Renal: Haemodialysis Patient Assessment – Doc #
Guideline and
Procedure
Haemodialysis Patient Assessment
Document Number:
Sites where Guideline and Procedure
applies:
All HNE facilities where a patient undergoes haemodialysis
Target audience:
Nephrology clinical staff, who provide care to haemodialysis
patients.
This document comprises part of the clinical information
package for care for Haemodialysis patients
Assessment , Haemodialysis
Description:
Keywords:
Replaces Existing Guideline and
Procedure:
Yes
Registration Number(s) and/or name and John Hunter Hospital SWP N.3.1
of Superseded Documents:
Relevant or related Documents, Australian Standards, Guidelines etc:
 NSW Health Policy Directive 2007_079 Correct patient, Correct procedure, correct site
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_079.pdf
 NSW Health Policy PD 2005_406 Consent to Medical Treatment
http://www.health.nsw.gov.au/policies/PD/2005/pdf/PD2005_406.pdf
 NSW Health Policy Directive PD 2007_036 Infection Control Policy
http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_036.pdf
Prerequisites (if required):
Registered or Endorsed Enrolled Nurses who have been deemed
competent in the performance of haemodialysis
Procedure Summary:
This Guideline and Procedure sets out the steps to be followed when
performing observations for a patient on haemodialysis. The procedural
components of the document such as, Preparation of patient, Preparation
of equipment, Technique, Cleaning up and Documentation are considered
mandatory.
Guideline Note :
This document reflects what is currently regarded as safe and appropriate
practice. However in any clinical situation there may be many factors that
cannot be covered by a single document and therefore does not replace
the need for the application of clinical judgment in respect to each
individual patient.
Date authorised:
Authorised by:
HNEAHS Renal Clinical Stream Leadership Group
Contact Person:
Contact Details:
Review due date:
TRIM Number:
Version 1
December 2010
Page 1 of 5
OUTCOMES
1
Provide safe efficient haemodialysis
2
Minimise risk of advents events to patients during haemodialysis
3
Minimise risk of adverse event to patient on discharge
ABBREVIATIONS & GLOSSARY
BSL
Blood Sugar Level
PPE
Personal protective Equipment
BP
Blood Pressure
RR
Respiratory Rate
PRA
Patient Risk Assessment Form
PR
Pulse Rate
GUIDELINE
Observations are taken to establish baseline parameters for each patient. They are then monitored
in order to clinically evaluate change and prevent or minimise adverse events during
haemodialysis treatment and to provide timely intervention or referral for medical management.
The nurse must establish a full set of baseline observations prior to commencement of treatment.
This includes Postural BP (may be contraindicated in some patients to ensure patient safety),
respiration rate, manual pulse and temperature. A blood glucose level for diabetic patients should
be attended at the start and completion of treatment unless a documented exemption is sought
from a Nephrologist.
If the patients’ observations are outside their normal parameters the results are to be conveyed to
the Team Leader / In charge Nurse prior to the commencement of treatment. If required review of
the patient will then be attended by a Medical Officer, the patients’ Nephrologist or the Nurse
Practitioner.
BP, RR and manual PR are to be attended not only at commencement but throughout the
throughout the treatment (recommended hourly). Other observations (and frequency) are
dependant on patient condition.
PROCEDURE
The procedure requires mandatory compliance.
Patient Preparation
It is mandatory to ensure that the patient has received appropriate information to provide informed
consent and, that patient identification, correct procedure and correct site process is completed
prior to any procedure.
Staff Preparation
It is mandatory for staff to follow relevant: “Five moments of hand hygiene”, infection control,
moving safely/safe manual handling, and documentation practices.
Version 1
December 2010
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Equipment Requirements
 Alcohol hand gel
 Personal Protective Equipment
 Standing/Chair Scales
 Blood Pressure Monitor
 Thermometer
 Oxygen Saturation Monitor
If required:
 Glucometer
Pre Dialysis
A postural blood pressure, manual pulse rate, respiratory rate, oxygen saturations and temperature
are to be recorded on the dialysis record sheet for every patient. Other observations are
dependant on individual patient requirements.

Patients weight to be attended and recorded onto the daily dialysis worksheet.

Patients’ fluid status to be assessed by the nurse and evaluated against patient previous
dialysis history, and current physical condition.

In-charge nurse should liaise with Medical staff for review if patient is unable to weigh or
has no established dry weight.

Review previous dialysis progress notes, to determine special requirements for dialysis
treatment. For example: blood tests, changes to prescription, anticoagulation and
concentrate selection.

Risk assessment (Red Dot or PRA system).
Intradialytic assessment

A double check of the dialysis machine parameters and fluid removal calculations should
occur by a second nurse and co-signed (single practitioner units exempt from second nurse
signature).

The patients vascular access must be place on a pale absorbent background and should
not be obstructed from view at any time during the dialysis treatment

Blood pressure and manual pulse rate to be attended throughout the procedure
(recommended hourly). Other observations are to be attended as required.

Machine checks for pressure trends and other issues should be included on the hourly
patient observation round

Decision for medical review to be made in conjunction with team leader if any recorded
results outside patients expected parameters.
Nursing Alert: Despite physical hourly observations of patient and machine, at least one nursing
staff member should be on the clinical floor at all times to maintain patient safety.
Post dialysis assessment

Post dialysis blood pressure should be attended prior to removal of cannulas or
disconnection of catheter

Postural blood pressure, manual pulse rate, respiratory rate and temperature to be
attended.

Other observations to be attended as per patient requirement.

Patient’s weight to be attended.
Version 1
December 2010
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Note:

Standing blood pressure and weight to be attended only if staff are able to adhere to the “no
lift policy”.

For in-patients post dialysis observations to be attended on SAGO chart before transfer to
the ward.
Nursing Alert: If observations are outside the regular parameters for that patient the results
should be forwarded to the Team Leader/In-charge nurse and/or Medical Officer for review before
discharging patient from unit.
Nursing Alert: The person should be seated quietly for 5 minutes in a chair with feet on the floor
and before measuring a postural blood pressure.
APPENDICES
Five Moments for Hand Hygiene
REFERENCES
Daugirdas. J., Blake. P.G. and Ing. T., (2001) Handbook of Dialysis, Lippincott Williams & Wilkins,
Philadelphia
PD2010_026 Recognition and Management of a Patient who is Clinically Deteriorating
PD2005_224 Manual Handling Incidents - NSW Public Health Services - Policy/Best Practice
Guidelines Prevention
Version 1
December 2010
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Appendix 1
Adopted from the World Health Organization and Hand Hygiene Australia.
Version 1
December 2010
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