Nursing care with surgical arteriovenous shunt in renal dialysis: a validation study

Silva, Eduardo Fernandes da; Lins, Silvia Maria de Sá Basilio; Tavares, Joyce Martins Arimatea Branco; Marta, Cristiano Bertolossi; Fuly, Patrícia dos Santos Claro; Broca, Priscilla Valadares

doi:10.1590/0034-7167-2019-0012

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Brasil

Revista Brasileira de Enfermagem

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Brasil

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Sumário

ORIGINAL ARTICLE • Rev. Bras. Enferm. 73 (6) • 2020 • https://doi.org/10.1590/0034-7167-2019-0012 copy

Nursing care with surgical arteriovenous shunt in renal dialysis: a validation study

Cuidado de enfermería con la derivación arteriovenosa quirúrgica en la diálisis renal: estudio de validación

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objectives:

to validate a care protocol for the monitoring and prevention of arteriovenous fistula complications.

Methods:

a validation methodological study with a quantitative approach, developed in a university hospital in the city of Rio de Janeiro.

Results:

scientific evidence was gathered from 20 researches. A care protocol was developed, composed of 15 items and divided into 3 sessions. The protocol was validated by a group of 11 experts, obtaining a content validity index of 0.95.

Conclusions:

the protocol proposes nursing care capable of preventing and monitoring arteriovenous fistula complications, punctured with a traditional technique, taking into account the actions implemented from patients’ entry into the machine until the end of therapy.

Descriptors:
Arteriovenous Shunt, Surgical; Renal Dialysis; Nurse’s Role; Nursing Care; Nephrology Nursing

ITEMS	STAGES
ITEMS	What to do?	What to observe?	What am I preventing?
Item 1	- To make sure patients have washed the arm⁽²2 Dos Anjos MD, Oselame GB. Cuidados de enfermagem para pacientes idosos com fístula arteriovenosa em terapia de hemodiálise. Rev UNIANDRADE [Internet]. 2013[cited 2018 Jun 08];14(3):251-62. Available from: https://www.uniandrade.br/revistauniandrade/index.php/revistauniandrade/article/view/80 https://www.uniandrade.br/revistauniandr... ⁾.	- Correct arm washing.	Infection
Item 2	- To perform AVF inspection and antisepsis and assess the rest of the arm, shoulder, breast, neck and face⁽⁸8 Sousa CN. Cuidar da pessoa com fístula arteriovenosa: modelo para a melhoria contínua. Rev Port Saúde Pública. 2012;30(1):11-17. doi: 10.1016/j.rpsp.2011.11.001. https://doi.org/10.1016/j.rpsp.2011.11.0... 9 Asif A, Leon C, Orozco-Vargas LC, Krishnamurthy G, Choi KL, Mercado C, et al. Accuracy of physical examination in the detection of arteriovenous graft stenosis. Semin Dial. 2008;21:85-88. doi: 10.1111/j.1525-139X.2007.00382.x https://doi.org/10.1111/j.1525-139X.2007... ^-¹⁰10 Beathard GA. An algorithm for the physical examination of early fistula failure. Semin Dial. 2015;18:331-335. doi: 10.1111/j.1525-139X.2005.18314.x https://doi.org/10.1111/j.1525-139X.2005... ⁾. - To record the presence of edema or collateral veins in any of these areas⁽⁸8 Sousa CN. Cuidar da pessoa com fístula arteriovenosa: modelo para a melhoria contínua. Rev Port Saúde Pública. 2012;30(1):11-17. doi: 10.1016/j.rpsp.2011.11.001. https://doi.org/10.1016/j.rpsp.2011.11.0... 9 Asif A, Leon C, Orozco-Vargas LC, Krishnamurthy G, Choi KL, Mercado C, et al. Accuracy of physical examination in the detection of arteriovenous graft stenosis. Semin Dial. 2008;21:85-88. doi: 10.1111/j.1525-139X.2007.00382.x https://doi.org/10.1111/j.1525-139X.2007... ^-¹⁰10 Beathard GA. An algorithm for the physical examination of early fistula failure. Semin Dial. 2015;18:331-335. doi: 10.1111/j.1525-139X.2005.18314.x https://doi.org/10.1111/j.1525-139X.2005... ⁾. - To perform the rapid examination of arteriovenous access through tests such as: pulse increase test and arm lift test. Pulse increase test performed with complete access occlusion several centimeters beyond arterial anastomosis and pulse strength assessment; Arm lift test: performed by arm lift and examination of normal collapse of an AVF⁽⁹9 Asif A, Leon C, Orozco-Vargas LC, Krishnamurthy G, Choi KL, Mercado C, et al. Accuracy of physical examination in the detection of arteriovenous graft stenosis. Semin Dial. 2008;21:85-88. doi: 10.1111/j.1525-139X.2007.00382.x https://doi.org/10.1111/j.1525-139X.2007... ⁾.	- If there are dirt or signs of infection. - Presence of edema and collateral veins. - In the pulse increase test, it is considered normal when there is a pulse increase in the upstream (arterial) part of the finger occlusion. - Usually when we occlude the exit of an arteriovenous access, we have two effects: fremitus disappears or the part of the upstream (arterial) access to the finger should become hyperpulsable. If the fremitus persists, suspect an accessory outlet. - Arm lift test is abnormal when the fistula becomes "full" after arm lift and there is no collapse, an indication of downstream (outflow or "venous") stenosis.	Infection Stenosis
Item 3	- To perform palpation of AVF⁽²2 Dos Anjos MD, Oselame GB. Cuidados de enfermagem para pacientes idosos com fístula arteriovenosa em terapia de hemodiálise. Rev UNIANDRADE [Internet]. 2013[cited 2018 Jun 08];14(3):251-62. Available from: https://www.uniandrade.br/revistauniandrade/index.php/revistauniandrade/article/view/80 https://www.uniandrade.br/revistauniandr... ⁾. - To auscultate AVF⁽²2 Dos Anjos MD, Oselame GB. Cuidados de enfermagem para pacientes idosos com fístula arteriovenosa em terapia de hemodiálise. Rev UNIANDRADE [Internet]. 2013[cited 2018 Jun 08];14(3):251-62. Available from: https://www.uniandrade.br/revistauniandrade/index.php/revistauniandrade/article/view/80 https://www.uniandrade.br/revistauniandr... ⁾.	- Perception of fremitus and murmur. - Normality presents with a soft pulse, i.e., the pressure necessary to interrupt the pulsations is small. - Normality of the fremitus resembles a "tinnitus" that can be palpated with the fingers continuously. - Intermittent fremitus suggests arterial stenosis. - Auscultation assesses the quality of the blow. It enables detection and localization of a stenosis by assessing the continuity or intermittence of the murmur.	Stenosis Thrombosis
Item 4	- To choose needle gauge according to vein size, maturity and volume to be reached⁽³3 Alfonso SM, Cruz DO, Cona YM, González BN. Aneurisma de fístula arteriovenosa para hemodiálisis. Rev Cuba Ci [Internet]. 2013[cited 2018 Jun 08];52(3)211-7. Available from: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-74932013000300006 http://scielo.sld.cu/scielo.php?script=s... ^-⁴4 Ministério da Saúde (BR). Portaria nº 1.675, de 7 de junho de 2018. Brasília (DF); 2018.^,¹¹11 Sousa CN, Apóstolo JL, Figueiredo MH, Martins MM, Dias VF. Physical examination: how to examine the arm with arteriovenous fistula. Hemodialysis Int. 2013;17:300-6. doi: 10.1111/j.1542-4758.2012.00714.x https://doi.org/10.1111/j.1542-4758.2012... ⁾. - To start use of AVF (1^st use) with smaller needle gauge⁽⁸8 Sousa CN. Cuidar da pessoa com fístula arteriovenosa: modelo para a melhoria contínua. Rev Port Saúde Pública. 2012;30(1):11-17. doi: 10.1016/j.rpsp.2011.11.001. https://doi.org/10.1016/j.rpsp.2011.11.0... ⁾. - 17 G - 250 ml flow⁽⁸8 Sousa CN. Cuidar da pessoa com fístula arteriovenosa: modelo para a melhoria contínua. Rev Port Saúde Pública. 2012;30(1):11-17. doi: 10.1016/j.rpsp.2011.11.001. https://doi.org/10.1016/j.rpsp.2011.11.0... ⁾. - 16 G - 350 ml flow⁽⁸8 Sousa CN. Cuidar da pessoa com fístula arteriovenosa: modelo para a melhoria contínua. Rev Port Saúde Pública. 2012;30(1):11-17. doi: 10.1016/j.rpsp.2011.11.001. https://doi.org/10.1016/j.rpsp.2011.11.0... ⁾. - To access more mature AVF with larger needle gauge⁽⁸8 Sousa CN. Cuidar da pessoa com fístula arteriovenosa: modelo para a melhoria contínua. Rev Port Saúde Pública. 2012;30(1):11-17. doi: 10.1016/j.rpsp.2011.11.001. https://doi.org/10.1016/j.rpsp.2011.11.0... ⁾. - 15 G -> 350 ml flow⁽⁸8 Sousa CN. Cuidar da pessoa com fístula arteriovenosa: modelo para a melhoria contínua. Rev Port Saúde Pública. 2012;30(1):11-17. doi: 10.1016/j.rpsp.2011.11.001. https://doi.org/10.1016/j.rpsp.2011.11.0... ⁾.	- If the chosen needle matches the prescribed blood flow volume and vessel maturity. - Rule of six: a mature AVF should follow the "rule of 6" - should be 6 mm in diameter, be less than 6 mm below the skin, have a minimum blood flow of 600 ml/min and have a straight cannulation segment minimum 6 cm. Maturation generally should occur around six weeks after surgery.
Item 5	- To avoid repeating the previous puncture site⁽⁸8 Sousa CN. Cuidar da pessoa com fístula arteriovenosa: modelo para a melhoria contínua. Rev Port Saúde Pública. 2012;30(1):11-17. doi: 10.1016/j.rpsp.2011.11.001. https://doi.org/10.1016/j.rpsp.2011.11.0... ^,¹²12 Medina IMF. Cuidados de la Fístula Arteriovenosa durante la sesión de Hemodiálisis. ENE-Rev Enferm. 2013;7(1). Available from: http://ene-enfermeria.org/ojs/index.php/ENE/article/view/199 http://ene-enfermeria.org/ojs/index.php/... ⁾. - To maintain a space of 3 (three) centimeters from the anastomosis site for the arterial puncture and for the venous to maintain a space of 5 (five) centimeters in relation to the arterial⁽⁸8 Sousa CN. Cuidar da pessoa com fístula arteriovenosa: modelo para a melhoria contínua. Rev Port Saúde Pública. 2012;30(1):11-17. doi: 10.1016/j.rpsp.2011.11.001. https://doi.org/10.1016/j.rpsp.2011.11.0... ^,¹²12 Medina IMF. Cuidados de la Fístula Arteriovenosa durante la sesión de Hemodiálisis. ENE-Rev Enferm. 2013;7(1). Available from: http://ene-enfermeria.org/ojs/index.php/ENE/article/view/199 http://ene-enfermeria.org/ojs/index.php/... ⁾.	- Vessel dilation, skin thickness and bleeding time after puncture. - Normal bleeding time: approximately 10 to 15 minutes - Excessive bleeding after puncture:> 20 minutes. - If the needles are too close. - If the space between them is being respected.	Pseudoaneurysm
Item 6	- Do not puncture eroded, reddened or injured areas⁽⁸8 Sousa CN. Cuidar da pessoa com fístula arteriovenosa: modelo para a melhoria contínua. Rev Port Saúde Pública. 2012;30(1):11-17. doi: 10.1016/j.rpsp.2011.11.001. https://doi.org/10.1016/j.rpsp.2011.11.0... ^,¹¹11 Sousa CN, Apóstolo JL, Figueiredo MH, Martins MM, Dias VF. Physical examination: how to examine the arm with arteriovenous fistula. Hemodialysis Int. 2013;17:300-6. doi: 10.1111/j.1542-4758.2012.00714.x https://doi.org/10.1111/j.1542-4758.2012... ^-¹²12 Medina IMF. Cuidados de la Fístula Arteriovenosa durante la sesión de Hemodiálisis. ENE-Rev Enferm. 2013;7(1). Available from: http://ene-enfermeria.org/ojs/index.php/ENE/article/view/199 http://ene-enfermeria.org/ojs/index.php/... ⁾.	- If the chosen area shows any of these signs.	Infection
Item 7	- To turn the needle bevel after puncturing downward, allowing full access channeling and to minimize post-puncture bleeding⁽³3 Alfonso SM, Cruz DO, Cona YM, González BN. Aneurisma de fístula arteriovenosa para hemodiálisis. Rev Cuba Ci [Internet]. 2013[cited 2018 Jun 08];52(3)211-7. Available from: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=S0034-74932013000300006 http://scielo.sld.cu/scielo.php?script=s... ^,¹³13 Toregeani JF, Kimura CJ, Rocha AST, Volpiani GG, Bortoncello A, Shirasu K, et. al. Avaliação da maturação das fístulas arteriovenosas para hemodiálise pelo eco-Doppler colorido. J Vasc Bras. 2008;7(3). doi: 10.1590/S1677-54492008000300005 https://doi.org/10.1590/S1677-5449200800... ⁾.	- If positioning is in agreement and proper flow.	Pseudoaneurysm
Item 8	- To ensure needle attachment following unit protocol⁽¹⁴14 Santos I, Rocha RPF, Berardinelli LMM. Necessidades de orientação de enfermagem para o autocuidado de clientes em terapia de hemodiálise. Rev Bras Enferm. 2011;64(2):335-42. doi: 10.1590/S0034-71672011000200018 https://doi.org/10.1590/S0034-7167201100... ⁾.	- If the fixing is adequate. - If the needle is too far out.	Pseudoaneurysm
Item 9	- To check correct channeling and permeability of vascular access with a syringe and saline⁽²2 Dos Anjos MD, Oselame GB. Cuidados de enfermagem para pacientes idosos com fístula arteriovenosa em terapia de hemodiálise. Rev UNIANDRADE [Internet]. 2013[cited 2018 Jun 08];14(3):251-62. Available from: https://www.uniandrade.br/revistauniandrade/index.php/revistauniandrade/article/view/80 https://www.uniandrade.br/revistauniandr... ⁾. - To connect patient to cardiopulmonary bypass after verification⁽²2 Dos Anjos MD, Oselame GB. Cuidados de enfermagem para pacientes idosos com fístula arteriovenosa em terapia de hemodiálise. Rev UNIANDRADE [Internet]. 2013[cited 2018 Jun 08];14(3):251-62. Available from: https://www.uniandrade.br/revistauniandrade/index.php/revistauniandrade/article/view/80 https://www.uniandrade.br/revistauniandr... ⁾.	- If there is proper flow.	Thrombosis
Item 10	- To pay attention to monitoring vital signs, especially blood pressure⁽²2 Dos Anjos MD, Oselame GB. Cuidados de enfermagem para pacientes idosos com fístula arteriovenosa em terapia de hemodiálise. Rev UNIANDRADE [Internet]. 2013[cited 2018 Jun 08];14(3):251-62. Available from: https://www.uniandrade.br/revistauniandrade/index.php/revistauniandrade/article/view/80 https://www.uniandrade.br/revistauniandr... ^,⁸8 Sousa CN. Cuidar da pessoa com fístula arteriovenosa: modelo para a melhoria contínua. Rev Port Saúde Pública. 2012;30(1):11-17. doi: 10.1016/j.rpsp.2011.11.001. https://doi.org/10.1016/j.rpsp.2011.11.0... ^,¹²12 Medina IMF. Cuidados de la Fístula Arteriovenosa durante la sesión de Hemodiálisis. ENE-Rev Enferm. 2013;7(1). Available from: http://ene-enfermeria.org/ojs/index.php/ENE/article/view/199 http://ene-enfermeria.org/ojs/index.php/... ⁾.	- Alteration of vital signs.	Thrombosis
Item 11	- Remove the needle if hematoma or blood leakage occurs at the time of puncture and do not manipulate the puncture site⁽¹²12 Medina IMF. Cuidados de la Fístula Arteriovenosa durante la sesión de Hemodiálisis. ENE-Rev Enferm. 2013;7(1). Available from: http://ene-enfermeria.org/ojs/index.php/ENE/article/view/199 http://ene-enfermeria.org/ojs/index.php/... ^,¹⁵15 Silva KA, Nunes ZB. As intervenções de enfermagem mais prevalentes em um serviço de hemodiálise frente às intercorrências com a fístula arteriovenosa durante a sessão de hemodiálise. J Health Sci Inst [Internet]. 2011[cited 2018 Jun 08];29(2):110-3. Available from: https://pesquisa.bvsalud.org/portal/resource/pt/lil-606306 https://pesquisa.bvsalud.org/portal/reso... ⁾. - To compress the site to hemostasis⁽¹²12 Medina IMF. Cuidados de la Fístula Arteriovenosa durante la sesión de Hemodiálisis. ENE-Rev Enferm. 2013;7(1). Available from: http://ene-enfermeria.org/ojs/index.php/ENE/article/view/199 http://ene-enfermeria.org/ojs/index.php/... ^,¹⁵15 Silva KA, Nunes ZB. As intervenções de enfermagem mais prevalentes em um serviço de hemodiálise frente às intercorrências com a fístula arteriovenosa durante a sessão de hemodiálise. J Health Sci Inst [Internet]. 2011[cited 2018 Jun 08];29(2):110-3. Available from: https://pesquisa.bvsalud.org/portal/resource/pt/lil-606306 https://pesquisa.bvsalud.org/portal/reso... ⁾. - To perform cold compress on site⁽¹⁵15 Silva KA, Nunes ZB. As intervenções de enfermagem mais prevalentes em um serviço de hemodiálise frente às intercorrências com a fístula arteriovenosa durante a sessão de hemodiálise. J Health Sci Inst [Internet]. 2011[cited 2018 Jun 08];29(2):110-3. Available from: https://pesquisa.bvsalud.org/portal/resource/pt/lil-606306 https://pesquisa.bvsalud.org/portal/reso... ⁾.	- Signs of extravasation or local hematoma.	Pseudoaneurysm Thrombosis
Item 12	- To monitor hemodynamic parameters during dialysis session, such as access flow, blood circuit flow and dynamic pressures; Pre-pumping blood pressure: -80 to -200 mmHg, should not exceed - 250 mmHg⁽¹⁰10 Beathard GA. An algorithm for the physical examination of early fistula failure. Semin Dial. 2015;18:331-335. doi: 10.1111/j.1525-139X.2005.18314.x https://doi.org/10.1111/j.1525-139X.2005... ⁾. - To check circuit venous pressure: always positive value. Ideal is between 50 and 250 mmHg. Increased venous pressure means that access is with problems such as recirculation of the fistula that worsens the quality of dialysis and increases the risk of thrombosis⁽¹⁰10 Beathard GA. An algorithm for the physical examination of early fistula failure. Semin Dial. 2015;18:331-335. doi: 10.1111/j.1525-139X.2005.18314.x https://doi.org/10.1111/j.1525-139X.2005... ⁾.	- If there is anything outside the parameter. - Normal operation of the dialysis machine.	Stenosis Thrombosis
Item 13	- To reposition the needle or perform a new puncture in case of (arterial) inflow, characterized by insufficient blood supply to the pump, as the needle may be attached to the vessel wall⁽²2 Dos Anjos MD, Oselame GB. Cuidados de enfermagem para pacientes idosos com fístula arteriovenosa em terapia de hemodiálise. Rev UNIANDRADE [Internet]. 2013[cited 2018 Jun 08];14(3):251-62. Available from: https://www.uniandrade.br/revistauniandrade/index.php/revistauniandrade/article/view/80 https://www.uniandrade.br/revistauniandr... ^,¹²12 Medina IMF. Cuidados de la Fístula Arteriovenosa durante la sesión de Hemodiálisis. ENE-Rev Enferm. 2013;7(1). Available from: http://ene-enfermeria.org/ojs/index.php/ENE/article/view/199 http://ene-enfermeria.org/ojs/index.php/... ^,¹⁶16 Paiva TRS, Lima FET. Manutenção das fístulas arteriovenosas confeccionadas no Centro de Nefrologia de Caucaia-CE. Rev Min Enferm [Internet]. 2008[cited 2018 Jun 08];12(3):313-20. Available from: http://www.reme.org.br/artigo/detalhes/271 http://www.reme.org.br/artigo/detalhes/2... ⁾.	- Whether the supplied flow is being adequate. - Gauge of the chosen needle compatible with access.	Thrombosis
Item 14	- To carefully remove the needle at the end of the session⁽²2 Dos Anjos MD, Oselame GB. Cuidados de enfermagem para pacientes idosos com fístula arteriovenosa em terapia de hemodiálise. Rev UNIANDRADE [Internet]. 2013[cited 2018 Jun 08];14(3):251-62. Available from: https://www.uniandrade.br/revistauniandrade/index.php/revistauniandrade/article/view/80 https://www.uniandrade.br/revistauniandr... ^,⁸8 Sousa CN. Cuidar da pessoa com fístula arteriovenosa: modelo para a melhoria contínua. Rev Port Saúde Pública. 2012;30(1):11-17. doi: 10.1016/j.rpsp.2011.11.001. https://doi.org/10.1016/j.rpsp.2011.11.0... ⁾. - To wait for a minimum hemostasis time of 10 to 15 minutes or until a stable clot is formed at the puncture site⁽²2 Dos Anjos MD, Oselame GB. Cuidados de enfermagem para pacientes idosos com fístula arteriovenosa em terapia de hemodiálise. Rev UNIANDRADE [Internet]. 2013[cited 2018 Jun 08];14(3):251-62. Available from: https://www.uniandrade.br/revistauniandrade/index.php/revistauniandrade/article/view/80 https://www.uniandrade.br/revistauniandr... ^,⁸8 Sousa CN. Cuidar da pessoa com fístula arteriovenosa: modelo para a melhoria contínua. Rev Port Saúde Pública. 2012;30(1):11-17. doi: 10.1016/j.rpsp.2011.11.001. https://doi.org/10.1016/j.rpsp.2011.11.0... ^,¹²12 Medina IMF. Cuidados de la Fístula Arteriovenosa durante la sesión de Hemodiálisis. ENE-Rev Enferm. 2013;7(1). Available from: http://ene-enfermeria.org/ojs/index.php/ENE/article/view/199 http://ene-enfermeria.org/ojs/index.php/... ⁾.	- If there was blood leakage. - Excessive bleeding (> 20 minutes). - A bleeding for more than twenty minutes may be related to the amount of anticoagulant and antihypertensive. - Emergence of hematoma.	Thrombosis Pseudoaneurysm
Item 15	- To perform dressing with light compression, with gauze, for approximately five minutes, with tape and gauze after complete hemostasis⁽¹²12 Medina IMF. Cuidados de la Fístula Arteriovenosa durante la sesión de Hemodiálisis. ENE-Rev Enferm. 2013;7(1). Available from: http://ene-enfermeria.org/ojs/index.php/ENE/article/view/199 http://ene-enfermeria.org/ojs/index.php/... ^,¹⁷17 Huber TS, Larive B, Imrey PB, Radeva MK, Kaufman JM, Kraiss LW, et al. Access related hand ischemia and the hemodialysis fistula maturation study. J Vasc Surg. 2016;64(4):1050-8. doi: 10.1016/j.jvs.2016.03.449 https://doi.org/10.1016/j.jvs.2016.03.44... ⁾. - To advise patients to be removed only six hours after the end of dialysis, guiding them to be kept dry and clean⁽¹²12 Medina IMF. Cuidados de la Fístula Arteriovenosa durante la sesión de Hemodiálisis. ENE-Rev Enferm. 2013;7(1). Available from: http://ene-enfermeria.org/ojs/index.php/ENE/article/view/199 http://ene-enfermeria.org/ojs/index.php/... ^,¹⁷17 Huber TS, Larive B, Imrey PB, Radeva MK, Kaufman JM, Kraiss LW, et al. Access related hand ischemia and the hemodialysis fistula maturation study. J Vasc Surg. 2016;64(4):1050-8. doi: 10.1016/j.jvs.2016.03.449 https://doi.org/10.1016/j.jvs.2016.03.44... ⁾.	- Whether the dressing stays clean until the moment patients are in the environment. - In case of extravasation, change the dressing after new hemostasis.	Infection

ITEM	CVI	ITEM	CVI	ITEM	CVI
1	1.0	6	1.0	11	1.0
2	1.0	7	0.63	12	1.0
3	0.9	8	1.0	13	1.0
4	1.0	9	0.81	14	1.0
5	1.0	10	1.0	15	1.0
TOOL'S FINAL CVI = 0.95

ITEM	COMMENT/SUGGESTION
1	- Patient guidance on arm washing (What to do?)
2	- Observation of distal cyanosis (What to do?)
5	- Blood recirculation (What am I preventing?)
7	- Hematoma (What am I preventing?)
8	- Preference for puncture with bevel down when possible (What to do?)
9	- Hematoma (What am I preventing?)
11	- Hematoma (What am I preventing?)
15	- Gauze change only if it is visibly soiled (What to do?)

Associação Brasileira de Enfermagem SGA Norte Quadra 603 Conj. "B" - Av. L2 Norte 70830-102 Brasília, DF, Brasil, Tel.: (55 61) 3226-0653, Fax: (55 61) 3225-4473 - Brasília - DF - Brazil
E-mail: reben@abennacional.org.br

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[1] Corresponding author: Eduardo Fernandes da Silva E-mail: eduardofsilva.enf@gmail.com