Basic Access Study Guide Flashcards
What are the 2 types of interal vascular access?
- Arteriovenous graft
2. Arteriovenous Fistula
What is the preferred type of vascular access?
AVF (arteriovenous fistula)
AV Fistula
access is the patients own artery surgically connected to a vein
What are the advantages to an AVF? (5)
- Decreased Thrombosis
- Less Infection
- cost lower
- Morbidity and Mortality decreased
- Increased life of access and good blood flow
Disadvantages to an AVF? (4)
- increased maturation time
- vein may fail to enlarge
- difficult cannulation
- enlarged vein perceived as unattractive
New Arteriovenous fistula Considerations: (3)
- only expert cannulators may place needles in a new AVF
- A maturation assessment of a new AVF should be completed at 4 WEEKS
- CVC should be removed after 6 consecutive successful cannulations with 2 needles and the prescribed BFR has been met
Arteriovenous GRAFTS:
is artificial tubing connected one one end to the patients vein and the other end to the patients artery
AV Grafts may be ____, ____, or _____ and may be located in the lower arm, upper arm thigh or chest.
LOOPED
STRAIGHT
CURVED
Advantages to an AVG include: (4)
- Large surface area to cannulate
- easy to cannulate
- healing time short
- easy to implant, construct, and repair
Disadvantages to an AVG include: (2)
- increased infection, thrombosis, stenosis, pain with creation
- expected to last 2 years
AVG considerations: (2)
- site rotation is essential and prevents one site itis, which will decrease the AVG life
- never place needles in a PSEUDOANURYSM
Patient Teaching for the AVF and AVG includes (12)
- PROTECT ACCESS FROM INJURY
- REPORT S/S OF INFECTION
- FEEL FOR THE THRILL DAILY AND REPORT CHANGES>
- KEEP CLEAN AND DRY
- BRUSING MAY OCCUR
- avf and avg for dialyisis only
- no bp access in the arm
- do not cover during dialysis
- apply pressure gently post dialysis
- notify staff of bleeding-line separation
11, pain - preform excecising for avf maturation
when cannulating a VASCULAR ACCESS it is necessary to wear PPE. This includes wearing PPE such as ____, ____, and _____ or ______.
Gloves
gowns
face shields or mask and goggles
_______ is the #1 infection control practice for reducing the transmission of disease.
handwashing
Patients should be instructed to ____ their access site for one full minute prior to dialysis
wash
Four components of vascualr access assessment:
- patient interview
- inspection (look)
- Auscultation (listen)
- Palpation (feel)
AVF/AVG patient interview: (4)
- Pain or bleeding?
- Numbness or Tingling?
- Medication Changes?
- Checking thrill daily? Any changes?
AVF/AVG Inspection:
Name at least 3 things the DPC staff would look for during the evaluation of an AVF or AVG?
- SKIN COLOR
- INCISION CLEAN DRY INTACT
- ABSENSENCE OF INFECTION
- prior cannulation site problem free
- compare to other arm (limB)
Give some abnormal findings while inspecting the AVF AVG:
- S/S OF INFECTION
- CHANGES IN THE EXTREMITY
- ANEURSYM/PSEUDOANEURSM
- BRUSING / HEMATOMA
- skin integrity issues
- collateral vein distention
- steel syndrome
AVG/AVF Ausculation:
A normal bruit would sound _____ and have a high continuous ______ sound.
low pitched
whooshing
AVG/AVF Ausculation:
An abnormal bruit might have a _____ or ____________.
High Pitched
no sound or Decreased Whooshing sound
Determine ________ through the access by compressing middle of vessell or graft and assessing bruit (listening) and thrill (feeling).
The bruit and thrill on the ______ side sounds louder and feels stronger.
DIRECTION OF BLOOD FLOW
Arterial
AVF/AVG palpation:
a vibrating sensation that can be felt in the access is called a ______.
Thrill
AVF/AVG palpation:
An abnormal thrill may have a _________ or be completely absent.
pounding choppy pulse
AVF/AVG palpation:
AVG/AVF Assessment Red Flags:
- S/s OF INFECTION
- ABSENCE OF A THRILL
- bruising or hematoma
- skin integrity issues
Cannulation is the _____ of a needle into a ________.
insertion
vascular access
Cannulation is an invasive procedure that requires ________ practices including aseptic technique, hand hygene, new clean gloves.
infection control
Recomended Needle Gauges:
<300 ml/min
17 g
Recomended Needle Gauges:
300-350 ml/min
16 g
Recomended Needle Gauges:
> 350-450ml/min
15 g
Recomended Needle Gauges:
> 450 ml/min
14 g
The use of topical anesthetics helps to minimize patient discomfort during cannulation. The 3 types of anethetics typically used are:
- EMLA Cream
- Lidocaine 1%
- ETHYL CHLORIDE SPRAY
AVF/AVG cannulation procedure:
- Select cannulation sites by rotating locations…. one technique for site rotation is known as a ________.
Rope and ladder technique
AVF/AVG cannulation procedure:
- Determine the ______ of the blood flow
direction
AVF/AVG cannulation procedure:
- Disinfect skin with the approved disinfection _____ and allow to dry
agent (ETOH, Iodine, ECT)
AVF/AVG cannulation procedure:
- Always apply a tourniquet to _______ each time you cannulate
AVF
AVF/AVG cannulation procedure:
- pull skin in the ______ direction of the needle insertion.
opposite
AVF/AVG cannulation procedure:
- Insert needle at the appropriate angle and place the bevel side _____.
up
AVF/AVG cannulation procedure:
- needle tips should be _______ apart to prevent recirculation of blood.
1.5 to 2 inches
AVF/AVG cannulation procedure:
- DO NOT ____ or _____ the needle after insertion to prevent infiltration.
flip or rotate
AVF/AVG cannulation procedure:
- Tape needles in place using the ______ technique
butterfly
AVF/AVG cannulation technique:
_______ is the needle placement with the direction of the blood flow.
antegrade
AVF/AVG cannulation technique:
______ is the needle placement against the direction of the blood flow.
retrograde
AVF/AVG cannulation technique:
arterial needle placement may be ____ and _______.
antegrade and retrograde
AVF/AVG cannulation technique:
Venous needle placement MUST ONLY be ______
antegrade
AVF/AVG cannulation technique:
always be aware if there are ______ labs ordered, and cannulate with dry needles
pre treatment
AVF/AVG cannulation technique:
draw lab samples pre treatment before the administration of _______
Heparin or Saline
Treatment Initiation:
review and _____ all treatment orders and always follow the physicians treatment orders.
verify
Treatment Initiation:
dialysate screen : select the correct acid ______ formula number; set the _____ and _______ to match the prescription.
concentrate
Base NA++ (sodium)
Bicarbonate
Treatment Initiation:
home screen: Cannulate and enter the UF _____ never guess, a UF _______, ______ flow and dialysate temperature.
UF Goal
UF Time
Dialysate Flow
Treatment Initiation:
Verify that the correct ______ is ready for use.
Dialyzer
Treatment Initiation:
Special Safety Precautions prior to treatment initiation: (4)
- Lines and dialyzer are free of AIR.
- Ensure clamps on needle lines are CLOSED when connecting blood lines.
- Both lines must be connected to needle lines BEFORE starting the blood pump
- Saline is DOUBLE clamped
always utilize _______ - ______ before starting the blood pump.
time out - take 10
List the TEN checks to be done prior to treatment initiation:
- *all connections secure
- *dialysate line attached properly
- *300ml of saline in bag and line double clamped.
- *unused administration lines clamped
- A&V chambers filled
- blood pump threaded properly
- A & V transducers secure
- V-chamber in housing with line in clamp
- no kinks or bends in tubing
- no air in dialyzer or blood lines
REFRESH THE PRIME (FRESH FILL) means that the salinefluid in the bloodlines and dialyzer will be replaced with fresh saline from the NS bag just prior to connecting bloodlines to access needles.
To refresh the prime, you will dump _____ of saline from the arterial patient end and ______ from the venous patient end.
50 ml
250ml
Treatment initiation steps:
1-8
- Saline line DOUBLE clamped
- Connect the blood lines to access needles
- unclamp needle lines and bloodlines
- start blood pump at 100-150 ml/min
- if no compliactions increase to prescribed BFR
- once PRESCRIBED BF is reached start treatment
- rotate dialyzer arterial end up
- Note time
It is mandatory that the _________ remain visible at all times during the dialysis treatment.
access and the blood line connections
pre pump arterial pressure should not be lower than _______. Rupturing of the RBC’s or _____ can be caused by negative pressures.
- 250
Hemolysis
Unacceptible (more negative) arterial pressure would be ______
- 260
- 270
- 280
- 290
- 300
ect
list at least 2 causes of negative pressure less than -250:`
- hypotension
- spasm or vasoconstriction of blood vessel
- blood pump speed greater than blood supply
- poor cardiac status
- clotting in access or poor needle placement
- kink in arterial bloodline
List at least 2 causes of high venous pressure (as a general rule, the venou pressure should be approximately 1/2 of the blood pump speed):
- kink in the venous blood line
- clot in venous chamber
- stenosis of vascular access
- poor venous needle placement, infiltration
Needle Removal Procedure:
PPE required to remove needles includes:
- face shield
- gown
- gloves
- gloves for patient
- family holding requires all PPE
Needle Removal Procedure:
supplies needed
- gauze pads
- blue pad under access
- bandaides or gauze and tape
Needle Removal Procedure:
to reduce the risk of a needle stick, remove the ______ needle first.
arteral
Always stabilize the needle and CAREFULLY remove ______ from the needle being removed.
all tape
_____ leave the patient after removing the tape
DO NOT
Place gauze over insertion site _____ appying pressure. While removing the needle ensure that it stays the same _____ of insertion.
WITHOUT
ANGLE
Engage needle ____ immediately upon removal and place the needle into the sharps container.
GUARD
Fistula clamps require a ________ before using and only ____ fistula clamp may be used at a time.
Doctors order
Check for ______ every ____ minutes when using clamps and the patient must be able to recognize bleeding.
Thrill
10 min
To acheive hemostasis ______ gauze over the needle site with ______.
Check for pulse above and below the site to endure the access is not _____, Pressure should be contiunous for ______ minutes.
COMPRESS
2 Fingers
Occuded
5-10 Minutes
Teach the patient to ________ over the exit site if they experience post treatment bleeding
apply pressure
Infiltration and hematoma of a vascular access is caused by the access needle _______ through a vessel or graft wall, leading to _____ leaking into the surround tissue causing _______ and _____.
Punctuing
blood
swelling
hardness
List at least 3 signs and symptoms of infiltration.
- PAIN
- SWELLING
- HARDNESS
- High venous pressure (venous needle infiltrated)
- More negative arterial pressure (arterial needle infiltrated )
List at least 4 causes of infiltration:
- IMPROPER CANNULATION TECH
- IMMATURE ACCESS
- PATIENT MOVES
- BFR too high for access
- pulling or tension on bloodline
- incorrect taping of neeles
- flipping needles
- compression of needle site prior to being removed
Interventions for needle infiltration: (8)
- STOP BLOOD / CLAMP LINES
- DISCONNECT BLOOD LINES AND RECIRCULATE BLOOD
- FLUSH UNAFFECTED NEEDLE WITH SALINE
- DO NOT REMOVE INFILTRATED NEEDLE UNLESS CAUSING PAIN
- cannulate access to replace infiltrated needle
- venous affected, cannulate downstream
arterial affected cannulate above/below - rest fistula for 1 treatment if possible
- patient education
list 10 ways to prevent infiltration of the vascular access:
- Avoid premature cannulation
- 2.Use Tourniquet with AVF
- Expert cannulator new AVF or difficult
- ask for helpwith diff access
- Evaluation of art/ven pressure
- tape needles securely
- avoid tension
- keep access uncovered at all times
- do not put pressure on needle insertion site until the needle is completely removed
- do not flip or rotate needles
RN must report to the MD the following adverse events related to infiltration:
- Infiltration extends to upper limb or trunk
2. inablity to recannulate and continue treatment
Bleeding related to the vascular access may occur during the treatment or post treatment.
bleeding during the treatment should not occur and may indicate a ________.
Fragile vessel wall
If bleeding post needle removal last longer than ________ this is excessive bleeding and may indicate outflow stenosis.
20 minutes
List at least 3 causes of bleeding from a vascular access:
- access dysfunction
- flipping needles
- repeated cannulation in the same site
- needle placement in anyeurysm/psudo
- using sharp needles in an established buttonhole access
- over anticoagulation
Prevention of bleeding from access:
- Regualr assessment of access
- rotate needle stick sites
- review anticoagulation dosing
- use only buttonhole needles on buttonholes
- Do not cannulate anurysms/psudo
Red flags for bleeding:
3 things the PCT must report to the RN
- any bleeding during dialysis
- bleeding greater than 20 min post dialysis
- visible break in the skin near access
A needle dislogement is when the venous or arterial needle is either parially or completely dislocated out of the vascular access resulting in ______.
blood loss
needle dislogement may occur during dialysis resulting in minor blood loss to ________, depending upon how quickly it is discovered.
Exanguination
__________ is extensive blood loss that may cause death.
exanguination
list 8 S/S of needle dislodgement
- blood saturating the underpad or clothing.
- blood visible in the chair or pooled on the floor
- Obvious bleeding source
- Machine pressure alarms may or may not accur
- hypotension
- shock
- seizure
- Cardiac arrest
List 4 causes of dislogement:
- improper taping techniques
- Using old tape
- bloodlines anchored to the chair or table
- excessive movement of the access arm
RN 4 steps for intervention:
- assess the patient and vascular access
- stimate blood loss and replace volume
- administer oxygen
- initiate emergency response if needed
Patients must have their ______ monitored at all times. Access arms must ALWAYS BE VISIBLE.
Access
________ the needles securely by following policy and procedure is KEY to preventing dislodgement
taping
Ensure that _________ is engaged. This may cause a low venous alarm to sound and stop the blood pump when there is a slight drop in venous pressure caused by the venous needle dislodgement.
Narrow Venous Limits (NVL)
Discard ______ after repositioning needle and use all new tape on the access.
old tape
Avoid ______ on the lines and needles.
tension
monitor how well the tape is holding during your _______ safety checks.
30 minute
any blood loss that is greater than ______ is an adverse event.
100ml
infection of the access or an access related blood stream infection is the leading cause of _______ and the 2nd leading cause of ______.
hospitalizations
death
list 3 causes of access infections:
- break in aseptic technique
- porr skin prep prior to cannulation
- aneursym or psudoaneursym with break in the skin
list 4 interventions taken with access infections:
- DO not cannulate without a MD order
- Do not cannulate at the site of infection
- take wound or blood cultures
- ABX per MD orders
list 6 ways to prevent infection at the vascular access:
- wash hands 60 sec
- hand hygiene and glove change prior to cannulation
- access assessment every treatment
- disinfect site per protocol
- rotate needle sites
- aseptic set up of ECC
________ in the AVF or ABG is called thrombosis.
blood clotting
this clotting may decrease or stop blood flow in the vessel or graft
_______ is the most common type of access failure
blood clotting
list 5 S/S of thrombosis:
- Decreased thrill/bruit
- development of hematoma at the access site
- hardness at access site
- poor blood flow through access
- increased venous pressure and TMP
list at least 4 causes of access thrombosis:
- stenosis
- infiltration
- occlusion of AVF/AVG
- infection
- injury
- inadequate coagulation
- low blood flow
interventions to take with thombosis:
- call MD
- DO NOT CANNULATE
- provided pt support and education
- MD order to schedule app with access center for declot
