Renal: Haemodialysis Patient Assessment – Doc #
HNE Local Health District
Clinical Guideline &
Procedure
Renal: Haemodialysis Patient Assessment
Sites where Clinical Procedure applies
Target audience:
Description
Document Number:
All HNE facilities where a patient undergoes haemodialysis
Nephrology clinical staff, who provide care to haemodialysis
patients.
This document comprises part of the clinical information
package for care for haemodialysis patients.
This Clinical Procedure applies to:
1. Adults
Yes
2. Children up to 16 years
No
3. Neonates – less than 29 days
No
Keywords
Renal Haemodialysis
Replaces Existing Procedure
Yes
Registration Number(s) and/or name and HNELHD GandP11_15
of Superseded Documents
Related Legislation, Australian Standards, NSW Health Policy Directive, NSQHS Standard/EQuIP
Criterion and/or other, HNE Health Documents, Professional Guidelines, Codes of Practice or Ethics:
 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
 NSW Health Policy Directive PD2010_026 Recognition and Management of a Patient who is Clinically
Deteriorating http://www0.health.nsw.gov.au/policies/pd/2011/PD2011_077.html
Prerequisites (if required)
Registered or Endorsed Enrolled Nurses who have been deemed
competent in the performance of haemodialysis
Procedure Note
This document reflects what is currently regarded as safe and
appropriate practice and requires mandatory compliance. If staff
believe that the procedure/s should not apply in a particular clinical
situation they must seek advice from their unit manager/delegate and
document the variance in the patients’ health record.
If this document needs to be utilised in a Non Nephrology Area please
liaise with the local Renal Service to ensure the appropriateness of the
information contained within the Clinical Procedure.
Renal Stream Leadership Group
Position responsible for the
procedure and authorised by
Procedure Contact Person
Contact Details
Date authorised
This Procedure contains
advice on therapeutics
Issue Date
Review due date
TRIM Number
Version 3
Tina Straker & Kelly Adams (Renal Coordinators)
Ph. 67769912 ph49 048800
No
October 2016
October 2013
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Renal: Haemodialysis Patient Assessment – Doc #
Consultation has occurred across the HNE Local District Renal network utilising a group of
identified haemodialysis specialists as well as broader consultation with the general nephrology
workforce, nephrologists and the HNELHD Renal Leadership Group.
Note: Over time links in this document may cease working. Where this occurs please source the
document in the PPG Directory at: http://ppg.hne.health.nsw.gov.au/
RISK STATEMENT
This clinical procedure has been developed to provide guidance to staff and to ensure that the risks of harm
to patients and staff associated with performing Haemodialysis are identified and managed.
Staff may potentially be exposed to body substance and needle injury when carrying out this procedure.
Therefore strict Infection Control and Occupational Health and Safety rules should be followed when
attending this procedure; including wearing recommended Personal Protective equipment and following the
procedure steps.
Any unplanned event resulting in, or with the potential for, injury, damage or other loss to
patients/HCN/visitors as a result of this procedure must be reported through the Incident Information
Management System and managed in accordance with the Ministry of Health Policy Directive: Incident
Management PD2007_061. This would include unintended injury that results in disability, death or prolonged
hospital stay.
RISK CATEGORY: Clinical Care & Patient Safety
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 and GLOSSARY
Abbreviation/Word
Definition
BSL
Blood Sugar Level
PPE
Personal protective Equipment
BP
Blood Pressure
RR
Respiratory Rate
PRA
Patient Risk Assessment Form
PR
Pulse Rate
GP
General Practitioner
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 blood pressures (may be contraindicated in some patients to ensure patient
safety), respiration rate, pulse, oxygen saturations and temperature. A blood glucose level for
insulin dependent diabetic patients should be attended at the start and completion of treatment
unless a documented exemption is sought from a Nephrologist.
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Renal: Haemodialysis Patient Assessment – Doc #
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.
Blood pressure and pulse rate are to be attended not only at commencement but throughout the
treatment (recommended hourly). Other observations (and frequency) are dependent on patient
condition.
Note: The person should be seated quietly for 5 minutes in a chair with feet on the floor before
measuring a postural blood pressure.
PROCEDURE
This 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.
Equipment Requirements






Alcohol hand gel
Personal Protective Equipment
Standing/Chair Scales
Blood Pressure Monitor
Thermometer
Oxygen Saturation Monitor
If required:
 Glucometer
Procedure Steps
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
dependent on individual patient requirements.

Patients weight to be attended and sighted by staff 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
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Renal: Haemodialysis Patient Assessment – Doc #

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)

If a patient has been dialysed within the previous 24 hours consideration of the dialysis
prescription (specifically potassium) needs to be attended
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 patient’s vascular access must be placed on a pale absorbent background and should
not be obstructed from view at any time during the dialysis treatment

Blood pressure and 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

Document heparin syringe rate and remaining volume, UF rate and cumulative UF volume

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

If post dialysis nursing assessment of patient shows symptomatic hypotension, maintain IV
access to patient while blood pressures are obtained, in case further fluid resuscitation is
required

Postural blood pressure, pulse rate, respiratory rate, oxygen saturations and temperature to
be attended

Other observations to be attended as per patient requirement

Patient’s weight to be attended and sighted by staff

If patient post dialysis observations are significantly varied from previous treatments,
conduct further assessment prior to allowing patient discharge to maintain patient safety
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. Staff should ensure that patients are stable and a nursing handover given to the
ward nurse prior to the patient being discharged from the care of the dialysis nurse
Nursing Alert 1: 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 2: Satellite Units: If post dialysis patient is requested to attend GP or ED for further
review, ensure thorough documentation of advice and discussion given as well as a clinical
handover to the GP / A&E department. If the patient does not wish to present for review,
document in patient medical record and inform the on call Nephrologist or Medical Registrar.
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Renal: Haemodialysis Patient Assessment – Doc #
APPENDICES
Nil
REFERENCES
Daugirdas. J., Blake. P.G. and Ing. T., (2001) Handbook of Dialysis, Lippincott Williams & Wilkins,
Philadelphia
PD2005_224 Manual Handling Incidents - NSW Public Health Services - Policy/Best Practice
Guidelines Prevention
FEEDBACK
Any feedback on this document should be sent to the Contact Officer listed on the front page.
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