A patient with end-stage renal disease is post-op day 1 from a left forearm arteriovenous (AV) fistula creation for future hemodialysis access. Which nursing assessments and interventions are appropriate? Select all that apply.
Select All That Apply
Choose your responses, then check the answer.
Explanation
AV fistula post-op care: assess for bruit (auscultate) and thrill (palpate) every shift — both are required for patency and absence indicates thrombosis; protect the limb (no BP/venipuncture/IV with signage and patient banding); encourage hand-grip exercises after the initial healing period to promote maturation; assess for steal syndrome (distal ischemia from arterial flow diversion). Choice 5 is wrong — a TIGHT circumferential dressing would compress the fistula and cause thrombosis; loose, non-compressive coverings are appropriate.
The fistula limb gets a "DO NOT" sign — no blood pressure, no venipuncture, no IV. Lifelong rule. Bruit + thrill = patent. Loss of either = STAT call. Steal syndrome (distal ischemia) is the second most-tested fistula complication after thrombosis.
End-stage renal disease patient, post-op day 1 after left forearm AV fistula creation. The fistula is not yet matured for cannulation — projected use in 8 to 12 weeks.
AV fistula — Surgically created direct connection between an artery and vein for long-term hemodialysis access; matures over 8-12 weeks.
Thrill / bruit — Palpable vibration (thrill) and audible whooshing (bruit) over a patent fistula; absence indicates thrombosis.
Steal syndrome — Distal limb ischemia from arterial flow diversion through the fistula; presents with pallor, coolness, pain, paresthesia.