Page 389 - Critical Care Nursing Demystified

374 CRITICAL CARE NURSING DeMYSTIFIED

Subclavian
vein

FIGURE 8–3 • Subclavian vascular access site.

Monitoring VS for elevated temperature, which can indicate infection
Checking and redressing the insertion site and monitoring for infection and
kinking
Maintaining strict aseptic technique when accessing the site 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.
A permanent type of internal vascular access site is needed if the patient is in
CRF or requires long-term dialysis. The most frequently used internal accesses
are the arteriovenous (AV) fistula and the AV graft. An AV fistula is the more
common surgically inserted internal vascular access. The most frequently accessed
site is the radial artery, although an artery and vein in the upper arm can be used
as well. A fistula is created when an artery and a vein are surgically connected.
This is done so that arterial pressure from the artery can strengthen the vein so
that less trauma occurs from faster blood flow in HD. The strengthening process
or maturing requires several weeks to months before a fistula can tolerate needles
and the HD process. Attempting to access an underdeveloped AV fistula can
cause arterial vascular spasm, reduced blood flow to the extremity, and damage it.
This preferred method of vascular access has blood vessel durability and fewer
complications than other types of internal access sites (see Figure 8–4).
An AV graft is used when a patient’s veins are too weak or too small to toler-
ate a fistula. A graft is a synthetic tube that connects an artery to a vein. Grafts
are generally placed in the forearm or the thigh, creating a telltale bulge that
can be seen and palpated under the skin at the site.
Accessing both fistulas and grafts requires two large-bore needles for each
HD treatment. Large bores are needed so that there is less trauma to the red
blood cells (RBCs) as they are shunted back and forth from body to machine.