distal to the insertion site every 1 to
2 hours.
 A constant small amount of fluid is delivered under
pressure to maintain the patency of the line.
 Calibrate the system to atmospheric pressure with the
transducer placed at the level of the phlebostatic axis.
 Use Luer-Lok connections on the line; close and cap
stopcocks when they are not in use.
 Central Venous Pressure
Description

Description
 Monitoring is indicated for any major condition that
compromises cardiac output, tissue perfusion, or fluid volume
status.
 An arterial pressure waveform (see image) is displayed on a bedside
monitor that shows continuous measurement of systolic, diastolic,
and mean arterial blood pressures (BPs).
 Mean arterial pressure (MAP) is an approximation of the average
pressure in the systemic circulation throughout the cardiac cycle; it
must be at least 60 mm Hg for adequate organ perfusion.  Central venous pressure (CVP) is the pressure within the superior
 Direct arterial access for the measurement of pressures is helpful for vena cava; this reading reflects the pressure under which blood is
clients who require frequent blood sampling, particularly for arterial returned to the superior vena cava and right atrium.
blood gases.  CVP is measured with the use of a central venous line in the superior
vena cava or a balloon flotation catheter in the pulmonary artery.
Nursing Considerations  Normal CVP pressure is 2 to 8 mm Hg.
 Place the client supine and flat.  An increased CVP indicates an increase in blood volume as a result of
 Level the transducer with the phlebostatic axis. sodium and water retention, excessive intravenous (IV) fluids,
1) Position the patient supine. alterations in fluid balance, or renal failure.
2) Palpate the fourth intercostal space at the sternum.  Decreased CVP indicates a decrease in circulating blood volume and
may be the result of fluid imbalance, hemorrhage, or severe
vasodilation with pooling of blood in the extremities that limits
venous return.
 Nursing Considerations
 The client lies in the supine position, with the head of the bed
elevated 45 degrees.
 The transducer is leveled with the phlebostatic axis.
 The client must be relaxed; any activity that increases intrathoracic
pressure (e.g., coughing or straining) will cause falsely increased
readings.
 If client is undergoing mechanical ventilation, the reading should be
taken at the point of end expiration.
 To maintain the patency of the line, a constant small amount of fluid
is delivered under pressure.
 Pulmonary Artery Pressure
Description
 A pulmonary artery catheter is used to measure right atrial and
indirect left atrial pressures or pulmonary artery wedge pressure
(PAWP), which is also known as pulmonary artery occlusive pressure
(PAOP).
 PAWP normally ranges between 6 and 12 mm Hg.
 Normal right atrial (RA) pressure ranges from 2 to 8 mm Hg.
 Normal pulmonary artery pressure (PAP) ranges from 15 to 26
mmHg systolic/5 to 15 mmHg diastolic.
 Normal pulmonary artery diastolic pressure (PADP) ranges from 4 to
12 mm Hg.
Nursing Considerations
 Elevations in PAWP may indicate left ventricular failure,
hypervolemia, mitral regurgitation, or intracardiac shunt, whereas
decreases may indicate hypovolemia or afterload reduction.
 Increases in right atrial (RA) pressure occur with right ventricular
failure, whereas decreases may indicate hypovolemia.
 Telemetry Monitoring
Description
 The client's heart rate and rhythm are monitored as a means of
rapidly diagnosing dysrhythmias, ischemia, or infarction.
 Electrodes placed on the client's chest are attached to a monitor or
transmitter; the transmitter sends a radio signal to a receiver,
usually located at the nurses’ station.
 The placement of the electrodes determines the part of the heart
being observed.
Nursing Considerations
 Monitor electrographic (ECG) or telemetry tracings for changes and
dysrhythmias.
 Maintain the appropriate electrode placement to obtain the desired
lead reading.
 If the client must be transported off the unit, determine whether
monitoring will be needed.
 Maintain a constant tight seal between the electrode and the skin
and monitor the skin for compromise or impairment in integrity.
 Do not remove the telemetry device or allow the client to shower
unless the health care provider has written a prescription that
permits this.
 Decreased Cardiac Output
Description
 The heart fails to pump adequately, thereby reducing cardiac output
and compromising tissue perfusion.
 The goal of treatment is to maintain tissue oxygenation and
perfusion and improve the pumping ability of the heart.
 The affected client experiences a wide range of irregularities.
Nursing Considerations
 Monitor the clients at risk for decreased cardiac output (e.g., those
with heart failure) closely, checking hemodynamic parameters
frequently.
 Assess the client for signs of acute decreased cardiac output and
decreased cerebral perfusion.
 Administer humidified oxygen as prescribed.
 Assist the client into a position of comfort, usually a semi-Fowler
position.
 Maintain optimal fluid balance, limiting fluids and sodium as
prescribed.
 Monitor intake and output and weigh the client daily.
 Administer medications such as inotropics, vasodilators, and other
medications as prescribed.
 Administer stool softeners as needed and prescribed.
 Provide client education.
 Avoid activities that produce a Valsalva response.
 Encourage the client to plan to balance activity with
periods of rest.
 Discourage excessive intake of beverages high in caffeine.
 Encourage the client to abstain from smoking and alcohol
use.
 Review the actions of prescribed medications and the
manifestations of drug toxicity.
 Teach the client how to take the pulse and when to notify
the health care provider.
 Cardiac Dysrhythmias
Normal Sinus Rhythm
Description
 The normal rhythm of the heart originates from the sinoatrial node.
 Atrial and ventricular rhythms are regular—60 to 100 beats/min.
 No ectopic beats are present.
Nursing Considerations
 Determine the client’s baseline rate and rhythm and document this
information.
 Monitor for changes from baseline status and for abnormal rates
and rhythms, also known as dysrhythmias.
Sinus Bradycardia
Description
 Atrial and ventricular rates are slower than 60 beats/min.
 Treatment may be necessary if the client is symptomatic.
 Note that a low heart rate is normal for some individuals.
Nursing Considerations
 Attempt to determine the cause; if a medication is suspected of
causing bradycardia, withhold the medication and notify the health
care provider.
 Administer oxygen as prescribed.
 Administer atropine sulfate as prescribed to increase the heart rate
to 60 beats/min.
 Be prepared to apply a noninvasive pacemaker initially if atropine
sulfate does not increase the heart rate sufficiently; additional doses
of atropine sulfate may induce tachycardia.
 Monitor the client for hypotension.
 Depending on the cause of the bradycardia, the client may need a
permanent pacemaker.
Sinus Tachycardia
Description
 Atrial and ventricular rates are 100 to 180 beats/min.
Nursing Considerations
 Identify and treat the cause of tachycardia.
 Medications may be used to reduce the heart rate.
Atrial Fibrillation
Description
 In atrial fibrillation (AF), multiple rapid impulses from many foci
depolarize in the atria in a totally disorganized manner at a rate of
350 to 600 times/min.
 Quivering of the atria may result in the formation of thrombi.
 The P wave is absent.
Nursing Considerations
 Administer oxygen.
 Administer anticoagulants as prescribed because of the risk of
emboli.
 Administer antidysrhythmic medications for conversion to and
maintenance of sinus rhythm and medications to control ventricular
rhythm and assist in the maintenance of cardiac output; these may
include calcium channel blockers (diltiazem), beta-adrenergic
blockers, and digoxin.
 Prepare the client for cardioversion.
 Radiofrequency catheter ablation may be considered for some
clients with drug-refractory AF.
Premature Ventricular Contractions
Description
 Early ventricular complexes (premature ventricular contractions,
a.k.a. PVCs) result from increased irritability of the ventricles.
 PVCs frequently occur in repetitive rhythms (e.g., bigeminy,
trigeminy, quadrigeminy):
o Bigeminy: a PVC every other heartbeat
o Trigeminy: a PVC every third heartbeat
o Quadrigeminy: a PVC every fourth heartbeat
o Couplet or pair: two sequential PVCs
 In the R-on-T phenomenon, a PVC falls on the preceding beat's T
wave, which is considered a vulnerable period, and may precipitate
ventricular fibrillation.
 QRS complexes may be unifocal or multifocal:
o Unifocal: uniform upward or downward deflection, arising from the
same ectopic focus
o Multifocal: different shapes with impulse generation from different
sites
Nursing Considerations
 Notify the health care provider if PVCs are detected.
 Identify the cause, then treat the PVCs on the basis of the cause.
 Evaluate electrolyte levels, particularly that of potassium;
hypokalemia can cause PVCs.
 Administer oxygen.
 Medications may be prescribed to treat the PVCs.
 Notify the health care provider if the client complains of chest pain
or if the PVCs increase in frequency, are multifocal, occur on the T
wave (R-on-T phenomenon), or occur in runs of ventricular
tachycardia.
Ventricular Tachycardia
Description
 Ventricular tachycardia (VT) is the repetitive firing of an irritable
ventricular ectopic focus at a rate of 140 to 250 beats/min or faster.
 The condition may present as paroxysm of three self-limiting beats
or more or may be a sustained rhythm.
 VT can cause cardiac arrest.

Nursing Considerations
 If the client is in a stable condition with sustained ventricular
tachycardia, administer oxygen and antidysrhythmic medications as
prescribed.
 If the client is in an unstable condition with VT:
o Administer oxygen and antidysrhythmic therapy.
o Prepare for synchronized cardioversion.
o Cough cardiopulmonary resuscitation (CPR) may be attempted by
the health care provider, who will ask the client to cough hard every
1 to 3 seconds.
 If the client is pulseless, prepare for defibrillation and CPR.
Ventricular Fibrillation
Description
 Impulses from many irritable foci fire in a totally disorganized
manner.
 In this chaotic rapid rhythm, also known as VF, the ventricles quiver.
 The affected individual lacks a pulse, BP, respirations, and heart
sounds.
 VF is rapidly fatal if not successfully terminated within 3 to 5
minutes.
Nursing Considerations
 Defibrillate the client immediately.
 Initiate CPR.
 Administer oxygen.
 Administer medications and antidysrhythmic therapy as prescribed.
 Management of Dysrhythmias: Vagal Maneuvers
Description
 Vagal stimulation of the cardiac conduction system is used to
terminate supraventricular tachydysrhythmias.
Nursing Considerations
Carotid Sinus Massage
 The health care provider massages over the carotid artery for 6 to 8
seconds until he or she detects a change in the cardiac rhythm.
 Monitor heart rate, rhythm, and BP.
 Watch the cardiac monitor for a change in rhythm.
 Record ECG rhythm strips before, during, and after the procedure.
 Have a defibrillator and resuscitation equipment available.
 Monitor vital signs, cardiac rhythm, and level of consciousness after
the procedure.
Valsalva Maneuvers
 The health care provider instructs the client to bear down or triggers
the gag reflex in the client, each of which stimulates a vagal reflex.
 Monitor heart rate, rhythm, and BP.
 Watch the cardiac monitor for a change in rhythm.
 Record ECG rhythm strips before, during, and after the procedure.
 Provide an emesis basin if the gag reflex is stimulated and initiate
precautions to prevent aspiration.
 Have a defibrillator and resuscitation equipment available.
 Monitor vital signs, cardiac rhythm, and level of consciousness after
the procedure.
 Management of Dysrhythmias: Cardioversion
Description
 In this elective procedure, performed by the health care provider, a
synchronized countershock is used to convert an undesirable rhythm
to a stable rhythm.
 A lower amount of energy is used in this procedure than in
defibrillation.
 The defibrillator is synchronized to the client's R wave to avoid
discharge of the shock during the vulnerable period (T wave).
 If the defibrillator is not synchronized, it will discharge on the T wave
and cause ventricular fibrillation.
Nursing Considerations
Before the Procedure
 Obtain informed consent.
 Administer sedation.
 Withhold digoxin for 48 hours before the procedure as prescribed to
help prevent postcardioversion ventricular irritability.
 Ensure that the skin is clean and dry in the area where electrode
paddles will be placed.
During the Procedure
 Stop oxygen administration to minimize the fire hazard.
 Be sure that no one is touching the bed or the client when the
countershock is delivered.
After the Procedure
 Maintain airway patency.
 Administer oxygen as prescribed.
 Assess vital signs and level of consciousness.
 Monitor the cardiac rhythm.
 Monitor the client for indications of a successful response (e.g.,
conversion to sinus rhythm, strong peripheral pulses, adequate BP).
 Management of Dysrhythmias: Defibrillation
Description
 An asynchronous countershock is used to terminate pulseless
ventricular tachycardia or ventricular fibrillation.
 Monophasic defibrillators deliver energy in one direction; this
includes an initial shock of 360 joules (J) followed by immediate CPR,
beginning with chest compressions.
 Biphasic defibrillators deliver energy in two directions; the first and
any successive shocks are 120 to 200 J.
Nursing Considerations
During the Procedure
 Stop oxygen during the procedure to minimize the fire hazard.
 Ensure that no one is touching the bed or client when the shock is
delivered.
The Procedure
 Apply conductive pads.
 One paddle is placed at the third intercostal space to the right of the
sternum; the other is placed at the fifth intercostal space on the left
midaxillary line.
 Apply firm pressure with the paddles.
 Ensure that no one is touching the bed or client when the shock is
delivered.
  Management of Dysrhythmias: Automated External
Defibrillator
Description
 The automated external defibrillator, or AED, is used by laypersons
and emergency medical technicians in cases of prehospital cardiac
arrest.
 Differentiates nonventricular fibrillation rhythms and is used to
convert ventricular fibrillation into a perfusing rhythm.
Nursing Considerations
 The electrode pads are placed on the client in the correct positions
(these are specified on the device for the benefit of laypersons).
 The analyzer button is turned on.
 The machine advises whether a shock should be delivered.
 Ensure that no one is touching the client when the shock is
delivered.
handheld screening wand is used, it should not be placed
directly over the ICD.
 Instruct the client to move away from the magnetic field
immediately if beeping tones are heard and to notify the
health care provider.
 The client should keep documentation of the pacemaker in
his or her wallet and obtain and wear a Medic-Alert
bracelet.
 Instruct the client to inform all health care providers that
an ICD has been inserted.
 Management of Dysrhythmias: Pacemakers
Description

 Management of Dysrhythmias: Implantable Cardioverter

Defibrillator

Description
 This device, also known as an ICD, is used to monitor the cardiac
rhythm and detect and terminate episodes of VT and VF.
 The ICD senses VT or VF and delivers 25 J or less as many as four
times if necessary.
 It is used in clients with episodes of spontaneous sustained VT or VF
unrelated to myocardial infarction and in clients whose medication
therapy has been unsuccessful in controlling life-threatening  A pacemaker is a device, temporary or permanent, that provides
dysrhythmias. electrical stimulation and maintains the heart rate when the client's
intrinsic pacemaker fails to deliver a perfusing rhythm.
Nursing Considerations  The synchronous or demand pacemaker senses the client's rhythm
 Electrodes are placed in the right atrium and ventricle and apical and paces only if the client's intrinsic rate falls below the set
pericardium; the generator is implanted subcutaneously over the pacemaker rate.
pectoral muscle on the nondominant side.  The asynchronous or fixed-rate pacemaker paces at a preset rate
 The client must be given certain instructions to help ensure safety regardless of the client's intrinsic rhythm.
and correct function of the device.  Overdrive pacing suppresses the underlying rhythm in
 Teach the client the basic function of the ICD. tachydysrhythmias, enabling the sinus node to regain control of the
heart.
 Teach the client to take the pulse daily and to keep a diary
of pulse rates.
Nursing Considerations
 The client should wear loose-fitting clothing over the ICD
 When a pacing stimulus is delivered to the heart, a spike (straight
generator site.
vertical line) is seen on the monitor or electrocardiographic strip.
 Contact sports should be avoided to help prevent trauma
to the ICD generator and lead wires.
 Instruct the client to report fever or redness, swelling, or
drainage at the insertion site.
 Fainting, nausea, weakness, blackouts, and a rapid pulse
should all be reported to the health care provider.
 During the shock discharge, the client may feel faint or
short of breath.
 Instruct the client to sit or lie down if he or she feels a
shock and to notify the health care provider.
 Instruct the client and family in how to access the  The spike should be followed by a P wave, indicating atrial
emergency medical system. depolarization, or a QRS complex, indicating ventricular
 Encourage the family to learn CPR. depolarization; this pattern is referred to as capture.
 Advise the client to maintain a diary of shocks, including  If the electrode is in the ventricle, the spike appears in front of the
the date, activity preceding the shock, the number of QRS complex; if the electrode is in the atrium, the spike is before the
shocks, and postshock sensations. P wave.
 Instruct the client to avoid electromagnetic fields directly  If the electrode is in both the atrium and ventricle, the spike appears
over the ICD, which may inactivate the device. before the P wave and QRS complex.
 Airport security should be informed of the presence of the
ICD, because it may set off the metal detector; if a
  Management of Dysrhythmias: Temporary Pacemakers
Noninvasive Temporary Pacing
Description
 A temporary pacemaker is used as an emergency measure or when a
client is being transported and the risk of bradydysrhythmia exists.
Nursing Considerations
 Large electrode patches are placed on the chest and back.
 Place the anterior electrode between V2 and V5 positions over the
heart.
 Place the posterior electrode between the spine and left scapula,
behind the heart; avoid placement over bone.
 Do not place the anterior electrode over female breast tissue;
rather, displace the breast tissue and place the electrode under the
breast.
 Do not take the pulse or BP on the left side; the results will not be
accurate because of muscle twitching and electrical current.
 Ensure that electrodes are in good contact with the skin.
 If loss of capture occurs, assess skin contact with the electrodes and
increase the current until capture is regained.
 Management of Dysrhythmias: Invasive Temporary
Pacemakers
Transvenous Pacemaker
Description
 This type of pacemaker is usually used as a temporary measure in
order to correct the dysrhythmia or until a permanent implanted
pacemaker can be placed.
 The lead pacing wire is threaded through the antecubital, femoral,
jugular, or subclavian vein and into the right atrium for atrial pacing
or sent through the right ventricle and positioned in contact with the
endocardium.
Nursing Considerations
 Monitor the insertion site.
 Restrict client movement to prevent displacement of the lead wire.
 Management of Dysrhythmias: Invasive Temporary
Pacemakers
Epicardial Pacemaker
Description
 This type of apparatus is applied by way of a transthoracic approach,
with the lead wires loosely threaded on the epicardial surface of the
heart after cardiac surgery.
Nursing Considerations
 Reducing the risk of microshock is crucial.
 Use only inspected and approved equipment.
 Insulate exposed portion of wires with plastic or rubber material
(e.g., fingers of rubber gloves) and cover them with nonconductive
tape.
 Ground all electrical equipment, using a three-prong plug.
 Wear gloves when handling exposed wires.
 Keep dressings dry.
 Management of Dysrhythmias: Permanent Pacemakers
Description
 The pulse generator is surgically implanted in a subcutaneous pocket
under the clavicle or over the pectoral muscle on the client’s
nondominant side.
 Leads are passed transvenously by way of the cephalic or subclavian
vein to the endocardium on the right side of the heart.
 The pacemaker is programmed during insertion; it may be
reprogrammed by means of noninvasive transmission from an
external programmer to an implanted generator.
Nursing Considerations
 Instruct the client in how the pacemaker works and discuss the
precautions to be taken to ensure the device’s proper function and
the client’s safety.
 Educate the client about the pacemaker, including the
programmed rate.
 Instruct the client in the signs of battery failure and explain
when to notify the health care provider.
 Instruct the client to report fever or redness, swelling, or
drainage at the insertion site.
 The client should report dizziness, weakness or fatigue,
swelling of the ankles or legs, chest pain, or shortness of
breath.
 Instruct the client to keep a pacemaker identification card
in the wallet and to obtain and wear a Medic-Alert
bracelet.
 Instruct the client to take the pulse daily and keep a diary
of pulse rates.
 The client should wear loose-fitting clothing.
 Participation in contact sports should be avoided.
 Tell the client to inform all health care providers that a
pacemaker has been inserted.
 Instruct the client to inform airport security of the
pacemaker, because it may set off security devices.
 Explain that most electrical appliances will not interfere
with the function of the pacemaker but advise the client
not to operate electrical appliances directly over the
pacemaker site.
 The client should avoid transmitter towers and antitheft
devices in stores.
  Tell the client to move 5 to 10 feet away and check the
pulse if he or she experiences any unusual feeling while
near an electrical device.
 Emphasize the importance of follow-up with the health
care provider.
 Hemodynamic Emergencies: Cardiogenic Shock
Description
 The heart fails to pump adequately, reducing cardiac output and
compromising tissue perfusion.
 Necrosis of more than 40% of the left ventricle occurs, usually as a
result of occlusion of major coronary vessels.
 Treatment is focused on maintaining tissue oxygenation and
perfusion and improving the pumping ability of the heart.
 The affected individual displays a variety of manifestations.
 Hypotension: BP lower than 90 mm Hg systolic or 30 mm
Hg lower than the client’s baseline
 Urine output of less than 30 mL/hr
 Cool, clammy skin
 Poor peripheral pulses
 Tachycardia
 Pulmonary congestion
 Tachypnea
 Disorientation, restlessness, and confusion
 Continuing chest discomfort
Nursing Considerations
 Administer oxygen as prescribed; prepare for intubation and
mechanical ventilation.
 Administer IV morphine sulfate as prescribed to ease pulmonary
congestion and pain.
 Diuretics, nitrates, vasopressors, and positive inotropics may be
prescribed to maintain organ perfusion; check the BP constantly.
 Prepare the client for insertion of an intraaortic balloon pump, if
prescribed, to improve coronary artery perfusion and improve
cardiac output.
 Reperfusion procedures such as percutaneous transluminal coronary
angioplasty (PTCA) or coronary artery bypass graft may be
performed.
 Monitor arterial blood gas levels and prepare to treat imbalances.
 Monitor urine output.
 Assist with the insertion of a pulmonary artery catheter, such as a
Swan-Ganz catheter, to assess the degree of heart failure; readings
obtained from the catheter correlating to cardiogenic shock include
increased PCWP and decreased cardiac output.
 Monitor the distal pulses and maintain the transducer at the level of
the right atrium if the client has a Swan-Ganz catheter.
 Hemodynamic Emergencies: Hypertensive Crisis
Description
 This acute and life-threatening condition requires immediate
reduction in BP before target organ damage (i.e., brain, heart,
kidneys, retina) occurs.
 Certain conditions such as pheochromocytoma, and certain
medications, such as monoamine oxidase inhibitors (MAOIs) can
cause hypertensive crisis.
 Death may result from stroke, renal failure, or cardiac disease.
 Assessment findings include:
o Extremely high blood pressure (diastolic pressure usually higher than
120 mm Hg)
o Headache
o Blurred vision
o Changes in neurological status
o Tachycardia and tachypnea
Nursing Considerations
 Maintain a patent airway.
 Maintain bed rest, with the head of the bed elevated.
 Administer diuretics and antihypertensive medications IV as
prescribed.
 Monitor vital signs, assessing the BP every 5 minutes.
 Assess the client for hypotension during the administration of
antihypertensives; place the client in a supine position if
hypotension occurs.
 Have emergency medications and resuscitation equipment readily
available.
 Hemodialysis
Description
 This procedure, performed for the client with acute kidney
injury or chronic kidney disease, cleanses the blood of accumulated
waste products and removes excess fluids.
 Hemodialysis maintains or restores the body's buffer system and
electrolyte levels.
 Client's blood flows into the dialyzer; substances move from the
blood to the dialysate through a semipermeable membrane by
means of the process of diffusion, osmosis, and ultrafiltration.
Nursing Considerations
 Monitor the client’s vital signs.
 Monitor laboratory values before, during, and after dialysis.
 Assess the client for fluid overload before the procedure; weigh the
client before and after the procedure to determine fluid loss.
 Assess the patency of the blood access device.
 Before the procedure, hold antihypertensives and other medications
that can affect the blood pressure and medications that can be
"dialyzed out" (e.g., water-soluble vitamins, certain antibiotics).
 Monitor the client for hypovolemia during the procedure.
 Provide adequate nutrition (the client may eat before the
procedure).
 Monitor the client for complications of the dialysis procedure
 Disequilibrium syndrome
 Dialysis encephalopathy
 Electrolyte changes
 Hepatitis
 Blood loss, hypotension, and shock
 Muscle cramping
 Sepsis
 Complications of Hemodialysis: Disequilibrium Syndrome
Description
 Solutes are removed from the blood faster than from the
cerebrospinal fluid and brain and fluid is pulled into the brain,
resulting in cerebral edema.
 Assessment findings include:
o Nausea and vomiting
o Headache
o Hypertension  Access for Hemodialysis: Internal Arteriovenous Fistula
o Restlessness and agitation
o Confusion
o Seizures

Nursing Considerations
 Monitor the client for signs of disequilibrium syndrome.
 Notify the health care provider if signs of disequilibrium syndrome
occur.
 Take steps to minimize environmental stimuli to reduce restlessness
and agitation.
 The client may undergo a shorter period of dialysis at a reduced rate
of blood flow as a means of helping prevent the syndrome.

 Complications of Hemodialysis: Dialysis Encephalophy

Description
 This condition is a result of aluminum toxicity caused by exposure to
aluminum in the water used in the dialysate and the ingestion of
aluminum-containing antacids (phosphate binders).
 Assessment findings include:
o Progressive neurological impairment
o Speech disturbances
o Muscle incoordination
o Bone pain
o Seizures
Nursing Considerations
 Monitor the client for signs of dialysis encephalopathy.
 Notify the health care provider if signs of dialysis encephalopathy
occur.
 Administer aluminum-chelating agents as prescribed to free up
aluminium, which will allow dialysis to remove it from the client’s
body.
 Access for Hemodialysis: Subclavian and Femoral
Catheter
Description
 A subclavian (subclavian vein) or femoral (femoral vein) catheter
may be inserted for short-term or temporary use in acute kidney
injury.
 This venous access may be used until a fistula or graft matures or
develops or when a fistula or graft access fails as a result of infection
or clotting.
Nursing Considerations
 Assess the insertion site for hematoma, bleeding, dislodgment, and
infection.
 Do not use these catheters for any purpose other than dialysis.
 Maintain an occlusive dressing over the site.
 The catheter may be left in place for as long as 6 weeks if
complications do not occur.
 If a femoral vein catheter is inserted, the client should not sit up
more than 45 degrees or lean forward, or the catheter may kink and
become occluded; assess the extremity for circulation,
temperature, and pulses.
Description
 An internal arteriovenous fistula, or AV fistula, is formed when
anastomosis of a large artery in the arm to a large vein is performed.
 The flow of arterial blood into the venous system causes veins to
become engorged (“matured” or “developed”).
 Maturity takes about 1 to 2 weeks and is required before the fistula
can be used; the engorged vein is punctured with a large-bore
needle for the dialysis procedure.
Nursing Considerations
 Do not take the blood pressure, draw blood, place an IV line, or
administer injections in an extremity bearing a fistula or graft.
 Palpate or auscultate for a bruit or thrill over the fistula or graft.
 Watch for signs of clotting (e.g., inability to palpate a thrill or
auscultate a bruit over the fistula or graft).
 Monitor the client for arterial steal syndrome.
 A condition that develops after the creation of an
arteriovenous (AV) fistula when too much blood is diverted
to the vein and arterial perfusion to the hand is
compromised.
 Palpate the pulses below the fistula or graft and monitor for hand
swelling as an indication of ischemia.
 Note the temperature and capillary refill in the extremity.
 Monitor the client for signs of infection.
 Assess lung and heart sounds for signs of fluid overload and heart
failure; notify the health care provider if these signs occur.
 Notify the health care provider immediately if signs of clotting,
infection, or arterial steal syndrome occur.
 Access for Hemodialysis: Internal Arteriovenous Graft
Description
 An internal graft is used primarily for clients undergoing long-term
dialysis who do not have blood vessels adequate for the creation of
a fistula.
 The procedure involves anastomosis of the graft to the artery, after
which the graft is tunneled under the skin and anastomosis to a vein
is performed.
 The graft may be used 2 weeks after insertion.
Nursing Considerations
 Procedures and precautions are the same as those for an internal
arteriovenous fistula.
 Peritoneal Dialysis
Description
 In peritoneal dialysis, the peritoneum is the dialyzing membrane
(semipermeable membrane) and a substitute for kidney function in
kidney failure.
 The procedure works on the principles of diffusion and osmosis;
dialysis occurs by way of transfer of fluid and solute from the
bloodstream through the peritoneum.
 Types include ambulatory (intermittent or continuous) and
automated (which requires the use of a cycling machine).
 Peritoneal dialysis is contraindicated in clients with peritonitis, those
who have recently undergone abdominal surgery or are about to
undergo kidney transplantation, and in people with abdominal
adhesions.
Dialysate Solution
 This sterile fluid is instilled into the peritoneum.
 The higher the glucose concentration, the greater the amount of
fluid removed during an exchange.
 If hyperkalemia is not a problem, potassium may be added to each
bag of solution.
 Heparin is added to the dialysate solution to prevent clotting in the
catheter.
 Prophylactic antibiotics may be added to the dialysate to help
prevent peritonitis.
 Insulin may be added to dialysate in a client with diabetes mellitus.
Access
 Surgical insertion of a siliconized rubber catheter into the abdominal
cavity (see image) is required to allow infusion of dialysis fluid.
 The catheter is tunneled under the skin to stabilize it and reduce the
risk of infection.
 For 1 to 2 weeks after insertion, ingrowth of fibroblasts and blood
vessels into the cuffs of the catheter occurs, fixing the catheter in
place and providing an extra barrier against dialysate leakage and
bacterial invasion.
Infusion and Outflow
 One infusion (inflow) period, one dwell period, and one outflow
period are considered one exchange.
 Between 1 and 2 L of dialysate, as prescribed, is infused by way of
gravity into the peritoneal space; this takes approximately 10 to 20
minutes.
 The fluid then drains from the body, by means of gravity, into a
collection bag.
Nursing Considerations
Before the Procedure
 Check the vital signs.
 Weigh the client.
 Have the client void, if possible.
 Assess the client’s electrolyte and glucose levels.
 Warm the dialysate solution, using a heating pad specifically
designed for heating this type of solution.
During the Procedure
 Monitor the vital signs.
 Monitor the client for signs of infection and other complications and
carry out the appropriate interventions.
 Place the client in a semi-Fowler position.
 Watch for respiratory distress, pain, and discomfort.
 Monitor the client for signs of heart failure and pulmonary edema.
 Assess the catheter site dressing for wetness and bleeding.
 Monitor the dwell time as prescribed by the health care provider
and initiate outflow.
 Do not allow dwell time to extend beyond the health care provider's
prescription; this increases the risk for hyperglycemia.
 Turn the client from side to side or have the client sit upright if
outflow is slow to start.
 Monitor outflow for amount, color, and clarity; outflow should be a
continuous stream after the clamp is opened.
 During initial exchanges, outflow may be bloody; outflow
should be clear and colorless thereafter.
 Brown outflow indicates bowel perforation.
 Outflow the same color as urine indicates bladder
perforation.
 Cloudy outflow indicates peritonitis.
 If outflow is less than inflow, the difference is equal to the amount
absorbed or retained by the client during dialysis and should be
counted as intake.
 Weigh the client before and after the procedure to assess fluid loss.
 COMPLICATIONS OF PERITONIAL DIALYSIS
Peritonitis
 Maintain meticulous sterile technique and follow agency
procedures when hooking up or clamping off solution bags
and when caring for the catheter insertion site.
 Monitor the client for fever, cloudy outflow, and rebound
abdominal tenderness.
 If peritonitis is suspected, obtain a culture of the outflow
to determine the infective organism.
 Administer antibiotics as prescribed.
Abdominal Pain
 Pain during inflow is common during the first few
exchanges; it is caused by peritoneal irritation and usually
disappears after a week or two of dialysis treatments.
 Cold dialysate aggravates the discomfort; dialysate should
be warmed before use, but only with the aforementioned
dialysate warmer pad.
Insufficient Outflow
  Insufficiency may be caused by catheter migration from
the peritoneal area; if this occurs, the catheter must be
repositioned by the health care provider.
 Insufficient outflow may also be caused by a full colon.
 Keep the drainage bag below the level of the client's
abdomen.
 Change the outflow position by turning the client or
helping him or her walk.
 Check for kinks in the tubing.
 Encourage a high-fiber diet.
 Administer stool softeners as prescribed.

Leakage at the Catheter Site

 For 1 to 2 weeks after catheter insertion, ingrowth of

fibroblasts and blood vessels into the cuffs of the catheter
fixes the catheter in place and provides an extra barrier
against dialysate leakage and bacterial invasion.
 It may take as long as 2 weeks for the client to tolerate a
full 2-L exchange with no leakage around the catheter site.

 Priority Points to Remember!

 Shock is a life-threatening condition that requires immediate
medical treatment because it can cause damage to multiple organs.
 An increased central venous pressure indicates an increase in blood
volume as a result of sodium and water retention, excessive IV
fluids, alterations in fluid balance, or kidney failure; a decreased
central venous pressure indicates a decrease in circulating blood
volume and may be the result of fluid imbalance, hemorrhage, or
severe vasodilation with pooling of blood in the extremities that
limits venous return.
 The goal of treatment for a client with decreased cardiac output is to
maintain tissue oxygenation and perfusion and improve the
pumping ability of the heart.
 Ventricular tachycardia is a life-threatening condition that can lead
to ventricular fibrillation and requires immediate intervention
(defibrillation and cardiopulmonary resuscitation).
 Ventricular fibrillation is rapidly fatal if not successfully terminated
within 3 to 5 minutes; defibrillation is the immediate intervention.
 During defibrillation, ensure that no one is touching the bed or client
when the shock is delivered.
 Instruct the client with a pacemaker to keep a pacemaker
identification card in the wallet and obtain and to wear a Medic-
Alert bracelet.
 Hypertensive crisis is an acute and life-threatening condition
requiring immediate reduction in the blood pressure; target organ
damage (i.e., brain, heart, kidneys, retinas) may occur quickly, with
death resulting from stroke, renal failure, or cardiac disease.
 In the client with an internal arteriovenous fistula or graft, palpate or
auscultate for a thrill and bruit, which indicate patency.
 A primary concern for the client undergoing peritoneal dialysis is
peritonitis.