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ISSN: 1981-8963 DOI: 10.5205/reuol.10544-93905-1-RV.1103201702

Guimarães GL, Goveia VR, Mendonza IYQ et al. interventions for ...

ORIGINAL ARTICLE NURSING INTERVENTIONS FOR HEMODIALYSIS PATIENTS THROUGH CENTRAL VENOUS INTERVENÇÕES DE ENFERMAGEM NO PACIENTE EM HEMODIÁLISE POR CATETER VENOSO CENTRAL INTERVENCIONES DE ENFERMERÍA EM EL PACIENTE EN HEMODIÁLISIS POR CATÉTER VENOSO CENTRAL Gilberto de Lima Guimarães1, Vânia Regina Goveia2, Isabel Yovana Quispe Mendonza3, Allana dos Reis Corrêa4, Selme Silqueira de Matos5, Juliana Oliveira Guimarães6 ABSTRACT Objective: to discuss nursing interventions undertaken by nurses to nursing prescription in patients using temporary double-lumen central for hemodialysis based on the Nursing Intervention Classification. Method: descriptive exploratory study with quantitative approach conducted in a private hemodialysis unit in the state of Minas Gerais (MG), Brazil, with 57 patients, aged >18 years and <60 years undergoing treatment for 90 days. Results: two nursing interventions were identified: care with the vascular device; maintaining access for . Eight activities were selected: measuring temperature; occlusive ; signs and symptoms of infection; maintaining the aseptic technique; standard precaution; changing protectors; use of in the lumen; guiding the patient and the family. Conclusion: nursing intervention is effective for maintaining the catheter, controlling and avoiding complications; it has scientific basis and promotes safety and well-being. The nurse must perform nursing care in patients using temporary double-lumen . Descriptors: Renal Dialysis; Renal Insufficiency; Catheters; Quality of life; Nursing. RESUMO Objetivo: discutir as intervenções de enfermagem assumidas por enfermeiros para a prescrição de enfermagem nos pacientes em hemodiálise por cateter venoso central temporário de duplo lúmen a partir da Classificação das Intervenções de Enfermagem. Método: estudo descritivo-exploratório, de abordagem quantitativa, realizado em unidade de hemodiálise privada, no interior do estado de Minas Gerais (MG), Brasil, com 57 pacientes, idade >18 anos e < 60 anos, em tratamento há 90 dias. Resultados: foram identificadas duas intervenções de enfermagem: cuidados com o dispositivo vascular; manutenção do acesso para diálise. Selecionadas oito atividades: aferir temperatura; curativo oclusivo; monitorar sinais e sintomas de infecção; manter técnica asséptica; precaução padrão; trocar protetores; uso de heparina no lúmen; orientar o paciente e familiares. Conclusão: a intervenção de enfermagem é efetiva para a manutenção do cateter, controle e combate de suas complicações; possui base científica, promove a segurança e bem-estar. O enfermeiro deve realizar o cuidado de enfermagem no paciente em uso de cateter venoso central temporário de duplo lúmen. Descritores: Diálise Renal; Insuficiência Renal; Cateteres; Qualidade de Vida; Enfermagem. RESUMEN Objetivo: discutir las intervenciones de enfermería asumidas por enfermeros para la prescripción de enfermería en los pacientes en hemodiálisis por catéter venoso central temporario de doble lumen a partir de la Clasificación de las Intervenciones de Enfermería. Método: estudio descriptivo-exploratorio, de enfoque cuantitativo, realizado en unidad de hemodiálisis privada, en el interior del estado de Minas Gerais (MG), Brasil, con 57 pacientes, edad >18 años y < 60 años, en tratamiento hace 90 días. Resultados: fueron identificadas dos intervenciones de la enfermería: cuidados con el dispositivo vascular; mantenimiento del acceso para diálisis. Seleccionadas ocho actividades: medir temperatura; curativo oclusivo; monitorear señales y síntomas de infección; mantener técnica aséptica; precaución padrón; cambiar protectores; uso de heparina en el lumen; orientar al paciente y familiares. Conclusión: la intervención de enfermería es efectiva para el mantenimiento del catéter, control y combate de sus complicaciones; posee base científica, promueve la seguridad y bien estar. El enfermero debe realizar el cuidado de enfermería en el paciente en uso del catéter venoso central temporario de doble lumen. Descriptors: Diálisis Renal; Insuficiencia Renal; Catéteres; Calidad de Vida; Atención de Enfermería. 1Nurse, PhD (Post-Doctor), Graduated in Nursing, Federal University of Minas Gerais/UFMG. Belo Horizonte (BH), Brazil. Email: [email protected]; 2Nurse, PhD Professor, Graduated in Nursing, Federal University of Minas Gerais/UFMG. Belo Horizonte (BH), Brazil. Email: [email protected]; 3Nurse, Professor, Undergraduate/Graduate Nursing Program/PPGENF, Federal University of Minas Gerais/UFMG. Belo Horizonte (BH), Brazil. Email: [email protected]; 3Nurse, Professor, Undergraduate/Graduate Nursing Program/PPGENF, Federal University of Minas Gerais/UFMG. Belo Horizonte (BH), Brazil. Email: [email protected]; 2Nurse, PhD Professor, Graduated in Nursing, Federal University of Minas Gerais/UFMG. Belo Horizonte (BH), Brazil. Email: [email protected]; 6Graphic Design, Communication Assistance, Faculty of , Federal University of Minas Gerais/UFMG. Belo Horizonte (BH), Brazil. Email: [email protected]

English/Portuguese J Nurs UFPE on line., Recife, 11(3):1127-35, Mar., 2017 1127 ISSN: 1981-8963 DOI: 10.5205/reuol.10544-93905-1-RV.1103201702

Guimarães GL, Goveia VR, Mendonza IYQ et al. Nursing interventions for hemodialysis...

INTRODUCTION trained professionals using maximum protection barriers, such as use of fields, Chronic (CKD) has diabetes gloves and sterile aprons, beanies, goggles and hypertension as main causes and has and masks. Studies show that the incidence of become a worldwide public health problem central venous catheter infection in ICU due to its high prevalence rate. Because of patients is less than 8% over two weeks. In one this, increasing numbers of patients need month, 25% of catheters become infected and dialysis therapy for the rest of life, due to the this percentage doubles in the second month. irreversible failure of renal function. In Brazil, Catheter-related may occur between 2% estimates of the Brazilian Society of and 20% of cases. This calls for reflections on Nephrology indicate that there are 100,397 the use of CVC in hemodialysis patients, and patients undergoing dialysis, and that the for criticism on aspects related to its use and number is increasing in the order of 3% per maintenance.1,7-8 year.1-3 In the United States, more than 200,000 The substitutive method employed on large patients need hemodialysis and 30% do so scale in patients with chronic kidney failure through a catheter. It is estimated that (CKF) in Brazil and worldwide is hemodialysis. 250,000 catheters are implanted per year and This therapy requires a technological 87% of are caused by apparatus involving machinery, materials, them. In Brazil, the overall rate of catheter- trained professionals and the preparation of related bloodstream infection is 17.05/1000 (VA) in the patient. The latter invasive devices per day, considering a can be obtained basically through two ways; percentile of 95%. This situation entails cost by creating an arteriovenous fistula (AVF) or to the health system because it can lead to by implanting a double-lumen central venous hospitalization, increasing the cost of catheter.4 treatment and reducing the quality of life of The catheter can be classified as long or hemodialysis patients, besides increasing short term. The first is implemented by a morbidity and mortality.6-7 vascular surgeon and has one or more Dacron Thus, the safe handling of CVC should be a cuff in its structure. The aim is to form a priority of the entire nursing staff that mechanical barrier against microorganism provides assistance to these patients, so that penetration in the subcutaneous and vascular technical and monitoring rigor and bed. The second type, the temporary double- surveillance happen to prevent and control lumen catheter (CVC), is usually implemented possible adverse events. Considering the by a nephrologist through percutaneous complexity of deployment and use of this type technique and has no cuff. This is one of the of vascular access, technical standardization main alternatives to obtain VA used in is indispensable. It is also important to note domestic clinical practice and its prevalence that prevention and control of CVC-related is 9.4%.2,5 complications are mostly of the nursing staff There is a tight link between the process of responsibility. This must ensure the quality of hemodialysis and life maintenance, as this health care, promoting safety for patients and treatment partially replaces kidney functions. professionals.6-7 For this, systematic nursing action becomes The justification and relevance of the study necessary for patient care in hemodialysis CVC is in the fact that the CVC is widely used in for maintenance and prevention against hemodialysis patients. Its use requires complications, whether infectious, thrombotic engagement from nurses in order to minimize or traumatic. The CVC is the faster and more risks to health by reducing morbidity and secure option of central in the mortality in this clientele. Therefore, it is case of hemodialysis for short periods of necessary to know the nursing interventions time.1 used in the care of patients using CVC, so that The use of CVC was introduced in the mid the relevance of each intervention be of the last century and, from then on, became evaluated. essential for hemodialysis. Although the In order to avoid doubts, we need to intravascular device allows fast access to the conceptualize the term nursing intervention bloodstream, its use is related to bacteremia (NI). Nursing Interventions consist in any and candidemia, with significant rates of treatment based on clinical judgment and morbidity and mortality and increased knowledge held by nurses to enhance patient hospital costs.6-7 outcomes and include direct and indirect care Because the CVC technique is a type of focused on persons-humans, families, central venous catheter, it must follow the communities and treatments started by nurses rules of asepsis and should be performed by or other professionals.8 With these

English/Portuguese J Nurs UFPE on line., Recife, 11(3):1127-35, Mar., 2017 1128 ISSN: 1981-8963 DOI: 10.5205/reuol.10544-93905-1-RV.1103201702

Guimarães GL, Goveia VR, Mendonza IYQ et al. Nursing interventions for hemodialysis... considerations in mind, the present study had American Association- the following objective: NANDA I, title of Nursing Interventions - NIC ● To discuss nursing interventions and the activities listed for the nursing undertaken by nurses to nursing prescription prescription for patients undergoing in patients using double-lumen catheterization hemodialysis with CVC. The analysis was for temporary hemodialysis based on the performed using descriptive statistics and Nursing Intervention Classification. data were discussed in the light of the 9 METHOD scientific literature. The study had the project approved by the Descriptive study with quantitative Ethics Committee of the Federal University of approach carried out in a hemodialysis unit of Minas Gerais/UFMG under CAAE nº a private institution located in the city of the 11813512.1.0000.5149. The survey meets the countryside of Minas Gerais, Brazil. The unit Resolution 466/12 of the National Health has 180 patients undergoing dialysis and has a Council, protecting the anonymity of people multidisciplinary team composed of three undergoing treatment and of professionals nurses and four doctors, all experts in who filled records. nephrology; one pharmacist, a social worker, RESULTS a nutritionist, a psychologist and a vascular surgeon. Among the 57 patients undergoing Data collection was conducted from hemodialysis using CVC, most (75%) were October 2014 to October 2015, totaling 12 males, ages ranged between 20 and 59 years, months, by consulting hospital records of 64% were married and 57% were Catholic patients undergoing hemodialysis using CVC in Christians. As for education, 46% had primary the period studied. In this time interval, 175 education and 20% were illiterate. About patients underwent hemodialysis three times implant of the CVC, it was observed that 70% per week, with an average duration of four were installed in the right internal jugular hours. Inclusion criteria were: adults of both , while 12%, in the right . As sexes; age > 18 years and < 60 years; and for the causes related to implant removal, undergoing treatment for at least ninety days. 70% were due to AVF maturation, and 20% due The sample was composed of 57 patients. to infection. Regarding hemodialysis dose A data collection instrument was designed measured by Kt/V, 70% values between 1.1 to for registering the information on socio- 1.2; 82% had blood flow above 250 ml/min. demographic data, aspects related to the Table 1 shows the causes of CKD in patients implant of the CVC, dialysis evaluation undergoing hemodialysis using CVC. parameters, laboratory tests of interest, identification of nursing diagnoses made by nurses according to Taxonomy II, North

Table 1. Etiology of patients undergoing hemodialysis using CVC - Unit of Renal Replacement in the State of Minas Gerais (MG), Brazil, 2015. Etiology of CVC n=57 % Hypertensive nephropathy 29 50 Diabetic nephropathy 14 35 Chronic glomerulonephritis 09 10 Other 05 05

Taking advantage of the Nursing Diagnosis technique whenever CVC is manipulated; (5) of Taxonomy II of NANDA I, nurses established maintaining standard precaution; (6) replacing two diagnoses related to vascular access in the protective covers of the CVC after each hemodialysis patients using CVC and from hemodialysis session; (7) maintaining these, professionals (100%) elected two titles permeability of the access with heparin after of Nursing Interventions - NIC, namely: care hemodialysis session; (8) guiding the patient with the vascular device and maintaining the and the family on maintenance of the CVC. access for dialysis. The association of DISCUSSION activities present in the interventions made it possible to list actions for the formulation of The study identified the prevalence of eight nursing prescriptions to patients males among hemodialysis patients using CVC. undergoing hemodialysis through CVC, Survival studies with patients using this namely: (1) measuring pre/post-treatment therapeutic modality indicate the axillary temperature; (2) maintaining an predominance of males, and they cite occlusive dressing; (3) monitoring signs and especially cardiovascular disease as the symptoms associated with local and systemic leading cause of mortality. Age ranged from infection; (4) maintaining the aseptic 50 to 59 years in the studied clientele. This English/Portuguese J Nurs UFPE on line., Recife, 11(3):1127-35, Mar., 2017 1129 ISSN: 1981-8963 DOI: 10.5205/reuol.10544-93905-1-RV.1103201702

Guimarães GL, Goveia VR, Mendonza IYQ et al. Nursing interventions for hemodialysis... variable has been listed as a risk factor for within the recommended by the Daugirdas mortality and diminished health-related formula.2,14 quality of life (HRQOL).9  Nursing interventions for handling The HRQL is defined as the person's patients using CVC perception of their own health through a  Measuring pre/post-treatment axillary subjective evaluation of symptoms, temperature satisfaction and adherence to the proposed Body temperature is the difference treatment. The CKF reduces the physical and between the heat generated by bodily working functions of individuals to a great processes and the heat lost to the extent, as well as affects the people's environment. It is regulated by the perception of their own health. This results in hypothalamus, located within the brain. The negative impacts on energy levels and vitality, anterior portion of the hypothalamus controls which can reduce or limit social interactions heat loss and the posterior region, heat and cause problems related to the mental production. It is known that several factors 10 health of the patient. can affect body temperature, including age, In the study, 57% of patients reported hormone levels, chronic , stress and having the Catholic faith. The mechanism by heart rate.15 which spirituality influences the health and Various parts of the body can be used for well-being of people is unclear, although measurement, but for the nursing staff, researchers and clinicians believe that studies indicate the axillary site is most spirituality and health have important frequently used in adults. This route is safe, connections. As for education, 46% of patients accessible and presents less risk. However, had primary education only, and 20% were studies indicate that measurement of the illiterate. This condition is a risk factor for tympanic membrane temperature with reduction of HRQOL, a fact confirmed by infrared device provides the best results, with 3,10-2 several studies. correspondence with the internal temperature As for etiology, 50% had hypertensive of the human body.15 nephropathy as cause of CKF, 35%, diabetic Hemodialysis patients have peculiarities nephropathy, 10%, chronic glomerulonephritis that must be considered when using the and 5% had other causes. These data were axillary temperature measurement technique. also found in the Brazilian Chronic Dialysis The first is that, for unknown reasons, 50% of Survey of 2013. There was no significant patients have subnormal body basal change in these causal agents in the last three temperature. Thus, a small change in the years. As for the site of CVC implantation, 70% temperature represents an increased risk for were in installed in the right internal jugular infection.16 vein. This is the site most often chosen The second is that the vascular access site because it presents less complications and for hemodialysis is responsible for 50 to 80% of easier access. The second site is controversial cases of infection related to the therapy. Such and should be set according to anatomical and infection may cause the patient to develop 2,7,13 functional characteristics of patients. bacteremia and in more severe cases, As for causes that led to removal of the , meningitis, , CVC, 70% were associated with maturation paraspinal abscess and septic emboli. These and 20% with AVF infection. It can be stated situations are serious in clinical practice and that catheter infection is a high risk factor corroborate the rise of morbidity and and represents the most frequent mortality.16 . The incidence of bacteremia So, it is very important that nurses who varies; it is greater among patients using non- assist hemodialysis patients using CVC, tunneled catheter in the order of 4 to 6 for promote educational activities in the nursing 1000 catheters/day. It is noteworthy that the staff to enable these professionals to infection associated with CVC can vary, and recognize the value and importance of clinical findings are nonspecific and have low measuring the patient's temperature before 1-2,7,13 sensitivity. and after treatment. Because of the CKF and Furthermore, the dose of dialysis, as of the risks of dialysis itself, these patients measured by Kt/V, is one quality indicator of may be more exposed to contaminants and the treatment. The recommended value for consequent infection. three sessions a week should be greater than  Maintaining occlusive dressing or equal to 1.2. The Kt/V result obtained in Study shows that the maintenance of the this study varied from 1.1 to 1.2, with blood occlusive dressing of the CVC is a way of flow higher than 250 mL/min. The average is protecting the catheter insertion site from colonization by microorganisms. There are English/Portuguese J Nurs UFPE on line., Recife, 11(3):1127-35, Mar., 2017 1130 ISSN: 1981-8963 DOI: 10.5205/reuol.10544-93905-1-RV.1103201702

Guimarães GL, Goveia VR, Mendonza IYQ et al. Nursing interventions for hemodialysis... different dressings in the domestic scene. without increasing the risk of infection. This is Gauze, tape and transparent polyurethane confirmed by a study that analyzed the film are most commonly used. These dressings maintenance of occlusive dressings for central vary in durability, ease of application, venous catheters used in intensive care probability to cause skin reaction and ability patients, which were exchanged within to prevent infection.17-8 intervals of 36 hours. Therefore, it is the There is controversy in the literature on responsibility of the nurse to establish the use of prophylactic in the CVC strategies for preventing, combating and insertion site. For some, the prophylactic use controlling adverse events related to the use of antibiotics does not determine the of CVC.17-8 reduction of catheter infection rates and  Monitoring signs and symptoms suggest that risks actually increase with this associated with local and systemic procedure. Blood infection associated with infection CVC, with Staphylococcus sp. as agent, is Infection is the second cause of mortality 17-8 commonly found in the literature. among CKF patients, surpassed only by The Center for Disease Control and cardiovascular complications. Thus, it is very Prevention - CDC recommends the use of important that nurses have a critical attitude dressing composed of gauze and tape in the towards the assistance to this population, case of diaphoretic patient. This fact is based especially the continuous search for the best on scientific evidence that the transparent scientific evidence available for handling the dressing does not have the ability to absorb vascular access, and recognizing the value of exudate and, therefore, may predispose the signs and symptoms monitoring associated patient to bloodstream infection. Fixing the with local and systemic CVC infection.18 bandage is considered also relevant, because In this sense, it is clear that CKF patients this allows it to remain occlusive up to the undergoing hemodialysis run a high risk of next change, preventing colonization of the infection due to compromised immunity, CVC implant site. The margins of the dressing comorbidity, inadequate nutrition and the are observed to come off easily from the skin need to maintain the CVC for long periods. in the case of transparent film. It is inferred Another relevant factor is the collective that each person's skin characteristics may environment in which the hemodialysis session interfere with the quality of fixation. most often takes place. This facilitates the Diaphoretic patients or patients with higher spread of microorganisms by contact through oiliness on the skin have difficulty to keep the devices, products, equipment, surfaces or dressing steady, in general, regardless of the hands of the nursing staff and other health 17-8 material used. professionals.18 Another important aspect to maintain the Data from the National Healthcare Safety CVC is the probability of the material of Network (NHSN) of the US show that inducing local reaction. Studies indicate that bloodstream infection rates, according to the the bandage made up of gauze and tape has types of access, are: arteriovenous fistula been associated with greater probability of (AVF) 0.5, graft 0.9, long stay central venous developing local reaction, most often, in the catheter (CVC) 4.2, and short stay CVC 27.1 contact areas of the adhesive tape with the per 100/patient-month. Microorganisms skin. On the other hand, there have also been isolated in blood cultures were skin observations that, though less incident, the contaminants, among them, the coagulase- local reaction is observed in the contact negative Staphylococcus sp. Regarding the region of the transparent dressing adhesive resistance profile of microorganisms, 42% of S. portion to the skin. As for the interval aureus were resistant to methicillin, and 39% between changes of the occlusive dressing, of Enterococcus sp to vancomycin resistant. this depends on the type of material used and The risk of CKF patients undergoing on the external aspect of the dressing. Thus, hemodialysis with CVC developing bacteremia if sterile gauze is used in the occlusive is seven times higher than those with dressing, a change must be processed every arteriovenous fistula.17-9 session and in the case of transparent film, The pathogenesis of the infection every seven days or even sooner, if associated with CVC can be observed arising 17-9 necessary. from infection of the exit point, followed by It is known that the presence of skin injury microorganism migration to the outer surface increases the risk of infectious complications of the catheter, colonization and in patients using catheter. Thus, the contamination of the lumen and, finally, procedure of maintaining an occlusive dressing hematogenous infection. Clinical data of can contribute to reduction of skin reaction, patients in this situation are nonspecific and English/Portuguese J Nurs UFPE on line., Recife, 11(3):1127-35, Mar., 2017 1131 ISSN: 1981-8963 DOI: 10.5205/reuol.10544-93905-1-RV.1103201702

Guimarães GL, Goveia VR, Mendonza IYQ et al. Nursing interventions for hemodialysis... have low sensitivity. Thus, the presence of It is worth highlighting the importance of infection signs and symptoms (fever, malaise, HH of the whole health team and especially of chills, pain or exudate in the exit site), nurses, once that, in the hemodialysis without evident source, must necessarily lead context, it is their responsibility to handle the professionals to consider the CVC presence in CVC before, during and after treatment. the patient as the source of the situation.7,13 Therefore, its members must be committed to The most common clinical sign is fever, patient safety and, in this case, they must which has a great sensitivity but low adopt the due precautions in their actions. specificity. In the other hand, the presence of Thus, it is up to the nurse to guide and inflammation and purulent exudate around supervise the staff in the adherence to proper the implant site has great specificity. HH.6,19 Furthermore, in case of the suspicion of CVC- It is noteworthy that the rates of related infection, must be done adherence to HH practice are still low. in order to accurately assess whether there is However, every effort should be undertaken concomitant bacteremia.1,2,7,13 to overcome the obstacles to the use of this Thus, it is necessary that nurses be technique. In view of various situations of attentive and aware, because adverse events clinical practice, HH can by performed using related to CVC infection are serious and can antiseptic solutions, and usually 70% alcohol cause the patient significant loss of quality of gel has been used because it has low cost, and life, and even death. With the information good effectiveness and acceptability. This available and the existing technological measure promotes cleanliness, and eliminates resources, there is no alternative other than or inhibits the growth of microorganisms, the strict monitoring of clinical aspects in preventing their penetration in the patients using CVC. bloodstream. The application should be broad,  Maintaining the aseptic technique subject to one-way direction, and its every time the venous access is handled; effectiveness depends on the friction for 30 maintaining standard precaution; seconds, which corresponds to five 20 exchanging occlusive protectors of the movements. It is important to respect fundamental CVC after each hemodialysis session. aspects for maintaining the dressing in the In this study we chose to discuss these CVC implant site. Thus, it is the nurse nursing interventions/activities in association, responsibility to undertake the following given its close relationship with biosecurity. actions: (1) proceed hand hygiene; (2) use of The application of these actions aims to mask, goggles and apron; (3) put on prevent infections associated with the use of examination gloves; (4) put the mask on the CVC and bloodstream infections. patient; (5) remove the dirty bandage; (6) Catheter-related bloodstream infection removing procedure gloves; (7) wash hands (BSI) refers to the situation in which isolated again; and (8) put on sterile gloves for microorganisms on the culture from the lumen handling sterile material for preparation of device are found in the bloodstream. BSI rate the dressing. As for replacement of related to presence of catheter varies connectors (cover), the safe practice according to the site and insertion technique, recommends replacing any and all device that the number of the lumen, catheter type, is designed for sterile and single use. This length of stay and idiosyncrasies of the must be replaced by another with the same patient.16 specification.16,18-9 The CDC developed the Guideline on Blood Maintaining permeability of the Stream Infection for the use of catheters. This  publication is important to guide the care catheter practice in accordance with technological and Maintaining CVC represents a great scientific advances. This movement was challenge, especially related to prevention adopted by the World Health Organization to against obstruction and infection. Thus, new support patient safety, resulting in a manual solutions have been studied for use in filling to prevent and control BSI. This guideline the catheter lumen. In clinical practice, after addresses BSI as important complications the dialysis session, the lumen is filled with caused by the use of catheters and points to heparin and some services employ it without 21 adherence to standard precautions (SP) as a any dilution. strategy to prevent it. The guide also Heparin acts on the coagulation system by emphasizes the need to incorporate measures inhibiting platelet aggregation. Nevertheless, such as hand hygiene (HH), use of protective the trivial use of heparin for maintaining equipment and aseptic technique during permeability of the CVC may cause adverse insertion and manipulation of the catheter.16 effects such as alopecia, allergic reactions, English/Portuguese J Nurs UFPE on line., Recife, 11(3):1127-35, Mar., 2017 1132 ISSN: 1981-8963 DOI: 10.5205/reuol.10544-93905-1-RV.1103201702

Guimarães GL, Goveia VR, Mendonza IYQ et al. Nursing interventions for hemodialysis... thrombocytopenia, bleeding and respective processing of materials, equipment and impacts on patient safety.22 immunization of all subjects involved.18-9,21-5 The dose of heparin used has been a source CONCLUSION of controversy in the literature. Studies indicate that the use of heparin 1000 IU/mL Two nursing interventions related to the presents lower risk of systemic heparinization care of patients undergoing hemodialysis with than the standard dose of 5000 IU/mL without CVC were identified and discussed, according loss of the conditions for use of CVC. to NIC, namely: care with the vascular device However, when 1000 IU/mL is used in CVC, and maintaining access for dialysis. These this demand at some point greater use of made it possible to list and discuss eight instillation of thrombolytics for clearance.21 nursing activities, namely: measuring Other solutions have been studied for pre/post-treatment axillary temperature; maintaining the CVC, notably maintaining an occlusive dressing; monitoring solutions and thrombolytics. A multicenter signs and symptoms associated with local and study using a solution composed of sodium systemic infection; maintaining the aseptic citrate, methylene blue, methyl paraben and technique whenever CVC is manipulated; propylparaben, as compared to heparin, maintaining standard precaution; replacing showed significant reduction in catheter- the protective covers of the CVC after each related infection rates. Another study showed hemodialysis session; maintaining similar results using minocycline and EDTA permeability of the access with heparin after solution.22 hemodialysis session; guiding the patient and Alternatively the use of these solutions, the the family on maintenance of the CVC. use of solution at 0.9% has been Due to the technical specificity of the basis reported in single lumen catheters in intensive of hemodialysis, nurses associated, in a plastic care unit patients, with satisfactory results on and dynamic way, intervention activities in permeability of this type of vascular access. order to formulate a current and relevant However, there is no evidence indicating the nursing prescription for patient safety. The success of its routine use in the clinical activities listed have robust scientific basis in practice related to patients undergoing the literature and this legitimizes their use for hemodialysis with CVC.21-2 the maintenance of the CVC in the fight and  Guiding the patient and the family on control of infectious, traumatic or thrombotic maintenance of the CVC complications. Therefore, nurses must assume Education of patients, caregivers and the care of patients using CVC as their professionals is recommended as strategy for function, as this is a highly complex the prevention of hemodialysis infections. This procedure. must take into account the context of the REFERENCES reality of patients' life. When patients and caregivers receive guidance regarding the 1. Nascimento VPC, Abud ACF, Inagaki ADM, maintenance of vascular access, they become Daltro AST, Viana LC. Avaliação da técnica de solidary in the pursuit of reaching the curativo em cliente com acesso venoso para therapeutic goal. In this sense, citizenship and hemodiálise. Rev enferm UERJ [Internet]. autonomy shall be exercised in an effective 2009 Apr/June [cited 2016 Jun 16];17(2):215- and productive way.18 9. Available from: It also important to point out that the http://ri.ufs.br:8080/bitstream/123456789/8 educational process should not be restricted 40/1/AvaliacaoCurativoHemodialise.pdf to the patient. Although the patient must be 2. Sesso RC, Lopes AA, Thomé FS, Lugon JR, the target of this nursing intervention, Santos DR. Inquérito brasileiro de diálise guidance to patients and families may crônica 2013 – Análise das tendências entre stimulate, along with the health team, 2011-2013. J bras nefrol [Internet]. 2014 permanent education and thus better results Oct/Dec [cited 2016 Mar 18];36(4):476-481. in maintaining the CVC in patients undergoing Available from: hemodialysis. A study conducted in a http://www.scielo.br/pdf/jbn/v36n4/0101- university hospital in São Paulo showed a 40% 2800-jbn-36-04-0476.pdf reduction in catheter-related bloodstream 3. Cavalcante MCV, Lamy ZC, Lamy-Filho F, infections after implementation of a care França AKTC, Santos AM, Abreu EB, Thomaz F, team education program focused on standard Silva AAM, Salgado-Filho N. Fatores associados precaution. This is the primary strategy for a qualidade de vida de adultos em preventing healthcare-related transmitted hemodiálise em uma cidade do nordeste infections and should be used in patient care, brasileiro. J bras nefrol [Internet]. 2013 environmental cleaning, appropriate Apr/June [cited 2016 Mar 18];35(2):79-86.

English/Portuguese J Nurs UFPE on line., Recife, 11(3):1127-35, Mar., 2017 1133 ISSN: 1981-8963 DOI: 10.5205/reuol.10544-93905-1-RV.1103201702

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