CARING PATIENT WITH AV FISTULA

Rushing, Jill MSN, RN

http://journals.lww.com/nursingmanagement/Fulltext/2010/10000/Caring_for_a_patient_s_vascu
lar_access_for.11.aspx

A PATIENT IN END-STAGE kidney disease relies on dialysis to mechanically remove fluid,

electrolytes, and waste products from the blood. For the most effective hemodialysis, the patient
needs good vascular access with an arteriovenous (AV) fistula or an AV graft that provides
adequate blood flow. Follow your facility's policies and procedures and these clinical tips to
protect and preserve the vascular access and avoid complications such as infection, stenosis,
thrombosis, and hemorrhage:

* Remove any restrictive clothing or jewelry from the arm.

* To prevent injuries, place an armband on the patient or a sign over the bed that says no BP
measurements, venipunctures, or injections on the affected side. When blood flow through the
vascular access is reduced, it can clot.

* Perform hand hygiene before you assess or touch the vascular access. If it's a new vascular
access with a wound, don gloves. Position the patient's arm so the vascular access is easily
visualized.

* Assess for patency at least every 8 hours.

* Palpate the vascular access to feel for a thrill or vibration that indicates arterial and venous
blood flow and patency.

* Auscultate the vascular access with a stethoscope to detect a bruit or "swishing" sound that
indicates patency.

* Check the patient's circulation by palpating his pulses distal to the vascular access; observing
capillary refill in his fingers; and assessing him for numbness, tingling, altered sensation,
coldness, and pallor in the affected extremity.

* Notify the healthcare provider promptly if you suspect clotting.

* Assess the vascular access for signs and symptoms of infection such as redness, warmth,
tenderness, purulent drainage, open sores, or swelling. Patients with end-stage kidney disease are
at increased risk of infection.

* After dialysis, assess the vascular access for any bleeding or hemorrhage.

* When you move the patient or help with ambulation, avoid trauma to or excessive pressure on
the affected arm.
* Assess for blebs (ballooning or bulging) of the vascular access that may indicate an aneurysm
that can rupture and cause hemorrhage.

* Monitor serum electrolytes, blood urea nitrogen, creatinine, and hemoglobin and hematocrit
levels before and after dialysis. Monitor fluid status. Monitor coagulation studies because
heparin is used to prevent clotting during dialysis.

* Teach the patient:

- to make sure that dialysis needlestick locations are rotated to prevent stenosis and thrombus
formation

- to check the function of the vascular access several times a day by palpating it and feeling for
vibration

- to monitor for any bleeding after dialysis

- to monitor for signs of infection

- to keep the site clean

- to avoid wearing any clothing or jewelry that restricts the access and to prevent anyone from
using the extremity to obtain BP or perform venipuncture

- not to use the arm with vascular access to carry heavy objects and not to sleep on the arm

- not to use any creams and lotions on the vascular access site.

* Document assessment findings, any interventions and patient responses, patient teaching, and
the patient's level of understanding.

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RESOURCES
Medical Education Institute. Vascular access: a lifeline for dialysis. http://www.kidneyschool.org
/m08/.
Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner and Suddarth's Textbook of Medical-Su
rgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.