Nursing diagnosis: risk for Injury
Risk factors may include
Clotting, hemorrhage related to accidental disconnection, infection
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Maintain patent vascular access.
Be free of infection.
Nursing intervention with rationale:
1. Assess client’s pulse and tissue color distal to shunt.
Rationale: Determines general circulatory status of limb.
2. Monitor internal AV fistula or graft patency at frequent intervals.
Rationale: Clotting (thrombosis) of the AV access is the most common complication.
3. Palpate for thrill.
Rationale: Should be palpable above venous exit site. If the thrill stops, or even feels different, this could indicate clotting. With early intervention, many clots can be dissolved or removed.
4. Auscultate for a bruit.
Rationale: Bruit is the sound caused by the turbulence of arterial blood entering the venous system and should be audible by stethoscope, although may be very faint. If the bruit gets higher in pitch, it could mean narrowing of the blood vessels; if it stops, clot may have formed.
5. Note color of blood and obvious separation of cells and serum.
Rationale: Change of color from uniform medium red to dark purplish red suggests sluggish blood flow and early clotting. Separation in tubing is indicative of clotting. Very dark reddish-black blood next to clear yellow fluid indicates full clot formation. Note: Prior to insertion of an AV fistula or graft, client may have a temporary or permanent central catheter, which is maintained with heparin to inhibit clot formation. Because heparin remains active in the body for 4 to 6 hours, the client is at risk for hemorrhage during and immediately after dialysis (Leydig 2005).
6. Palpate skin around shunt for warmth.
Rationale: Diminished blood flow results in “coolness” of shunt.
7. Notify physician and initiate declotting procedure if there is evidence of loss of shunt patency.
Rationale: Rapid intervention may save access; however, declotting must be done by experienced personnel.
8. Evaluate reports of pain, numbness, and tingling; note extremity swelling distal to access.
Rationale: May indicate inadequate blood supply.
9. Avoid trauma to shunt; for example, handle tubing gently and maintain cannula alignment. Limit activity of extremity. Avoid taking blood pressure (BP) or drawing blood samples in shunt extremity. Instruct client not to sleep on side with shunt or carry packages, books, or purse on affected extremity.
Rationale: Decreases risks of clotting and disconnection. It is critical that the catheter be used only for dialysis as it is the client’s lifeline (Leydig, 2005).
10. Attach two cannula clamps to shunt dressing. Have tourniquet available. If cannulae separate, clamp the arterial cannula first, then the venous. If tubing comes out of vessel, clamp cannula that is still in place and apply direct pressure to bleeding site. Place tourniquet above site or inflate BP cuff to pressure just above client’s systolic BP.
Rationale: Prevents massive blood loss while awaiting medical assistance if cannula separates or shunt is dislodged.