Additional Care Plans 1 Gulanick: Nursing Care Plans, 6th Edition Vascular Access for Hemodialysis Internal Arteriovenous Fistula; Shunt; Central Venous Catheter Dialysis is the diffusion of solute molecules and fluids across a semipermeable membrane. Dialysis is often necessary to sustain life in persons with no or very little kidney function. The purpose of dialysis is to remove excess fluids, toxins, and metabolic wastes from the blood during renal failure. Hemodialysis requires a vascular access. This can be accomplished by surgically creating an arteriovenous (A-V) fistula or graft (synthetic material used to connect an artery and a vein); or by insertion of an external catheter into a large central vein. The internal A-V fistula is made by surgically creating an anastomosis between an artery and a vein, thus allowing arterial blood to flow through the vein, causing engorgement and enlargement. Placement may be in either forearm, using the radial artery and cephalic vein or brachial artery and cephalic vein. The internal A-V fistula is the preferred access for long-term hemodialysis and must mature before it may be used for access in hemodialysis. The central venous catheter may be either single- or double- lumen. A single-lumen catheter serves as the arterial source, and the venous return is made through a peripheral vein or by the use of an alternating flow device. A double- lumen catheter is used for both the arterial source and the venous return. Because of their location and low durability, femoral catheters are usually used only with inpatients on a short-term basis. Central venous catheters can be used for weeks or even months on an outpatient basis. External A-V shunts are currently considered obsolete. This care plan focuses on both immediate and/or long-term care of the vascular access for hemodialysis. Nursing Diagnosis Risk for Infection Common Risk Factors Hemodialysis access site A-V access cannulation Common Expected Outcome NOC Outcomes Patient’ s risk for infection is reduced Infection Status; Risk Control through ongoing assessment and early NIC Intervention intervention. Infection Protection Additional Care Plans 2 Ongoing Assessment Actions/Interventions Rationale Assess for signs and symptoms of Temporary vascular accesses are at infection: pain around the catheter site highest risk for infection. or over the access site; fever; red, swollen, warm area around catheter exit or access site; drainage from catheter exit or access site. Obtain blood and catheter exit site This allows for identification of the culture if there is evidence of infection. causative agent and allows for appropriate antibiotic therapy. Visually inspect and palpate the areas Early assessment facilitates immediate around and over intact dressing for recognition of problems that may be phlebitis, tenderness, inflammation, life-threatening. and infiltration. Therapeutic Interventions Actions/Interventions Rationale Central venous catheter Maintain asepsis with the catheter during dialysis: Clean area with antiseptic. The antiseptics used for site care will vary and must be compatible with the catheter material. Commonly used antiseptics include povidone-iodine, chlorhexidine, and electrolyte chloroxidizers (e.g., ExSept). Use aseptic technique when initiating This method reduces introduction of or discontinuing dialysis. pathogens via the access site. Catheter hub caps and blood line Disinfectants used must be compatible connections should be disinfected with catheter materials; acceptable before separation. agents include povidone-iodine and electrolyte chloroxidizers. Additional Care Plans 3 Catheter lumens and tips should This measure reduces the risk of never be left open to air. contamination by airborne pathogens. Dialysis staff members and patients It is important to prevent the spread of should wear surgical masks for all infectious droplets that may connect and disconnect procedures contaminate connection sites and and dressing changes. catheter exit sites. Change the sterile dressing over the Dry gauze dressings and povidone- catheter exit site after each dialysis iodine ointment at the catheter exit site treatment. should be used unless ointments are incompatible with catheter material. Instill heparin into the catheter and Anticoagulation promotes catheter secure placement of catheter and caps patency and prevents clotting. after dialysis. Do not use catheter for any purpose Use of the catheter for multiple but hemodialysis. purposes increases the risk of infection. Explain the importance of maintaining Although initial infection may be asepsis with catheter. localized at the exit site, septicemia can occur. Instruct the patient to keep the dressing Meticulous care of the catheter site and clean and dry at all times: maintenance of dry intact dressing Protect the catheter dressing during lessens infection risk. The patient bathing. needs to recognize when to seek Advise against swimming. professional help to maintain the If the dressing loosens, instruct the access site integrity. patient to reinforce with tape. If the dressing comes off or becomes wet, instruct the patient to go to the dialysis unit, clinic, or emergency department, as appropriate, as soon as possible for aseptic catheter site care if he or she is incapable of performing such at home. Additional Care Plans 4 Femoral catheters Maintain asepsis with femoral catheter during dialysis: Use aseptic technique when initiating This reduces infection risk. or discontinuing dialysis. Instill heparin into the catheter and Anticoagulation promotes catheter secure placement of catheter end caps patency and prevents clotting. after dialysis. Maintain femoral catheter: Change all dressings every 48 hours, Routine dressing changes reduce or more often if soiled. infection risk. Notify the physician if infection is Prompt treatment is necessary to suspected. prevent more serious complications. Anticipate need to change femoral This reduces infection risk. catheter every 48 to 72 hours. If the patient has a femoral catheter, This prevents kinking of the maintain strict bed rest with the intravenous (IV) catheter. cannulated leg flat. In the acute setting: If an IV line The more often a catheter is used, the cannot be started in a peripheral greater the risk of infection. vessel, a femoral catheter may be used but extreme caution is necessary to prevent infection. A-V fistula or A-V graft Maintain asepsis with A-V fistula or graft during dialysis: Wash access site with antibacterial Cleansing the skin first decreases the soap and water before disinfection and number of microorganisms present on cannulation. the skin and increases the effectiveness of antiseptics. Using circular motions, disinfect the Commonly used antiseptics include cannulation sites with antiseptic agent. povidone-iodine, alcohol, chlorhexidine, and electrolyte chloroxidizers. Additional Care Plans 5 Cover cannulation sites with sterile Dressings can usually be removed 4 to dressings during treatment and after 6 hours after dialysis. fistula needle removal. Allow only dialysis staff to cannulate Only persons trained to perform A-V access. venipuncture on a fistula or graft should do so. The access is the patient’ s lifeline and requires expert care and use. Nursing Diagnosis Risk for Ineffective Peripheral Tissue Perfusion Common Risk Factor Interruption in arteriovenous (A-V) access blood flow Common Expected Outcome NOC Outcomes Patient’ s A-V access remains patent Circulation Status; Tissue Perfusion: as evidenced by palpable thrill, bruit on Peripheral auscultation, and adequate color or NIC Interventions temperature in extremity. Circulatory Care; Skin Surveillance Ongoing Assessment Actions/Interventions Rationale Assess A-V fistula or graft for presence of adequate blood flow: Palpate for thrill. Absence of a thrill over the anastomosis is a sign of inadequate blood flow. Auscultate for bruit. A “ swishing” sound should be audible. When the artery is connected to the vein, blood is shunted from artery into vein, causing turbulence. This may be palpated above the venous side of the access for thrill or Additional Care Plans 6 buzzing and is heard as a swishing or bruit with stethoscope auscultation. Check for blanching of nail beds of This method evaluates capillary refill. the affected limb. Prolonged blanching indicates impaired circulation. Check for mottling of skin and A cool extremity denotes compromised temperature of the affected limb. perfusion. Assess for pain in the extremity distal Pain results from inadequate tissue to access. perfusion. Therapeutic Interventions Actions/Interventions Rationale Instruct the patient to maintain proper These actions reduce dependent positioning of the access limb. edema. Consider elevating the limb postoperatively in an arm sling when the patient is ambulatory. As the access site heals, encourage This promotes healing and reduces normal use of the access limb. edema. Notify the physician when pain in the These are symptoms of seriously extremity is accompanied by inadequate perfusion that require decreased sensation and decreased surgical revision of the access to temperature in the extremity with pallor prevent permanent damage to the or cyanosis. extremity’ s nerves and tissues. Instruct the patient regarding the following preventive measures: Do not allow blood pressure (BP) Activities that constrict arterial blood measurement in access limb. increase the risk for obstruction of the vascular access. Do not allow blood to be drawn from Venipunctures increase the risk of the access limb. compromised circulation. Instruct the patient to avoid devices Thrombosis is a common complication and activities that endanger access of vascular access. Causes include Additional Care Plans 7 patency, including the following: thrombi (caused by venipuncture), Sleeping on access limb extrinsic pressure (BP cuff, tourniquet, Wearing tight clothing over the limb sleeping on limb or tight clothes), or with access trauma to the access limb (related to Carrying bags, purses, or packages activities or sports that involve active over the access arm use of limb). Participating in activities or sports that involve active use of and/or trauma to the access limb Nursing Diagnosis Deficient Knowledge Common Related Factors Defining Characteristics New procedure Questions New diagnosis Confusion about treatment Home management required Inability to comply with treatment Lack of questions Common Expected Outcome NOC Outcome Patient or caregiver is able to verbalize Knowledge: Treatment Regimen home care of catheter access or NIC Interventions arteriovenous (A-V) fistula or graft, Teaching: Procedure/Treatment; recognizes signs and symptoms of Teaching: Prescribed Activity/Exercise infection and occlusion, and knows how to notify the physician or dialysis staff if infection is suspected. Ongoing Assessment Actions/Interventions Rationale Assess current knowledge level Patients receiving hemodialysis in an regarding dialysis vascular access and outpatient center may feel dependent home maintenance. on nursing staff for all care and not realize their responsibility in maintaining the vascular access. Additional Care Plans 8 Therapeutic Interventions Actions/Interventions Rationale Review the purpose of dialysis and This reinforces the need for the rationale for the access device. vascular access placement and maintenance. Patients need to understand that this is their lifeline. Demonstrate and request return This approach to teaching supports the demonstration of access care before patient’ s learning of new skills. The discharge. Recommend a home health home health nurse can reinforce this nurse visit as appropriate. learning. Instruct the patient to inform dialysis Prompt intervention is necessary to staff immediately of any signs and prevent more serious complications. symptoms of infection: pain over access site; fever; red, swollen, and warm access site; drainage from access; red streaks along access area. Explain the importance of maintaining Infection is almost an inevitable asepsis with the external catheter. complication of an external vascular Protect catheter dressing while device. Infection may be localized bathing (tub and sponge baths only); cellulitis, but septicemia can occur. no swimming; no showers. Meticulous daily care and avoidance of Apply dressing to the catheter exit trauma to the area can lessen the risk site as ordered. of infection. Secure the catheter to prevent This measure prevents accidental tugging and pulling on catheter exit dislodging of the catheter. site. Teach the patient how to manage Information given to the patient or accidental separation or dislodgment of caregiver will increase awareness of the external access connections or troubleshooting measures and reduce accidental removal of the central possible anxiety. venous catheter. Instruct the patient or caregiver in care This knowledge helps reduce the risk of dressings, if applicable. of infection. Additional Care Plans 9 Inform the patient with an A-V fistula Exercises should be initiated only at that maturation may be hastened by the direction of the dialysis staff and exercising: physician. Begin resistance exercises 10 to 14 Resistance exercises cause vessels to days after surgery. stretch and engorge with blood. Use light tourniquet to the upper arm. This pumps arterial blood against Be careful, however, not to occlude venous resistance caused by the blood flow with the tourniquet; apply tourniquet. The patient’ s squeezing tightly enough to distend vessels. rubber ball, tennis ball, hand grips, or a Instruct the patient to open and close rolled-up pair of socks helps exert his or her fist. pressure. Repeat exercises for 5 to 10 minutes, four or five times daily. Teach the patient how to check for Absence of a thrill may indicate clotting adequate blood flow through the fistula of access with the need to inform or graft: dialysis staff immediately. Waiting to Designate specific areas to feel for declot access may result in inability to pulses and thrill. “ save access” and may require Demonstrate how to feel for pulses surgery to establish new vascular and thrill. access. Discuss dietary and fluid requirements Patients receiving hemodialysis have and restrictions: low sodium, low stricter restrictions than peritoneal potassium, adequate protein, high dialysis patients because of the calories, free fluids. Arrange dietary intermittent provision of hemodialysis. consultation if necessary. Recommend medical alert bracelet. The vascular access is the patient’ s lifeline that must be treated carefully.
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