Clinical Practice and Patient Care
Assessment and monitoring
Before treatment, verify patient identity and orders, obtain pre-dialysis weight and vital signs, and assess the vascular access for thrill, bruit, warmth, redness, swelling, or drainage. Review symptoms, medications, and fluid gain. During treatment, monitor blood pressure, pulse, and symptoms; calculate the ultrafiltration goal as pre-dialysis weight minus target (dry) weight, adjusting for prime/rinseback per policy. Common intradialytic problems include hypotension, cramping, nausea, headache, access infiltration, and disequilibrium syndrome. Hypotension usually reflects excessive or rapid fluid removal: slow or stop UF, reposition the patient, and give saline per orders. Cramping often follows rapid UF or low sodium; reducing UF and giving saline per protocol is more appropriate than increasing UF. Disequilibrium causes headache, confusion, or seizure, especially with high urea removal; slow blood flow and UF.
Cannulation and access care
For a fistula, the arterial needle is directed toward the anastomosis (inflow) and the venous needle toward venous outflow, separated by at least about 2 inches; follow facility policy for grafts and buttonholes. Rotate sites and inspect for infiltration.
Traps and rule of thumb
Questions often confuse hypotension with disequilibrium and cramping with needing more UF. Dry weight is a clinical estimate and must be reassessed. Rule of thumb: if the patient becomes symptomatic, reduce or stop UF and assess; never catch up by increasing UF. Keep the UF rate generally below about 13 mL/kg/h when possible.