As part of the profession nurses work to uphold and follow all relevant guidelines to shape the care given to patients to ensure effectiveness. The KHA-CARI Guidelines work are used by Renal nurses to ensure best possible outcomes for Chronic Kidney disease patients living within New Zealand and Australia (KHA – CARI nd). These guidelines are applied to patients by nurses to provide evidence based practice recommendations using the best evidence available and ensure the most effective care. This case study involves a 77 year old Caucasian male patient. Patient has a 5 month history of being on haemodialysis, dialyzing through a L) upper arm Arteriovenous Fistula, now dialyzing in the home setting with a private nurse. Patients kidney failure caused by complications from Diabetes type 2. Patient has been non compliant with insulin and medications for diabetes diagnosis. Pt has been diagnosed with mild heart failure but does not require a pacemaker. Patient does have mobility issues, currently using a walker to mobilize and patient lives alone. Patient has sustained a laceration to L) forearm, distal to AVF. Due to history of type 2 diabetes and haemodialysis patient is immune compromised. Patient is at high risk of developing a serious infection. Patient has also begun to complain of a cold L) hand on fistula arm during dialysis with a short term history of increasing arterial pressures during haemodialysis.
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Pt in question is an uncontrolled type 2 Diabetic. Diabetes is the leading cause of kidney disease worldwide. High blood glucose levels over an extended period damages the blood vessels in kidneys, and can lead to kidney failure. (Afkarian et al 2016). Patients with diabetes are more likely to develop infections, for reasons such as; hyperglycaemic levels in the patients blood encouraging immune deficiencies such as impairment to the neutrophils, diabetic neuropathy and that diabetic patients frequent clinical settings and are exposed to bacteria frequently (Casqueiro, J et al 2012). Infections increase the rate and duration of hospitalisations as well as mortality (Gilroy, N & Wong, M 2017). Uncontrolled diabetics often have damaged white blood vessels from years of high sugar levels. White blood cells work with the immune system to fight bacteria and heal wounds. If circulation is impaired, blood is forced to travel around the body at slower speeds which slows the rate of healing (Villines, Z 2019). This is why it is critical to take a proactive approach to any and every sign of infection to a diabetic patient.
The patient sustained acute to left forearm while cooking that is showing early signs of infection. Wound is leaking haemo serous ooze and patient is complaining of pain to site. Swab taken by dialysis nurse and sent to pathology for review of microbacteria present. Broad spectrum oral antibiotics ordered by GP and started by patient prior to results of swab result being available. Nurse unit manager of in centre haemodialysis unit in charge of patient informed of wound to keep unit updated on patients condition.
Chronic inflammation is existing in most Chronic kidney disease patients on dialysis for a number of reasons which include being uremic, fluid overload, sodium overload, hypoxia, comorbidities, immune dysfunction and the dialysis procedure itself. (Cobo, G et al 2018). The dialyzer used in haemodialysis is an artificial membrane so by having frequent contact with the patients blood this produces an increased amount of inflammation. Most haemodiaysis patients have chronically elevated levels of cytokines which are released during inflammation (Poppelaars, F et al 2018). For this case it can be hard to assess inflammation and see warning signs of infection in a dialysis patient.
In the case study the patient has their bloods checked after identification of a possible infection. Results show an elevated white cell count and a high C-reactive protein. A raised white cell count can be an indicator of infection in the body (Mayo Clinic 2018). CRP is a protein found in the blood and can also be an indicator of inflammation or infection. (Lab Tests Online, 2016). The main causes of death in Chronic kidney disease patients are infections and cardiac death (Hauser, A et al. 2008). Due to the increased risk of infection in dialysis patients they are at an increased risk of sepsis which can be deadly (Wang, H et al. 2011), which is why fast and effective treatment of potential infections is needed.
Due to the patients compromised immune system, risk of developing a serious infection through the forearm cut and the proximity to the patients AVF it is vital that correct infection control standard precautions be upheld. Patient has dressing changed to forearm on dialysis days by nurse. Dialysis nurse ensuring to follow CARI guidelines for Infection Control in Haemodialysis Units to ensure wound healing, including correct hand hygiene protocol and use of personal protective equipment when doing dressing. Dressing is not attended to during connection or disconnection to dialysis machine and new PPE is used to reduce risk of cross contamination (Gilroy, N & Wong, M 2017). Due to patient being a home patient this reduces the risk for cross contamination, but nurse must still be mindful of this. Single-use detergent based wipes are used for cleaning of trolley before and after dressing as well as single use of supplies used for dressing (Gilroy, N & Wong, M 2017). The challenges to infection control within the home setting is that it is harder to adhere to environmental hygiene.While nurse can still maintain correct hand hygiene, personal protective equipment and ensure a clean working space it is still within the confines of the patients home so it is important to provide patient education about a clean home setting to help decrease the risk of infection. The patient in question has a cleaner who visits their home weekly. Discussion had with cleaner about keeping the dialysis area clean. Before sending a patient home for home haemodialysis a house assessment must be undertaken to ensure environment is suitable for dialysis. Dialysis units must prioritise patient education, and preparing the patient’s home environment prior to a patient going home (Agency for Clinical Innovation 2014) as well as maintaining a clean home environment to minimize risks of infection and that in the event a patient does develop an infection it is not made worse by an unclean home setting. Nurse also explained to patient importance of keeping wound clean and dry as well as dressing intact.
The early signs of infection to the forearm laceration quickly resolved with no spread of infection and the swab results returned showing patient had been prescribed the appropriate antibiotics. Through correct patient education and upholding proper infection control the infection was controlled, dressed and treated appropriately. The patient also worked to have a cleaner home environment to decrease their risk of further infections.
Patient’s left upper arm Arteriovenous fistula is one year old. It has matured well, can run at 300ml/min for dialysis and is a good established access for dialysis. Apart from original surgery to create AVF it has not required any intervention up until this point. Nurse has noticed and documented increasing arterial pressures in last dialysis sessions. Patient has also begun to complain of coldness to left hand while on dialysis.
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An effective vascular access is a dialysis patients lifeline, as it is used for their hemodialysis. (Transonic 2019). The access must be able to run at a rate of 300ml/min while on dialysis as this is optimal for urea clearance (St. George, K et al. 2017). In some cases the flow can become too powerful and cause problems such as; heart chamber enlargement and cardiac overload (Miller, G 2012). A transonic machine can be used to check the vascular access flow to determine this and the effectiveness of dialysis (Transonic 2019). Last access flow was 1400ml/min 3 months prior. This rate is described as within normal limits for a dialysis access (Miller, G 2012) Patient’s base haemodialysis unit called and Nurse unit manager advised of need for fistula assessment within unit. Pt has also had a slow decrease in dialysis adequacy as measured by discans while on haemodialysis (MORE ABOUT DISCAN)and has displayed mild signs of steal syndrome to fistula limb. Patient booked to come into unit with dialysis nurse for access assessment with vascular access nurse. Home nurse conducts monthly fistula assessments as per Guideline 16 B. Pt had been experiencing coolness distal to fingers for last 2 weeks, no color changes noted by nurse but pt reports slight decreased sensation. Nil weakness or reduction in function noted by nurse or patient.
As per the Cari Guideline 16 B. Patients with an established fistula should be assessed monthly. As part of a fistula assessment nurses should gather any history of worsening pain or coldness on dialysis, reduced sensation, weakness or other decrease in function, or changes to the skin. A physical examination should also be undertaken at this time. Patients with any changes that could suggests ischemia should be referred to a vascular access surgeon for emergency review. Reduced skin temperature, as an isolated finding, requires follow up observation but no emergent intervention. (Russell, C 2011). In dialysis the rule of 6 is used when dealing with AVFs which includes; blood flow of a 600 mL/min as a minimum, fistula must be 0.6 cm under the skin surface and have a minimal diameter of 0.6 cm. (Bashar, K et al 2016). Following fistula assessment with findings that patient is having higher arterial pressures while on haemodialysis as well as the cold hand on dialysis patient is sent in centre for Access flow using the Transonic machine. Patients access flow rate recorded at 2300ml/min. On assessment patient has weak peripheral pulse to fistula arm. Steal syndrome in Dialysis patients is very dangerous, and can often result in or tissue loss or substantial neurologic damage to the patient. (Bavare, C et al 2013) Patients with diabetes, are more likely to develop steal syndrome. The operations to correct steal syndrome include AVF ligation, banding procedures, distal revascularization interval ligation and percutaneous transluminal angioplasty (P & Wilson, S 2007).
Patient was reviewed by vascular surgeon in centre following nursing assessment and access flow and it was decided patient would undergo a banding procedure. This was scheduled for 2 weeks time. Procedure done in day surgery. Following banding patients access flow had reduced to 1500ml/min. While still elevated it was a vast improvement. Vascular surgeon happy with reduced amount of access flow and would like regular monitoring to vascular access to check that blood flow does not increase again. Patient reported a decrease in cold sensation to hand while on dialysis, still reports mild sensation but states vast improvement. Patient continues to have slightly weak peripheral pulse but has improved. Nurse happy to continue regular fistula assessments within the home setting and reporting any changes to the in centre nurse unit manager and vascular surgeon.
Due to the frequent nature of dialysis it is the renal nurses role to always try tand maintain a stable patient, and report and treat any issues that may develop. Due to intervention within the case study the nurse was able to reduce the impact of the forearm infection and ensure the patient received proper treatment efficiently. The developing steal syndrome was also quickly identified and managed appropriately before more intense intervention was needed. By following relevant CARI guidelines nurses can take a proactive and best practice approach to caring for dialysis patients to ensure the finest possible patient outcomes.
- Afkarian M, Zelnick, LR, Hall, YN, Heagerty, PJ, Tuttle, K, Weiss, NS & De Boer IH 2016, Clinical manifestations of kidney disease among US adults with diabetes, Journal of the American Medical Association, vol 316, no. 5, pp. 602-610.
- Agency for Clinical Innovation 2014, Home First Dialysis Model Of Care, Clinical Innocation Program, viewed 3 August 2019, <https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0003/285078/Home-First-Dialysis-Model.pdf>.
- Bashar, K, Zafar, A, Elsheikh, S, Healy, D, Clarke-Moloney, M, Casserly, L, Burke, P, Kavanagh, E & Walsh, S 2016, Predictive Parameters of Arteriovenous Fistula Functional Maturation in a Population of Patients with End-Stage Renal Disease, European Journal of Vascular & Endovascular Surgery, vol. 52, no. 6, pp. 76.
- Bavare, C, Bismuth, J, El-Sayed, H, Huynk, T, Peden, E ,Davies, M, Lumsden, A & Naoum, J 2013, Volume Flow Measurements in Arteriovenous Dialysis Access in Patients with and without Steal Syndrome, International Journal of Vascular Medicine, vol. 2013, no. 328601, pp. 4.
- Casqueiro, J, Casqueiro, J & Alves, C 2012, Infections in patients with diabetes mellitus: A review of pathogenesis, Indian Journal of Endocrinology and Metabolism, vol. 16, no. 7, pp. 27-36.
- Cobo, G, Lindholm, B & Stenvinkel, P 2018, Chronic inflammation in end-stage renal disease and dialysis, Nephrology Dialsis Transplant Journal, vol. 33, no. 3, pp. 35-40.
- Gilroy, N & Wong, M 2017, Infection control for Haemodialysis Units, Kidney Health Australia, Cari Guidelines, viewed 3 August 2019, <http://www.cari.org.au/Dialysis/dialysis%20infection%20control/Harmonised%20ID%20Guideline_FINAL_short.pdf>.
- Hauser, A, Stinghen, A, Kato, S, Bucharles, S, Aita, C, Yuzawa, Y & Pecoits-Filho, R 2008, Characteristics and Causes of Immune Dysfunction related to uremia and dialysis, Peritoneal dialysis international: journal of the International Society for Peritoneal Dialysis, vol. 28, no. Supplement 3 S183-S187.
- Lab Tests Online Au, 2016, C-reactive Protein, July 11, viewed 31 July 2019, <https://www.labtestsonline.org.au/learning/test-index/crp 2016>.
- Mayo Clinic 2018, High white blood cell count, viewed 5 August 2019, <https://www.mayoclinic.org/symptoms/high-white-blood-cell-count/basics/causes/sym-20050611>.
- Miller, G 2012, Challenges and management of high-flow arteriovenous fistulae Seminars in Nephrology, vol. 32, no. 6, pp. 545-550.
- Poppelaars, F, Faria, B, Gaya Da Costa, M, Franssen, C, J Van Son, W, Berger, S, Daha, M & Seelen M 2018, The Complement System in Dialysis: A Forgotten Story?, Fronteirs in Immunology, vol 9, pp. 71.
- Russell, C 2011, Treatment of vascular steal syndrome, Kidney Health Australia, Cari Guidelines, viewed 1 August 2019, <http://www.cari.org.au/Dialysis/dialysis%20vascular%20access/Treatment_of_steal_syndrome.pdf>.
- Suding, PN& Wilson, SE 2007, Strategies for management of ischemic steal syndrome, Seminars in Vascular Surgery, vol. 20, no. 3, pp. 184-188.
- St. George, K, Whitlum, L & Duncan, J 2017, Examining the effect of blood flow rate on hemodialysis urea clearance, the Canadian Association of Nephrology Nurses and Technologists Journal, vol. 27, no. 3, pp. 13-19.
- Transonic 2019, AV Fistula/Grafts in Haemodialysis & Transit Time Flow Measurement, viewed 5 August 2019, <https://www.transonic.com/applications/hemodialysis-vascular-access/hemodialysis/av-fistulagraft-flow/>.
- Transonic 2019, Haemodialyis & Vascular access, viewed 5 August 2019, <https://www.transonic.com/applications/hemodialysis-vascular-access/>.
- Villines, Z 2019, How does Diabetes affect wound healing?, Medical News Today, Newsletter, viewed 4 August 2019, <https://www.medicalnewstoday.com/articles/320739.php>.
- Wang, H, Gamoboa, C, Warnock, D, & Muntner, P 2011, Chronic Kidney Disease And Risk Of Death From Infection, American Journal of Nephrology, vol. 34, no. 4, pp. 330-336.
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