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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

  • Maintain patent vascular access.
  • Be free of infection.

Risk for Injury-Hemodialysis Nursing Care Plan

Nursing actionsRationale
Monitor internal AV shunt patency at frequent intervals:
Palpate for distal thrill;
Thrill is caused by turbulence of high-pressure arterial blood flow entering low-pressure venous system and should be palpable above venous exit site.

 

Auscultate for a bruit;Bruit is the sound caused by the turbulence of arterial blood entering venous system and should be audible by stethoscope, although may be very faint.
Note color of blood and/or obvious separation of cells and serum;Change of color from uniform medium red to dark purplish red suggests sluggish blood flow/early clotting. Separation in tubing is indicative of clotting. Very dark reddish-black blood next to clear yellow fluid indicates full clot formation.
Palpate skin around shunt for warmth.Diminished blood flow results in “coolness” of shunt.

 

Notify physician and/or initiate declotting procedure if there is evidence of loss of shunt patencyRapid intervention may save access; however, declotting must be done by experienced personnel.
Evaluate reports of pain, numbness/tingling; note extremity swelling distal to access.May indicate inadequate blood supply.
Avoid trauma to shunt; e.g., handle tubing gently, maintain cannula alignment. Limit activity of extremity. Avoid taking BP or drawing blood samples in shunt extremity. Instruct patient not to sleep on side with shunt or carry packages, books, purse on affected extremity.Decreases risk of clotting/disconnection.

 

Attach two cannula clamps to shunt dressing. Have tourniquet available. If cannulas 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 patient’s systolic BP.Prevents massive blood loss while awaiting medical assistance if cannula separates or shunt is dislodged.
Assess skin around vascular access, noting redness, swelling, local warmth, exudate, tenderness.Signs of local infection, which can progress to sepsis if untreated.
Avoid contamination of access site. Use aseptic technique and masks when giving shunt care, applying/changing dressings, and when starting/completing dialysis processPrevents introduction of organisms that can cause infection.
Monitor temperature. Note presence of fever, chills, hypotension.Signs of infection/sepsis requiring prompt medical intervention.
Culture the site/obtain blood samples as indicated.Determines presence of pathogens.
Monitor PT, activated partial thromboplastin time (aPTT) as appropriate.Provides information about coagulation status, identifies treatment needs, and evaluates effectiveness.
Administer medications as indicated, e.g.:
Heparin (low-dose); 
Infused on arterial side of filter to prevent clotting in the filter without systemic side effects.

 

Discuss use of acetylsalicylic acid (ASA), warfarin sodium (Coumadin) as appropriate.Ongoing low-dose anticoagulation may be useful in maintaining patency of shunt.
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