Policy Manual sample

MDT Home Health Care Agency, Inc. 9 ARTERIOVENOUS FISTULA ASSESSMENT PURPOSE: All care and instruction is given in accordance with the physician's plan of care. The nurse is responsible for assessing patency and reporting adverse symptoms to the physician in order to ensure continued patency of the shunt. Patients with low blood pressure may require more frequent assessments for patency. Patients or caregivers who will be taught to perform this assessment between skilled visits must be able to provide return demonstrations indicating the ability to identify the site, the ability to identify bruit, and an understanding of the symptoms which require an immediate report to medical personnel. Constrictive restraints, body weight, or pressure should not be exerted upon the affected limb. If a restraint is necessary, a mitten restraint should be used. The patient should be positioned so that body pressure is not exerted against the fistula site. The affected limb cannot be used to measure blood pressure or perform venipuncture. RESPONSIBLE PERSONNEL: RN, LPN EQUIPMENT: Stethoscope PROCEDURE: 1. Wash hands. 2. Explain procedure to patient or caregiver. 3. Place stethoscope over AV fistula and listen for a bruit. 4. Palpate over AV fistula for a “thrill”. 5. Report sharply diminished or absent sounds to physician immediately. 6. If ordered, teach the patient or caregiver steps 1 – 4. 7. Instruct patient or caregiver to report signs and symptoms that would indicate occlusion or infection of arteriovenous fistula site. DOCUMENTATION: Document that patency was checked and the results of the assessment on the Clinical Visit Note. If a physician is notified, document who was called, when, and specific orders. Document all patient and caregiver teaching and the response to such teaching. ___________________________________________________