When the doctor, nurses and techs listen to my heart what are they listening for? It is scarey to me, because they listen to it every treatment and nothing is wrong. One day I suppose they're going to tell me something's wrong? They also listen to my arm once in a great while. Why is that done?

Dear Grace,

You are right about the heart assessment being scary if you have never been given an explanation of the heart assessment. Healthcare workers perform the same assessment tasks over and over again. Often we forget that what we do as a normal physical assessment can be very scary if you are the one in the dialysis chair. So please read my explanation of the assessment and then ask your dialysis staff about any other questions you might have. We just sometimes forgot how scary it would be to have the roles reversed. Knowledge can help to change fear into mutual understanding and thus better outcomes for all.

The pre-dialysis and post dialysis assessment includes a basic physical exam.

Vital Signs: Heart rate (pulse), breathing (may be rate or a question about shortness of breath), temperature and blood pressure.

Other assessment items: signs of fluid overload such as edema (swelling), lung sounds, questions about any chest pain, bruit and thrill in an AV graft or fistula, AV graft or fistula exam for any signs or symptoms of infection, catheter exit site exam for any signs or symptoms of an infection, questions about how you feel and if you any complaints (headache, cramps, nausea/vomiting, cold symptoms, pain, or how well you are eating.)

Listening to your heart pre and post dialysis is done to assess your apical heart rate (pulse rate counted by listening to your heart). An apical pulse is the most accurate way to get your pulse rate.

So what does your pulse rate tell us?
A slow pulse rate is called bradycardia (rate less than 60 beats/minute).
A fast pulse rate is called tachycardia (rate greater than 100 beats/minute).
Normal pulse rate is between 61-100 beats/minute.
A slow or fast pulse can be a side effect of blood pressure or heart medications. Your pulse rate also changes as your fluid volume changes. With dialysis, fluid is removed (ultrafiltration). Your heart may need to increase the number of beats/minute too keep your blood pressure up (prevent hypotension or low BP). At the end of dialysis your pulse should return to your normal (everyone has a normal pulse rate range). If your heart rate at the end of dialysis is very rapid, then you may need to sit and wait until your blood pressure increases and your heart rate falls. Post dialysis you may need some fluids (drink by mouth such as soup broth, IV fluid such as saline) or you may just need to sit and rest for a few minutes. What the dialysis staff is checking for is a rapid or slow heart rate. An abnormal rate can help them to determine if your heart is tolerating your dialysis treatment and current dry weight.

The other reason to listen to an apical pulse is to hear any abnormal heart sounds. Years ago dialysis patients commonly got a condition called pericarditis. It is an inflammation of the sac that surrounds the heart (pericardium). A rub can be heard in patients with pericarditis. This condition can still occur. It is usually linked to inadequate dialysis and is caused for the uremia (high poison level of BUN).
Your nephrologist and dialysis staff can gain much insight to how you are doing on dialysis from the pre and post dialysis assessments. The assessment it meant to keep you healthy. If any abnormal findings are found, the dialysis staff and nephrologist can then take actions to help treat the cause of any problem.

Your AV access (graft or fistula) should also be assessed with a stethoscope. The access should be palpated (felt with the finger tips) for the thrill (buzzing feeling within the vascular access). The vascular access should be osculated (listen to with a stethoscope) for the swishing sound within the access. The access should be check every day by you at home for the thrill. Feel over your access for the buzz. If the thrill is absent, you need to notify the dialysis unit. The bruit and thrill are the physical signs that the vascular access has blood flow through the access and is not clotted. The dialysis staff should at least feel for the thrill before placing any needles each treatment. If the thrill is weak or absent, then the staff member needs to listen for the bruit before sticking a needle into the access. If the access is clotted, no needles should be placed into the access �just to make sure it is clotted�. The access assessment can determine if the graft or fistula is open with a blood flow or clotted.

The NKF DOQI Guideline 10 recommends a physical exam of the graft or fistula be performed weekly as a minimum. DOQI Guidelines are online www.kidney.org under DOQI Vascular Access. (now called K/DOQI)

Thanks for the great question. Please post any more questions you have. Please also talk with your dialysis staff and or nephrologist about any additional questions or for more detailed information.

Deborah


[This message has been edited by Deborah Brouwer (edited 08-24-2000).]