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Haemodialysis: caring for the fistula, graft or catheter, and before and after a session

  • Procedure

The ward nurse checks the dialysis access every day, weighs and assesses the patient before and after each session, and teaches access care.

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What it is

Haemodialysis needs a vascular access: a fistula (an artery joined to a vein), a graft (a tube under the skin joining the two) or a central venous catheter. Fistulas take weeks to mature; catheters can be used at once but infect and clot more often. The dialysis team runs the machine; the ward nurse protects and checks the access, prevents infection, prepares the patient (weight, vital signs, the medicines the prescriber wants given or held) and assesses the patient on return, when low blood pressure, cramps, nausea and bleeding from the needle sites are the main risks.

Indications

  • A patient on haemodialysis for chronic kidney disease or acute kidney injury who is in hospital.
  • Daily care of a fistula, graft or dialysis catheter.
  • Getting the patient ready for a session and assessing them on return.

Contraindications and precautions

  • A fistula takes about 4 to 6 weeks to mature and a graft about 2 to 4 weeks: they are not used before the team clears them.
  • Do not take blood pressure, start an IV or draw blood in the access arm; avoid tight clothing, jewellery and lying on that arm.
  • Use the dialysis catheter only for dialysis unless the institutional protocol says otherwise.
  • Keep the catheter dressing dry; no baths, swimming or soaking.
  • Do not hold or give medicines before dialysis on your own: confirm with the prescriber, especially blood pressure medicines.

Equipment

  • Scale (the same one every time) and vital-sign monitor.
  • Alcohol-based chlorhexidine for skin antisepsis, or the alternative the protocol names.
  • Antiseptic pads for the catheter hubs, sterile dressing and gloves.
  • Access observation sheet and the dialysis record.

Step by step (and why)

  1. Before the session, weigh the patient on the same scale and in similar clothing — the team uses the weight to plan fluid removal.
  2. Take blood pressure, pulse, breathing and temperature — they are the baseline for judging tolerance.
  3. Clean your hands before and after touching the access — the access is a direct route into the bloodstream.
  4. Fistula or graft: feel for the thrill and look for redness, swelling or pus — a weak thrill suggests a clot.
  5. Catheter: inspect the exit site and dressing and scrub the hubs with antiseptic each time they are opened — catheters infect most.
  6. Confirm with the prescriber which medicines are given or held before dialysis — blood pressure medicines can cause hypotension.
  7. On return, weigh again and repeat the vital signs — the difference shows the fluid removed and the patient's response.
  8. Check the needle sites and dressing for bleeding and feel the thrill again — bleeding and clotting are the early access problems.
  9. Ask about dizziness, cramps, nausea and headache — they are common after early sessions and with low blood pressure.
  10. Teach daily thrill checks, washing the access, no scratching, no heavy lifting and no tight clothing on that arm — it protects the access.

Complications

  • Low blood pressure during or after dialysis, with dizziness, nausea, cramps or vomiting.
  • Bleeding from the needle sites or the catheter.
  • Access or catheter infection and bloodstream infection (more common with grafts and catheters).
  • Clotting or narrowing of the access, with a weak or absent thrill.
  • Fluid build-up between sessions if the fluid limit is not kept.

Next step: when to call for help

  • Call if the thrill is weaker or absent, or the access arm is swollen with a cold, numb or weak hand.
  • Call for bleeding from the access that does not stop.
  • Call for a temperature of 38.0 °C or more, or redness, swelling, warmth or pus at the site.
  • Call for low blood pressure with dizziness, chest pain, shortness of breath, confusion or fainting after the session.
  • Report the pre- and post-session weights and any symptoms to the dialysis team at handoff.

Test yourself

Think of the answer, then tap the question to see it.

What is the thrill of a fistula, and why is it checked?

The vibration of blood flowing through the access; a weak or absent thrill may mean a clot and needs a call.

Which three things are never done in the arm with a fistula or graft?

Taking blood pressure, drawing blood and starting an IV.

Why are the patient's weight and vital signs taken before and after haemodialysis?

The weight shows the fluid removed and the vital signs show tolerance, especially low blood pressure after fluid removal.

What does the nurse do each time a dialysis catheter hub is opened?

Scrubs the hub with an appropriate antiseptic, with clean hands and aseptic technique, to prevent bloodstream infection.

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Connections

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Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: Taking care of your vascular access for hemodialysis, MedlinePlus Medical Encyclopedia (MedlinePlus, US National Library of Medicine, 2024); Dialysis centers - what to expect, MedlinePlus Medical Encyclopedia (MedlinePlus, US National Library of Medicine, 2026); Best Practices for Bloodstream Infection Prevention in Dialysis Setting (Centers for Disease Control and Prevention (CDC), 2024); Mussnig S et al. Ten tips for how to prevent and treat hemodynamic instability during hemodialysis. Clin Kidney J (Clinical Kidney Journal (Europe PMC, open access), 2026).

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