Skill 12-14

Caring for a Hemodialysis Access (Arteriovenous Fistula or Graft)

Hemodialysis , a mechanical way of filtering waste products and excess electrolytes from the blood, requires access to the patient's vascular system to remove and return blood from the patient's body. This vascular access, an arteriovenous (AV) fistula or AV graft, allows for access to the bloodstream. A temporary or permanent double-lumen central venous catheter can also be used to provide vascular access for hemodialysis (ANNA, 2018). If a catheter is used (Figure 1 on page 784), the site is cared for in the same manner as a central venous access device (see Skill 16-7). An arteriovenous fistula is a surgically created passage that connects an artery and vein (Figure 2 on page 784). An arteriovenous graft is a surgically created connection between an artery and vein using a synthetic material (Figure 3 on page 784). Accessing a hemodialysis arteriovenous graft or fistula is done only by specially trained health care team members.

Delegation Considerations

The assessment of, and care for, a hemodialysis access is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, these procedures may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Stethoscope
PPE, as indicated

Assessment

Ask the patient how much they know about caring for the site. Ask the patient to describe important observations to be made. Note the location of the access site. Assess the site for signs of infection, including inflammation, edema, and drainage, and for healing of the incision. Assess for patency by assessing for presence of bruit and thrill (refer to the explanation in Step 4).

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Altered skin integrity risk
Knowledge deficiency
Infection risk

Outcome Identification and Planning

The expected outcomes to achieve when caring for a hemodialysis catheter are that the graft or fistula remains patent, the patient verbalizes appropriate care measures and observations to be made, and the patient demonstrates appropriate care measures.

Implementation

Action	Rationale
1. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
2. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
3. Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement.
4. Question the patient about the presence of muscle weakness and cramping; changes in temperature; and sensations, such as numbness, tingling, pain, burning, itchiness; and pain.	This aids in determining the patency of the hemodialysis access as well as the presence of complications.
5. Inspect the area over the access site for continuity of skin color. Inspect for any redness, warmth, tenderness, edema, rash, blemishes, bleeding, tremors, and twitches. Inspect the muscle strength and the patient's ability to perform range of motion in the extremity/body part with the hemodialysis access.	Inspection aids in determining the patency of the hemodialysis access as well as the status of the patient's circulatory, neurologic, and muscular function and presence of infection. Compare with the opposite body area/part.
6. Put on gloves if the site is not completely healed. Palpate over the access site, feeling for a thrill or pulse/vibration (Morton & Fontaine, 2018) (Figure 4). Palpate pulses above and below the site. Palpate the continuity of the skin temperature along and around the extremity. Check capillary refill in fingers or toes of the extremity with the fistula or graft.	Gloves prevent contact with blood and body fluids. Palpation aids in determining the patency of the hemodialysis access as well as the status of the patient's circulatory, neurologic, and muscular function and presence of infection. Compare with the opposite body area/part.
7. Remove gloves and perform hand hygiene. Auscultate over the access site with the bell of the stethoscope, listening for a bruit or swishing/blowing (Morton & Fontaine, 2018).	Proper removal of gloves and hand hygiene prevents the spread of microorganisms. Palpation aids in determining the patency of the hemodialysis access.
8. Ensure that a sign is placed over the head of the bed informing the health care team which arm is affected. Do not measure blood pressure, perform a venipuncture, or start an IV on the access arm (National Kidney Foundation, 2017).	The affected arm should not be used for any other procedures, such as obtaining blood pressure, which could lead to clotting of the graft or fistula. Venipuncture or IV access could lead to an infection of the affected arm and could cause the loss of the graft or fistula.
9. Instruct the patient not to sleep with the arm with the access site under the head or body (National Kidney Foundation, 2017).	This could lead to clotting of the fistula or graft.
10. Instruct the patient not to lift heavy objects with, or put pressure on, the arm with the access site. Advise the patient not to carry heavy bags (including purses) on the shoulder of that arm (National Kidney Foundation, 2017).	This could lead to clotting of the fistula or graft.
11. Remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the access site has an audible bruit and a palpable thrill, the site has remained intact without signs of adverse complications or pain, and the patient has verbalized appropriate information about caring for the access site and observations to be made.

Documentation

Guidelines

Document assessment findings, including the presence or absence of a bruit and thrill. Document any patient education and patient response.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Thrill is diminished or not palpable and/or bruit is diminished or not audible: Notify the health care team. The thrill and bruit are caused by arterial blood flowing into the vein. If these signs are not present, the access may be clotting off.
Site is warm to touch, erythematous, or painful or has a skin blemish: Notify the health care team. These signs can indicate a site infection.

Special Considerations

Teach patients the importance of not wearing tight clothes or jewelry on the access arm and avoiding carrying or doing anything that would put pressure on the access (National Kidney Foundation, 2017).
Patients should be aware that they should not allow anyone to use a blood pressure cuff on the access arm or let anyone draw blood from the access arm (NIDDK, 2018b).
Teach patients to check the pulse (thrill) in the access every day (Latif, 2018).
Teach patients to be aware of signs of possible complications and to call their health care provider right away if they notice any of these problems (Latif, 2018):
- Bleeding from the vascular access site
- Signs of infection (redness, swelling, soreness, pain, warmth, pus around site)
- Fever ≥100.3°F
- Pulse (thrill) in the access slowing down or not present
- Access arm swelling
- Hand on the access arm getting cold, numb, or weak

EVIDENCE FOR PRACTICE

Hemodialysis and Patient Fatigue

Patients receiving chronic hemodialysis experience troubling symptoms that cause distress and anxiety, and adversely affect their quality of life. Fatigue is common and can be debilitating. How can nurses assist patients in dealing with this issue?

Related Research

Karadag, E., & Baglama, S. S. (2019). The effect of aromatherapy on fatigue and anxiety in patients undergoing hemodialysis treatment. A randomized controlled study. Holistic Nursing Practice, 33(4), 222-229. https://doi.org/10.1097/HNP.0000000000000334

The aim of this randomized-controlled study was to examine the effect of the application of lavender oil on fatigue and anxiety levels in patients undergoing hemodialysis treatment. A power analysis determined that 60 participants were needed. The participants were randomly assigned to the intervention (n = 30) and control groups (n = 30). Patients in both groups completed the Fatigue Severity Scale (FSS) and Beck Anxiety Inventory (BAI) on the initial day of the study. Patients in the intervention group inhaled 2% lavender oil for 20 minutes before hemodialysis during weekly (2 to 3 days/week) hemodialysis sessions for 30 days. Patients in the control group underwent routine care during hemodialysis without the application of lavender oil for 30 days. The FSS and BAI were completed by participants in both groups at the end of day 30. There was no significant difference (p = .208) between pretest-posttest scores of FSS in the control group, with a significant increase in anxiety levels at the end of the 30 days (p = .001). In the intervention group, a statistically significant difference was identified between pretest and posttest scores of the FSS (p = .001) and the BAI (p = .001). Comparison of the FSS and BAI scores of the patients in the control and intervention groups before and after the intervention revealed a statistically significant difference in favor of the intervention group (p ; .05). The researchers concluded that lavender aromatherapy decreased fatigue and anxiety levels in patients undergoing hemodialysis. The researchers suggested lavender aromatherapy should be considered as an effective nursing intervention to reduce the fatigue and anxiety of patients undergoing hemodialysis treatment.

Relevance to Nursing Practice

This information can be valuable to nurses caring for these patients and may be useful in planning evidence-based nursing interventions to support patients with fatigue and anxiety. The information can also be used to plan and implement appropriate patient education related to the fatigue and anxiety associated with hemodialysis; devising ways to manage symptoms is important to improve quality of life.

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Skill 12-14

EVIDENCE FOR PRACTICE