Hemodialysis and Peritoneal Dialysis

Medical-Surgical · Renal & Genitourinary·Updated 2026-10-28

What it is

Dialysis removes wastes, excess fluid and electrolytes when the kidneys fail, using diffusion (solutes move from higher to lower concentration across a semipermeable membrane), osmosis and ultrafiltration. Hemodialysis (HD) uses an external dialyzer through a vascular access, usually 3 times a week for 3 to 4 hours; peritoneal dialysis (PD) uses the peritoneum as the membrane, with hypertonic dextrose dialysate drawing fluid out, and is done daily at home. The rapid fluid and solute shifts of HD and the infection risk of the PD catheter explain most nursing care.

What the NCLEX focuses on

Arteriovenous (AV) fistula or graft: palpate the thrill and auscultate the bruit every shift; absence means thrombosis.
No blood pressure, venipuncture, IV line or tight clothing on the access arm; a cold, pale, painful hand signals steal syndrome.
Before HD: weigh, take vital signs, and hold prescribed antihypertensives, water-soluble vitamins and drugs removed by dialysis until after treatment.
Hypotension is the most common HD complication (nausea, dizziness, yawning); muscle cramps and bleeding from heparin also occur.
Dialysis disequilibrium syndrome occurs in early treatments: headache, nausea, restlessness, confusion and seizures from cerebral edema as urea falls faster in the blood than in the brain.
A tunneled HD catheter is used only for dialysis; it is never used for IV medications or blood draws.
PD: warm dialysate with dry heat, never a microwave; mask and strict asepsis; slow outflow is corrected by turning side to side, checking tubing and treating constipation; cloudy effluent signals peritonitis.

Priority nursing actions

Before HD, weigh the client, take vital signs, assess the access for thrill and bruit and listen to lung sounds.
During HD, monitor blood pressure and symptoms; for hypotension, reduce the ultrafiltration rate, give a saline bolus per protocol and raise the legs.
Stop and report headache, confusion or seizure as possible disequilibrium syndrome.
After HD, weigh again, assess puncture sites for bleeding and check for orthostatic hypotension.
During PD, compare drained with instilled volume, inspect effluent with every exchange, and report cloudy fluid, fever or abdominal pain.

Numbers to know

Value	Normal or target	Why it matters
HD schedule	3 times a week, 3 to 4 hours each	Missed sessions cause hyperkalemia and pulmonary edema
Fistula readiness	At least 6 weeks, often 2 to 3 months; graft 2 to 3 weeks	Early cannulation damages the access
PD dextrose	1.5%, 2.5% or 4.25%	Higher concentration removes more fluid and raises blood glucose
PD effluent	Clear, pale yellow	Cloudy fluid means peritonitis until proven otherwise
Dialysate temperature	Body temperature, about 98.6 F (37 C)	Cold dialysate causes cramping and discomfort
Drained vs instilled volume	Drained equal to or more than instilled	Less drainage means retained fluid

Common exam traps

Choosing to take blood pressure or draw blood from the fistula arm: wrong because compression and puncture cause thrombosis and infection.
Choosing to give the morning antihypertensive before HD: wrong because it worsens intradialytic hypotension.
Choosing to use the tunneled dialysis catheter for IV antibiotics: wrong because it is reserved for dialysis to prevent infection and clotting.
Choosing to warm PD solution in a microwave: wrong because uneven heating burns the peritoneum.
Choosing to watch cloudy effluent until the next exchange: wrong because peritonitis needs same-day evaluation; send the bag.

What to teach

Check the thrill every day; avoid tight sleeves, watches, sleeping on the access arm and carrying heavy bags; report loss of the thrill, redness, drainage or a cold, numb hand.
Follow the fluid, sodium, potassium and phosphorus limits, weigh daily and take phosphate binders with meals.
For PD, wash hands and wear a mask for every connection; report cloudy fluid, fever, abdominal pain or redness at the exit site.
Never miss a dialysis session.

Client handout: Caring for Your Dialysis Fistula or Graft (nurse guide and printable patient handout).

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Question 1 · QID C6484E1C

For each client finding, click to specify whether it belongs to hemodialysis or peritoneal dialysis care.

	Hemodialysis	Peritoneal dialysis
Palpate for a thrill and auscultate for a bruit each shift
Cloudy drained fluid requires same-day evaluation
Hold the morning antihypertensive before treatment as prescribed
Warm the solution with dry heat before instillation
Sudden headache and confusion during an early treatment
Slow drainage corrected with position changes and treating constipation

Question 2 · QID 2F7C21D0

Two hours into hemodialysis, a client becomes nauseated, dizzy, and yawns repeatedly. Blood pressure falls from 142/84 to 96/58 mm Hg. Which action should the dialysis nurse take first?

A. Stop ultrafiltration and terminate the dialysis treatment immediately without first attempting the hypotension protocol
B. Administer the scheduled antihypertensive because the rapid pressure decrease suggests excessive sympathetic activation
C. Lower the head of the chair and reduce the fluid removal rate per protocol
D. Give oral sodium and additional fluid to restore circulating volume before changing the dialysis fluid-removal rate

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Sources

Harding MM, Kwong J, Hagler D, Reinisch C. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 12th ed. Elsevier; 2023; Chapter: Acute Kidney Injury and Chronic Kidney Disease.
Lok CE, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4 Suppl 2):S1-S164.
Li PK, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Perit Dial Int. 2022;42(2):110-153.

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