Maintaining vascular access for hemodialysis
Jill Rushing is an instructor and assistant coordinator of the BSN program at the University of Southern Mississippi School of Nursing in Hattiesburg.
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.
Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner and Suddarth's Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2008.