Arteriovenous Fistula or Graft: Thrill and Bruit Checks, Arm Protection, and Bleeding Control
Teach the client to feel the thrill and listen for the bruit every day; report a weaker thrill or bruit the same day, and call 911 when both are absent. Protect the access arm: no blood pressure, blood draws, or IVs, no constriction, no sleeping on it, and no carrying more than 10 lb with it. Hold firm pressure for 10 minutes on a bleeding needle site and call 911 if bleeding does not stop.
Who needs this teaching
Clients receiving hemodialysis through an arteriovenous (AV) fistula or AV graft, and clients waiting for a new fistula to mature. An AV fistula is a surgical anastomosis of an artery and a vein. An AV graft joins an artery and a vein with a synthetic tube. Thrombosis, stenosis, and infection cause loss of the access, which is the client's lifeline for dialysis.
The priority teaching points
- Maturation. A fistula must mature before cannulation, usually 6 to 8 weeks or longer. Arterial pressure enlarges the vein and thickens its wall. A graft is usually ready in 2 to 3 weeks. Perform prescribed hand exercises, such as squeezing a soft ball, to promote maturation.
- Daily thrill and bruit. Palpate the thrill, a continuous vibration over the access, every day. Auscultate the bruit, a continuous whooshing sound, with a stethoscope. Check after waking and after dialysis. A weaker thrill or bruit, or a high-pitched bruit, indicates stenosis. Absence of both indicates thrombosis.
- Protect the access arm. Allow no blood pressure measurement, venipuncture, or IV insertion in the access arm. Tell every provider and wear medical alert identification.
- Prevent compression. Wear no tight sleeves, watches, jewelry, or bands on the access arm. Do not sleep on the arm. Do not carry objects heavier than 10 lb or bag straps on that arm. Compression reduces flow and causes thrombosis.
- Infection prevention. Keep the site clean and dry. Wash the access with soap and water before each dialysis treatment. Do not scratch the site or pick at scabs. Report erythema, warmth, drainage, or fever the same day.
- Bleeding after dialysis. If a needle site bleeds at home, apply firm pressure with clean gauze for 10 minutes. Do not lift the gauze to check. Call 911 if the bleeding does not stop with pressure.
- Hand perfusion. A cold, numb, pale, or painful hand on the access side indicates arterial steal syndrome (diversion of arterial blood into the access). Call 911 for these findings.
Red flags the client reports
| Call the provider the same day | Call 911 or the local emergency number |
|---|---|
| Weaker thrill or bruit, or a change in its sound | No thrill and no bruit |
| Erythema, warmth, swelling, or drainage at the access | Bleeding that does not stop with firm pressure |
| Fever or chills | A cold, numb, pale, or painful hand on the access side |
Teach-back questions
- "Show me how you check your access each day."
- "What will you do if you cannot feel the buzz?"
- "Which procedures are never done on this arm?"
- "How long will you hold pressure if a needle site bleeds at home?"
- "Why will you not sleep on this arm?"
Teaching tips
- Place the client's fingers on the thrill during the first session. Use the words "buzz" and "whoosh".
- Observe a return demonstration of the daily check.
- In the hospital, post a sign that restricts blood pressure measurement and venipuncture in the access arm.
- Include the caregiver in bleeding control and emergency steps.
Read more on NCLEXPace
Sources
- Harding MM, Kwong J, Hagler D, Reinisch C. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 12th ed. Elsevier; 2023; Chapter: Acute Kidney Injury and Chronic Kidney Disease.
- Lok CE, et al. KDOQI Clinical Practice Guideline for Vascular Access: 2019 Update. Am J Kidney Dis. 2020;75(4 Suppl 2):S1-S164.
Why this matters for the NCLEX
Teaching is effective when the client states, "I feel for the buzz in my fistula every day," and "I remind staff not to take my blood pressure in this arm." Statements requiring further teaching include, "I carry my grocery bags on my fistula arm," "I wear my watch on that wrist," and "A quiet fistula means it is healing well."
Frequently asked questions
Can a new fistula be used right after surgery?
No. A fistula matures over 6 to 8 weeks or longer before cannulation. A graft is usually ready in 2 to 3 weeks.
What does absence of the thrill and bruit indicate?
Absence of the thrill and bruit indicates thrombosis of the access. Immediate treatment restores flow and saves the access.
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