A nurse is planning care for a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the plan of care?
A.
Insert a saline lock into a site 10 cm (4 in) distal to the graft.
B.
Instruct the client to avoid lifting the right arm for 72 hr.
C.
Palpate the site for a thrill.
D.
Check blood pressure in the right arm.
The Correct answer and Explanation is:
The correct answer is C. Palpate the site for a thrill.
Explanation
An arteriovenous (AV) graft is a synthetic connection between an artery and a vein, commonly used for dialysis access in patients with chronic kidney disease. Proper care and monitoring of an AV graft are essential to ensure its functionality and prevent complications.
Palpating the site for a thrill (Option C) is crucial for monitoring the patency of the AV graft. A thrill is a palpable vibration or buzzing sensation that should be felt over the graft. It indicates that blood is flowing through the graft and that it is functioning correctly. Regularly assessing for a thrill helps in early detection of potential issues such as graft occlusion or stenosis, which can impede dialysis treatment. The presence of a thrill confirms that the graft is patent, whereas its absence might suggest a blockage or other problems requiring medical intervention.
Inserting a saline lock into a site 10 cm (4 in) distal to the graft (Option A) is not recommended as it could potentially damage the graft or lead to complications. The area around the graft should be avoided for any invasive procedures, including inserting saline locks or intravenous catheters. Any intervention in this region can increase the risk of infection or compromise the graft’s function.
Instructing the client to avoid lifting the right arm for 72 hours (Option B) is generally not necessary unless specified by the healthcare provider. Typically, patients are advised to avoid heavy lifting or strenuous activities involving the arm with the graft to prevent stress on the graft and potential complications, but complete immobilization is usually not required.
Checking blood pressure in the right arm (Option D) where the graft is located is contraindicated. The AV graft is a delicate structure, and taking blood pressure measurements or drawing blood from this arm could disrupt the graft or lead to complications. Blood pressure should be monitored in the opposite arm or using alternative methods.
In summary, regular palpation of the graft site for a thrill is essential for ensuring the graft is functioning properly and is the most appropriate action to include in the care plan.