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Question

Difficulty: HardReduction of Risk Potential

An intensive care nurse is monitoring a client with end-stage renal disease who is undergoing their first hemodialysis treatment via a newly placed right internal jugular central venous catheter. Approximately 90 minutes90\text{ minutes} into the session, the client becomes increasingly restless and reports a severe, throbbing headache accompanied by nausea. The client's vital signs display a blood pressure of 184/106 mm Hg184/106\text{ mm Hg}, elevated from a pre-dialysis baseline of 152/86 mm Hg152/86\text{ mm Hg}. Which immediate action should the nurse take to mitigate this developing complication?

  1. Decrease the blood flow rate on the hemodialysis machine.Answer
  2. B
    Administer a rapid intravenous fluid bolus of 0.9%0.9\% sodium chloride.
  3. C
    Position the client in the left lateral position with the head of the bed lowered.
  4. D
    Administer a prescribed intravenous PRN dose of an antihypertensive medication.

Answer

The correct action is to decrease the blood flow rate on the hemodialysis machine.
The client is exhibiting classic signs of dialysis disequilibrium syndrome (DDS), a life-threatening neurologic complication that occurs most frequently during a client's first few hemodialysis treatments. DDS is caused by the rapid removal of solutes (such as urea) from the blood, which clears faster than solutes in the cerebrospinal fluid and brain tissue. This creates an osmotic gradient that draws water into the brain cells, resulting in cerebral edema and increased intracranial pressure (ICP). The symptoms of restlessness, severe headache, nausea, and hypertension are indicative of rising ICP. The priority action to mitigate this risk is to immediately decrease the blood flow rate on the hemodialysis machine. This slows the rate of solute removal, allowing the osmotic gradient between the intravascular space and the brain tissue to equilibrate, preventing further cerebral edema.

Step-by-Step Solution

1
Analyze the client's clinical presentation and vital signs during the hemodialysis treatment.
The client is experiencing a new onset of restlessness, severe headache, nausea, and significant hypertension (184/106 mm Hg184/106\text{ mm Hg}) during their first hemodialysis session.
Identifying symptom clusters is necessary to differentiate between various intra-dialytic complications.
2
Correlate the findings with potential hemodialysis complications.
The symptoms strongly indicate dialysis disequilibrium syndrome (DDS), a life-threatening complication caused by the rapid removal of urea from the blood, leading to cerebral edema and increased intracranial pressure.
DDS is most common during a client's initial dialysis treatments when blood urea nitrogen (BUN) levels are highest.
3
Determine the priority risk-reduction intervention.
The nurse must immediately slow the rate of solute removal by decreasing the blood flow rate on the dialysis machine, or stop the treatment entirely if symptoms become severe.
Slowing the clearance rate minimizes the osmotic gradient between the brain tissue and the blood, halting the progression of cerebral edema.

Key Concept

Dialysis disequilibrium syndrome (DDS) is a potentially fatal complication occurring primarily during initial hemodialysis treatments. It is characterized by neurological deterioration due to rapid solute removal and subsequent cerebral edema. The immediate priority is to slow or stop the dialysis process to stabilize the osmotic gradient.
Estimated Time:1m 30s
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Reduction of Risk Potential

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