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This study investigated the impact of meticulous nursing on dialysis adequacy in 69 elderly patients undergoing maintenance hemodialysis at a single center between September 2022 and February 2023. Patients were randomized to a study group (meticulous nursing, n = 35) or a control group (conventional nursing, n = 34). Post-nursing comfort scores improved in both groups; however, the study group exhibited higher scores (90.87 ± 10.26 vs. 84.54 ± 5.84, p = 0.012). Both groups showed increased albumin and hemoglobin levels post-nursing (p < 0.05), with the study group additionally demonstrating greater reductions in blood potassium, blood sodium, and blood urea nitrogen than the control group (p < 0.05). Analysis of dialysis adequacy using Kt/V values revealed significant treatment effects (Ftreatment = 178.587, p < 0.001); although the study group's Kt/V increase from September to October was non-significant (t = 1.164, p = 0.249), significant gains occurred from November to December (Δ = 0.18, t = 3.854, p < 0.001) and January to February (Δ = 0.28, t = 4.811, p < 0.001). No differences were observed in nursing satisfaction (χ² = 0.111, p = 0.740) or complication rates (χ² = 1.176, p = 0.278) between groups. These findings indicate that meticulous nursing enhances patient comfort, improves biochemical markers, boosts treatment compliance and duration, and ultimately increases dialysis adequacy.