# A nurse is caring for a client receiving hemodialysis. Which assessment finding would be the most concerning and require immediate intervention?

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> subject: Adult Health

## 문제

A nurse is caring for a client receiving hemodialysis. Which assessment finding would be the most concerning and require immediate intervention?

## 보기

1. Blood pressure decrease from 140/90 mmHg to 120/80 mmHg with mild dizziness
2. Sudden onset of chest pain with shortness of breath and anxiety **✔ 정답**
3. Mild cramping in the lower extremities with slight numbness
4. Feeling of fatigue and drowsiness with slight confusion

**정답: 2**

## 해설

Sudden chest pain with dyspnea and anxiety during hemodialysis indicates air embolism, a life-threatening complication requiring immediate intervention. Other options represent common but less urgent issues manageable with standard care.

## 심화 해설

Understanding Dialysis Disequilibrium Syndrome (DDS)

Dialysis disequilibrium syndrome is a serious neurological complication of hemodialysis. The underlying pathophysiology involves rapid osmotic shifts during the procedure. In patients with severe uremia, the blood is quickly cleared of urea and other osmoles. However, the brain is slower to clear these substances. This creates an osmotic gradient, drawing water into brain cells and causing cerebral edema and increased intracranial pressure (ICP) [2, 3]. This syndrome is most common during the initiation of dialysis in patients with extreme azotemia [1, 3].

Analysis of the Correct Answer

The most critical indicator is sudden onset of severe headache with altered mental status. DDS is fundamentally a neurological syndrome stemming from cerebral edema [2, 3]. The clinical presentation is a constellation of neurological symptoms. A severe headache reflects rising intracranial pressure, and an altered mental status—which can range from confusion and decreased responsiveness to staring spells as noted in clinical reports—signals direct brain parenchymal involvement [1, 2]. These signs indicate that the central nervous system is acutely compromised, making this a potentially fatal emergency if not recognized immediately [4]. Early recognition of these subtle neurological signs is essential to prevent progression to seizures, coma, or death [1].

Analysis of Incorrect Answers

Option 2: Sudden onset of severe muscle cramping in the lower extremities. Muscle cramps are a common complication of hemodialysis, typically related to rapid fluid and electrolyte shifts, particularly hypovolemia or hyponatremia. While distressing, they do not directly indicate the life-threatening cerebral edema that defines DDS.

Option 3: Sudden onset of severe hypotension with dizziness. Hypotension is a frequent intradialytic complication caused by rapid fluid removal and decreased intravascular volume. Dizziness can be a symptom of cerebral hypoperfusion. Although DDS can present with non-specific symptoms, hypotension is a hemodynamic event, not a primary neurological manifestation of the osmotic brain injury central to DDS pathophysiology [3].

Option 4: Sudden onset of severe nausea and vomiting. Nausea and vomiting are indeed recognized early, albeit non-specific, symptoms of DDS and can occur due to increased ICP [1, 3]. However, they are not the most critical indicators when compared to direct neurological signs. A patient can vomit from uremia or rapid fluid shifts without developing the dangerous cerebral edema that defines DDS. The presence of altered mentation with a headache provides a more definitive and critical warning of rising ICP [2].References (research sources)

- [1]Early-Onset Dialysis Disequilibrium Syndrome Presenting With Hypoxia and Subtle Neurological Signs During Initial Hemodialysis.Research articleTahir MH, Tahir F, Asghar S. (2026) · DOI: 10.7759/cureus.108587

- [2]Dialysis disequilibrium syndrome: An overview of the current neurosurgical state.Research articleGould J, Patel S, Chaurasia B. (2026) · DOI: 10.25259/sni_1287_2025

- [3]<p>Dialysis disequilibrium syndrome prevention and management</p>Research articleKirtida Mistry (2019) · DOI: 10.2147/ijnrd.s165925

- [4]Dialysis Disequilibrium Syndrome and Severe Metabolic Acidosis: A Fatal Case.Research articleRodriguez Lopez AF, Ameduite MK, Maddipati V, Coore H. (2025) · DOI: 10.7759/cureus.89369

## 임상 시나리오

Clinical Scenario

A patient undergoing hemodialysis suddenly develops chest pain, dyspnea, and anxiety. The nurse suspects a venous air embolism (VAE).

Immediate Nursing Actions

- **Clamp the venous line and stop the blood pump immediately.** This prevents further air entry into the patient's circulation.

- **Place the patient in the left lateral Trendelenburg position (Durant's maneuver).** This traps air in the right atrium apex, preventing it from entering the pulmonary artery.

- **Administer 100% oxygen via a non-rebreather mask.** High-concentration oxygen reduces the size of the air embolus by promoting nitrogen washout.

- **Notify the healthcare provider and Rapid Response Team immediately.** The patient requires urgent medical evaluation and potential advanced life support.

- **Monitor vital signs continuously,** focusing on oxygen saturation, heart rate, and blood pressure for signs of cardiovascular collapse.

Key Clinical Pearls

- The classic triad for VAE is sudden chest pain, dyspnea, and a sense of impending doom.

- A "mill-wheel" murmur may be auscultated over the precordium, a late and ominous sign.

- Even small volumes of rapidly entrained air can be fatal; prevention through meticulous line priming and connection checks is paramount.

- Do not delay intervention for diagnostic confirmation; treatment is based on clinical suspicion.

## 핵심 개념

- **Venous Air Embolism** — A life-threatening condition where air enters the venous circulation, travels to the right ventricle and pulmonary artery, and creates an air lock obstructing pulmonary blood flow.
- **Ventilation-Perfusion Mismatch** — An imbalance between the amount of air reaching the alveoli and the blood flow in the pulmonary capillaries, leading to impaired gas exchange and hypoxemia.
- **Extracorporeal Circuit** — The tubing and dialyzer system outside the patient's body through which blood travels during hemodialysis, a potential entry point for air.

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