A Day in the Life of a Haemodialysis Nurse

Written by Jeanelle Classen

Today I want to share with you a day in the life of a hemodialysis nurse in a hospital-based setting. 

A quick intro to what got me into haemodialysis; I did my final nursing practical placement at a tertiary hospital dialysis unit and absolutely loved it! Though I didn't immediately get a job in this specialty I kept my eye open for positions as I worked my way through rehabilitation, emergency department and intensive care nursing. My approach to my career has been ceasing every and any opportunity to build your portfolio until you find your specialty - one of the many that make you tick!

A basic overview…

Working as a haemodialysis nurse is one of those specialities that I started in about a month ago and I must say, so far so good! I've really been enjoying the different work-life balance that is Monday to Saturday (added bonus of NO nightshift)!

Some might think that dialysis is one of those specialties you go to retire but ‘au contrare’, sister. In dialysis you still have the excitement of patients who can potentially deteriorate quite quickly because they can become actually quite unwell. Many of them live with more chronic conditions such as end-stage renal failure to acute kidney injury.

Your Day-to-Day

I’ve decided to use a morning shift as today’s example though most shifts will have a similar structure, whether you're working a morning or afternoon shift.

0700 - Start of shift. You will begin by setting up your machines where you're lining them priming and making sure that they've been cleaned between every single patient to optimize infection control practices.

0730 - Handover. Here you will have a standard handover with the rest of the unit nurses on the patients who have been booked in for that day. The average patient load is 2-4 patients, depending on acuity, in a day. Important aspects such as:

• How their previous session went
• Any complications and how they were managed (and if it was managed is there anything that needs to be followed up)
• What their most recent blood results were - specifically, their potassium, sodium, urea, C-Reactive protein and haemoglobin to name a few. This is particularly important because the dialysate is often chosen by the nurses and as a result, can be a significant effect on the patient’s outcome.
• What access they've got - there are 3 main types; central venous catheter/hickman line, arteriovenous fistula (AVF) or graft with the first two types of access being the most prevalent.
• Side note on access: Both AVF and grafts require cannulation competency and is different to your standard intravenous cannulation since the vessels you are accessing have significantly higher pressures compared to a peripheral vein.
  
  Both the cannulation and CVC access skills are quite important in making sure that you're using appropriate aseptic non-touch technique (ANTT) to prevent infection as these access types are your patients’ lifeline; no dialysis = becoming extremely ill or worse...

• Finally, you’ll also discuss finer details such as 
• What time they're coming in?
• How long is their session scheduled for? - on average, this is anywhere between 3-5 hours
• What transport needs do they have? - do we need to organise community transport, taxi, family members, ambulance etc which is often funded by the hospital so that all our patients have access to the care they need, in a timely manner.

0800 - Patients arrive. In times of COVID, your patient will go for a RAT test just to rule out this risk as dialysis patients are immunocompromised. Once that result comes back and the relevant protocols are in place, they will also be asked to weigh themselves.

Each dialysis patient has an ideal body weight (IBW) or “dry weight”, which is what we aim for post-dialysis. The risks of a patient being fluid overloaded means that these patients will often experience shortness of breath, headaches, oedema all of which if untreated, can lead to further complications. When patients come in for dialysis they tend to feel generally unwell because once you stop producing urine, your body simply carries all its waste products and is not able to excrete them like a healthy person whose kidneys are functioning.

0830 - Treatment. The dialysis nurse is responsible for calculating the UF goal or the ultrafiltration goal where we'll calculate the difference between the patient’s pre-dialysis weight and their IBW which will give us our  UF goal in Litres for how much fluid we'll be taking off.

When a patient is especially fluid overloaded, we can't always get them down to their IBW as they don't always tolerate high amounts being ‘pulled off’ and start to experience cramps, hypotension and nausea.  If this happens more often than not, the nurse will have to consider whether the patient has lost or gained weight and as a result may need their IBW recalculated. 

Some patients will also be on Heparin while they're on dialysis to prevent the dialyzer from clotting up, others will be on clexane for the same purpose and occasionally, if the patient is at high risk of bleeding, will be on a heparin free circuit.

Prior to commencing you’ll do a basic set of vital observations and ask about any symptoms, they may be experiencing

Once connected, you'll have to monitor the patient quite closely for any signs of hypo or hypertension. Patients at the beginning of the session or usually in the first half of the session tend to be at their most stable. Once you've taken more and more fluid off they're at higher risk of developing hypotension. As a result, in severe cases, they can have cases of loss of consciousness and even seizures and heart attacks. 

0900 - During dialysis. Throughout the session, you continue to take monitor their vitals for signs of deterioration. You’ll also commonly administer medications for the treatment of anaemia including;  Epoetin alfa (commonly known as Eprex/EPO) and ferritin as well as any other of their regular medications forming part of their treatment (this is quite variable). Again, each patient has this treatment tailored to their blood results that's rechecked monthly or PRN and often reviewed by two dialysis nurses or by a doctor.

1300 - End of dialysis. CVC dressings are changed weekly unless they've become loose, so that's another thing you'll do during this session. Towards the end, patients tend to be more unstable so more frequent obs and continue to monitor their condition so that once the dialysis session is complete, we will make sure that they are in a stable condition before they're discharged. 

1330 - Clean up and Patient discharge. Once disconnected from the machine, they'll be weighed for their post-weight to help determine how effective the treatment was. The machine will give you a rough idea of how much you were able to remove. Sometimes fluid from the interstitial tissues will make its way over into the bloodstream once the blood is dialysed, and as a result, sometimes throws this measure off. Once a patient has been disconnected, you'll also clean your machine and restart a heat disinfection cycle to ensure adequate infection control practices. The patient is then discharged, given the next dialysis session details, and sent on their way! 

1400 - Documentation. The nurse will proceed to finish off their notes. This includes an in-depth picture of what has happened during the session, what our initial goal was and what we were able to manage. Any complications that may have come up during the session, how it was managed and whether it was effective or not. 

Sometimes we'll also put in recommendations for the next nurse of what could help mitigate this next time.

And that is a day in the life of a haemodialysis nurse! I trust that you have enjoyed getting a glimpse into the world of haemodialysis nursing and would be happy to answer any questions you may have - simply reach out to me on Facebook and let's get chatting!