# N22 · Access and Worsening Heart Failure

Persistent congestion or poor tolerance may need a cardiac and access review, even near target weight.

![Infographic: N22 · Access and Worsening Heart Failure](https://urinenephrology.org/visual-reference/images/nursing-n22.png?v=20261003c)

## Put symptoms on the access timeline

Record access creation/revision dates beside new orthopnea, edema, abdominal swelling, walking limitation, and admissions. Symptoms persisting near prescribed target weight still need review; do not assume the only answer is more fluid removal.

## Assess today’s stability

Check vital signs, oxygen saturation, perfusion, weights, and treatment tolerance. Dyspnea at rest, new hypoxemia, chest pain, syncope, confusion, or shock requires urgent assessment before any elective access-flow investigation.

## Understand the possible link

An arteriovenous access returns blood directly to the venous circulation and increases cardiac workload. Limited left- or right-heart reserve can make this harder to tolerate; a preserved ejection fraction does not exclude a problem.

## Keep the differential broad

Volume excess, anemia, ischemia, arrhythmia, valve disease, and other causes may contribute. A prominent thrill, BNP value, or single flow measurement does not establish access-related high-output heart failure.

## Bring Qa, not the pump setting

If available, provide measured access flow (Qa), its date/trend, echo findings, BP, oxygen saturation, and UF tolerance. The dialysis pump’s blood-flow setting is not Qa. Request joint nephrology/cardiology/access review; do not compress the fistula as a bedside test.

## State the unresolved decision

Handoff the timeline and competing causes—volume excess, anemia, ischemia, rhythm/valve disease, or access burden. Confirm who arranges assessment and the dialysis backup. Severe breathlessness, hypoxemia, syncope, or poor perfusion needs urgent assessment first.

## Source lessons

- [N22 Fistulas and Worsening Heart Failure](https://urinenephrology.org/mastery/maintenance-hd/nursing/N22-Fistulas-and-Worsening-Heart-Failure.html)

Read alongside the full lessons; the findings and decisions shown here require the stated clinical context.