DEFINITION
Connecting patient with arterio-venous fistula to the haemodialysis machine.
PURPOSE
1. To demonstrate safe and skilled use of dialysis equipment
2. To demonstrate safe and skilled venepuncture technique
3. To prevent complications and hazards that can occur when cannulating arterio-venous fistula and when commencing dialysis.
4. To safely prepare and administer prescribed dialysis treatment.
CONDITIONS
1. Applies to all Registered Nursing Personnel working in dialysis centres in Oman
2. This procedure can be performed by a nurse undertaking nephrology / haemodialysis training program, provided he/she is closely supervised by an experienced dialysis nurse at all times
3. A strict aseptic technique should be maintained throughout the procedure in accordance with the policy and procedure on aseptic technique.
4. Hand washing should be performed according to policy and procedure on hand washing.
5. Rotating fistula needle must be used where possible.
6. This procedure should be performed by two(2) nurses.
EQUIPMENT
1. Heamodialysis chart
2. On / off pack
3. Skin disinfectant
4. Sterile gloves
5. Two (2) fistula needles
6. Syringes – 20 cc x 1, 10 cc x 2, 1 cc x 1.
7. Injection Heparin, Lidocaine 1%
8. Laboratory specimen tubes and specimen bags
9. Laboratory requisition Forms
PROCEDURE
| SN | Nursing Action | Rationale |
| 01 | Advise the patient not to eat heavy meals and if possible to finish meals one (1) hour before commencing heamodialysis. | Eating during dialysis can result in vomiting and hypotension during dialysis. |
| 02 | Supervise the patient in washing the fistula arm with hibiscrub. | To prevent infection. |
| 03 | Check pre-dialysis instructions, and ensure that the machine is set up as per dialysis prescription and following pre-dialysis assessment. Ensure privacy. | To make sure that the patient is receiving appropriate treatment. |
| 04 | Assess fistula to identify sites for insertion of needles. Assessment of fistula is carried out when patient is in a comfortable position. See pre-dialysis policy for general fistula preparation and assessment. | Assessment is carried out to ensure needles are inserted in the correct position to achieve maximum blood flow. |
| 05 | Clean the table as per policy and procedures on infection control. | To prevent cross infection. |
| 06 | Wash and dry hands as per policy and procedure on hand washing. | To prevent cross infection. |
| 07 | Open out on/off pack and lay out sterile field. | |
| 08 | Place all necessary accessories in the sterile field. | |
| 09 | Wash and dry hands as per policy and procedure on hand washing. | To prevent cross-infection. |
| 10 | Clean the patient’s fistula limb with disinfectant (use thumb forceps for cleaning the limb) and put the limb on a sterile towel. | |
| 11 | Don gloves and prepare fistula needles. Heparinize needles if no blood sample is required. | Heparinized saline may interfere with the effectiveness of sample. |
| 12 | Apply pressure tourniquet above insertion site to select sites for fistula needles and local anaesthetic if required, and release. | The need to assess the fistula prior to insertion of fistula needles. |
| SN | Nursing Action | Rationale |
| 13 | Give local anaesthetic sub-cutaneously to sites according to the preference of the patient. | To minimize pain for the patient. |
| 14 | Apply pressure tourniquet above insertion site. | To examine fistula patency and strength and to make vessels prominent for needling. |
| 15 | Insertion of arterial needle Insert the needle at least 5 cm away from the site of arterio-venous anastomosis insertion (the site should be changed). | To avoid puncturing of anastomosis and to prevent fistula complications. |
| 16 | Release pressure. | |
| 17 | Secure the needle in position by tape. Check the flow by aspirating the blood using 10 ml syringe. Take any samples required and then flush with heparinized saline. | To ensure the correct placement of needle. To ensure needle remains patent. |
| 18 | Second nurse to flush dialyser with 100 ml normal saline whilst the first nurse inserts fistula needles. | To remove any air pockets and flush out ethylene oxide. |
| 19 | Clamp the fistula needle tubing and recap. | To avoid spillage of blood. To prevent infection and maintain safety. |
| 20 | Insertion of venous needle Insert venous needle in a suitable position site away from arterial needle. Secure the needle in position with tape. Check blood-flow, and administer heparin-loading dose. | To minimize re-circulation. |
| 21 | Clamp the needle tubing and recap. | To avoid spillage of blood. To prevent infection and maintain safety. |
| 22 | Attach “A“ line to “A“ needle. Put “V“ line into sterile plastic bag. | |
| 23 | Turn on blood pump slowly to 100 ml/minute. | To prevent a rapid reduction in plasma volume and therefore prevent its consequences. |
| SN | Nursing Action | Rationale |
| 24 | It is necessary to perform a straight connection for some patients (no bleeding out) | Some patients can not tolerate bleeding out on single or recurring circumstances. |
| 25 | When the blood reaches the bubble trap, turn off blood pump and clamp the venous line. | To minimize blood loss. |
| 26 | When bleeding out, observe patient for any deterioration in his/her condition. | To prevent complications. |
| 27 | Connect venous bloodline to venous needle. | |
| 28 | Unclamp venous lines and venous needle tubing. | |
| 29 | Secure the bloodlines. | To maintain patient safety. |
| 30 | Re-start blood-pump and increase the speed gradually to the prescribed pump speed. | |
| 31 | Turn the dialyser with “A“ blood post uppermost. | To ensure and maintain countercurrent flow. |
| 32 | Make sure that the machine is in dialysis mode. | |
| 33 | Set up the machine with the dialysis prescription as per patient assessment. Ensure alarm limits are set appropriately. | To ensure the dialysis prescription is delivered as prescribed. |
| 34 | Place on/off pack on top of the machine for post dialysis use. | |
| 35 | Wash and dry hands as per policy and procedure on hand washing. | To prevent cross-infection. |
| 36 | Check and record hourly according to the need. * General condition * Blood Pressure / Pulse * Pump speed * Venous pressure * TMP * UFR * Hourly weight reduction * Heparin dose * Arterial pressure | To deliver safe and effective dialysis treatment. |
| SN | Nursing Action | Rationale |
| 37 | Obtain and record observation hourly or more frequently depending on the condition of the patient. | To maintain safety of the patient. |
| 37 | Ensure that the patient is comfortable. | |
| 39 | Clean and tidy the area. |