First time posting on this site!
I recently graduated from an LPN Program in Calgary, AB in June of 2016 and got hired in a community dialysis unit in September of 2016. I have worked on my own for 6 months now but I am still running into some struggles.
I am having difficulty cannulating new AVF's. My main struggle is that I cannot landmark where the vessel is when it is a fresh arm. I ask for help when I can as this is the patient's lifeline.
I'm just looking for any helpful tips and hints any of you may have for me.
I haven't had issues locating new AVF's but I have had difficulty locating new AVG's especially deep in the thigh or upper arm, I will listen around the area and then mark out a path that I can follow. It hasn't steered me wrong yet. I listen to just about every access before I cannulate anyhow but especially with new access's. As the previous poster mentioned, FistulaFirst is a great resource.
You can always ask the patient to cough a few times and sometimes you'll get your access to pulse strong enough to palpate it and it's course. Did not always work but in a pinch it might buy you a little extra info.
Ive been doing HD for 13 years or so and still don't hesitate to ask someone else for what they feel. Sometimes stripping back for a minute to reset my fingers helps too. It sounds dumb but if I've been looking on a new AVF and am just not positive I'll either do this and reset or close my eyes and feel very lightly on the vessel, almost with minimal pressure. I'll just do this and vary my pressure until I can visualize it in my head.
When needling I find some newer staff might go just a touch too far with their needle too and nick the back side. I'm not sure if they don't let off pressure once in the vessel or if a but if anxiety hits them. I still can feel a patient's anxiety effect me and some days I just know I don't have 'it' and defer to someone else.
One other stupid sounding tip but I used to watch a lot of the Dog Whisperer. His whole thing about how the nervous owner's tension on the leash transfers to the dog and makes it anxious as well sounds corny but I think of it when I've had a bad day or just don't feel confident. I try to see the needle as the leash and it makes me focus on not gripping it too tight because that will make the fistula tense up (not really but whatever works works).
I worked with really good mentors when I began and they never hesitated to needle of I could not get one but I always appreciated that they encouraged me to try when safe, obviously. You just learn the feel by doing. The little tells and that tiny almost non-existent push back by the fistula that leads you where you need to go only comes by trying and watching others when an experienced needler is required.
Hi. Yes, newer fistula can be tricky sometimes! I work in Saskatchewan and our policy has now changed, it is recommended to tourniquet all new fistula either with an actual tourniquet or by hand. Check your policy, if you are allowed then this does help. Before, however we were not supposed to, , then your best approach is to full assess - auscultation all the way up (we do with everyone each time anyway), and palpate all the way up. Take your time, go slow to make sure you don't go right through, as new fistula can be quite soft. Good luck!
We shouldn't be blindly sticking fistulas without ultrasound confirmation that the fistula is at least 6 mm in diameter, 6 mm from the surface, and have a flow of 600ml/min.
Renal Fellow Network: Rule of 6s for Dialysis Access Placement
Living in the boonies as I do lol, we don't have the equipment to check our fistula with ultrasound. After the initial healing and maturing process we send our patients to our base hospital for transonic testing to determine readiness to use. After that we assess the fistula each HD and they are only reassessed at base if they develop abnormalities with bruit, thrill, pressures or declining ktv. We cannot always rely on equipment, we need to develop our judgment and assessment skills.
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