CHAPTER 43 NURSING CARE OF MALE PATIENTS WITH

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CHAPTER 43 NURSING CARE OF MALE PATIENTS WITH GENITOURINARY DISORDERS

CHAPTER 43 NURSING CARE OF MALE PATIENTS WITH GENITOURINARY DISORDERS

PROSTATE DISORDERS • Prostatitis • Benign Prostatic Hyperplasia • Prostate Cancer

PROSTATE DISORDERS • Prostatitis • Benign Prostatic Hyperplasia • Prostate Cancer

PROSTATITIS • Inflammation of prostate gland • Can be acute or chronic • 4

PROSTATITIS • Inflammation of prostate gland • Can be acute or chronic • 4 types • Acute bacterial • Chronic prostatitis/chronic pelvic pain syndrome • Asymptomatic inflammatory prostatitis

PROSTATITIS • Signs and Symptoms • Urine Retention • Pain • Fever, Chills •

PROSTATITIS • Signs and Symptoms • Urine Retention • Pain • Fever, Chills • Urgency • Low back pain • Frequency • Perineal pain • Hesitancy • Postejaculation pain • Dribbling • Dysuria

PROSTATITIS • Diagnosis • Interventions • Digital Rectal Exam (DRE) • Antibiotics • Urine

PROSTATITIS • Diagnosis • Interventions • Digital Rectal Exam (DRE) • Antibiotics • Urine Culture • Anti-inflammatory Agents • Expressed Prostate Secretion (EPS) • Stool Softeners • Cystoscopy • Prostatic Massage • Sitz Baths • Dietary Changes • Alpha-Adrenergic Blockers • Surgery

PROSTATITIS • Prevention • Complications • Regular and complete emptying of bladder • Urinary

PROSTATITIS • Prevention • Complications • Regular and complete emptying of bladder • Urinary retention • Safe sexual practices • Secondary infections • Avoid bladder irritants • Erectile dysfunction

PROSTATITIS • Nursing Diagnoses • Urinary Retention • Knowledge deficit related to cause, treatment

PROSTATITIS • Nursing Diagnoses • Urinary Retention • Knowledge deficit related to cause, treatment and prevention of prostatitis • Acute Pain • Anxiety

BENIGN PROSTATIC HYPERPLASIA (BPH) • Increase in number of cells • Signs and Symptoms

BENIGN PROSTATIC HYPERPLASIA (BPH) • Increase in number of cells • Signs and Symptoms • Obstruction • • • Decrease in force of stream Hesitancy Dribbling Urinary retention Incontinence Feelings of incomplete emptying • Irritation • Nocturia • Dysuria • Urgency

BENIGN PROSTATIC HYPERPLASIA (BPH) • Diagnosis • DRE • Urinalysis • BUN, Creatinine •

BENIGN PROSTATIC HYPERPLASIA (BPH) • Diagnosis • DRE • Urinalysis • BUN, Creatinine • Prostate Specific Antigen (PSA) • Urodynamic Flow Studies • Transrectal Ultrasound • Cystoscopy

THERAPEUTIC INTERVENTIONS • Symptom Control • Interventions • Catheterization • “Watchful Waiting” • Fluids

THERAPEUTIC INTERVENTIONS • Symptom Control • Interventions • Catheterization • “Watchful Waiting” • Fluids • Alpha-Adrenergic Blockers • Antibiotics • Nonsurgical Invasive Treatments • Surgery

TRANSURETHRAL RESECTION OF THE PROSTATE (TURP) • Resectoscope into Urethra • Overgrown Tissue Chipped

TRANSURETHRAL RESECTION OF THE PROSTATE (TURP) • Resectoscope into Urethra • Overgrown Tissue Chipped Away • Prostate Tissue Regenerates • Continuous Catheter Irrigation • Monitor Urine

BLADDER IRRIGATION

BLADDER IRRIGATION

TURP • Complications • Clots • Bladder Spasms • Infection • Urinary Incontinent •

TURP • Complications • Clots • Bladder Spasms • Infection • Urinary Incontinent • Hemorrhage • Erectile Dysfunction • Retrograde Ejaculation

RADICAL PROSTATECTOMY • Removal of entire prostate gland • Methods • Open prostatectomy •

RADICAL PROSTATECTOMY • Removal of entire prostate gland • Methods • Open prostatectomy • Suprapubic • Retropubic • Perineal • Minimally invasive prostatectomy • Laparoscopic

PROSTATECTOMY

PROSTATECTOMY

POSTOPERATIVE NURSING DIAGNOSES • Risk for Bleeding • Monitor Urine Output and Bleeding •

POSTOPERATIVE NURSING DIAGNOSES • Risk for Bleeding • Monitor Urine Output and Bleeding • Encourage Fluids • Teach Patient to Avoid • Constipation • Lifting • Aspirin and NSAIDS

POSTOPERATIVE NURSING DIAGNOSES • Acute Pain • Monitor Pain • Irrigate Catheter as Ordered

POSTOPERATIVE NURSING DIAGNOSES • Acute Pain • Monitor Pain • Irrigate Catheter as Ordered • Administer Analgesics, Antispasmodics • Teach Relaxation and Deep Breathing

POSTOPERATIVE NURSING DIAGNOSES • Urge Urinary Incontinence • Teach Kegel Exercises • Offer Condom

POSTOPERATIVE NURSING DIAGNOSES • Urge Urinary Incontinence • Teach Kegel Exercises • Offer Condom Catheter or Pads • Encourage to Continue Fluids • Discuss Prolonged Incontinence with Physician

POSTOPERATIVE NURSING DIAGNOSES • Knowledge Deficit • Teach to Avoid (About 6 Weeks) •

POSTOPERATIVE NURSING DIAGNOSES • Knowledge Deficit • Teach to Avoid (About 6 Weeks) • Heavy Lifting • Stairs • Driving • Strenuous Exercise • Straining • Sexual Activity • Aspirin and NSAIDS

POSTOPERATIVE NURSING DIAGNOSES • Anxiety • Educate • Retrograde Ejaculation • Talk with Physician

POSTOPERATIVE NURSING DIAGNOSES • Anxiety • Educate • Retrograde Ejaculation • Talk with Physician if Erectile Dysfunction Occurs

PROSTATE CANCER • Most common cancer for men • Testosterone driven • Spreads by

PROSTATE CANCER • Most common cancer for men • Testosterone driven • Spreads by 3 routes • Local invasion • Lymph nodes • Vascular system

PROSTATE CANCER • Risk Factors • Age • High Testosterone • High Fat Diet

PROSTATE CANCER • Risk Factors • Age • High Testosterone • High Fat Diet • Family History • African American • Occupational Exposures

PROSTATE CANCER • Signs and Symptoms • Rare in Early Stages • Later Stages

PROSTATE CANCER • Signs and Symptoms • Rare in Early Stages • Later Stages • Urinary Obstruction • Hematuria • Urinary Retention • Advanced (Metastatic) • Bone Pain • Anemia • Weakness • Weight Loss • Fatigue

PROSTATE CANCER • Diagnosis • DRE • PSA • PAP • Transurethral Ultrasound with

PROSTATE CANCER • Diagnosis • DRE • PSA • PAP • Transurethral Ultrasound with Biopsy • Bone Scan

PROSTATE CANCER • Therapeutic Interventions • Early • Testosterone-Suppressing Medications • Later Stages •

PROSTATE CANCER • Therapeutic Interventions • Early • Testosterone-Suppressing Medications • Later Stages • TURP or Prostatectomy • Radiation Therapy • Brachytherapy • Metastatic • • Bilateral Orchiectomy Estrogen Therapy Chemotherapy, Radiation Radical Prostatectomy

PROSTATE CANCER • Complications • Difficulty Urinating • Infection • Erectile Dysfunction • Pain

PROSTATE CANCER • Complications • Difficulty Urinating • Infection • Erectile Dysfunction • Pain • Fractures • Weight Loss • Depression

PENILE DISORDERS • Peyronie’s Disease • Curved/Crooked when Erect • Priapism • Prolonged Painful

PENILE DISORDERS • Peyronie’s Disease • Curved/Crooked when Erect • Priapism • Prolonged Painful Erection • Phimosis/Paraphimosis • Foreskin not Retractable

CANCER OF THE PENIS • Risk Factors • Not Circumcised as Baby • HPV

CANCER OF THE PENIS • Risk Factors • Not Circumcised as Baby • HPV • Therapeutic Interventions • Surgery • Radiation • Chemotherapy

TESTICULAR DISORDERS • Cryptorchidism • Undescended Testes • Hydrocele • Fluid in Scrotal Sac

TESTICULAR DISORDERS • Cryptorchidism • Undescended Testes • Hydrocele • Fluid in Scrotal Sac • Varicocele • Varicose Veins of Scrotum • Epididymitis • Inflammation or Infection of Epididymis • Orchitis • Inflammation or Infection of Testes

TESTICULAR CANCER • Risk Factors • Cryptorchidism • Family History • DES Use by

TESTICULAR CANCER • Risk Factors • Cryptorchidism • Family History • DES Use by Mother • Caucasian • High Socioeconomic Status

TESTICULAR CANCER • Signs and Symptoms • Early • Small Painless Lump • Swelling

TESTICULAR CANCER • Signs and Symptoms • Early • Small Painless Lump • Swelling • Heavy Feeling • Breast Enlargement and Tenderness • Late • Symptoms of Metastasis

TESTICULAR CANCER • Diagnosis • Ultrasound • Chest X-Ray and CT • Blood for

TESTICULAR CANCER • Diagnosis • Ultrasound • Chest X-Ray and CT • Blood for Tumor Markers • Biopsy • Staging

TESTICULAR CANCER • Therapeutic Interventions • Surgery • Radiation • Chemotherapy

TESTICULAR CANCER • Therapeutic Interventions • Surgery • Radiation • Chemotherapy

TESTICULAR CANCER • Nursing Care • Teach Testicular Self-Examination • Provide Emotional Support •

TESTICULAR CANCER • Nursing Care • Teach Testicular Self-Examination • Provide Emotional Support • Discuss Sperm Bank Deposit • Offer Cancer Support Group

VASECTOMY • Cut or Cauterize Vas Deferens • Provides Permanent Birth Control • Effective

VASECTOMY • Cut or Cauterize Vas Deferens • Provides Permanent Birth Control • Effective About 3 Months Following Surgery

VASECTOMY

VASECTOMY

ERECTILE DYSFUNCTION (ED) • Problem Obtaining or Maintaining Erection • Pathophysiology/Etiology § Circulation §

ERECTILE DYSFUNCTION (ED) • Problem Obtaining or Maintaining Erection • Pathophysiology/Etiology § Circulation § Nerve Supply § Hormone Balance § Limbic System § Obstructive Sleep Apnea § § § Medications Stress Illness Fatigue Alcohol/Drugs

ERECTILE DYSFUNCTION • Diagnosis • History • Blood Tests • Glucose • Testosterone •

ERECTILE DYSFUNCTION • Diagnosis • History • Blood Tests • Glucose • Testosterone • Liver, Cardiac, and Kidney • Blood Disorders • Infection • Evaluation of Circulation • Psychosocial Evaluation

ERECTILE DYSFUNCTION • Therapeutic Interventions • Medication • Meaningful Relationship • Injection • Medication

ERECTILE DYSFUNCTION • Therapeutic Interventions • Medication • Meaningful Relationship • Injection • Medication Changes • Transurethral • Oral Medication • Viagra, Cialis, Levitra • Hormone Therapy • Herbal Remedies • Sexual Devices • Surgery • Implants • Vascular Surgery

PENILE IMPLANTS

PENILE IMPLANTS

INFERTILITY • Causes • Pretesticular • Endocrine • Testicular • Varicocele • Idiopathic (spontaneous)

INFERTILITY • Causes • Pretesticular • Endocrine • Testicular • Varicocele • Idiopathic (spontaneous) • Post-testicular • Surgery • Injury

INFERTILITY • Diagnosis • History • Physical Examination • Diagnostics

INFERTILITY • Diagnosis • History • Physical Examination • Diagnostics

INFERTILITY • Therapeutic Interventions • Changes in Sexual or Lifestyle Practices • Surgery if

INFERTILITY • Therapeutic Interventions • Changes in Sexual or Lifestyle Practices • Surgery if Indicated • In Vitro Procedures • Adoption

A man comes to a clinic with complaints of frequency, urgency, and feeling that

A man comes to a clinic with complaints of frequency, urgency, and feeling that he canno empty his bladder. The nurse expects to prepare him for which procedure? 1. Blood test for prostate-specific antigen 2. Blood test for human chorionic gonadotropin 3. Digital rectal exam of the prostrate 4. Urodynamic flow study

A client has a diagnosis of Benign prostatic hyperplasia (BPH) and asks what the

A client has a diagnosis of Benign prostatic hyperplasia (BPH) and asks what the doctor means by “watchful waiting. ” Which response by the nurse is best? 1. “The doctor will have you visit once a month to check out your prostate. ” 2. “The doctor will want you to report back on your symptoms regularly to monitor your condition. ” 3. “You don’t have anything wrong with your prostate yet, but you will need to get it checked on often. ” 4. “ I am not really sure what he means by that, but I will have him come back and talk to you. ”

Which assessment finding is expected in a man diagnosed with varicocele? 1. Scrotum is

Which assessment finding is expected in a man diagnosed with varicocele? 1. Scrotum is tender and red. 2. Scrotum feels like a “bag of worms. ” 3. Painless lump is noted on testicle. 4. Testicle is extremely tender.

A 28 year male reports to the nurse that he has been having trouble

A 28 year male reports to the nurse that he has been having trouble maintaining an erection. Which assessment finding should the nurse further explore? 1. His father had prostate cancer at 70 years of age. 2. He has had multiple sex partners over the last five years. 3. He drinks about a case of beer over each weekend. 4. He smokes 2 packs of cigarettes per day.

A client has returned from a transurethral prostatectomy (TURP) with a continuous bladder irrigation.

A client has returned from a transurethral prostatectomy (TURP) with a continuous bladder irrigation. Which of the following assessment findings should the LPN/LVN report to the registered nurse? 1. BP 135/80, Pulse 88, Respirations 20, Temp 98. 0 2. Client states his pain is a level 6 out of 10 3. The catheter bag contains bright cherry red urine 4. The catheter tubing is secured to his abdomen

CHAPTER 37 ACUTE KIDNEY INJURY AND CHRONIC KIDNEY DISEASE

CHAPTER 37 ACUTE KIDNEY INJURY AND CHRONIC KIDNEY DISEASE

ACUTE KIDNEY INJURY (AKI) • Sudden Loss of Kidney Function • Azotemia • Accumulation

ACUTE KIDNEY INJURY (AKI) • Sudden Loss of Kidney Function • Azotemia • Accumulation of Toxic Waste • Fluid and Electrolyte Imbalance • 3 Phases: Oliguric, Diuretic, & Recovery • Can be Reversible

ACUTE KIDNEY INJURY • Oliguric Phase • Less than 20 -30 ml/hr or 400

ACUTE KIDNEY INJURY • Oliguric Phase • Less than 20 -30 ml/hr or 400 ml/day • Can last 2 weeks to several months • Fluid retention • Electrolyte imbalances • Metabolic acidosis

ACUTE KIDNEY INJURY • Diuretic Phase • Excretion of waste products again • Kidneys

ACUTE KIDNEY INJURY • Diuretic Phase • Excretion of waste products again • Kidneys unable to concentrate urine • Hypovolemia, Hypokalemia, and Hypotension • Can last 1 -3 weeks

ACUTE KIDNEY INJURY • Recovery Phase • Begins as glomerular filtration rate rises •

ACUTE KIDNEY INJURY • Recovery Phase • Begins as glomerular filtration rate rises • BUN and Creatinine decrease • Can take up to one year to fully recover

ACUTE KIDNEY INJURY CAUSES • Prerenal Failure • Intrarenal Failure • Postrenal Failure

ACUTE KIDNEY INJURY CAUSES • Prerenal Failure • Intrarenal Failure • Postrenal Failure

ACUTE KIDNEY INJURY CAUSES • Prerenal Injury • Decreased blood supply to the kidney

ACUTE KIDNEY INJURY CAUSES • Prerenal Injury • Decreased blood supply to the kidney • Causes • Dehydration, blood loss, shock, trauma or blockage in renal arteries, NSAIDs, COX inhibitors • Diagnosis • Determine the cause

ACUTE KIDNEY INJURY CAUSES • Intrarenal Injury • Damage to nephrons inside the kidney

ACUTE KIDNEY INJURY CAUSES • Intrarenal Injury • Damage to nephrons inside the kidney • Causes • Ischemia, reduced blood flow, toxins, infection, trauma, nephrotoxins, allergic reactions, and severe muscle injury

ACUTE KIDNEY INJURY CAUSES • Nephrotoxins • Diagnostic Contrast Media • Antibiotics • Analgesics

ACUTE KIDNEY INJURY CAUSES • Nephrotoxins • Diagnostic Contrast Media • Antibiotics • Analgesics • Other • Heavy Metals • Chemicals

ACUTE KIDNEY INJURY CAUSES • Postrenal Injury • Obstruction that blocks flow of urine

ACUTE KIDNEY INJURY CAUSES • Postrenal Injury • Obstruction that blocks flow of urine out of the body • Causes • Stones, tumors of ureters or bladder, enlarged prostate • Diagnosis • Radiology exams • Surgery

ACUTE KIDNEY INJURY • Prevention • Check Serum Creatinine Prior to Contrast Media or

ACUTE KIDNEY INJURY • Prevention • Check Serum Creatinine Prior to Contrast Media or Nephrotoxic Meds • Follow Protocols to Prevent Contrast Induced Nephropathy • Hydrate Before/After Contrast Media • Monitor Peak/Through Levels of Nephrotoxic Drugs per Institutional Policy

ACUTE KIDNEY INJURY • Therapeutic Interventions • Treat Cause • Supportive Treatment • Dialysis

ACUTE KIDNEY INJURY • Therapeutic Interventions • Treat Cause • Supportive Treatment • Dialysis • Continuous Renal Replacement Therapy

CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) • Removes Fluid/Solutes in Controlled, Continuous Manner in Unstable

CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) • Removes Fluid/Solutes in Controlled, Continuous Manner in Unstable AKI Patients • Can be done in Conjunction with Hemodialysis • Removes Fluids/Solutes • Returns Blood

CHRONIC KIDNEY DISEASE • Gradual Decrease in Kidney Function • Progressive & Irreversible •

CHRONIC KIDNEY DISEASE • Gradual Decrease in Kidney Function • Progressive & Irreversible • Build Up of Nitrogenous Waste Product and Uremia • Unable to Maintain Metabolic, Fluid, & Electrolyte Balance

CHRONIC KIDNEY DISEASE • Pathophysiology • Large Proportion of Nephrons are Damaged • Early

CHRONIC KIDNEY DISEASE • Pathophysiology • Large Proportion of Nephrons are Damaged • Early (Silent) Stage • 50% of Nephrons Lost • Renal Insufficiency Stage • 75% of Nephrons Lost • End-stage • 90% of Nephrons Lost

CHRONIC KIDNEY DISEASE • Causes • Diabetic Nephropathy • Nephrosclerosis • Glomerulonephritis • Autoimmune

CHRONIC KIDNEY DISEASE • Causes • Diabetic Nephropathy • Nephrosclerosis • Glomerulonephritis • Autoimmune Diseases

CHRONIC KIDNEY DISEASE • Signs & Symptoms • Fluid Accumulation • Electrolyte Imbalances •

CHRONIC KIDNEY DISEASE • Signs & Symptoms • Fluid Accumulation • Electrolyte Imbalances • Waste Products Retained • Acid-base Imbalances • Anemia

CHRONIC KIDNEY DISEASE

CHRONIC KIDNEY DISEASE

CHRONIC KIDNEY DISEASE • Therapeutic Interventions • Diet • High Calorie • Low Protein

CHRONIC KIDNEY DISEASE • Therapeutic Interventions • Diet • High Calorie • Low Protein (Unless Dialysis) • Low Sodium, Potassium, Phosphorus • Increased Calcium • Vitamins • Fluid Restriction

CHRONIC KIDNEY DISEASE • Therapeutic Interventions • Medications • Diuretics • Antihypertensives • Phosphate

CHRONIC KIDNEY DISEASE • Therapeutic Interventions • Medications • Diuretics • Antihypertensives • Phosphate Binders • Vitamin D/Calcium Supplements • Kayexalate prn

CHRONIC KIDNEY DISEASE • Dialysis is Needed When: • Symptoms of Fluid Overload •

CHRONIC KIDNEY DISEASE • Dialysis is Needed When: • Symptoms of Fluid Overload • High Potassium • Acidosis • Pericarditis • Vomiting • Neurological Signs • Uremia

DIALYSIS • 2 types • Hemodialysis and Peritoneal Dialysis • Remove toxins • Correct

DIALYSIS • 2 types • Hemodialysis and Peritoneal Dialysis • Remove toxins • Correct fluid and electrolyte imbalances • Can be used to treat drug overdoses

 HEMODIALYSIS

HEMODIALYSIS

PERITONEAL DIALYSIS

PERITONEAL DIALYSIS

HEMODIALYSIS • Artificial Kidney Removes Waste Products and Excess Water from Blood • Side

HEMODIALYSIS • Artificial Kidney Removes Waste Products and Excess Water from Blood • Side Effects • Weakness, Fatigue • Hypotension • Cardiac Dysrhythmias • Angina • Muscle Cramps • Bleeding

HEMODIALYSIS • Requires vascular access • Temporary • Central Vein • Permanent • A-V

HEMODIALYSIS • Requires vascular access • Temporary • Central Vein • Permanent • A-V Fistula • A-V Graft

HEMODIALYSIS • Vascular Access Care • Thrill, Bruit • Protect • Neurovascular Checks •

HEMODIALYSIS • Vascular Access Care • Thrill, Bruit • Protect • Neurovascular Checks • Dressings and Incisions • tourniquets, needle sticks or BP

 HEMODIALYSIS ACCESS SITES

HEMODIALYSIS ACCESS SITES

PERITONEAL DIALYSIS • Continuous Dialysis Done by Patient or Family • Removes Wastes/Fluids from

PERITONEAL DIALYSIS • Continuous Dialysis Done by Patient or Family • Removes Wastes/Fluids from Peritoneal Cavity • Peritoneal Catheter • Exchange Process: Fill, Dwell Time, Drain

PERITONEAL DIALYSIS • Education • Sterile technique • Clean environment • Site care •

PERITONEAL DIALYSIS • Education • Sterile technique • Clean environment • Site care • Diet & fluid restrictions • Complication • Peritonitis

KIDNEY TRANSPLANT • Advantages over dialysis • Can reverse damage • Patient not dependent

KIDNEY TRANSPLANT • Advantages over dialysis • Can reverse damage • Patient not dependent on dialysis • No dietary restrictions

KIDNEY TRANSPLANT • 3 options • Family donor • Living, non-related donor • Cadaver

KIDNEY TRANSPLANT • 3 options • Family donor • Living, non-related donor • Cadaver • Immunosuppressants

KIDNEY TRANSPLANT • Nursing Diagnoses • Excess Fluid Volume • Impaired Skin Integrity •

KIDNEY TRANSPLANT • Nursing Diagnoses • Excess Fluid Volume • Impaired Skin Integrity • Activity Intolerance • Risk for Injury • Risk for Infection • Imbalanced Nutrition: Less Than Body Requirements

KIDNEY TRANSPLANT • Nursing Care • Excess Fluid Volume • Monitor Weight • Intake

KIDNEY TRANSPLANT • Nursing Care • Excess Fluid Volume • Monitor Weight • Intake and Output • Fluid Restriction • Monitor for Fluid Retention • Electrolyte Imbalance • Monitor Levels • Dietary Restrictions • Monitor Dysrhythmias

KIDNEY TRANSPLANT • Nursing Care (cont’d) • Waste Products • Oral Care, Skin Care

KIDNEY TRANSPLANT • Nursing Care (cont’d) • Waste Products • Oral Care, Skin Care • Lotion • Protect from Injury • Impaired Hematological Function • Protect from Injury/Infection

REVIEW QUESTION Which of these actions is the priority action to prevent acute kidney

REVIEW QUESTION Which of these actions is the priority action to prevent acute kidney injury? 1. Check Serum Creatinine Prior to Contrast Media or Nephrotoxic Meds 2. Follow Protocols to Prevent Contrast Induced Nephropathy 3. Hydrate Before/After Contrast Media 4. Monitor Peak/Through Levels of Nephrotoxic Drugs per Institutional Policy

 Which of these is the priority during data collection for a patient with

Which of these is the priority during data collection for a patient with a vascular access? Select all that apply. 1. 2. 3. 4. 5. Listen for a bruit at the access Palpate thrill at the access Flush access with heparin Observe bruising at site Note tenderness at site