In the world of dialysis care, the access site is the resident’s literal lifeline. Whether it’s an arteriovenous (AV) fistula, a synthetic graft, or a central venous catheter (CVC), proper care and vigilant monitoring of dialysis access sites are essential to maintaining treatment efficacy and preventing complications.
Nursing home staff play a critical frontline role in protecting this access. With many residents traveling off-site multiple times a week for treatment, or receiving it in-house, your ability to recognize early warning signs, practice safe care, and respond appropriately can mean the difference between continued treatment and a serious setback.
Understanding the Types of Dialysis Access
Each type of dialysis access requires specific care techniques and carries different risks:
1. Arteriovenous (AV) Fistula
- A surgically created connection between an artery and vein (usually in the arm).
- Preferred method due to longevity and lowest infection risk.
- Takes several weeks to mature before use.
2. Arteriovenous (AV) Graft
- A synthetic tube connects artery to vein.
- Used when resident’s veins aren’t strong enough for a fistula.
- Higher infection and clotting risk compared to fistulas.
3. Central Venous Catheter (CVC)
- A flexible tube inserted into a central vein (e.g., neck, chest, or groin).
- Used for short-term or emergency dialysis access.
- Highest risk of infection, clotting, and accidental dislodgement.
Daily Access Site Monitoring: What to Look For
Daily assessments by nursing staff can help catch complications early. Here’s what to monitor:
Visual Inspection
- Look for redness, swelling, warmth, or drainage, all of which could indicate infection.
- Monitor for bruising, bulging, or unusual protrusions along the access pathway.
Palpation: Feel for the Thrill
- A thrill is the buzzing or vibrating sensation at the access site that indicates blood flow.
- If it’s absent or significantly diminished, this could signal a blockage or clot—notify the dialysis team immediately.
Auscultation: Listen for the Bruit
- Use a stethoscope to listen for a bruit (a whooshing sound).
- Changes in pitch, volume, or absence of bruit may indicate stenosis or thrombosis.
Symptoms to Report
- Numbness, coldness, pain, or discoloration in the extremity below the access site may indicate steal syndrome—a condition where the fistula diverts too much blood from the hand.
Infection Prevention: Your First Line of Defense
Residents with CVCs or grafts are at especially high risk for bloodstream infections. Your role in infection control is vital.
Best Practices:
- Perform hand hygiene before and after access site care.
- Keep access dressing clean, dry, and intact.
- Use aseptic technique during dressing changes.
- Do not use the dialysis access for IVs, blood draws, or injections unless ordered specifically by the physician.
If a resident with a CVC has a fever, chills, or low blood pressure, consider the catheter a possible infection source and alert the physician immediately.
When Something Goes Wrong: Know the Signs
Report these red flags immediately:
- No thrill or bruit
- Sudden swelling or hardness around the access
- Active bleeding from the access site
- Drainage, pus, or foul odor
- Sudden pain or discoloration in the extremity
- Dislodged or broken catheter
Be prepared to follow facility protocols for bleeding control or emergency transport if needed.
Documentation and Communication
Consistent documentation ensures accountability and safe transitions of care.
- Use a standardized form or EMR template for access site checks.
- Record any changes, interventions, and communication with providers or dialysis staff.
- Include access care in the resident’s care plan and update regularly.
Communicate proactively with the dialysis center about:
- Skin integrity or wound concerns near the access
- Any difficulties during dressing changes
- Post-dialysis bleeding that exceeds normal expectations
Education and Staff Training
All nursing staff should be:
- Trained on the different types of access
- Competent in access assessment, dressing changes, and infection prevention
- Aware of emergency procedures for dislodgement or excessive bleeding
Consider incorporating mock scenarios into your in-services (e.g., managing an AV fistula bleed, identifying access site infection, or documenting absent thrill findings).
Support from Qsource
Qsource ESRD Network provides educational tools to help your facility meet care standards for dialysis residents. Resources include:
- Access site monitoring guides
- Staff training modules
- Tools for coordinating with dialysis providers and reducing hospitalizations
Explore these resources at esrd.qsource.org.