Early detection can help prevent the
CHRONIC KIDNEY
DISEASE
Patient’s Name: Precita P. Gatchalian
Age: 71 years old
Diagnosis: Chronic Kidney Disease Stage
V status post Arteriovenous Fistula
Creation
Operation Performed: Arteriovenous
Fistula Creation
Date of Operation: February 18, 2020
Anesthesia: Local Anesthesia
Surgeon: Dr. Joseph Bautista
Assistant Surgeon: Dr. Reginald Rapuso
Scrub Nurse: Ms. Alma Marquez, RN
OVERVIEW
Chronic kidney disease, also called chronic
kidney failure, describes the gradual loss of
kidney function. Your kidneys filter wastes and
excess fluids from your blood, which are then
excreted in your urine. When chronic kidney
disease reaches an advanced stage, dangerous
levels of fluid, electrolytes and wastes can
build up in your body.
In the early stages of chronic kidney disease,
you may have few signs or symptoms. Chronic
kidney disease may not become apparent until
your kidney function is significantly impaired.
Treatment for chronic kidney disease focuses
on slowing the progression of the kidney
damage, usually by controlling the underlying
cause. Chronic kidney disease can progress to
end-stage kidney failure, which is fatal without
artificial filtering (dialysis) or a kidney
transplant.
The Facts about Chronic Kidney
Disease (CKD)
37 million American adults have CKD and
millions of others are at increased risk.
progression of kidney disease to kidney
failure.
Heart disease is the major cause of death
for all people with CKD.
Glomerular filtration rate (GFR) is the best
estimate of kidney function.
Hypertension causes CKD and CKD causes
hypertension.
Persistent proteinuria (protein in the urine)
means CKD is present.
High risk groups include those with
diabetes, hypertension and family history of
kidney failure.
African Americans, Hispanics, Pacific
Islanders, American Indians and Seniors are
at increased risk.
Two simple tests can detect CKD: blood
pressure, urine albumin and serum
creatinine.
CAUSES
Anyone can get CKD. Some people are more at
risk than others. Some things that increase
your risk for CKD include:
Type 1 or Type 2 Diabetes
High blood pressure (hypertension)
Heart disease
Glomerulonephritis, an inflammation of the
kidney's filtering units (glomeruli)
Interstitial nephritis, an inflammation of the
kidney's tubules and surrounding structures
Polycystic kidney disease
Prolonged obstruction of the urinary tract,
from conditions such as enlarged prostate,
kidney stones and some cancers
Vesicoureteral reflux, a condition that
causes urine to back up into your kidneys
Recurrent kidney infection, also called
pyelonephritis
Having a family member with kidney
disease
Being African-American, Hispanic, Native
American or Asian
Being over 60 years old
STAGES OF CKD
Stage 1 CKD: eGFR 90 or Greater
Stage 1 CKD means you have mild kidney
damage and an eGFR of 90 or greater.
Most of the time, an eGFR of 90 or greater
means your kidneys are healthy and working
well, but you have other signs of kidney
damage. Signs of kidney damage could be
protein in your urine (pee) or physical damage
to your kidneys.
Stage 2 CKD: eGFR Between 60 and 89
Stage 2 CKD means you have mild kidney
damage and an eGFR between 60 and 89.
Most of the time, an eGFR between 60 and 89
means your kidneys are healthy and working
well. But if you have Stage 2 kidney disease,
this means you have other signs of kidney
damage even though your eGFR is normal.
Stage 3 CKD: eGFR between 30 and 59
Stage 3 CKD means you have an eGFR
between 30 and 59.
An eGFR between 30 and 59 means that there
is some damage to your kidneys and they are
not working as well as they should.  lungs
Stage 3 is separated into two stages:  Decreased mental sharpness
Stage 3a means you have
an eGFR between 45 and 59
Stage 3b means you have an eGFR
between 30 and 44
Stage 4 CKD: eGFR between 15 and 29
Stage 4 CKD means you have an eGFR
between 15 and 29.
An eGFR between 15 and 30 means your
kidneys are moderately or severely damaged
and are not working as they should. Stage 4
kidney disease should be taken very seriously –
it is the last stage before kidney failure.
Stage 5 CKD: eGFR Less than 15
Stage 5 CKD means you have an eGFR less
than 15.
An eGFR less than 15 means the kidneys are
getting very close to failure or have completely
failed. If your kidneys fail, waste builds up in
your blood, which makes you very sick.
Once your kidneys have failed, you will need to
start dialysis or have a kidney transplant to
live.
SYMPTOMS
You may notice one or more of the following
symptoms if your kidneys are beginning to fail:
Itching
Muscle cramps
Nausea and vomiting
Not feeling hungry or Loss of appetite
Fatigue and weakness
Swelling in your feet and ankles
Too much urine (pee) or not enough urine
Shortness of breath, if fluid builds up in the
Trouble sleeping
Chest pain, if fluid builds up around the
lining of the heart
High blood pressure (hypertension) that's
difficult to control
If your kidneys stop working suddenly (acute
kidney failure), you may notice one or more of
the following symptoms:
Abdominal (belly) pain
Back pain
Diarrhea
Fever
 Nosebleeds Pericarditis, an inflammation of the
Rash saclike membrane that envelops your heart
Vomiting (pericardium)
Pregnancy complications that carry risks for
the mother and the developing fetus
RISK FACTORS Irreversible damage to your kidneys
Factors that may increase your risk of chronic (end-stage kidney disease), eventually
kidney disease include: requiring either dialysis or a kidney
transplant for survival
Diabetes
High blood pressure
Heart and blood vessel (cardiovascular) Assessment and Diagnostic Findings
disease Laboratory studies required to establish the
Smoking diagnosis of CRF include:
Obesity
Being African-American, Native American or Glomerular filtration rate. GFR
Asian-American and creatinine clearance decrease while
Family history of kidney disease serum creatinine (more sensitive indicator
Abnormal kidney structure
of renal function) and BUN levels increase.
Older age
Sodium and water retention. Some
patients retain sodium and water,
COMPLICATIONS increasing the risk for edema, heart failure,
Chronic kidney disease can affect almost every and hypertension.
part of your body. Potential complications may Acidosis. Metabolic acidosis occurs in
include: ESRD because the kidneys are unable to
Fluid retention, which could lead to excrete increased loads of acid.
swelling in your arms and legs, high blood Anemia. In ESRD, erythropoietin
pressure, or fluid in your lungs production decreases and profound anemia
(pulmonary edema) results, producing fatigue, angina, and
A sudden rise in potassium levels in your shortness of breath.
blood (hyperkalemia), which could impair
Urine
your heart's ability to function and may be
Volume: Usually less than 400 mL/24
life-threatening
Heart and blood vessel (cardiovascular) hr (oliguria) or urine is absent (anuria).
disease Color: Abnormally cloudy urine may be
Weak bones and an increased risk of bone caused by pus, bacteria, fat, colloidal
fractures particles, phosphates, or urates. Dirty,
Anemia brown sediment indicates presence of
Decreased sex drive, erectile dysfunction or
RBCs, hemoglobin, myoglobin,
reduced fertility
Damage to your central nervous porphyrins.
system, which can cause difficulty Specific gravity: Less than 1.015
concentrating, personality changes or (fixed at 1.010 reflects severe renal
seizures damage).
Decreased immune response, which Osmolality: Less than 350 mOsm/kg is
makes you more vulnerable to infection indicative of tubular damage, and
urine/serum ratio is often 1:1.
 Creatinine clearance: May be Serum osmolality: Higher than 285
significantly decreased (less than 80 mOsm/kg; often equal to urine.
mL/min in early failure; less than 10 KUB x-rays: Demonstrates size of
mL/min in ESRD). kidneys/ureters/bladder and presence of
Sodium: More than 40 mEq/L because obstruction (stones).
kidney is not able to reabsorb sodium. Retrograde pyelogram: Outlines
Protein: High-grade proteinuria (3–4+) abnormalities of renal pelvis and ureters.
strongly indicates glomerular damage Renal arteriogram: Assesses renal
when RBCs and casts are also present. circulation and identifies extravascularities,
Blood masses.
BUN/Cr: Elevated, usually in Voiding cystourethrogram: Shows
proportion. Creatinine level of 12 mg/dL bladder size, reflux into ureters, retention.
suggests ESRD. A BUN of >25 mg/dL is Renal ultrasound: Determines kidney size
indicative of renal damage. and presence of masses, cysts, obstruction
CBC: Hb decreased because of anemia, in upper urinary tract.
usually less than 7–8 g/dL. Renal biopsy: May be done endoscopically
RBCs: Life span decreased because of to examine tissue cells for histological
erythropoietin deficiency, and azotemia. diagnosis.
ABGs: pH decreased. Metabolic acidosis Renal endoscopy, nephroscopy: Done
(less than 7.2) occurs because of loss of to examine renal pelvis; flush out calculi,
renal ability to excrete hydrogen and hematuria; and remove selected tumors.
ammonia or end products of protein ECG: May be abnormal, reflecting
catabolism. Bicarbonate and PCO2 electrolyte and acid-base imbalances.
Decreased. X-ray of feet, skull, spinal column, and
Serum sodium: May be low (if kidney hands: May reveal
“wastes sodium”) or normal (reflecting demineralization/calcifications resulting
dilutional state of hypernatremia). from electrolyte shifts associated with CRF.
Potassium: Elevated related to
retention and cellular shifts (acidosis) or
PREVENTION
tissue release (RBC hemolysis). In
Damage to your kidneys is usually permanent.
ESRD, ECG changes may not occur until
Although the damage cannot be fixed, you can
potassium is 6.5 mEq or higher.
take steps to keep your kidneys as healthy as
Potassium may also be decreased if
possible for as long as possible. You may even
patient is on potassium-
be able to stop the damage from getting
wasting diuretics or when patient is
worse.
receiving dialysis treatment.
Magnesium, phosphorus: Elevated. Control your blood sugar if you have
Calcium/phosphorus: Decreased. diabetes.
Proteins (especially Keep a healthy blood pressure.
albumin): Decreased serum level may Follow a low-salt, low-fat diet.
reflect protein loss via urine, fluid shifts, Exercise at least 30 minutes on most days
decreased intake, or decreased synthesis of the week.
because of lack of essential amino acids. Keep a healthy weight.
 Do not smoke or use tobacco.
Limit alcohol.
Talk to your doctor about medicines that
can help protect your kidneys.
If you catch kidney disease early, you may be
able to prevent kidney failure. If your kidneys
fail, you will need dialysis or a kidney
transplant to survive.
Medical Management
The goal of management is to maintain kidney
function and homeostasis for as long as
possible.
Pharmacologic therapy:  Assess for signs of hyperkalemia.
Calcium and phosphorus binders treat
hyperphosphatemia and hypocalcemia;
Antihypertensive and cardiovascular
agents (digoxin and dobutamine) manage
hypertension;
Anti-seizure agents (IV diazepam
or phenytoin) are used for seizures, and;
Erythropoietin (Epogen) is used to treat
anemia associated ESRD.
Nutritional therapy. Dietary intervention
includes careful regulation of protein intake,
fluid intake to balance fluid losses, sodium
intake to balance sodium losses, and some
restriction of potassium.
Dialysis.  Dialysis is usually initiated if the
patient cannot maintain a reasonable lifestyle
with conservative treatment.
Nursing Management
The patient with ESRD requires astute nursing
care to avoid the complications of reduced
renal function and the stresses and anxieties of
dealing with a life-threatening illness.
Nursing Assessment
Assessment of a patient with ESRD includes
the following:
Assess fluid status (daily weight, intake and
output, skin turgor, distention of neck
veins, vital signs, and respiratory effort).
Assess nutritional dietary patterns (diet
history, food preference, and calorie
counts).
Assess nutritional status (weight changes,
laboratory values).
Assess understanding of cause of renal
failure, its consequences and its treatment.
Assess patient’s and family’s responses and
reactions to illness and treatment.
Nursing Diagnosis
Based on the assessment data, the
following nursing diagnoses for a patient with
chronic renal failure were developed:
Excess fluid volume related to decreased
urine output, dietary excesses, and
retention of sodium and water.
Imbalanced nutrition less than body
requirements related to anorexia, nausea,
vomiting, dietary restrictions, and altered
oral mucous membranes.
Activity intolerance related to fatigue,
anemia, retention of waste products, and
dialysis procedure.
Risk for situational low self-esteem related
to dependency, role changes, changes
in body image, and change in sexual
function.
Planning & Goals
The goals for a patient with chronic renal
failure include:
 Maintenance of ideal body weight without
excess fluid.
Maintenance of adequate nutritional intake.
Participation in activity within tolerance.
Improve self-esteem.
Nursing Priorities
Maintain homeostasis.
Prevent complications.
Provide information about disease
process/prognosis and treatment needs.
Support adjustment to lifestyle changes.
Nursing Interventions
Nursing care is directed towards the following:
Fluid status. Assess fluid status and identify
potential sources of imbalance.
Nutritional intake. Implement a dietary
program to ensure proper nutritional intake
within the limits of the treatment regimen.
Independence. Promote positive feelings by
encouraging increased self-care and greater
independence.
Protein. Promote intake of high-biologic –
value protein foods: eggs, dairy products,
meats.
Medications. Alter schedule of medications
so that they are not given immediately
before meals.
Rest. Encourage alternating activity with
rest.
Evaluation
A successful nursing care plan has achieved
the following:
Maintained ideal body weight without
excess fluid.
Maintained adequate nutritional intake.
Participated in activity within tolerance.
Improved self-esteem.
Discharge and Home Care Guidelines
The nurse should promote home and self-
care to increase the esteem of the patient.
Vascular access care. The patient should be
taught how to check the vascular access
device for patency and appropriate
precautions, such as avoiding venipuncture
and blood pressure measurements on the
arm with the access device.
Problems to report. The patient and the
family need to know what problems to
report: nausea, vomiting, change in usual
urine output, ammonia odor on
breath, muscle weakness, diarrhea,
abdominal cramps, clotted fistula or graft,
and signs of infection.
Follow-up. The importance of follow-up
examinations and treatment is stressed to
the patient and family because of changing
physical status, renal function, and dialysis
requirements.
Home care referral. Referral for home care
gives the nurse an opportunity to assess
the patient’s environment and emotional
status and the coping strategies used by
the patient and family.
Documentation Guidelines
The documentation in a patient with chronic
renal failure should focus on the following:
Existing conditions contributing to and
degree of fluid retention.
I&O and fluid balance.
Results of laboratory tests.
Caloric intake.
Individual cultural or religious restrictions
and personal preferences.
Level of activity.
Plan of care.
Teaching plan.
Response to interventions, teaching, and
actions performed.
 Attainment or progress toward desired
outcomes.
Modifications to plan of care.
Long term needs.
ARTERIOVENOUS
FISTULA CREATION
An AV fistula is a connection, made by a
vascular surgeon, of an artery to a vein.
Arteries carry blood from the heart to the
body, while veins carry blood from the body
back to the heart. Vascular surgeons specialize
in blood vessel surgery. The surgeon usually
places an AV fistula in the forearm or upper
arm. An AV fistula causes extra pressure and
extra blood to flow into the vein, making it
grow large and strong. The larger vein
provides easy, reliable access to blood vessels.
Without this kind of access, regular
hemodialysis sessions would not be possible.
Untreated veins cannot withstand repeated
needle insertions, because they would collapse
the way a straw collapses under strong
suction.
Before AV fistula surgery, the surgeon may
perform a vessel mapping test. Vessel mapping
uses Doppler ultrasound to evaluate blood
vessels that the surgeon may use to make the
AV fistula. Ultrasound uses a device, called a
transducer that bounces safe, painless sound
waves off organs to create an image of their
structure. A specially trained technician
performs the procedure in a health care
provider’s office, an outpatient center, or a
hospital. A radiologist—a doctor who
specializes in medical imaging—interprets the
images. A Doppler ultrasound shows how much
and how quickly blood flows through arteries
and veins so the surgeon can select the best
blood vessels to use.
A surgeon performs AV fistula surgery in an
outpatient center or a hospital. The vascular
access procedure may require an overnight
stay in the hospital; however, many patients
go home afterward. A health care provider
uses local anesthesia to numb the area where
the surgeon creates the AV fistula.
An AV fistula frequently requires 2 to 3 months
to develop, or mature, before the patient can
use it for hemodialysis. If an AV fistula fails to
mature after surgery, the surgeon must repeat
the procedure.
Advantages of an AV fistula
Remains functional longer than other
forms of vascular access
No synthetic material implanted in your
body
Provides the necessary blood
flow needed for effective dialysis, which
may help to decrease treatment time
Low risk of infection
Less prone to clotting than other dialysis
access options
Created in an outpatient procedure
under local anesthesia
Fast return to your daily activities
Recovering from AV fistula creation
AV fistula creation can be done as an
outpatient procedure and does not require an
overnight hospitalization.  In general, you
should be able to go home a few hours after
the procedure is completed.
You will be instructed to keep your access arm
elevated to reduce swelling and pain at the
access site. Your physician may also prescribe
a painkiller to help manage any post-operative
pain.
Before you are sent home, you will be given
specific instructions on how to care for your
access.
BASIC SURGICAL
INSTRUMENTS
CLASSIFICATIONS
AND FUNCTIONS
1. CUTTING AND DISSECTING
INSTRUMENTS
These instruments usually have sharp edges
or tips to cut through skin, tissue and
suture material. Surgeons need to cut and
dissect tissue to explore irregular growths
and to remove dangerous or damaged
tissue. These instruments have single or
double razor-sharp edges or blades. Nurses
and OR personnel need to be very careful to
avoid injuries, and regularly inspect these
instruments before using, for re-sharpening
or replacement.
A. BLADE HOLDER
Main function: To hold scalpel blades
Where used mostly: All surgery Important
Product features: Many different types of
handles are used. The different styles are
numbered and hold a variety of scalpel
blade sizes.
Useful hints in usage: Extreme care must be
taken when attaching and removing the
scalpel blades.
Other comments: Disposable blade and
handle combinations are widely available
from different manufacturers.
B. SCALPEL
Surgical scalpels are used to make incisions and
for excision of tissues or organs. A surgical
scalpel is a very sharp knife. Often the handle
and the blade are packaged separately and
assembled by the surgeon at the beginning of
the operation; this maintains the sterile field. In
some cases, the surgical scalpel is a single unit.
Replaceable blades and handles come in different
sizes and styles.
Scalpels (disposable)
Handle 4 – blade 20-24 sizes
Blade 20 – initial for skin knife
Blade 10 – most common
Blade 11 – vascular, to puncture aorta, to
cut blood vessel
Blade 12 – EENT, tonsillectomy
Blade 15 – Plastic, pedia
Bone cutters – to cut ribs, thoracotomy
C. MAYO SCISSORS
Main function: To cut and dissect tissue To
cut sutures, clothing, bandages
Where used mostly: General surgery
Important product features: They come in
many styles. Super-Cut Scissors have one
razor-sharp cutting edge and one regular
cutting edge. They have superior cutting
ability because of the improved geometry
and cutting action.
The advantages are: -More control and
precision -Reduction of hand fatigue -Edges
retain sharpness longer Useful hints in
 usage: Dedicate the different types for their
specific purpose¾for example, using fine
dissecting scissors to cut suture can ruin the
cutting edge.
Special care instructions: To maintain
scissors in peak operating condition, they
must be sharpened regularly. Special razor
edge requires special sharpening
requirements.
Other comments: The most popular types
are the Mayo and Metzenbaum. On special
request one blade can be serrated.
They are used in eye surgery as a surgical
scissor. They are often kept in operating
rooms for other medical applications,
including making detailed cuts in small
areas where larger instruments are
unwieldy. Curved iris scissors are often
used in autopsies, when a small part of the
body must be cut without damaging organs
or tissue. Curved iris scissors are often very
small, very sharp, and are ideally kept as
sharp as possible

D. METZENBAUM SCISSORS

Main function: To dissect tissue 2. CLAMPING AND OCCLUDING

Are used in many surgical procedures for
Where used mostly: General surgery
compressing blood vessels or hollow organs, to
Important product features: The curved prevent their contents from leaking. Occlude
pattern is preferred by most surgeons for means to close or shut. Therefore, these
dissecting, since it provides a better field of instruments are also used to control bleeding.
vision for the areas to be dissected. The They are straight, curved or angled, and have
very tips of scissors are also used to spread a variety of inner jaw patterns. Hemostats and
and probe the area of incision. The smaller mosquito forceps are some examples of these
types of instruments.
sizes are used at the surface, the larger
sizes deeper in the cavities. Useful hints in
A. TOWEL CLAMPS
usage:
Special care instructions: To maintain
scissors in peak operating condition, they
must be sharpened regularly.
Other comments: The most popular types
of dissecting scissors are Mayo,
Metzenbaum, Iris and Stevens Scissors. For
small dissecting scissors surgeons often
prefer the Stevens Tenotomy Scissors.
is a perforating clamp used for grasping tissue,
E. Iris Scissor securing towels or drapes and holding or
reducing small bone fractures. This product is
curved with 1X1 perforating prongs and 5-
Curved iris scissors are used in medical
1/4inches in length.
applications for ophthalmic applications.
B. NEEDLE HOLDER
is a ratcheted, finger ring instrument available in
a wide range of lengths, and used in multiple
types of surgical procedures.
Due to its versatility, it is one of the most
commonly used surgical tools for both human and
animal procedures. Shorter length products may
be used in oral, gynecological, or dermatological
procedures, as well as with small animals. Larger
lengths of this product may be used for deep
tissue suturing such as in bariatric procedures, or
in large animal procedures.
The Mayo-Hegar needle holder is commonly used
with larger, heavier suture needles because of its
wide jaws.
This product is straight with cross-serrated jaws
featuring a central groove with which the needle
can be held, and a length of 7 inches.
C. Bulldog Clamp
A. SELF RETAINING RETRACTOR
The Bulldog clamp is a useful instrument
for stopping blood flow to a particular
organ of interest. One of the most common
applications where a bulldog clamp can be
used is during coronary surgery where
blood flow must be stopped. In general the
bulldog clamp, with its many angled
varieties and surgical applications, is an
essential tool during surgery where blood
flow to an organ must be stopped or
controlled.
D. MOSQUITO FORCEPS
used in multiple procedures as a hemostat for small
blood vessels. The ratcheted finger ring handle
provides a secure, locking grip to halt blood flow.
They are not appropriate for use with large vessels
or arteries.
A toothed variation is available for grasping delicate
tissue in skin grafting, biopsies, or ophthalmologic
procedures.
Mosquito forceps are known for their fine tips, and
short, fully serrated jaws. They are available curved
or straight. The standard length for this instrument
is 5 inches, although Sklar does offer some with a
length of 5-1/2 inches.
Halsted Mosquito Forceps are very similar to
Hartmann Mosquito Forceps, however, the
Hartmann style is finer and more delicate. This
product is straight with serrated tips and a length of
5 inches.
Main function: To retract or hold back tissue or
bone for surgical exposure
Where used mostly: General surgery Orthopedic
surgery Spinal surgery
Important product features: They may be set in a
fixed position with adjustable ratchet lock
handles. They reduce slippage. Some variations
have curved or hinged handles to minimize
interference and maximize visibility.
 : Other comments: The most popular types are Uses: Castroviejo needle holder is used for
the Gelpi 7 1/2”, the Weitlaner 4” and 5 1/2”, and anastomosis suturing in microsurgery.
the Inge 6 1/2”.

POTTS SCISSORS Adson Needle Holder

The name Potts has been given to Category: Holding and clamping

these scissors because they were designed Description: Fine and straight needle holder
by Willis J. Potts an American Pediatric with ring handles and fenestrated jaws.
Surgeon. They are also known as Potts- Uses: These types of needle holders are used
Smith Scissors or Potts Demartel in suturing for surgical procedures.
Scissors.  The blades of the scissors are
usually angled at the joint (25, 45, 60 and VASCULAR CLAMP
90 degrees) or they may be straight. Both
the blades of the scissors are sharp and
pointed.
The scissors are widely used to cut vessels
and hence are a very handy instrument in
vascular surgery. It is also used to cut fine,
delicate tissue when surgeon is working in
close space.

CASTROVIEJO NEEDLE HOLDER

A vascular clamp is used for occluding

Other names: Castro needle holder
Category: Suturing, stapling, and holding
Description: This needle holder has a flat
catch-spring handle. And, it comes in a variety
of lengths.
blood vessels or duct in a human or animal.
The vascular clamp includes a pair of
pivoting arms, with a clamping jaw rigidly
attached to a distal end of each pivoting
arm. The clamping jaws are movable
between an open position and a closed
position, and are also aligned so as to form
a substantially cylindrical chamber in the
closed position.
 B. SENN RETRACTOR
 is a handheld, double-ended retractor
used to retract primarily surface tissue.
It is often used in plastic surgery, small
bone and joint procedures, or
thyroidectomy and dissection of neck
tissue.
This instrument has one angled, blunt
end and, at the opposite end, facing the
opposite direction has a three prong,
rake tip. The prongs may be sharp or
blunt. This product has a straight, flat
handle with one squared off blunt end
and a second rake end with sharp tips.
The overall length is 6-1/4 inches
COOLEY DILATORS
Used to dilate vessels during vascular
or coronary surgery.
REFERENCES:
AVF
https://www.azuravascularcare.com/medical-
services/dialysis-access-management/av-fistula-
creation/
https://surgery.ucsf.edu/conditions--
procedures/vascular-access-for-hemodialysis.aspx
Chronic Kidney Disease (CKD)
https://www.kidneyfund.org/kidney-
disease/chronic-kidney-disease-ckd/
https://www.kidney.org/atoz/content/about
-chronic-kidney-disease
https://www.mayoclinic.org/diseases-
conditions/chronic-kidney-
disease/symptoms-causes/syc-20354521
https://nurseslabs.com/chronic-renal-
failure/#Pathophysiology
INSTRUMENTS
Heller, Michelle. (2016). Clinical Medical
Assisting: A professional, Field Smart Approach
to the Workplace.
Surgical Instruments slideshare.
Hurov, L. (1978). Handbook of veterinary
surgical instruments and glossary of surgical
terms. Philadelphia, PA: Saunders.
Miller, C. W. (2003). Bandages and drains. In:
Textbook of small animal surgery (pp. 244-
249). Philadelphia, PA: Saunders.