Risk for Injury | Nursing Care Plan for Hemodialysis

Nursing diagnosis: risk for Injury

Risk factors may include
Clotting, hemorrhage related to accidental disconnection, infection

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Hemodialysis Access
Maintain patent vascular access.
Be free of infection.

Nursing intervention with rationale:
1. Assess client’s pulse and tissue color distal to shunt.
Rationale: Determines general circulatory status of limb.

2. Monitor internal AV fistula or graft patency at frequent intervals.
Rationale: Clotting (thrombosis) of the AV access is the most common complication.

3. Palpate for thrill.
Rationale: Should be palpable above venous exit site. If the thrill stops, or even feels different, this could indicate clotting. With early intervention, many clots can be dissolved or removed.

4. Auscultate for a bruit.
Rationale: Bruit is the sound caused by the turbulence of arterial blood entering the venous system and should be audible by stethoscope, although may be very faint. If the bruit gets higher in pitch, it could mean narrowing of the blood vessels; if it stops, clot may have formed.

5. Note color of blood and obvious separation of cells and serum.
Rationale: Change of color from uniform medium red to dark purplish red suggests sluggish blood flow and early clotting. Separation in tubing is indicative of clotting. Very dark reddish-black blood next to clear yellow fluid indicates full clot formation. Note: Prior to insertion of an AV fistula or graft, client may have a temporary or permanent central catheter, which is maintained with heparin to inhibit clot formation. Because heparin remains active in the body for 4 to 6 hours, the client is at risk for hemorrhage during and immediately after dialysis (Leydig 2005).

6. Palpate skin around shunt for warmth.
Rationale: Diminished blood flow results in “coolness” of shunt.

7. Notify physician and initiate declotting procedure if there is evidence of loss of shunt patency.
Rationale: Rapid intervention may save access; however, declotting must be done by experienced personnel.

8. Evaluate reports of pain, numbness, and tingling; note extremity swelling distal to access.
Rationale: May indicate inadequate blood supply.

9. Avoid trauma to shunt; for example, handle tubing gently and maintain cannula alignment. Limit activity of extremity. Avoid taking blood pressure (BP) or drawing blood samples in shunt extremity. Instruct client not to sleep on side with shunt or carry packages, books, or purse on affected extremity.
Rationale: Decreases risks of clotting and disconnection. It is critical that the catheter be used only for dialysis as it is the client’s lifeline (Leydig, 2005).

10. Attach two cannula clamps to shunt dressing. Have tourniquet available. If cannulae separate, clamp the arterial cannula first, then the venous. If tubing comes out of vessel, clamp cannula that is still in place and apply direct pressure to bleeding site. Place tourniquet above site or inflate BP cuff to pressure just above client’s systolic BP.
Rationale: Prevents massive blood loss while awaiting medical assistance if cannula separates or shunt is dislodged.

Risk for Injury | Nursing Care Plan Total Nutritional Support

Nursing diagnosis: risk for injury

Risk factors may include
External environment—catheter-related complications such as air emboli and septic thrombophlebitis
Internal factors—effects of therapy, drug interactions

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Risk Control
Be free of complications associated with nutritional support.
Modify environment and correct hazards to enhance safety for in-home therapy.

Nursing intervention with rationale:
1. Maintain a closed central IV system using Luer-Lok connections and taping of all connections.
Rationale: Inadvertent disconnection of central IV system can result in lethal air emboli.

2. Administer appropriate TPN solution via peripheral or central venous route, including peripherally inserted central catheter (PICC) lines and tunneled catheters.
Rationale: Solutions containing high concentrations of dextrose more than 10% must be delivered via a central vein because they result in chemical phlebitis when delivered through small peripheral veins.

3. Monitor for potential drug and nutrient interactions.
Rationale: Various interactions are possible, such as digoxin in conjunction with diuretic therapy, which can cause hypomagnesemia; hypokalemia may result from chronic use of laxatives, mineralocorticoid steroids, diuretics, or amphotericin.

4. Assess catheter for signs of displacement out of central venous position: extended length of catheter on skin surface, leaking of IV solution onto dressing, client complaints of neck arm pain, tenderness at catheter site, or swelling of extremity on side of catheter insertion.
Rationale: Central venous catheter tip may slip out of superior vena cava and migrate into smaller innominate and jugular veins, causing a chemical thrombophlebitis. Incidence of subclavian or superior vena cava thrombosis is increased with extended use of central venous catheters.

5. Inspect peripheral TPN catheter site routinely and change sites at least every other day or per protocol.
Rationale: Peripheral TPN solutions, although less hyperosmolar, can still irritate small veins and cause phlebitis. Peripheral venous access is often limited in malnourished clients, but site should still be changed if signs of irritation develop.

6. Investigate reports of severe chest pain or coughing in clients with central line. Turn client to left side in Trendelenburg position, if indicated, and notify physician.
Rationale: Suggests presence of air embolus requiring immediate intervention to displace air into apex of heart away from the pulmonary artery.

7. Maintain an occlusive dressing on catheter insertion sites for 24 hours after subclavian catheter is removed.
Rationale: Extended catheter use may result in development of catheter skin tract. Once the catheter is removed, air embolus is still a potential risk until skin tract has sealed.