The Buttonhole Technique for Arteriovenous Fistula Cannulation

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Fistula First: Vascular AFistula First: Vccess Updateascular AThe Buttonhole Technique forArteriovenous Fistula CannulationLynda K. BallIn the United States, the rope lad-der and site rotation techniquesThe buttonhole technique began 30 years ago in Europe and Japan, and 25 years ago inare commonly utilized for the can-Seattle, Washington. Some believe its failure to “catch on” in the United States is due to thenulation of arteriovenous fistulaegraft culture of the last 20 years. Now with an increase of AV fistulae, this technique is(AVFs). Almost 30 years ago inbecoming known as a viable cannulation option. The purpose of this article is to provide tech-Europe and Japan, and 25 years agonical information for nephrology nurses performing this Seattle, Washington another tech-nique for cannulating AV fistulaewas started – the buttonhole tech-Goalnique.To provide an evidence-based educational tool for nephrology nurses to enableThe buttonhole technique is nowthem to perform and troubleshoot the buttonhole cannulation technique forwidely supported and used in theaccessing an arteriovenous fistula.Pacific Northwest and, from commu-nications with patient care staff fromObjectivesaround the country and Canada, it is1. Identify at least one barrier that may preclude a patientevident that the use of this techniquefrom utilizing the buttonhole spreading. This article will2. List two patient benefits for the buttonhole technique.describe buttonhole cannulation and3. Explain the changes that indicate readiness to switch fromprovide patient care staff with trou-sharp needles to blunt needles.bleshooting techniques as they addthe buttonhole technique to theirvascular access programs and poten-Dispelling the Mythsonly for the home hemodialysis pop-tially increase the number of patientsulation and is not to be used in theutilizing the technique.There have been many inquiriesin-center setting. Having an accessabout who is or is not a candidate forwith the fewest cannulation issues orthis technique. There are some physi-Lynda K. Ball, BS, BSN, RN, CNN, is Qualitycomplications is ideal for the homeImprovement Coordinator, Northwest Renalcians who think the technique is onlyhemodialysis patient, but it is alsoNetwork, Seattle, WA; an instructor at Clover Parkfor those patients with limited lengthideal for the in-center population.Technical College Hemodialysis Technicianaccesses. The first published articlesBesides, in the event that a homeProgram, Tacoma, WA; and a national speaker onwere from Dr. Twardowski and col-cannulation. She is a member of ANNA’s Greaterpatient requires in-center treatmentPuget Sound Chapter.leagues (in 1977 in the Polish litera-or a unit accepts transient patients, itture and in 1979 in the United States)is important to have staff with knowl-where they indicated that buttonholeDisclaimer: The analysis upon which this pub-edge on how to cannulate and/orlication is based were performed under Contracttechnique was first used on a patientcare for buttonholes.Number 500-03-NW16 entitled End Stagewith a very limited accessStill others believe that button-Renal Disease Networks Organization for the(Twardowski, Lebek, & Kubara, 1977;holes can only be used on brand newStates of Alaska, Idaho, Montana, Oregon andTwardowski & Kubara, 1979). Obser-Washington, sponsored by the Centers forAVFs. New AVFs are pristine, not yetvations of this patient showedMedicare & Medicaid Services, Department ofhaving developed scarring, aneurysmsHealth and Human Services. The content of thisdecreased pain associated with can-or hematomas that may add to thepublication does not necessarily reflect the viewsnulation, less time required for needlechallenge of a successful cannulationor policies of the Department of Health andinsertion, and no complications.Human Services, nor does mention of tradeprocedure. In the Pacific Northwest,Eventually, all of the patients in thatnames, commercial products, or organizationsthere are accesses that range from sev-imply endorsement by the U.S. Government. Theunit utilized this technique.eral months to decades old being can-author assumes full responsibility for the accura-Some believe that buttonhole iscy and completeness of the ideas presented. Thisarticle is a direct result of the Health CareQuality Improvement Program initiated by theThis offering for 1.4 contact hours is being provided by the American Nephrology Nurses’Centers for Medicare & Medicaid Services, whichAssociation (ANNA). ANNA is accredited as a provider of continuing nursing education by the Americanhas encouraged identification of quality improve-ment projects derived from analysis of patterns ofNurses Credentialing Center’s Commission on Accreditation. ANNA is a provider approved by thecare, and therefore required no special funding onCalifornia Board of Registered Nursing, provider number CEP 00910.the part of this contractor. Ideas and contributionsThe Nephrology Nursing Certification Commission (NNCC) requires 60 contact hours for eachto the author concerning experience in engagingrecertification period for all nephrology nurses. Forty-five of these 60 hours must be specific to nephrologywith issues presented are welcomed.nursing practice. This CE article may be applied to the 45 required contact hours in nephrology nursing.NEPHROLOGY NURSING JOURNAL ■ May-June 2006 ■ Vol. 33, No. 3299The Buttonhole Technique for Arteriovenous Fistula Cannulationnulated using the buttonhole tech-found that fistula failure using siteperson create the tunnel, which takesnique very successfully. A thoroughrotation was a result of hematoma for-anywhere from 3 to 4 weeks to formassessment should be completed tomation and that this did not occur(Ball, 2005b). Cannulation is a veryevaluate any potential problems anwith the buttonhole. They identifiedindividualized process as each clinicianaccess may possess.that the buttonhole had a 10-foldchooses the angle of insertion based onProbably the biggest fear withreduction in hematomas, and thattheir independent assessment of thethis technique is whether aneurysmcannulation took much less time thandepth of the access. Because of this, twoformation occurs from cannulatingwith site rotation.different individuals may determinein the same spot time and time again.For patient care staff, cannulationthe angle of entry to be slightly differ-In 1984, Dr. Kronung compared thetime is decreased with the button-ent. The result will be a tunnel that willrope ladder, area puncture, and but-hole. There is no need to identifynot have the same shape as the needletonhole techniques and found thatnew sites, there are fewer missedand will result in oozing when thethe area puncture technique causedsticks and infiltrations, and nopatient is heparinized.the greatest aneurysm formation andhematoma formation at the insertionBarriers need to be thought of asthe buttonhole technique showed nosites. In other words, the potentialchallenges to the technique ratheraneurysm formation (Kronung,complications associated with cannu-than reasons to exclude patients1984). The Northwest Renallation are decreased and/or are elim-from using the technique. One of theNetwork has published a patientinated, causing overall time for can-biggest barriers is the amount of scarflyer in English, Spanish, andnulation to be decreased. Anothertissue over the patient’s fistula.Russian entitled Using the Buttonholeplus is that patients can self-cannu-Scarring can occur for many differ-Technique for Your AV Fistula (Ball,late, which allows more indepen-ent reasons: multiple problematic2004) that is set in a question-answerdence for the patients and moreneedle sticks, lidocaine use, keloidformat to help patients understandavailable patient care time for theformation, or long-lived AVFs.that aneurysm formation resultsstaff for challenging accesses.Cannulators know how difficult it isfrom inserting needles into the sameThe overall benefits to patients ofto place needles correctly throughgeneral area (area puncture) of thethe buttonhole technique are that can-tough scar tissue without the accessfistula, allowing the vessel wall tonulation is less painful (Goovaerts,moving beneath their fingers.weaken and balloon out. When can-2005; Toma, 2005; Twardowski &The other major barrier to but-nulating in the same identical spotKubara, 1979), allowing patients totonholes is an upper arm with largeover and over, there is no weakeningeliminate the use of anesthetics; theamounts of subcutaneous or adiposeof the wall, hence no aneurysm for-needles are easier to insert into thetissue or one with excessive skin duemation. At a conference in 2005,track; and patients can use blunt nee-to loss of muscle mass or weight.Tony Goovaerts, an RN fromdles that reduce the cutting of the tun-This tissue is not stable or firm, mak-Belgium, presented ultrasounds ofnel and subsequent oozing during dial-ing it very difficult to cannulate thebuttonholes and Dr. Toma fromysis. Over the course of the Londonaccess beneath it. One suggestionJapan presented an excision of a but-Daily/Nocturnal Hemodialysis Studywould be to have the patient hold thetonhole site from a deceased patient,(Lindsay, Leitch, Heidenheim, &skin in the same position over theboth reporting there was noKortas, 2003), patients preferred theaccess for each cannulation. Button-aneurysm formation from this tech-buttonhole technique because ofhole tunnels need to be straight – ifnique (Goovaerts, 2005; Toma,decreased pain, speed, and ease ofthere is no way to keep the skin stable2005). Also, observational create a straight tunnel, then thefrom facilities across the Unitedbuttonhole technique will not workStates and Canada indicates noBarriers to Buttonholefor that individual.aneurysm development has beenBecause of these barriers, younoted to date (Ball, 2005b).One of the biggest barriers to themight identify these patients as onesbuttonhole technique has nothing to dowho could greatly benefit from thisPatient Benefits of thewith patients; rather, it has everythingtechnique, and they can, but knowButtonhole Techniqueto do with staffing patterns. The idealthat it will take patience and perse-staffing pattern would have staff work-verance by both staff and patients forIn order for a cannulation tech-ing every Monday-Wednesday-Fridaythe technique to be successful.nique to be of value, it needs to bene-or Tuesday-Thursday-Saturday, but infit the patient’s fistula, be a benefit toreality staffs work a variety of shifts andDifferences Between Sitethe patient care staff, but most impor-hours (part time, per diem, 8-hour, 10-Rotation and Buttonholetantly benefit the patient overall.hour, and 12-hour shifts) that make itCannulationTwardowski and Kubara (1979) com-unlikely that the same person is withpared site rotation and constant sitethe patient on a regular basis. It isThere are three major differences(buttonhole) needle insertion andstrongly recommended that the samebetween site rotation and buttonhole300NEPHROLOGY NURSING JOURNAL ■ May-June 2006 ■ Vol. 33, No. 3cannulation – individualization ofTable 1cannulation, scab removal, and whoDo’s and Don’ts of Scab Removalcan cannulate.Don’t flip the scab off with the needle you will use for cannulation – Individualization ofthis contaminates the needle.CannulationDon’t use a sterile needle – you could cut the patient’s skin and break The first difference has alreadythe scab into little pieces.been addressed – individualization ofDon’t let the patient remove their scabs with their fingernails.cannulation. As a cannulator, youevaluate and determine the angle ofDo use either:entry you will use for each site.➤ aseptic tweezers;However, when it comes to a button-➤ soak 2 x 2s with sterile saline and lay over the scab;hole site, the originator of the tunnel➤ moisten 2 x 2s with alcohol-based gel; orhas established the angle of entry. It is➤ tape an alcohol wipe over sites prior to dialysisvery difficult to change that mind-setand give up that independence, espe-cially if the angle is different than theforemost, we have to adhere tomicrobes remain present in the sub-cannulator would have chosen. Theproven infection control methodsungual area (base) of the nail evenmain point is that it is not about thewith regard to sterile needles.after hand washing (Centers forcannulator and what they would haveFlipping scabs off with the tip of theDisease Control, 2002). In addition,done, but rather what the originatorsterile needle you are going to insertpatient hygiene has been identifiedhas done and now must be not appropriate. The skin ofas a potential cause of some vascularIt would be very convenient if wepatients on dialysis has been shownaccess infections (Arduino & Tokars,could use just one angle of entry forto have more Staphylococcus aureus on2005).all AVFs, but until all surgeons areit than the skin of the general popu-Soaking the scabs make them eas-creating all AVFs within 6 mm of thelation of individuals. It stands to rea-ier to remove. This can be done bysurface of the skin, it’s not practicalson that a scab, with all its nooks andseveral different methods. Most facil-and we will fail at cannulation unlesscrannies, will have a lot ofities have 2 x 2s that they use afterwe use our assessment skills to deter-Staphylococcus aureus “hiding” there asneedle removal to stop bleeding atmine depth of the access.well. This should lead you to the log-the needle sites. Draw up some nor-Each needle site will probablyical conclusion that the scab shouldmal saline from the bag you arehave a different angle of removed prior to the skin beingpriming the system with and squirtThe originator of the buttonholeprepped. The next thing that shouldthe saline onto two 2 x 2s and placeshould either take a photo of thetouch the skin after prepping shouldthem over the scabs while you areinsertion angle, have direct discussionbe the sterile needle.completing the patient assessment.with the next cannulator, or write aAnother way staff have suggestedThen pinch the 2 x 2s with yournote on the care plan indicating theto remove the scabs is by using a sep-thumb and forefinger and pull theangle of insertion. Communication isarate sterile needle. That can bescab off, turning the 2 x 2 over tothe key to successful buttonhole can-done, but you risk cutting themake sure you got the entire scab,nulation.patient’s skin while you are remov-and then you are ready to prep theing the scab. There is also the risk ofsites. If you use alcohol-based gels inScab Removalfragmenting the scab and then hav-your facility, you could use that inThe second major difference hasing to remove the remainingplace of normal do with the scabs. In site rotation,piece(s). You also would need toOne of the most ingenious meth-you always look for prior scabs tohave a sharps container available toods of scab removal came from aindicate where the last puncture sitesdispose of the needle. One of thefacility in Oregon, where they sendwere so you can avoid them. But withadvantages of the buttonhole tech-the patients home with a roll of tapethe buttonhole technique, you need tonique is that the blunt needle is clas-and some alcohol squares. Theylook for those scabs and remove themsified as a safe needle device and,instruct the patients to open the alco-in order to insert the needles intotherefore, reduces the risk of needlehol squares and place over the scabs,those same holes.sticks. Using a sterile needle wouldsecuring with the tape prior to com-How should scabs be removed?nullify the safety aspect of the but-ing to dialysis. By the time theHaving many conversations withtonhole technique.patients arrives at the unit, the scabspatient care staff all across the coun-A third area that should be avoid-are moist and ready for preppingtry, there are several different waysed is allowing patients to removewhen the patients sit down in theirbeing used, both good and bad, totheir scabs with their fingernails.chairs.remove scabs (see Table 1). First andThere is research to suggest thatNEPHROLOGY NURSING JOURNAL ■ May-June 2006 ■ Vol. 33, No. 3301The Buttonhole Technique for Arteriovenous Fistula CannulationFigure 1Three particular observedCreation of a Buttonhole – Day 5 changes have been identified thatindicate the change from sharp toblunt can occur.• When dialysis needles areinserted into the skin theymake a “v” cut. As the needlesare placed into the same spoteach time, the “v” cut gradual-ly changes to a “u” and finallyto a round hole.• The next change is the forma-tion of granular tissue aroundthe exterior of the arterial site.A small ridge, similar to apouty lip, forms on the arteri-al site and then encircles thebuttonhole site. It is notentirely clear why this hap-pens, but one idea is that thearterial needle is “pulling”blood out, so there may beneedle movement in thatdirection, causing the tissue tofold outward. The venous siteappears to look like dimpleswithout granular tissue forma-tion. The thought being thatthe venous needle is “push-ing” blood in and thereforeneedle movement would beFigure 2towards the skin, causing aSharp Vs. Blunt Needlesslight depression.• The third change is actuallythe change in the resistance ofthe needle. As there is less andless skin along with tissues andnerves within the tunnel, theneedle should slide in withless and less resistance. As amatter of fact, a well-madetunnel will literally suck theneedle down the track to thevessel wall and then just asmall push is needed to enterthe fistula.A 5-day old arterial buttonholeWho Can Cannulate?Knowing When to Change tosite is shown in Figure 1. It is clearThe third difference between siteBlunt Needlesthat two out of the three observationsrotation and buttonhole is who canThe time for the transition ofcan be seen in this picture: the cut iscannulate. In a facility that utilizes sitechanging from sharp to blunt needlesno longer “v” shaped, but is more “u”rotation, staff members can cannulatewill vary by individual. In the Pacificshaped; and you can see granular tis-a patient’s fistula. With the buttonholeNorthwest, it is taking approximatelysue formation around buttonhole site.technique, you need to have the same8-10 cannulations for patients who doEven from the European literaturecannulator until the tunnel is formed.not have diabetes and approximately(six sticks), this site is not yet ready forAfter the tunnel has been formed, then12 cannulations for patients who doblunt needles. This actual buttonholeother staff may cannulate the fistula.(Ball, 2005b).was ready at day 8 and the patient302NEPHROLOGY NURSING JOURNAL ■ May-June 2006 ■ Vol. 33, No. 3was changed to blunt needles (seethe needle in at an angle they think isis usually no problem. If a nurse does-Figure 2) on that day.appropriate. This will stretch then’t want to utilize a technique they arehole and will allow blood to seepnot familiar with, they can rotate sites,The Buttonhole Techniquearound the needles. Another prob-making sure they stay at least 3/4-inchlem that this issue will create is dead-in front of the tunnel to prevent acci-The buttonhole technique siteend tunnels, which can collect withdentally cannulating through the tun-selection should include a thoroughblood and then become sites for pos-nel wall. When the patient returns tophysical assessment as described insible infection.the in-center facility, the patient careImproving Your AV Fistula CannulationIf you have more than one origi-staff may need to use sharp needlesSkills (Ball, 2005a), and ultimatelynator of the buttonholes and they useuntil they get the buttonhole tunnelyou want to create two sites that haveslightly different angles, this willre-established, and then they cangood (low) arterial and venous pres-cause a cone-shaped tunnel to formchange back to blunt needles. Eachsures, good (high) blood flow rates,instead of a tunnel with the samepatient is different, and just like withand will be least likely to infiltrate.diameter for the entire length. Thispierced earrings, some of us cannotThe next step is to remove the scab,cone-shape will allow blood to seepleave our earrings out without ourusing one of the previously men-around the needles.tunnels closing or becoming nar-tioned techniques. The site thenUsing sharp needles can causerowed, while others never have aneeds to be prepped using your facil-the tunnel to be cut during the inser-problem with that. The same is trueity-approved antimicrobial agent ortion process. Great care has to bewith the buttonhole tunnel.solution. The insertion angle is thentaken when using sharp needles todetermined based on prior experi-avoid this situation. However, thereBlood Flow Problemsence with the patient’s buttonhole,will be certain situations that willThe buttonhole technique is justdirect discussion with the previousalways require the use of sharp nee-another method of inserting needlescannulator, or written documentationdles.into an AV fistula. It should not causeof previous cannulations. Removal ofa decrease in blood flow rates,the needle from the buttonhole is theThe Trampoline Effectincrease in alarms, increase insame as removal of the needle whenLiz Swift, a nurse educator at onemachine pressures or a decrease inusing other cannulation techniques.of our local dialysis facilities, hasadequacy. A couple of problems havedescribed a phenomenon thatbeen identified. One patient wasTroubleshootingoccurred at her facility. On some oflearning to self-cannulate and whenthe patients, the tunnel developedshe inserted the needle, there was aAny technique will have issuesnicely, but when they tried to use theslight change in the direction of theassociated with it, and the buttonholeblunt needles to enter the blood ves-needle. Over the course of her treat-technique is no exception. With littlesel wall, it just bounced off it – boing,ment, her pressures started rising,published literature available aboutboing, boing, just like a trampoline.causing alarms and subsequently thehow to actually create the accesses forAfter having several more facilitiesblood pump was turned down. Whenbuttonholes, facilities have mostlynote the same problem, I now refer toI observed how she cannulated, it wasused trial and error. As a result, thisit as the “trampoline effect” whenapparent that by the end of the treat-author has started a training programteaching. Excessive force with bluntment, the needle was migrating backthat includes tips and troubleshootingneedles could possibly tear tissue andto the original angle of entry and thefor successful buttonhole creation,that hurts the patients, so the recom-needle was ending up against thesimply called The Buttonhole Technique.mendation is to use sharp needles onwall, causing her alarm condition.these individuals all the time, beingOnce she chose a new site where herOozing from Needle Sitescareful not to cut their tracks. Usingentry was straight down the fistula,One of the first problems staffsharp needles has reduced the painshe no longer had those problems.have identified is oozing from thethat these patients had complained ofAnother problem occurs whenneedle sites during dialysis. Oozingand allowed them to continue usingtaping the needles too tightly, forcingoccurs for a couple of reasons. Thethe buttonhole technique.the needle up against the wall. Thefirst would be that the tunnel is notneedles should be taped securely,the same diameter as the needleHospitalizationbut not tightly. Taping across thebeing used, so that when a patient isBecause the buttonhole techniquewings just stabilizes the needle fromheparinized, oozing occurs aroundis used for home and in-center pro-moving within the access – it is thethe needles. The needle should fit likegrams, acute dialysis nurses may notchevron, the “v” or “u,” that preventsa finger being inserted into a glove.have knowledge of this technique. Ifthe needle from falling out.Another reason for oozing occursthe patient is well enough to explainFinally, if the patient experienceswhen staff members do not followhow to insert the needles and theconstant pain at a buttonhole site orthe buttonhole track, but try to putnurse is comfortable doing that, thereyou are seeing pressure problemsNEPHROLOGY NURSING JOURNAL ■ May-June 2006 ■ Vol. 33, No. 3303The Buttonhole Technique for Arteriovenous Fistula Cannulationthat you just cannot figure out, it isReferencesture. Dialysis & Transplantation,OK to abandon that site and find a13(10), 635-638.Arduino, M.J., & Tokars, J.I. (2005). Whynew one.Lindsay, R.M., Leitch, R., Heidenheim,is an infection control program need-A.P., & Kortas, C. (2003). Theed in the hemodialysis setting?London daily/nocturnal hemodialy-ConclusionNephrology News & Issues, 19(6), 44-48.sis study – Study design, morbidity,Ball, L.K. (2004). Using the buttonhole tech-and mortality results. AmericanWhy should we offer the button-nique for your AV fistula. RetrievedJournal of Kidney Diseases, 42(1, Supplhole technique to our patients?May 8, 2006, from www.nwrenal1), 5-12.Through the use of some simple ButtonholeToma, S.T. (2005). A timesaving techniqueing plus observation, there has beenBrochureForPatients1.pdf(polypropylene peg) to create a fixedBall, L.K. (2005a). Improving AV fistulano documented aneurysm formationpuncture route for the buttonhole tech-cannulation skills. Nephrology Nursingwith this technique, which could pos-nique. Paper presented March 1,Journal, 32(6), 611-618.sibly extend the life of fistulae.2005 at the Annual DialysisBall, L.K. (2005b). Buttonhole technique forWithout missed sticks, hematoma for-Conference, Tampa, FL.cannulating AV fistulas. Paper pre-mation or infiltrations, there will be aTwardowski, Z., & Kubara, H. (1979).sented February 27, 2006 at theDifferent sites versus constant sites ofreduction in hospitalizations andAnnual Dialysis Conference, Sanneedle insertion into arteriovenousmissed treatments associated withFrancisco, CA.fistulas for treatment by repeatedcomplications. Through many patientCenters for Disease Control. (2002).dialysis. Dialysis & Transplantation,surveys, it has been found that theGuideline for hand hygiene in health-8(10), 978-980.buttonhole technique is a viable tech-care settings. Retrieved May 8, 2006,Twardowski, Z., Lebek, R., & Kubara, H.from for reducing pain of cannula-(1977). Szescioletnie klinicznepreview/mmwrhtml/rr5116a1.htmtion and may help those patients whodoswiadczenie z wytwarzaniem IGoovaerts, T. (2005). Long-term experiencehave needle fears. And, finally, theuzytkowaniem wewnetrznych prze-with buttonhole technique of fistula can-buttonhole technique can promotetok tetniczo-zylnych u chlorych lec-nulation. Paper presented March 1,self-cannulation and allow patients tozonych powtarzanymi hemodializa-2005 at the Annual Dialysismi. Polish Archives of Internal Medicine,be self-sufficient, more confident, andConference, Tampa, FL.57(3), control of the biggest aspect of theirKronung, G. (1984). Plastic deformationtreatment – the access.of Cimino fistula by repeated punc-Reprinted with permission of the American Nephrology Nurses' Association, publisher, Nephrology Nursing Journal, June 2006,Volume 33/Number 3, pages 299-305.304ANNJ612ANSWER/EVALUATION FORMThe Buttonhole Technique for Arteriovenous Fistula CannulationLynda K. Ball, BS, BSN, RN, CNNPosttest InstructionsComplete the Following:•Answer the open-ended question(s)Name: ____________________________________________________________below.•Complete the evaluation.Address: __________________________________________________________•Send only the answer form to theANNA National Office; East Holly__________________________________________________________________Avenue Box 56; Pitman, NJ 08071-0056; or fax this form to (856) 589-Telephone: ______________________ Email: _____________________________7463.•Enclose a check or money orderCNN: ___ Yes ___ No CDN: ___ Yes ___ No CCHT: ___ Yes ___ Nopayable to ANNA. Fees listed in pay-ment section.Payment:•Posttests must be postmarked byANNA Member - $15 Non-Member - $25 Rush Processing - Additional $5June 20, 2008. Upon completion ofthe answer/evaluation form, a certifi-ANNA Member: ____ Yes ____ No Member #___________________________cate for 1.4 contact hours will be■ Check Enclosed ■ American Express ■ Visa ■ MasterCardawarded and sent to you.•Please allow 2-3 weeks for process-Total Amount Submitted: _________________ing. You may submit multiple answerforms in one mailing, however,Credit Card Number: _______________________________ Exp. Date: _______because of various processing pro-Name as it Appears on the Card: ______________________________________cedures for each answer form, youmay not receive all of your certificatesreturned in one mailing.Special NoteYour posttest can be processed in 1 week for an additional rush charge of $5.00. ■ Yes, I would like this posttest rush processed. I have included an additional fee of$5.00 for rush processing.Note: If you wish to keep the journal intact, you may photocopy the answer sheet or access this posttest Online submissions through a partnership with are accepted on this posttest at $20 for ANNA members and $30 for nonmembers. CE certificates will be available immediatelyupon successful completion of the posttest.To provide an evidence-based educational tool1. What would be different in your practice if you applied what you havefor nephrology nurses to enable them to performlearned from this activity?and troubleshoot the buttonhole cannulation____________________________________________________________technique for assessing an arteriovenous fistula.____________________________________________________________New Posttest FormatPlease note that this continuing education activity does not contain____________________________________________________________multiple-choice questions. We have introduced a new type of____________________________________________________________posttest that substitutes the multiple-choice questions with an open-ended question. Simply answer the open-ended question(s) direct-____________________________________________________________ly above the evaluation portion of the Answer/Evaluation Form and____________________________________________________________return the form, with payment, to the National Office as usual.________________________________________________________________________________________________________________________StronglyStronglyEvaluationdisagreeagree2. By completing this offering, I was able to meet the stated objectivesa. Identify at least one barrier that may preclude a patient from utilizing the buttonhole technique.1 2 3 4 5b. List two patient benefits for the buttonhole technique.1 2 3 4 5c. Explain the changes that indicate readiness to switch from sharp needles to blunt needles.1 2 3 4 53. The content was current and relevant.1 2 3 4 54. This was an effective method to learn this content.1 2 3 4 55. Time required to complete reading assignment: _________ minutes.I verify that I have completed this activity ________________________________________________________________________________(Signature)NEPHROLOGY NURSING JOURNAL ■ May-June 2006 ■ Vol. 33, No. 3305