Nursing Field Notes / Renal + Fluid · Med-Surg Course

Hemodialysis 🩸

The machine version of the kidney · AV fistula care · DDS

NG-248 Renal ADHD-friendly visual edition

Hemodialysis is a machine version of the kidney. Blood leaves the body, runs past a filter, and comes back clean — it removes waste, excess fluid & electrolytes the failed kidney can no longer clear. Almost every test question is about the access arm 🖐️ or pulling fluid off too fast 🧠.

📄 Simple Nursing original — opens in Drive →

🧼 “DIAL” = the soapAny word with DIAL — think Dial soap. It cleans the blood.

🖐️ Thrill + BruitFEEL the vibration, HEAR the whoosh. Every shift, every visit.

🧠 DDS is the killerSolutes pulled too fast → brain swells → ↑ICP. Slow or stop it.

🚫 The fistula armNo BP · no sticks · no watch · no lotion · no purse (>5 lb).

🧼

WHAT IT IS

STEP 1 · THE CIRCUIT

Blood out, through a filter, back in — and the whole thing runs through one precious arm.

🩸 The hemodialysis circuit — follow one drop of blood

Blood out ➜ pump ➜ dialyzer ➜ air trap ➜ blood back. The dialyzer is the artificial kidney. It does not "make urine" — it lets waste diffuse out of the blood into a fluid called dialysate running the other direction.

Dirty blood out Clean blood back Dialysate Waste removed

🧠 “DIAL the soap.” Any time you see the word DIAL — dialysis, dialyzer, dialysate — picture a bar of Dial soap scrubbing the blood clean. Soap in, dirt out.

🔬 Inside the dialyzer — 2 forces, 2 jobs

Diffusion — solutes move from high to low: urea, creatinine, K⁺ leave the blood.
Ultrafiltration — pressure pulls water off. That's how fluid comes off.

🧠 Diffusion cleans, ultrafiltration dries. One takes the trash, the other takes the water.

🚪 Three ways in — pick the right access

Access	What it is	Ready to use
AV fistula ⭐ best / longest life	Surgeon sews the client's own artery to vein	Needs weeks to mature — commonly 6 wk–4 mo (varies)
AV graft	Synthetic tube bridges artery → vein	Sooner than a fistula, but clots & infects more
Central venous catheter	Large tunneled/temporary line in a central vein	Immediate — but highest infection risk; short-term

🧠 “Fistula First.” Own vessels > plastic graft > catheter. The catheter is the fastest and the most dangerous.

🖐️ The AV fistula — feel the THRILL, hear the BRUIT

No thrill + no bruit = the fistula has clotted. That is not "wait and see" — report it immediately.

🧠 “Thrill you Touch, Bruit you Blisten.” (Say it wrong on purpose — Bruit = listen with the Bell.) Thrill = Touch. Teach her to check it several times a day at home.

💪 Help the new fistula mature

🎾 Squeeze or grip a “rubber ball” or sponge — exercise enlarges the vein.
💧 Keep the arm warm, keep the client hydrated and not hypotensive — low BP clots a new fistula.
👀 Look at the site daily for redness, warmth, drainage.

🧠 Ball in the hand, blood in the vein. Squeezing is the fistula's workout.

🩺

BEFORE DIALYSIS

STEP 2 · SET THE BASELINE

Weight, vitals, fistula, and the meds you must NOT give — this is where the exam lives.

✅ The pre-dialysis checklist

⚖️ Weigh the client — current AND previous weight. Weight is the #1 measure of fluid status. 1 kg = 1 L of fluid.

🌡️ Full vital signs — especially BP (baseline for the hypotension that follows) and temp (infection screen).

🖐️ Assess the fistula — FEEL a thrill, HEAR a bruit, inspect for infection & bleeding.

💧 Assess fluid status — lungs, edema, JVD, breath sounds, I&O.

💊 HOLD the meds that will be washed out or drop the BP.

🧠 “W-V-F-F-M” → Weigh · Vitals · Fistula · Fluid · Meds. Say it as “We Very Fully Fix Meds.”

💊 HOLD antihypertensives — dialysis already drops the BP

Dialysis pulls volume off. Give a BP pill on top of that and you get hypotension during the run — the most common complication of hemodialysis.

🧠 “A-B-C-D-D” — ACE/ARB · Beta blocker · Calcium channel blocker · Diuretic · Dilator. Five letters, five held bottles.

🧪 “Washed out” meds — the dialyzer eats them NCLEX TIP

Small, water-soluble molecules cross the membrane and get thrown away with the dialysate. Giving them before the run wastes the dose — give them AFTER dialysis.

Washed out	Examples
Antibiotics 💉	Penicillins, cephalosporins
Digoxin ❤️	Narrow therapeutic range — and a low K⁺ after dialysis makes dig toxicity worse
Water-soluble vitamins 🍊	B vitamins, C, folic acid — replaced daily in dialysis clients

🧠 “A-D-V goes down the drain” — Antibiotics · Digoxin · Vitamins (water-soluble). Picture them swirling down the dialysate drain 🌀. Fat-soluble vitamins (A, D, E, K) stay put — fat floats.

🧪 Labs that drive the treatment STANDARD ADULT RANGES

Lab	Normal	In renal failure
BUN	10–20 mg/dL	📈 HIGH
Creatinine	0.6–1.2 mg/dL	📈 HIGH (best kidney marker)
Potassium	3.5–5.0 mEq/L	📈 HIGH ⚠️ peaked T waves
Phosphorus	3.0–4.5 mg/dL	📈 HIGH
Calcium	8.6–10.2 mg/dL	📉 LOW (mirror of phosphorus)
Hgb / Hct	12–18 g/dL	📉 LOW (no erythropoietin)

🧠 Phosphorus and calcium are on a see-saw ⚖️ — one up, the other down. Every time.

💊 The take-home renal meds

Phosphate binders (calcium acetate, sevelamer) — give WITH meals, not between. They bind the phosphorus in the food.
Epoetin alfa — replaces the erythropoietin the kidney no longer makes; treats the anemia. Monitor BP and Hgb.
Active vitamin D (calcitriol) — the failed kidney can't activate vitamin D, so calcium can't be absorbed.

🧠 Binders eat with you. If the client swallows it away from food, there's no phosphorus there to bind — wasted dose.

⚙️

DURING DIALYSIS

STEP 3 · WATCH THE BRAIN & THE BP

Everything that goes wrong during the run goes wrong because something was pulled off too fast.

🚨 DEADLY: Dialysis Disequilibrium Syndrome (DDS)

Definition: solutes are removed too quickly from the blood. Urea stays high inside the brain cells, so water rushes into the brain — the cells swell, and ICP rises. Untreated it goes to seizures, coma & death.

🔎 KEY SIGNS

😵 Restless & disoriented (first change = LOC)
🤢 Vomiting
🤕 Headache
➕ later: twitching, seizures, ↓LOC

🚑 PRIORITY ACTION NCLEX TIP

1️⃣ STOP or SLOW the dialysis — fix the cause first.
2️⃣ Report to the provider.
3️⃣ Seizure precautions · protect the airway · reorient.

🧠 “Fast dialysis = swollen brain.” Any new confusion, headache or vomiting during a run is DDS until proven otherwise. The fix is always slow it down — never speed it up to "finish faster." Most likely in the FIRST few treatments and in clients with very high BUN.

📉 Hypotension — the MOST common complication

Why: volume is coming off faster than the vessels can refill.

😵‍💫 Dizzy, nauseated, pale, diaphoretic, cramping
✅ Slow/stop ultrafiltration, lay flat & raise the legs (Trendelenburg per policy)
✅ Give normal saline bolus per order · recheck BP

🧠 Water out too fast = pressure down. Same fix as DDS: slow the machine.

🫧 Air embolism — rare but instant

Signs: sudden dyspnea, chest pain, cyanosis, ↓LOC
1️⃣ Clamp the line · stop the pump
2️⃣ Place left side-lying, head down (traps air in the right atrium)
3️⃣ 100% oxygen · call for help

🧠 “Clamp · Left · Low · O₂.” Air floats — so put the air where it can't reach the lungs.

🩸 Bleeding — heparin is running

The circuit is heparinized to stop clotting, so during and just after a run the client bleeds easily.

Watch: gums, GI bleed, bruising, the needle sites
Hold pressure longer after any stick
Antidote to heparin: protamine sulfate

🧠 Heparin in the tubing = thin blood in the client.

💪 Muscle cramps & nausea

From rapid fluid and sodium shifts, usually late in the run.

✅ Slow the ultrafiltration rate
✅ Normal saline per order
📉 Often a sign the client gained too much between treatments

🧠 Big gain = rough run. Cramping is the body's receipt for skipping the fluid restriction.

✅

AFTER + TEACHING

STEP 4 · PROTECT THE ARM

Weigh, watch the BP, guard the access — and the four NO-NOs she has to know by heart.

⚖️ Post-dialysis assessment — weight tells the story

🧠 The scale is the kidney's report card. 1 kg = 1 L = 2.2 lb. A client who gains 2 kg between runs drank 2 L more than they should have.

🚫 The fistula arm NO-NOs — never on that arm

🩺NO blood pressureuse the other arm

💉NO IVs or lab drawsno venipuncture

⌚NO tight clothingor watches / jewelry

😴NO sleeping on itcompression clots it

🧴NO creams or lotionsskin breakdown + infection

👜NO lifting >5 lbno purse on that arm

Every one of these does the same thing: it squeezes the fistula shut or lets bacteria in. A clotted fistula means surgery.

🧠 “No BP, no needles, no bling, no bag, no bed, no balm.” Six NOs — say them in one breath while pointing at your own arm.

🚨 Report to the HCP — the 5 P's distal to the shunt NCLEX TIP

Pallor — pale skin below the fistula
Paresthesia — numbness or tingling
Pulses diminished
Poor cap refill (over 3 seconds)
Pain distal to the shunt

These mean the fistula is stealing blood from the hand. ✅ Mild pitting edema of that arm is NORMAL.

🧠 5 P's = “Please Protect Pale Poor Painful hands.” Edema = fine. Cold, white, numb = call.

🌡️ Monitor the access site itself

🔥 Infection — warm, red, tender, or drainage at the shunt site
🩸 Bleeding — hold firm pressure, do NOT occlude the flow
🔇 No thrill / no bruit = clotted = report NOW

🧠 Hot & red = infected. Silent = clotted. Both get a phone call.

🍽️ Diet & fluid teaching for the dialysis client

Restrict	Why · examples
Potassium 🍌	The kidney can't excrete it → fatal dysrhythmias. Limit bananas, oranges, potatoes, tomatoes, avocado, salt substitutes.
Sodium 🧂	Sodium holds water → weight gain, edema, high BP between runs.
Phosphorus 🥛	Dairy, dark colas, nuts, processed foods. Take binders with meals.
Fluid 💧	Usually restricted; goal is a small gain between treatments. Exact limit is individualized — follow the order.
Protein 🍗	Different rule: pre-dialysis CKD restricts protein, but on hemodialysis protein is INCREASED — amino acids are lost through the dialyzer.

🧠 “Na · K · P · H₂O down — protein UP once dialysis starts.” The trap answer is telling a dialysis client to eat less protein.

📅 Living with it — daily teaching

🤚 Check the thrill several times a day — teach the client and the family.
⚖️ Weigh daily at the same time, same clothes; report rapid gains.
💉 Never skip a treatment — missed runs = hyperkalemia + fluid overload.
🆘 Carry ID that says "dialysis access — no BP/no sticks this arm."

🧠 Touch it, weigh it, show up. Three habits that keep a dialysis client alive.

⚡

QUICK RECALL

SAY IT OUT LOUD

🧼 DIAL = clean bloodMachine kidney: removes waste, fluid & electrolytes.

🖐️ Thrill + bruitFeel the buzz, hear the whoosh — before every run.

🧠 DDS = brain swellsRestless · vomiting · headache ➜ SLOW/STOP + report.

💊 Hold BP meds+ antibiotics, digoxin & water-soluble vitamins get washed out.

🚫 That armNo BP · no sticks · no watch · no lotion · no >5 lb purse · no sleeping on it.

🖐️ 5 P'sPallor · Paresthesia · Pulses ↓ · Poor refill · Pain = report. Pitting edema = OK.

⚖️ 1 kg = 1 LWeigh before AND after. The scale is the fluid record.

🍗 Protein UPOn dialysis, protein increases — K⁺, Na⁺, phosphorus & fluid go DOWN.

🎯 Cover & check — 6 rapid-fire questions

Q1: You assess the fistula and feel nothing and hear nothing. Now what?

No thrill + no bruit = the fistula has clotted. Report to the provider immediately — do not use the access.

Q2: Two hours into dialysis the client is restless, disoriented, vomiting and has a headache. Priority?

Dialysis disequilibrium syndrome — solutes removed too fast, brain cells swell, ICP rises. STOP or SLOW the treatment first, then report to the provider. Seizure precautions.

Q3: Which meds are held before dialysis, and which are just given after?

HOLD antihypertensives (ACE/ARBs, beta blockers, calcium channel blockers, diuretics, nitroglycerin) — dialysis already drops the BP. Give AFTER the run: antibiotics (penicillins, cephalosporins), digoxin, and water-soluble vitamins (B, C, folic acid) — they get washed out through the dialyzer.

Q4: The client's hand below the fistula is pale, numb and has a cap refill of 4 seconds. Expected or report?

REPORT — that's the 5 P's (pallor, paresthesia, pulses diminished, poor cap refill, pain) = the access is stealing blood from the hand. Mild pitting edema of that arm, on the other hand, is expected.

Q5: The client weighed 72 kg before and 69 kg after. How much fluid came off?

3 L. 1 kg = 1 L = 2.2 lb.

Q6: Name four things that must never happen to the fistula arm.

No blood pressure cuff, no IVs/venipuncture/lab draws, no restrictive clothing or jewelry (watches), no sleeping on it, no creams or lotions, no lifting over 5 lb (no purse).

📌

STUDY SHEETS

FROM YOUR SAVED SET

Hemodialysis versus peritoneal dialysis — access, location, diet, risks and complications, with the cloudy-outflow-means-peritonitis rule. — swipe it sideways if it is cut off, or tap to open it full size.

Saved study graphics from your own collection. Each one is someone else’s work — check anything clinical against your course materials before you rely on it.