A client is being treated in a nephrology ward with hemodialysis. The on-duty nurse should monitor IV access… - AIIMS Delhi NO - 2017

AIIMS Delhi NO - 2017

Medical & Surgical Nursing

Easy

Appeared in: AIIMS Delhi NO - 2017

Explanation

A bruit is the audible 'whooshing' or 'rushing' sound created by turbulent, high-velocity blood flow through the arteriovenous fistula or graft.
It is a normal and expected finding, which confirms that the access is patent (open) and has adequate blood flow for successful hemodialysis.
Auscultating for a bruit is a primary and essential nursing assessment for all patients with a hemodialysis access.
The presence of a bruit is often accompanied by a palpable thrill (a vibrating or purring sensation), which also indicates patency.

Option B: While assessing skin colour is part of a comprehensive assessment to check for infection or ischemia, it does not directly confirm the patency (internal openness and blood flow) of the fistula or graft.
Option C: An AV fistula or graft is a surgically created, permanent vascular access. Its position is fixed and does not change. Monitoring 'position' is critical for temporary devices like peripheral IV catheters or central lines to ensure they haven't dislodged.
Option D: The nurse assesses the potential for adequate flow by listening for a bruit and feeling for a thrill. The actual blood flow rate (measured in mL/min) is a parameter that is set, controlled, and monitored by the hemodialysis machine during the treatment session.

Clinical Relevance

Nursing practice connection: Use the key finding related to Nursing assessment of arteriovenous (AV) access for hemodialysis to guide bedside assessment, documentation, and the next nursing action.
The mantra for AV access care is 'Feel the thrill, Hear the bruit.' This simple, regular check is the most effective way for nurses and patients to monitor access patency between dialysis sessions.
Absence of a bruit or thrill is a medical emergency. It signifies a clotted or failed access, which requires immediate intervention (thrombectomy or angioplasty) to salvage it. Without a functional access, the patient cannot receive life-sustaining hemodialysis.
What if? If the bruit, which is normally a low-pitched whoosh, suddenly becomes high-pitched and whistling, it indicates a stenosis (narrowing) within the access. This requires urgent referral to a nephrologist or vascular surgeon as it can lead to thrombosis.

How to Approach the Question

First, identify the key elements of the question: a patient on 'hemodialysis' needs their 'IV access' monitored. This points specifically to a long-term access like an AV fistula or graft.
Recall the standard nursing assessment for this specific type of access. The primary goal is to confirm patency (that it's open and blood is flowing).
Remember the key assessment technique: auscultating for a 'bruit' (sound) and palpating for a 'thrill' (vibration).
Evaluate the options based on this specific knowledge. 'Bruit' directly matches the auscultation part of the standard assessment.
Systematically eliminate the other options. 'Colour' is a general skin assessment, not a direct patency check. 'Position' is irrelevant for a surgically fixed access. 'Flow rate' is a machine parameter, not a physical assessment of the site's patency.

Concept Tested & Keywords

Concept Tested: Nursing assessment of arteriovenous (AV) access for hemodialysis.
Stem keywords: hemodialysis, IV access, monitor
Lead-in keywords: should monitor for
Clinical cues: The patient is on hemodialysis, which points to a specific type of long-term vascular access (AV fistula or graft).

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E6 Medicine Harrison 22e Part 2 p. 308-310