Dialysis: Hemodialysis and Peritoneal Dialysis Nursing Review

Dialysis replaces kidney function in patients with end-stage renal disease. This note compares hemodialysis and peritoneal dialysis, focusing on access, complications, dietary needs, and high-yield nursing priorities for the NCLEX.

Hemodialysis vs Peritoneal Dialysis

• Access: Hemodialysis uses an AV fistula, AV graft, or central catheter; peritoneal dialysis uses a Tenckhoff catheter.
• Location: Hemodialysis is performed at a dialysis center or home; peritoneal dialysis is done at home.
• Frequency: Hemodialysis 3 times weekly; peritoneal dialysis daily (4-6 exchanges).
• Duration: Hemodialysis 3-5 hours per session; peritoneal dialysis 30-60 minutes per exchange.
• Anticoagulation: Required (heparin) for hemodialysis; not required for peritoneal dialysis.
• Main infection risk: Bloodstream infection in hemodialysis; peritonitis in peritoneal dialysis.

Hemodialysis Access

• AV fistula joins an artery and vein — the gold standard with the lowest complication rate.
• AV fistula requires 4-8 weeks to mature before use.
• Assess thrill (vibration) and bruit (whooshing sound) daily to confirm patency.
• Never take blood pressure, draw blood, or apply tight clothing on the fistula arm.
• AV graft uses synthetic tubing and matures faster but has higher complication rates.
• Central venous catheter is temporary and carries the highest infection risk.

Hemodialysis Complications

• Hypotension — most common complication, from rapid fluid removal. Manage by slowing fluid removal and placing the patient in Trendelenburg.
• Muscle cramps — from fluid shifts; treat with slower fluid removal and saline.
• Disequilibrium syndrome — confusion and seizures from rapid urea removal; prevent with slower initial dialysis. Most common after the first sessions.
• Access site infection — redness, warmth, or drainage; requires strict aseptic technique.
• Bleeding from anticoagulation — apply direct pressure to the access site.

Hemodialysis Nursing Care

• Obtain pre-dialysis weight to determine fluid removal goal; post-dialysis weight confirms fluid removed.
• Monitor vital signs before, during, and after treatment.
• Assess access site for thrill and bruit before each session.
• Monitor for hypotension, cramping, and bleeding during treatment.

Peritoneal Dialysis

• Uses the peritoneum as a natural filter.
• Dialysate is infused through a Tenckhoff catheter into the peritoneal cavity.
• Wastes move from blood into dialysate during the prescribed dwell time.
• Dialysate is drained and discarded; exchanges occur 4-6 times daily.
• Warm dialysate to body temperature before infusion to prevent cramping.

Peritoneal Dialysis Complications

• Peritonitis — most serious complication; presents with cloudy effluent, abdominal pain, and fever.
• Obtain a culture of the effluent before starting antibiotics; antibiotics are added to the dialysate.
• Exit site infection — redness, tenderness, or drainage at the catheter site.
• Catheter malfunction — from kinking, fibrin clots, or constipation; enemas may be needed.
• Respiratory distress — dialysate pushes on the diaphragm; elevate the head of the bed.

Peritoneal Dialysis Nursing Care

• Use strict aseptic technique for all connections to prevent peritonitis.
• Monitor effluent for cloudiness and measure output to calculate net fluid removal.
• Keep catheter exit site clean and dry; report redness or drainage promptly.

Dietary Restrictions

• Hemodialysis: strict fluid restriction (1-2 L daily) and strict potassium restriction (avoid bananas, oranges).
• Peritoneal dialysis: less strict fluid and potassium limits due to continuous treatment.
• Both: phosphorus restriction (avoid dairy, nuts) and increased protein to replace losses.

Nursing Assessment

• Weigh patient daily before and after dialysis to assess fluid removal.
• Monitor vital signs, especially blood pressure.
• Assess access site for thrill, bruit, redness, or drainage.
• Monitor labs: BUN, creatinine, potassium, phosphorus.
• Assess for fluid overload: edema, crackles, JVD, dyspnea.

Patient Teaching

• Hemodialysis: protect the fistula arm; check thrill daily; avoid tight clothing and blood pressure on that arm.
• Peritoneal dialysis: use sterile technique; report cloudy effluent immediately.
• Weigh yourself daily and follow fluid and dietary restrictions.
• Take medications as prescribed; some are held before dialysis.
• Report signs of infection: fever, redness, swelling, drainage.

Common NCLEX Traps

• Absence of thrill or bruit indicates AV fistula clotting — report immediately.
• Never take blood pressure or draw blood from the fistula arm.
• Peritonitis presents with cloudy effluent, not just abdominal pain.
• Disequilibrium syndrome occurs after the first hemodialysis sessions.
• Warm dialysate to body temperature; cold causes cramping.
• Peritoneal dialysis requires sterile technique; hemodialysis access care is aseptic but not sterile to the same degree.

Key takeaways

• AV fistula is the gold standard for hemodialysis — check thrill and bruit daily, and never use that arm for BP or blood draws.
• Peritonitis is the most serious peritoneal dialysis complication — suspect it with cloudy effluent, fever, and abdominal pain.
• Hypotension and disequilibrium syndrome are the highest-yield hemodialysis complications.
• Both modalities require low phosphorus and high protein; hemodialysis adds strict fluid and potassium restrictions.
• Always obtain pre- and post-dialysis weights to evaluate fluid removal.