Page 376 - Critical Care Nursing Demystified

Chapter 8 CARE OF THE PATIENT WITH CRITICAL RENAL NEEDS 361

by excessive building up of metabolic by-products leading to an increased respi-
ratory rate to compensate with a respiratory alkalosis. The patient may also
have a foul odor to his or her breath from urea exiting the body (uremic fetor).
Ask the patient if he or she gets short of breath and if so, when it occurs—with
rest or exercise? In renal difficulties, the lack of erythropoietin stimulation can
lead to a reduction in red blood cell production, resulting in hypoxemia. Com-
pensation for the lack of oxygen stimulates increased breathing.
Look at the patient’s neck veins; are they flat or are the jugular veins enlarged
when the patient is at high Fowler’s position? Jugular venous distention (JVD)
will result from the right side of the heart’s inability to pump excess fluid from
renal failure.
Next, focus on an abdominal assessment noting symmetry and contour; are
there any scars, bruises, or abnormalities? Examine the abdomen, asking the
patient if this is normal for him or her. Is it tense and shiny? This can indicate
ascites, which can occur with fluid-retaining kidney conditions.
Look at the arms; if the patient has an arteriovenous (AV) graft for dialysis,
you can see that the veins on the affected side are larger than those on the other
arm. Make sure it is clearly communicated to the health care team that this arm
should not be used for IVs, venipunctures, or BP. Doing these procedures can Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
prevent clotting of these much-needed dialysis patient access lines or lifelines.

Auscultation

Take the patient’s BP, noting the baseline or changes from normal. Is the patient
hypertensive? Many patients with renal problems retain fluid, which increases
intravascular volume raising the BP. Next, check the lungs for sounds of fluid
by listening for crackles, gurgles, or wheezing. They can indicate that the patient
has excessive retained fluid, too.
Auscultation is also used to determine if an AV fistula or graft for hemodialysis
is functioning normally. It may be necessary to use a Doppler to detect a bruit or
swishing sound in a new vascular access until spasm from the surgery diminishes.

NURSING ALERT
An AV fistula or graft patency is determined by auscultating a bruit and palpat-

ing a thrill over the access site. Absence of a bruit or thrill should be reported to the
vascular surgeon/nephrologist immediately. The site may be thrombosed and can be
reopened if discovered early. Otherwise the patient will need a temporary access site
and a new permanent access site. Never use these sites for phlebotomy, IVs, or BPs.
They can traumatize the access and set up clotting.