Gulanick Nursing Care Plans, 6th Edition Vascular Access for by LiamMessam

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									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
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
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

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
 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.
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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