透析看護認定看護師が用いる内シャント穿刺部位の選定技術

The skills of marking arteriovenous fistula (AVF) positions by Dialysis Nursing Certified Nurses

【目的】透析看護認定看護師が用いる内シャント穿刺部位の選定技術を明らかにする．

【方法】国内在住の透析看護認定看護師197名を対象とし，横断研究（質問紙調査）を郵送法で実施した．

【結果】対象者の大部分がガイドラインに記載のある観察を実施し，穿刺部位を選定していた．また，ガイドラインにない観察の視点として，視診13項目，聴診3項目，触診1項目が明らかとなった．対象者特性で強い相関があったのは，透析看護経験年数と自己血管内シャント穿刺経験年数（r＝0.756，p＜0.01）であった．対象者は，穿刺部位の選定時に，［穿刺によるvascular access（VA）トラブル（感染・腫脹・止血不良等）を起こしにくい部位］を最も重要度の高いアセスメントの視点と捉えていた．また，透析看護認定看護師経験年数の長い対象者は，［皮膚に発赤や滲出液のある患者が穿刺部位を指定する］ことに困難を感じ（p＜0.05）,〈患者へ感染の可能性やリスクを説明し，納得を得て他の穿刺部位を選定する〉ことを実践していた．

【考察】対象者は，患者の生命予後や，生活におけるQOLの向上をアセスメントの視点としてVAトラブルを予防し，血液再循環を避ける部位への穿刺部位の選定を行っていることが示唆された．このことこそ，透析看護認定看護師が内シャントを観察し穿刺する意義であり，極めて専門性が高い看護技術があると考えた．

【Purpose】The objective of this research is making it clear to clarify the procedures for marking the AV position by dialysis nursing certified nurses (DNCN).

【Method】As the data gathering method, I carried out the survey by the mailed Cross-sectional research (Questionnaire survey) from 197 DNCN living in Japan.

【Result】The result of the data, most of participants have followed the procedures described in guidelines when selecting a marking AV position. At the same time, some markings which are not described in guidelines have been set by 13 items by inspection, 3 items by stethoscope, and 1 item by palpitation. The strong correlation between years of their experience in being DNCN and number of their experience in operating AVF is strongly found in participants' characteristics (r＝0.756．p＜0.01). The participants have made use of the objective data such as echo, angiogram and so on to prevent from VA troubles and blood recirculation. Then, they also have captured the marking positions hard to cause bad infection, swelling, bleeding and so on as the first priority for their assessment. In the case the participants having many years of experience in being DNCN feel difficulty setting the mark on the redden or leaching position (p＜0.05), they have practiced setting another position for puncture after explaining to their patients about the possibility and risk of infection.

【Discussion】It is suggested that the participants give patients the life prognosis and the improvement of QOL in living as the point of assessment, then, they should select the position of mark avoiding the blood recirculation. This especially is the significance that DNCN mark and puncture an arteriovenous fistula. I figure that those are the extreme high level expert skills of nursing.