Dialysis - Hemodialysis 

Policy: 

Athena Health Care Systems provides comprehensive care to individuals receiving hemodialysis treatments. This system includes staff education on the care of the hemodialysis resident, admission screening, initial and ongoing assessment of the resident, communication among the interdisciplinary team and the dialysis center, emergency care procedures, and individualized care planning. Our goal is to provide an interdisciplinary approach to address the current needs of the resident and to anticipate and prevent complications. 

Staff Education: 

Direct Care staff shall receive training prior to taking care of the resident with hemodialysis treatments. The following staff members have been identified as needing job-specific training to care for residents receiving hemodialysis: 

• Licensed Nursing Staff 

• Certified Nurses Assistant 

• Dietician 

• Social Services Staff 

• Admissions Director 

The competency of staff will be assessed on an ongoing basis. 

Admission Screening: 

• The Admissions Director will communicate with the Director of Nurses and/or Director of Staff Development when a potential admission of a resident requiring hemodialysis treatments occurs to ensure staff have been trained to care for the resident receiving hemodialysis treatments. 

• The Admissions Director will communicate with the hemodialysis center to coordinate the treatment schedule that the resident had been receiving prior to admission. 

• The Admissions Director will communicate with the Nursing Department to ensure that equipment is available to care for the resident. 

Assessment: 

Admission Assessment: 

• Determine the type of hemodialysis Access Device that is present. 

• Vital Signs 

• Weight 

• Access Site 

• Signs/Symptoms of Infection 

• Pain 

• Swelling 

• Redness 

• Tenderness 

• Exudate 

For AV Fistulas Only: 

• Feel for a thrill by palpating the fistula, especially the area of the anastomosis. 

• Listen for a bruit by auscultating the fistula with a stethoscope, especially the anastomosis. 

• Notify Physician and Hemodialysis Unit if fistula does not have a positive thrill or bruit. 

Ongoing Assessment: 

Assess access site every shift: 

• Venous Catheter: 

• Pain 

• Infection (drainage, swelling, redness, tenderness) 

• Fever, chills 

• Bleeding 

• Dislodgement 

• AV Fistula: 

• Pain 

• Scab formation 

• Signs/symptoms of infection 

• Color, motion & sensitivity of access arm. 

• Palpate fistula for a thrill 

• Auscultate fistula for a bruit 

Fluid Balance: 

• If resident is placed on a fluid restriction, monitor I&O. Allocate fluids to be given by nursing and dietary and amounts per shift. 

• Monitor weights per MD Order. Review dialysis pre & post-treatment weights. 

• Monitor for increase in edema. 

• Monitor for signs and symptoms of decreased intravascular volume, e.g. dizziness, vital sign changes, leg cramps, headache 

Weights: 

• Pre & post-treatment weights will be obtained by the dialysis unit. 

• Weights will be monitored per MD Order. 

Anticoagulation: 

• Monitor for signs and symptoms of bleeding. 

Upon return from a dialysis treatment: 

• Vital Signs 

• Access Site 

• Signs/Symptoms of Infection 

• Pain 

• Swelling 

• Redness 

• Tenderness 

• Exudate 

Maintenance Care for a Venous Catheter: 

• Hemodialysis catheters are not to be accessed by any nurse at an Athena Health Care facility. 

• The nurse will assess the resident and the insertion site every shift for signs of the following: 

• Pain 

• Infection (drainage, swelling, redness, tenderness) 

• Fever, chills 

• Bleeding 

• Dislodgement 

• Documentation of the assessment will be kept in the resident’s medical record. 

• Keep dressing clean and dry. 

• Keep catheter taped to the skin to prevent from pulling. 

• Avoid activities that may irritate or traumatize the exit site. 

• Showers and/or baths should not be given. 

• A non-serrated clamp is to be kept at the resident’s bedside for emergencies. 

Maintenance Care for AV Fistula: 

• AV fistulas are not to be accessed by any nurse at an Athena Health Care Facility. 

• Do not take blood pressure readings or perform venipuncture on the access arm. 

• Bathing is allowed and the site may be cleansed with warm soapy water and rinsed. 

• Do not put excessive pressure on the access arm. 

• Assess AV fistula every shift for the following: 

• Pain 

• Scab Formation 

• Signs and symptoms of infection. 

• Color, motion, and sensitivity of access arm. 

• Palpate fistula for a thrill. 

• Auscultate fistula for a bruit. 

• Documentation of the assessment will be kept in the resident’s medical record. 

• Notify Physician and Hemodialysis Unit if fistula does not have a positive thrill or bruit. 

• Notify family of change in condition. 

Communication: 

• Communication between the facility and the hemodialysis center will occur using a communication sheet that consists of: 

• Vital Signs 

• Copy of MAR 

• Any change in condition from last hemodialysis treatment, i.e. 

• Changes in Weight 

• Medications 

• Behavior 

• Appetite 

• Falls 

• Documentation will be entered prior to transfer to dialysis center. 

• The communication sheet will be reviewed upon return to the facility. 

Emergency Care: 

Accidental removal of a catheter dressing: 

• Check insertion site for bleeding or signs of dislodgement. If present, proceed to ‘Accidental removal of catheter’ procedure. 

• Apply a sterile dressing over the catheter insertion site and notify the hemodialysis unit. 

Accidental dislodgement or removal of a catheter: 

• Clamp the catheter using a non-serrated clamp if present. 

• Apply direct pressure with an occlusive dressing at the insertion site and transfer resident to the area hospital for treatment. 

• Notify the physician immediately. 

• Notify the hemodialysis unit. 

• Notify family of change in condition. 

Bleeding from the AV Fistula: 

• Apply direct pressure with an occlusive dressing to the fistula site and transfer the resident to the area hospital for treatment. 

• Notify the physician immediately. 

• Notify the hemodialysis unit. 

• Notify family of change in condition. 

Care Planning: 

Residents who receive hemodialysis treatments or who have a hemodialysis access site will have an individualized care plan. This care plan will include risk factors, emergency care, and other areas of monitoring based on the assessment of the resident and psychosocial needs. 

Physician Notification: 

• Significant change in vital signs. 

• Signs and symptoms of infection. 

• Bleeding 

• Significant increase in edema and/or weight gain. 

• Dislodged venous catheter. 

• Absence of thrill and bruit in AV fistula. 

Compliance and Documentation: 

• Adhere to CMS guidelines and Requirements of Participation for Long-Term Care Facilities. 

• Document the hemodialysis procedure, including the resident’s response and any observations, in their medical record. 

• Note any abnormalities or difficulties encountered during the procedure. 

• Regularly review and update techniques for hemodialysis care according to the latest clinical best practices and regulatory standards. 

• Provide training to staff on proper hemodialysis care procedures to ensure resident safety and comfort. 

• Conduct regular audits to ensure compliance with this policy and address any gaps in practice or documentation. 

References: 

• Centers for Medicare & Medicaid Services (CMS). State Operations Manual (SOM), Appendix PP - Guidance to Surveyors for Long-Term Care Facilities. 

• CMS Requirements of Participation for Nursing Homes.