Dialysis Dina — Chronic Kidney Disease & Hemodialysis
Never take a BP or draw blood from the fistula arm — a thrill and bruit confirm it's still patent
Dina arrives for her regular hemodialysis session with an AV fistula in her left forearm that she guards fiercely from every blood pressure cuff. Today the nurse notices the usual buzzing thrill under her fingertips is gone.
Dina's kidneys have progressively lost function, leading to fluid overload, hyperkalemia, metabolic acidosis, anemia and uremia. Hemodialysis filters her blood through an arteriovenous fistula, which must be protected from any blood pressure cuffs, venipunctures or IV lines in that extremity. A palpable thrill and audible bruit confirm patency; their absence signals clotting and requires immediate provider notification. Interdialytic weight gain and dietary potassium/phosphorus/sodium restriction round out her ongoing management.
Read Dialysis Dina's full story →The story arc
The setup
Dina has end-stage chronic kidney disease and relies on hemodialysis three times a week through a left forearm AV fistula.
The turn
Between sessions, Dina gains 4 kg, develops shortness of breath, and her potassium rises to 6.2 mEq/L with peaked T waves on ECG.
The crisis
On assessment, the nurse cannot palpate a thrill or auscultate a bruit over Dina's fistula, and the arm feels cool with no distal pulse.
The save
The nurse immediately notifies the provider, avoids any further manipulation of the site, ensures no BP or venipuncture is ever performed on that arm, and prepares Dina for emergent thrombectomy or new access placement while managing her hyperkalemia.
NCLEX study section — Chronic Kidney Disease & Hemodialysis
What this chapter is testing: the recognition cues, the numbers and the priority action.
Study section: Gastrointestinal & Renal
Take this chapter into practice questions on the same topic.