Caring of Hemodialysis Access

(Arteriovenous Fistula or Graft)

Hemodialysis
It is a method of removing fluid and wastes from the body,
requires access to the patient’s vascular system. This is done
via the insertion of a catheter into a vein or the creation of a
fistula or graft. If a catheter is used, it is cared for in the same
manner as a central venous access device. An arteriovenous
fistula is a surgically created passage that connects an artery
and vein. An arteriovenous graft is a surgically created connection between an artery and vein
using a synthetic material. Accessing a hemodialysis arteriovenous graft or fistula should be
done only by specially trained healthcare team members.

Equipment
• Stethoscope
• PPE, as indicated
Assessment
• Ask the patient how much he or she knows about caring for the site.
• Ask the patient to describe important observations to be made.
• Note the location of the access site.
• Assess the site for signs of infection, including inflammation, edema, and drainage, and
healing of the incision.
• Assess for patency by assessing for presence of bruit and thrill (refer to explanation in
Step 4, below).
Nursing diagnosis
Determine the related factors for the nursing diagnosis based on the patient’s current status.
Possible nursing diagnoses include:
• Deficient Knowledge
• Risk for Injury
Expected outcome
The expected outcomes to achieve when caring for a hemodialysis catheter are that the patient
verbalizes appropriate care measures and observations to be made, the patient demonstrates
care measures, and the graft or fistula remains patent.

The procedure of Caring of Hemodialysis Access

Steps Performance sale

Performed Incomplete Not done
1 0.5 0
1 Perform hand hygiene and put on PPE, if
indicated.
2 Identify the patient.
3 Close curtains around the bed and close the
door to the room, if possible.
4 Explain what you are going to do, and why you
are going to do it, to the patient.
5 Inspect area over access site for any redness,
warmth, tenderness, or blemishes. Palpate
over access site, feeling for a thrill or
vibration.
6 Palpate pulses distal to the site.
7 Auscultate over access site with the bell of the
stethoscope, listening for a bruit or vibration.
8 Ensure that a sign is placed overhead of the
bed informing the healthcare team which arm
is affected. Do not measure blood pressure,
perform a venipuncture, or start an IV on the
access arm.
9 Instruct the patient not to sleep with the arm
with the access site under the head or body.
 Steps Performance sale
Performed Incomplete Not done
1 0.5 0
10 Instruct patient not to lift heavy objects with,
or put pressure on, the arm with the access site.
Advise the patient not to carry heavy bags
(including purses) on the shoulder of that arm.
11 Remove the PPE, if used. Perform hand
hygiene.
12 Document assessment findings, including the
presence or absence of a bruit and thrill.
Document any patient education and patient
response.
Example of documentation:
5/10/12 0830 Arteriovenous fistula patent in the left upper arm. Area without redness, pain,
and edema; skin at a site similar to surrounding skin tone. The patient denies pain and
tenderness. Positive bruit and thrill noted. Patient verbalized understanding of the importance
of avoiding venipuncture in the left arm.
 1

Name ________________________________________ Date _______________________

Unit _________________________________________ Position _____________________
Instructor/Evaluator: ___________________________ Position ____________________

PROCEDURE 33-3 Comments

Satisfactory

Administering Specialized Nutritional Support

via Small-Bore Nasogastric, Gastrostomy, or
Excellent

Practice

Jejunostomy Tube
Needs

Goal: Provide enteral nutrition for patients who

cannot swallow or who have an esophageal
obstruction; Provide nutrition to comatose or
semiconscious patients; Provide additional nutrients
for patients who cannot orally consume adequate
calories.
1. Review chart for food allergies and provider’s order
for type, amount, rate, route, and frequency of
feeding.
2. Perform hand hygiene and don gloves.
3. Identify the patient.
4. Close door or bed curtains and explain the
procedure to the patient.
5. Help the patient to Fowler’s position by elevating
the head of the bed at least 30 to 45 degrees or
assisting to a chair. If an upright position is
contraindicated, help the patient to a right side-
lying position with the head elevated 30 degrees.
6. Confirm placement of tube. Following initial tube
insertion, placement is confirmed by x-ray. At that
time, tube is marked where it exits naris with tape
or indelible marker. External portion is also
measured and documented. At each feeding, tube
must be examined to assure that marked portion
remains in place and that length of remaining tube
has not changed. Routine x-rays of the abdomen
and chest should also be reviewed. If available,
test pH of aspirate per facility protocol.
7. Check GRVs.
a. If GRVs are requested, note amount
aspirated in documentation. Notify
provider if GRV exceeds 500 mL.
b. Replace all gastric contents after residual
check.
8. Prepare correct amount and strength of formula.
Formula should be room temperature.

Copyright © 2021 Wolters Kluwer. From Fundamentals of Nursing: Concepts and Competencies for Practice, 9th edition,
by Ruth Craven, Constance Hirnle, and Christine M. Henshaw. For accompanying rationales, images,
and other information, please consult the textbook.
 2

PROCEDURE 33-3 Comments

Satisfactory Administering Specialized Nutritional Support
via Small-Bore Nasogastric, Gastrostomy, or
Excellent

Practice
Jejunostomy Tube
Needs

9. Select steps 10a through 16a below for bolus or

intermittent feeding or steps 10b through 18b
below for continuous feeding.
Bolus or Intermittent Feeding
10a.Remove plunger from irrigation syringe. Clamp
gastric tubing and attach syringe or feeding bag. If
using a feeding bag, prime the tubing and attach
feeding bag and tubing to the patient’s feeding
tube.
11a.Fill syringe or feeding bag with formula. Allow
feeding to flow in slowly (10 to 15 minutes). If
using syringe, raise or lower syringe to adjust flow
rate by gravity. Refill syringe as needed without
disconnecting, avoiding airspaces in tubing. If a
feeding bag is used, hang bag on IV pole, and
adjust flow rate with clamp on tubing. Stop feeding
if the patient shows signs of intolerance.
12a.Clamp tubing just as feeding is completing. Rinse
tube with 30 to 60 mL warm tap water. Do not
allow air to enter tubing.
13a.Clamp gastric tube, and disconnect from syringe
or feeding bag.
14a.Have the patient remain in Fowler’s or elevated
side-lying position for 30 to 60 minutes after
feeding.
15a.Wash any reusable equipment with soap and
water. Change equipment every 24 hours or
according to agency policy.
16a.Perform hand hygiene.
Continuous Feeding
10b.Connect feeding bag and tubing to the patient’s
feeding tube.
11b.Pour in desired amount of formula. (Note:
Usually, hang amount of formula to infuse in 3 to 4
hours; check manufacturer’s recommendations and
agency policy.) Place label on bag with the
patient’s name, date, and time feeding was
initiated.
12b.Hang feeding bag on IV pole. Allow formula to

Copyright © 2021 Wolters Kluwer. From Fundamentals of Nursing: Concepts and Competencies for Practice, 9th edition,
by Ruth Craven, Constance Hirnle, and Christine M. Henshaw. For accompanying rationales, images,
and other information, please consult the textbook.
 3

PROCEDURE 33-3 Comments

Satisfactory Administering Specialized Nutritional Support
via Small-Bore Nasogastric, Gastrostomy, or
Excellent

Practice
Jejunostomy Tube
Needs

flow through bag.

13b.Connect tubing to infusion pump and set rate
ordered by provider
14b.Patients receiving continuous feedings should
have gastric residuals checked every 4 to 6 hours,
according to agency policy. After checking residual
and replacing stomach contents, flush the tubing
with 30 to 60 mL of warm water.
15b.Have the patient remain in Fowler’s or in slightly
elevated side-lying position.
16b.Wash any reusable equipment with soap and
water. Change equipment every 24 hours or
according to agency policy.
17b.Perform hand hygiene.
18b.Document appropriately.

Copyright © 2021 Wolters Kluwer. From Fundamentals of Nursing: Concepts and Competencies for Practice, 9th edition,
by Ruth Craven, Constance Hirnle, and Christine M. Henshaw. For accompanying rationales, images,
and other information, please consult the textbook.
 1

Name ________________________________________ Date _______________________

Unit _________________________________________ Position _____________________
Instructor/Evaluator: ___________________________ Position ____________________

PROCEDURE 35-4 Comments

Satisfactory

Inserting a Nasogastric Tube

Excellent

Practice
Needs

Goal: Decompresses the stomach to relieve pressure

and prevent vomiting; Provides a means for irrigating
the stomach (lavage); Provides access to gastric
specimens for laboratory analysis; Provides a route for
delivering liquid enteral feedings (gavage) in patients
who can’t swallow or ingest adequate calorie intake.
1. Perform hand hygiene.
2. Identify the patient.
3. Close door or bed curtains and explain the
procedure to the patient. Insertion is not painful,
but it is uncomfortable because the gag reflex is
usually stimulated.
4. Raise bed to high Fowler position, cover chest with
towel or drape, and place emesis basin nearby.
5. Put on gloves and, as needed, other personal
protective equipment.
6. Determine length of tubing to be inserted by
measuring nasogastric tube from tip of the nose to
tip of the earlobe, then to tip of xiphoid process
and midway to the umbilicus. Mark tubing with
adhesive tape or note striped markings already on
the tube.
7. Lubricate tip of tube with water-soluble lubricant.
8. Gently insert tube into the nostril, at angle parallel
to floor of the nares. Advance toward posterior
pharynx.
9. Have patient tilt head forward, with chin tuck, and
encourage patient to sip water slowly through
straw, unless contraindicated (alternatively,
encourage dry swallows). Advance tube without
using force as patient swallows. Advance tube until
desired insertion length is reached.
10.Temporarily tape the tube to the patient’s nose;
then assess placement of the tube:
a. Aspirate gastric content with 20- to 50-mL
syringe; note color and test pH. If the pH is
Copyright © 2021 Wolters Kluwer. From Fundamentals of Nursing: Concepts and Competencies for Practice, 9th edition,
by Ruth Craven, Constance Hirnle, and Christine M. Henshaw. For accompanying rationales, images,
and other information, please consult the textbook.
 2

PROCEDURE 35-4 Comments

Satisfactory Inserting a Nasogastric Tube
Excellent

Practice
Needs

5 or less, it can be assumed that the tube

is in the stomach.
b. If feeding tube is placed, x-ray
confirmation of placement is required
before feeding is administered.
11.If placement in the stomach is not correct, untape
tube, advance tube 5 cm, and repeat assessment
in step 10.
12.Secure tube with securement device or by taping
to bridge of patient’s nose. Anchor tubing to
patient’s gown.
13.Clamp end of tubing or attach to suction, as
ordered by healthcare provider.
14.Wash hands, provide for patient’s comfort, and
remove equipment.
15.Establish and document a plan for daily care of the
nasogastric tube:
a. Inspect nostril for irritation.
b. Cleanse nostril frequently.
c. Change adhesive as required to prevent
skin irritation or pressure sores on the
nostril from the tube.
d. Increase frequency of oral care because
patients with nasogastric tubes often
mouth breathe and may be NPO.

Copyright © 2021 Wolters Kluwer. From Fundamentals of Nursing: Concepts and Competencies for Practice, 9th edition,
by Ruth Craven, Constance Hirnle, and Christine M. Henshaw. For accompanying rationales, images,
and other information, please consult the textbook.
Providing Safety for Clients with Seizure Activity
 Cast care
Student’s name: Student’s ID:
Steps Performe Incomplet Not done comment
d e
1 0.5 0
Preparation
1. Review the medical record and the nursing
plan of care to determine the need for cast
care and care for the affected body part.
2. Perform hand hygiene.
3. Put on PPE, as indicated.
4. Identify the correct patient.
5. Explain the procedure to the patient,
emphasizing the importance of maintaining
counterbalance, alignment, and position.
6. Perform a pain assessment and assess for
muscle spasm.
7. Administer prescribed medications in
sufficient time to allow for the full effect of
the analgesic and/or muscle relaxant.
8. Close curtains around bed and close the door
to the room, if possible.
9. Place the bed at an appropriate and
comfortable working height.
Cast care
1. If a plaster cast was applied, handle the casted
extremity or body area with the palms of your
hands for the first 24 to 36 hours, until the
cast is fully dry.
2. If the cast is on an extremity, elevate the
affected area on pillows covered with
waterproof pads. Maintain the normal
curvatures and angles of the cast.

3. Keep cast (plaster) uncovered until fully dry.

4. Assess the condition of the cast. Be alert for
cracks, dents, or the presence of drainage
from the cast.
Steps Performe Incomplet Not done comment
d e
1 0.5 0
Preparation

5. Perform skin and neurovascular assessments

according to facility policy, as often as every
1 to 2 hours.
6. Check for pain, edema, and inability to move
body parts distal to the cast, pallor, pulses,
and abnormal sensations. If the cast is on an
extremity, compare it with the uncasted
extremity.

7. If breakthrough bleeding or drainage is noted

on the cast, mark the area on the cast,
according to facility policy.

8. Indicate the date and time next to the area.

Follow physician orders or facility policy
regarding the amount of drainage that needs
to be reported to the physician.
9. Assess for signs of infection. Monitor the
patient’s temperature, foul odor from the
cast, increased pain, or extreme warmth over
an area of the cast.
10. Reposition the patient every 2 hours.
11. Provide back and skin care frequently.
 Steps Performe Incomplet Not done comment
d e
1 0.5 0
Preparation
12. Encourage range-of-motion exercises for
unaffected joints.
13. Encourage the patient to cough and deep
breathe.
14. Instruct the patient to report pain, odor,
drainage, changes in sensation, abnormal
sensation, or the inability to move fingers or
toes of the affected extremity.
Aseptic technique
1. Remove PPE, if used.
2. Place bed in lowest position.
3. Perform hand hygiene.
Documentation
1. Document all assessments and care provided.
2. Document the patient’s response to the cast,
repositioning, and any teaching.
Comments:----------------------------------------------------------------------------------------------
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Student’s Signature: Evaluator’s name:
Signature:
 Skin Traction Care
Student’s name: Student’s ID:

Steps Performe Incomplet Not done comment

d e
1 0.5 0
Preparation
1 Perform hand hygiene.
2 Introduced self
3 Identify the correct patient with two
identifiers.
4 Close curtains around bed and close the
door to the room, if possible.
Instructions
5 Determined whether client was
preoperative. If so, did not manipulate the
extremity.
6 Determined whether client had condition
(diabetes, peripheral vascular disease) that
predisposes to skin damage with traction.
7 Determined whether traction was
continuous or intermittent.
8 Recruited an assistant to apply manual
traction when removing and replacing
traction. Washed hands.
9 Examined type of traction used that
attaches weights to the extremity.
10 Examined all bony prominences of the
involved extremity for abrasions or
pressure areas.
11 Examined extremity distal to the traction.
12 Assessed for possible neurologic
impediment from traction slings
encroaching on popliteal space, peroneal
nerve, or axilla.
13 Examined traction system to see that the
pull aligned with the long axis of the
fractured bone.
14 Checked the traction mechanism.
15 Positioned correctly in bed: client
positioned in the center of the bed; affected
leg or arm should have been aligned with
trunk of body.
Documentation
16 Document all assessments and care
provided.
Comments:----------------------------------------------------------------------------------------------
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 Skeletal Traction Care
Student’s name: Student’s ID:

Steps Performance sale Comment

Complet Incomplete Not done
e 0.5 0
1
Preparation
1. Review the medical record and the
nursing plan of care to determine the
type of traction being used and the
prescribed care.
2. Perform hand hygiene.
3. Put on PPE, as indicated.
4. Identify the correct patient.
5. Explain the procedure to the patient.
6. Perform a pain assessment and assess for
muscle spasm.
7. Administer prescribed medications in
sufficient time to allow for the full effect
of the analgesic and/or muscle relaxant.
8. Keep the patient’s privacy.
Procedure
9. Place the bed at an appropriate and
comfortable working height.
10. Ensure the traction apparatus is attached
securely to the bed.
11. Assess the traction setup; be sure that the
weights hang freely, not touching the bed
or the floor.
12. Check that the ropes move freely
through the pulleys.
13. Check that all knots are tight and are
positioned away from the pulleys.
Pulleys should be free from the linens.
14. Check the alignment of the patient’s
body, as prescribed.
15. Perform a skin assessment. Pay attention
to pressure bony prominent areas.
16. Check the 5P’s (pulse, pain, paler,
paralysis, paresthesia), edema,
temperature, capillary refill and
compare with the unaffected limb.
17. Assess for indicators of deep-vein
thrombosis, including calf tenderness,
and swelling.
18. Assess the site at and around the pins for
inflammation signs (redness, edema, and
odor).
 Steps Performance sale Comment
Complet Incomplete Not done
e 0.5 0
1
19. Provide pin site care.
a. Using sterile technique, open the
applicator package and pour the
cleansing agent into the sterile
container.
b. Put on the sterile gloves.
Place the applicators into the solution.
c. Clean the pin site starting at the
insertion area and working outward,
away from the pin site.
d. Use each applicator once. Use a new
applicator for each pin site.
20. Replace the traction if needed.
21. Depending on physician order and
facility policy, apply the antimicrobial
ointment to pin sites and apply a
dressing.
22. Discarded gloves & remove PPE, if used
23. Perform hand hygiene.
24. Documentation.
Comments:----------------------------------------------------------------------------------------------
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Student’s signature: Evaluator’s name:
Signature: