Questions

I had an adult client that I followed for the last two years of my education. He had a fistula in his wrist. They always applied the clamps without direct pressure because you don't want the fistula to clot or worse you don't want to damage it. Even with the clamps he would sometimes bleed. It was just a fact of life. I never did his dialysis. So I'm not an expert by any means. I just know what he told me, and I studied while taking care of him.

How much heparin is the patient getting? I put extra gauze over the bandaid to help stop bleeding and put plastic tape over it. it seems to work really good, and the patient does not bleed as much after dialysis.

question if you suspect lotting in your dialyzer what intervention will you do first

Our Doctor doesn't allow clamps. Some accesses require more or less pressure than others depending on lots of things like size, configuration, age, B/P, diet, PT&PTT, and more. He says clamps can damage some fistulas, and it's true. I use pinpoint pressure with a medium amount of gauze. Don't keep checking if it's a known bleeder. Lighten up gradually after a minute or so to allow the initial clot more space to form. Time it and make a note for next time. Compare with others who have had the patient. If you use a clamp, ball up a small amount of gauze and put it right over the opening, then more gauze then the clamp taped in place. Also, the needle bevels are like razors and must be inserted and removed in such a way as not to slice the access. I've seen sliced fistulas that required stitches for repair, and grafts essentially ruined by plain old carelessness.

Steve

OK, now that I have been on the floor for awhile, I have a couple questions.

I am having a hard time with my patients bleeding after I take them off the machine. I feel like I am applying enough pressure, but they bleed and bleed and bleed.

I have never used the Master Guards before and am wondering if that is why.

Can a person apply to much pressure to the access to stop the bleeding? If not, I am going to apply more pressure and if so, then is there a trick to the Masterguards? I don't really apply pressure until the needle is out, so it won't puncture the fistula/graft. Should I apply some pressure while pulling that needle out?

I had 2 patients today, start bleeding after I had put their clamps on.

I have better luck with patients who actually hold thier sites, then I do with those durned clamps.

I had an RN show me his trick, he uses the gauze just like usual but tapes it down before he pulls the needle out, not tight, but it is already taped down to where the actual whole is in the center of the gause. Once you pull the needle out and you here the MasterGuard snap you apply pressure to the center of the taped down gauze and then can determine how much snugger you need to tape it down. The patients I have used this on seem to appreciate it. I have not had any bleeders since doing this. The ones who's BP's are up, I use a little extra gauze, pressure and time on.

The accesses seem to be the hardest for me to get comfortable with, since first of all this is their lifelines and the patients will not let just anybody stick them and also don't want to bleed afterwards. I don't want to be the reason anyone has to have a repair because of a punctured access or because it clotted up. I am very uneasy still in this area. It has only been a month though, so I am thinking each month I will get a little less nervous about it.

Dialysis is hard to get but for me has been easy to get attached to.