What will the nurse do when caring for a patient with an atrioventricular fistula in the forearm for hemodialysis?

Question

1. Percuss the fistula for presence of a bruit each shift
2. Take the blood pressure in the unaffected arm
3. Position the patient so there is pressure on the access area
4. Flush the fistula with heparin every shift

Answer 1

2
Rationale 1: It is recommended to palpate for the thrill and auscultate, not percuss, the bruit over the access every 8 hours to assess for patency.
Rationale 2: This is the appropriate nursing care. Taking the blood pressure in the arm with fistula is contraindicated. When caring for a patient with an AV fistula or graft, the nurse assesses and maintains the patency of the access by avoiding any obstruction of blood flow in that extremity, such as blood pressure measurement, IV placement, phlebotomy, or positioning the patient so there is pressure on the access.
Rationale 3: No pressure should be placed on the arm with the fistula as this could cause the fistula to become clotted.
Rationale 4: Around-the-clock heparin flushes would not be utilized because the fistula is not an IV access but is part of the general circulation. Flushing would also increase the potential for infection. Access needs to be limited by HD personnel only.