# A nurse is caring for a client receiving hemodialysis. Which nursing intervention should be the priority during the dialysis procedure?

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## 문제

A nurse is caring for a client receiving hemodialysis. Which nursing intervention should be the priority during the dialysis procedure?

## 보기

1. Monitor blood pressure and pulse every 15 minutes throughout the procedure **✔ 정답**
2. Ensure the client maintains a supine position during the entire treatment
3. Administer prescribed medications through the dialysis access site
4. Encourage the client to drink fluids to prevent dehydration

**정답: 1**

## 해설

Continuous BP and pulse monitoring is critical during hemodialysis to detect hypotension and cardiovascular complications from fluid shifts. This allows immediate intervention to prevent serious events. Other interventions are less urgent or inappropriate during dialysis.

## 심화 해설

Understanding the Priority During Hemodialysis

When caring for a client undergoing hemodialysis, the nurse's primary focus must be on preventing and promptly detecting life-threatening complications. The procedure involves the rapid removal of fluid and solutes, which creates significant hemodynamic stress. The most common and dangerous acute complication is intradialytic hypotension (IDH). Research identifies IDH as a prevalent and critical event that is strongly associated with increased morbidity, mortality, and reduced quality of life in patients with end-stage renal disease [2]. The underlying pathophysiology is multifactorial, driven primarily by an excessive ultrafiltration rate (UFR) that outpaces the body's ability to refill the intravascular space from the interstitial and intracellular compartments [2]. This rapid volume depletion triggers hypovolemic stress, which can lead to myocardial stunning, cerebral ischemia, and other end-organ dysfunction [2].

Therefore, vigilant hemodynamic monitoring is the cornerstone of safe dialysis practice. Assessing blood pressure and pulse at frequent intervals, such as every 15 minutes, allows the nurse to detect early signs of IDH—a dropping systolic pressure, narrowing pulse pressure, or a compensatory tachycardia. Early recognition is crucial because it enables immediate, life-saving interventions like reducing the UFR, placing the client in the Trendelenburg position, or administering a fluid bolus, thereby preventing the cascade of hypovolemic shock and its severe consequences. A study evaluating nursing knowledge and practice confirms that competent management of IDH is essential to prevent adverse clinical outcomes and maintain the efficiency of the dialysis procedure [1].

The other options are inappropriate or dangerous. Maintaining a strict supine position is not required and can be uncomfortable; the client's position can be adjusted for comfort as long as the vascular access is protected. The dialysis access site is dedicated solely to the extracorporeal circuit and must never be used for medication administration due to the risk of infection, thrombosis, or inadvertent bolus of a concentrated drug. Encouraging fluid intake directly contradicts the purpose of the treatment, which is to remove excess fluid; doing so would undermine the prescribed fluid removal goal and could lead to fluid overload.

References (research sources)

- [1]Knowledge and Practice of Nurses on Prevention and Management of Intradialytic Hypotension at Kiruddu and Mulago National Referral Hospitals.Research articleNakabugo S, Twinamatsiko J, Kyarikunda L, Chelimo P, Asaasira D, Niyonzima V. (2025) · DOI: 10.2147/ijnrd.s528836

- [2]Updates in the management of intradialytic hypotension: Emerging strategies and innovations.Research articleHaddiya I, Simanjuntak GDFI, Ramdani S. (2025) · DOI: 10.5527/wjn.v14.i4.109168

## 임상 시나리오

Clinical Practice Guide: Hemodialysis Monitoring

Priority Assessment

- **Vital Signs:** Monitor blood pressure and pulse every 15 minutes throughout the treatment. More frequent checks are required if the patient is unstable or has a history of intradialytic hypotension (IDH).

- **Signs of IDH:** Assess for lightheadedness, nausea, yawning, muscle cramps, and restlessness. A dropping systolic pressure, narrowing pulse pressure, or compensatory tachycardia are early indicators.

Preventive Strategies

- **Ultrafiltration Management:** Set a safe ultrafiltration rate (UFR) based on the patient's estimated dry weight and cardiovascular stability. Avoid exceeding a UFR of 10-13 mL/kg/hour.

- **Dialysate Composition:** Use a dialysate sodium concentration of 138-140 mEq/L and a temperature of 36.0-36.5°C (cool dialysis) to improve hemodynamic stability.

- **Medication Timing:** Withhold antihypertensive medications prior to dialysis unless otherwise ordered, as they can exacerbate hypotension.

Emergency Interventions for IDH

- Immediately reduce the ultrafiltration rate (UFR) to zero or minimum.

- Place the patient in the Trendelenburg position to promote venous return.

- Administer a 100-200 mL normal saline bolus via the venous line, as ordered.

- Administer oxygen if the patient is hypoxic or symptomatic.

- Reassess vital signs within 2-3 minutes and notify the nephrologist if hypotension persists.

Key Safety Points

- **Access Site Integrity:** The dialysis access (fistula, graft, or catheter) is dedicated to the extracorporeal circuit. Never use it for routine medication administration or IV fluids unless in a documented emergency.

- **Fluid Balance:** Do not encourage oral fluid intake during treatment. The goal is controlled fluid removal to achieve the prescribed dry weight.

- **Positioning:** While comfort is important, the priority is hemodynamic stability. Position changes should be made cautiously and with monitoring.

## 핵심 개념

- **Intradialytic Hypotension (IDH)** — A significant drop in blood pressure during hemodialysis, commonly defined as a decrease in systolic BP ≥20 mmHg or a decrease in mean arterial pressure by 10 mmHg, associated with adverse outcomes.
- **Ultrafiltration Rate (UFR)** — The rate at which fluid is removed from the patient's blood during hemodialysis; excessive UFR is a primary cause of IDH.
- **Hemodynamic Monitoring** — Continuous or frequent assessment of cardiovascular status, including blood pressure and heart rate, to detect instability.
- **Trendelenburg Position** — A position where the patient's head is low and legs are elevated, used as an emergency intervention to promote venous return during hypotensive episodes.

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