Nrsg 301 midterm

CVAD Indications:

*Administer intravenous fluids and blood products (including administering large volumes of intravenous fluid quickly)

*Administer medications (including vasopressor or vasodilator therapy)

*Administer vesicants (e.g. chemotherapy)

*Administer irritants (eg. Cloxacillin)

*Administer solutions with extreme pH values (eg. Vancomycin)

*Administer hypertonic solutions (eg. TPN - a higher dextrose content should be be infused through a CVAD)

*Obtain venous blood samples

*Monitor central venous pressure (CVP)

*Provide access for pulmonary artery catheters or transvenous pacemaker

*Provide hemodialysis access

*Consider length of time client needs IV access

What is the difference between a PVAD and a CVAD?

location of the tip of the catheter,

insertion site can be different,

catheter dwell time

types of infusion

blood sampling reliability

availability of home IV therapy

cost

what is a pvad

IV inserted into the peripheries

what is a cvad

central venous access device

where is a CVAD tip located

lower third of the superior vena cava

How long can a CVAD remain in a patient?

6 months to a year

Where is a PICC inserted?

in the cephalic, basilic or median cubital vein above the ACF (antecubital fossa)

where is the tip of the PICC catheter

rests in the lower portion of the distal superior vena cava

Who inserts a PICC line?

iv nurse w/ ultrasound machineat bedside, takes 30-35min, and MUST be verified w/ chest x-ray

when is a picc appropariate

for treatments lasing more than 1 month and less than a year

PICCs are classified by

valved or non-valved

Catheters positioned within the heart have

increased mortality risk

Catheter tips positioned perpendicular to the vein wall have

an increased risk of vessel erosion, hydrothorax, hydromediastinum, tamponade, and extravasation

nurses should ........ until tip is confirmed

never use a CVAD

valved PICC

-venous access device with an internal (integrated) valve or device located at either the proximal or distal end

-The valve allows infusion and aspiration through the VAD, but it remains closed when not in use, thus preventing back flow and providing a safety mechanism

-Valves prevent things from coming into the catheter

*There is no need for routine clamping or heparinizing

how does a valved picc work

A positive pressure flush takes place when the syringe is removed from the end of the PICC whilst still flushing - this is to close the valve to prevent blood reflux back into the catheter which could cause an occlusion.

what do valves look like on PICC

round balls

groshong valve

-valve is closed when no pressure

-positive pressure from thesyringe opens the valve for med admin

-negative pressure opens valve inward for blood draw

-flush w/ NS

-NO HEPARIN

non-valved PICC (open ended)

-Is a venous access device without an internal (integrated) valve or device

-Has a clamp to prevent reflux or black flow of fluid contents or blood.

-Non-valved VADs require a heparin lock to keep patent (eg. using heparin 100 units/mL prefilled syringes)

PICC: Power Injectable

-a purple central venous catheter that allows power injection of contrast media for scans

-usually all lumens are 18 gauge

-usually are non-valved (require heparin flush)

Higher rate of admin 5ml/sec (for CT scans contrast

- displays the mL/sec max

CVAD Types of Lumens

If more than one lumen, usually at least one lumen is a different gauge (eg. 19g, 20g and 20g)

- May administer multiple medications/treatments at the same time

- May administer multiple incompatible medications at the same time

NB: need to flush each lumen per facility protocol to keep all lumens patent

Role of the Nurse Caring for a Client with a CVAD:

1) Need to ensure asepsis with all central lines and venous access ports

´2) Need to assess site (inspect and palpate) for redness, drainage, swelling, pain, tenderness, warmth, numbness, parasthesia. Report any concerns.

´3) Need to ensure patency of all PICC/CVADS before use:

´

´Perform flushes (per agency policy)

´Check for resistance on aspiration, ability to withdraw blood, and ability to infuse fluids without resistance

´Use a start-stop flush technique (push-pause). Never flush with force

´Use at least twice the volume of the catheter and add-on devices (Goossens, 2015)

´Use a 10 mL or greater syringe for flushing to decrease risk of catheter damage. Does not apply when using power-injectable lines (Goosens, 2015)

´Need to flush pre- and post-medication administration (per agency policy)

´Lock the line after use with saline or heparin (per agency policy)

´A patency check is often done once every shift to ensure line is correctly placed, patent, and ready to use

´If line not flushing properly or unable to aspirate, need to notify the IV team as soon as possible

´

´NB: DO NOT USE a line that is not patent!

how often do you flush a PVAD thats not in use

Q24hr

how often do you flush a CVAD

weekly

how much do you flush a CVAD with

patency flush 10mL before med

medication flush 20mL after med

how often do you change a CVAD dressing

Q7days and PRN

what do you measure with a PICC

external length

what size flush is best for VAD

10mL or larger otherwise pressure is too great

positive pressure disconnect

when locking a VAD with a neutral displacement end cap hold pressure to keep positive pressure

why do we need to flush and aspirate central lines

catheter tip can become adhered and create a fibrin sheath

how often does a gauze PICC dressing get changed

Q2days

how often does a securement device for a PICC get changed

Q7days

how often is a PICC needleless cap changed

Q7days, and PRN for blood on cap

what wipe do you use for the peri-skin of a picc

chlorhexidine

PICC Complication: Air embolism

-mechanism of death or injury depends on the size of the air embolism and where it lodges in the body

-- if an air bubble travels to the brain, heart, or lungs it can cause an MI, CVA, or respiratory failure

what to do for a PICC air embolism

-If a venous air embolism, place client on left side and in trendelenburg position (encourages air bubble to move into the right atrium preventing CV collapse)

If an arterial air embolism, client should be kept in supine flat position

PICC Complication: Pneumothorax or Hemothorax

´Caused by accidental puncture of the pleura or lung during insertion

´One of the most common complications of central venous catheter (CVC) insertion (1-1.5% incidence in insertion of hemodialysis catheters)

PICC Complication: Arrhythmia

If the CVAD is advanced into the right atrium, there is risk of irritating the heart and causing an arrhythmia

Labelling medication syringe: in IH, must be labelled with

drug name, dose/volume (concentration), and route, plus 2 patient identifiers

when do you choose a non-tunneled CVAD

7days to one month

when do you choose a PICC

more than one month less than a year

when do you choose a tunneled CVAD or IVAD

more than 1 year

Non-Tunneled CVADS

short term emergent therapy

internal/external jugular or subclavian vein

surgical insertion

verify with chest xray

sterile dressing

requires heparin flush

usually less than 7 days

tunneled CVAD

•Surgical insertion by provider; portion of catheter lies in sub-q tunnel to prevent infection

•Intended for frequent, long term infusion therapy (months to years)

implanted venous access device (IVAD)

´The IVAD port consists of a reservoir, a hollow metal disk with a self-sealing membrane, and a catheter

´The distal end of the catheter is usually placed in the distal third of the superior vena cava

´Surgically implanted by vascular surgeon into a small subcutaneous pocket usually on the upper anterior chest (the line is tunneled to the vein and secured with sutures)

´Have a decreased risk of infection

´No dressing required when not being used. If being used needs an aseptic dressing over Huber needle, site, and tubing (usually a transparent dressing)

´The port is accessed using a "Huber needle" (with attached extension tubing) following sterile technique

´Requires Heparin flush solution (usually 5 mL) to lock line

´Used for long-term IV therapy (eg. on-going intermittent medications, chemotherapy, frequent blood samples)

´Usually used for treatments expected to last more than one year (IH)

Hemodialysis Catheter

Large lumens accommodate hemodialysis or pheresis procedure (harvests specific blood cells)

Catheter-related bloodstream infections (CR-BSI), vein thrombosis are common problems

Do not use for administering other fluids/medications (except in emergency)

CVAD Tip Position

´For subclavian and jugular vein CVADs, the tip of the catheter should be located within the lower third of the superior vena cava

´Catheters positioned within the heart have an increased risk of mortality

´Catheter tips positioned perpendicular to the vein wall have an increased risk of vessel erosion, hydrothorax, hydro- mediastinum, tamponade, and extravasation

´*Nurses should never use a CVAD until the tip position is confirmed

Administering Total Parenteral Nutrition (TPN) through a CVAD

´CVAD is always used for total parenteral nutrition (TPN) (A peripheral line is used for PPN)

´An in-line filter is required for TPN

´Needs a dedicated line

´The white port of a multi-lumen CVAD may be the port used for TPN

´Solutions are prepared by pharmacy daily

´Solutions need to be checked with another RN prior to hanging to ensure solution matches daily doctor orders

´Solution/tubing needs to be changed every 24 hours

´Why would you use a PICC to draw blood?

´If a client's peripheral veins are no longer accessible

Clinically significant reasons (eg. risk of hemorrhage, needle phobia, client refusal

concerns with CVAD blood draw

´Increased risk of catheter-related infection and CVAD occlusion

´Can a good blood sample be obtained when drawn from a PICC?

´Not always. Lab results are not as accurate as with direct fresh blood access

Thrombotic Occlusions

1st common cz of catheter occlusion

the blocking of an artery by a thrombus

intraluminal clot

a type of catheter thrombosis where there is resistance upon aspiration and decreased ability to infuse fluids

fibrin tail

In some cases, the fibrin sheath can grow over the tip of the catheter, or may accumulate exclusively at the distal tip of the catheter creating a "fibrin tail."Cannot aspirate

mural thrombus

a thrombus formed within the wall of the heart (myocardium) or vessel (media)

fibrin sheath

is a cluster of blood clotting fibers that build up on the outside of a catheter lumen. The fibers can form a cap that blocks the end of a catheter and reduces blood flow.

chemical occlusions

´Risk Factors:

´Recent infusion of incompatible drugs (eg, heparin, morphine, potassium, erythromycin, and dobutamine)

´Medications with high-risk for precipitation (eg, phenytoin and heparin)

´High concentrations of calcium and phosphorous in parenteral nutrition solutions

´S & S:

´Line is sluggish and difficult to flush

´Vary depending on type of occlusion

´Treatment:

´Depends on cause (see agency policy)

´Consult a pharmacist (may recommend a fibrinolytic or non-fibrinolytic agent)

Mechanical Occlusions

Kinked tubing

- Cracks or leakage in CVAD

- Constriction of CVAD due to improperly placed sutures at insertion site

- Catheter tip migration

- Malposition of the catheter

- Closed clamps

- Clientposition

Catheter Fracture

´S & S:

´palpitations, arrhythmias, dyspnea, cough, or thoracic pain not associated with client's diagnosis or comorbidities

´Prevention:

´Do not withdraw a catheter through a needle during insertion.

´Never use vascular access devices for power-injection that are not rated for this purpose.

´The size of the flush syringe should be appropriate for the type of CVAD and its intended use.

´Intervention:

´Upon removal, inspect all catheters for damage and possible fragmentation.

´Notify MD and treat symptoms

´Save catheter and report per agency policy

catheter migration

´the CVAD catheter migrates in or out changing the position of the tip

´S & S:

´sluggish infusion or aspiration

´edema of chest or neck during infusion

´client complaint of gurgling sound in ear

´dysrhythmias

´Treatment:

´STOP infusion. DO NOT USE.

´Re-confirm placement with CXR

´Consult with trained RN or MRP prior to re-accessing

NB: DO NOT USE until tip position is confirmed

Pneumothorax/Hemothorax

´caused by accidental puncture of the pleura or lung during CVAD insertion

´S & S:

´Respiratory distress (dyspnea, tachypnea, cyanosis)

´Chest or shoulder pain

´Unilateral distension of chest

´Decreased or absence of breath sounds

´Tachycardia

´Treatment:

´Oxygen

´Elevate head of bed

´Call MRP STAT

´Prepare for chest tube insertion

dacron cuff

stabilizes the catheter and decreases incidence of infection tunneled catheter

normal blood pH is_____, normal osmolarity is ______)

7.35-7.45

280-300

what pH is meant for CVAD

less than 5 or mre than 9

what osmolality is meant for a cvad

more than 600

Blood Draw Procedure:

*Choose largest CVAD lumen (preferably designated- usually the red lumen)

*May use vacutainer for all samples except blood cultures (use a syringe)

*Must draw blood in order using a certain vacutainer tube order (red, green, blue, lavender)

*Method 1: (preferred)

*Stop infusion(s), remove the administration set, and attach the luer lock vacutainer directly to the catheter lumen

*Method 2:

*For a capped (SL) CVAD, may luer lock the vacutainer directly to the needleless cap and then change the needleless cap following the blood draw (check agency policy)

*Method 3:

*Stop infusion for 2 min. Attach 10 mL syringe directly to the needleless cap, draw blood into syringe then attach vacuatiner to syringe to fill blood sample tubes

*Usually 5-10 mL of blood is discarded prior to taking blood sample or at least three times the catheter volume (an exception is blood cultures)

*NB: for coagulation studies should not use Heparinized CVADS

what to do for CVAD infusing blood draw

turn off for 2 minutes before blood draw

how much do you discard in a cvad blood draw

Must draw and discard 5-10 mL (IHA policy is 6 mL) blood prior to sample collection, except if taking blood culture, you want the first blood in the lumen

CVAD blood draw flush

Post blood sampling flush is 20 mL

risks of CVAD blood draw

hemolysis, inaccurate coagulation studies if line is locked with Heparin, inaccurate therapeutic drug levels from medication administration, catheter related blood infection from access

Benefits of CVAD blood draws

decrease risk of hematoma from venipuncture, vein preservation, decreased pain and anxiety from needle phobia

PICC Dressing Change

Change dressing if becomes damp, loosened, visibility soiled, or if moisture, drainage or blood is present under the dressing

Change dressing, securement device, and needleless caps per agency policy

IHA policy is to change dressing Q7days and PRN

IHA policy is to change needleless caps every 4-7 days, when unable to clear blood from cap, if sterility is compromised, following blood sampling or if removed for any reason

Use 2% chlorhexidine with alcohol (pink swab) for cleaning the site in a circular or back and forth motion and allow to air dry

PICC Dressing Change Procedure

vThe two step process with securement device is the preferred method (current IH policy)

vClean technique is used to peel the dressing back to expose the securement device and remove it

vAseptic technique is used to apply the new secure device and remove the remaining of the dressing

vSterile technique is used to complete the rest of the dressing change

vYou may see a StatSeal Disc used at the site for the first 7 days after insertion, this is to stop bleeding and keep the site dry. It is removed at 1st dressing change (7 days).

PICC dressing change complications

- Migration

- Bleeding at site

- Introduction of contaminants leading to infection

- Accidental removal of PICC

Key Points for CVAD's

1.Dressings should be changed routinely, and whenever the dressing is compromised

2.Change transparent semipermeable membrane (TSM) dressings q 5-7 days. Change gauze dressings q 2 days.

3.Dressings should be labelled with the date, time, and initials of the nurse performing the dressing change

4.Chlorhexidine with alcohol is the preferred antiseptic for CVAD site care (pink chlorhexidine with alcohol swabsticks - make sure to let dry before applying dressing)

5.Use sterile gloves for site care (e.g. dressing changes). Masks are sometimes recommended, but there is no evidence to support their use

6.Cap is changed q7days with dressing change, or if blood visible inside cap and can't be cleared (blood draw or aspirated blood)

PICC Removal

vAlways verify the physician's order

vGrasp the catheter at the insertion site and withdraw slowly in 2-3cm increments

vDo not apply pressure directly over catheter, support surrounding tissue with sterile gauze

vIf resistance is felt during procedure, stop and apply heat for 15 minutes to upper arm and shoulder

vPlace sterile gauze and large transparent dressing over site

vMaintain sterility at insertion site

Jugular or Subclavian Removal CVAD

vAlways verify the physician's order

vPractice Val Salva with patient, deep breath and hold, bearing down

vPosition in Trendelenburg without pillows and have patient turn head away, both nurse and patient should be wearing a mask

vDon sterile gloves. Use chlorhexidine to cleanse.

vVal Salva maneuver while withdrawing catheter and applying direct pressure over site with sterile gauze

vIf any resistance, stop, tape in place, report to MRP

vNormal breathing while applying pressure for 5-10 minutes without occluding carotid artery

vPlace sterile gauze and large transparent dressing over site

Post CVAD Removal Assessment

vAssess site q15min for 1 hour, then hourly for hemorrhage

vMonitor respiratory status q15min for 1 hour for SOB, PE (pulmomary embolus)

vMinimize patient activity for 1 hour, 2 hours for femoral

vIf suspected infection of catheter, cut off 1 inch of tip of catheter with sterile scissors and place in sterile C&S container, label and send to lab

vThe C&S removal and sampling is often done with 2 people to avoid contamination of catheter tip while maintaining pressure

vDressing can be removed after 48 hours if no complications

CVAD Removal Basics: PICC

uFor routine removal cleansing is not required

uGrasp the catheter at the insertion site and withdraw slowly in 2cm - 3 cm increments

uDO NOT apply pressure directly over catheter during removal

uIf resistance is felt during removal:

uStop withdrawing catheter;

uApply heat to upper arm and shoulder for 15-30 minutes;

uPlace sterile gauze over insertion site and then place large transparent semi - permeable dressing (TSM) over gauze

CVAD removal basics: Jugular or Subclavian

uPosition patient flat or in Trendelenberg. Remove pillows from under head

uAsk patient to take a deep breath and hold (Val salva)

uWithdraw the catheter while applying direct pressure with sterile gauze to the site (sterile technique used)

uTell patient to breath normally

uIf any resistance is felt: STOP, tape in place and report to MRP

uApply pressure for 5-10 minutes without occluding the carotid artery

uPlace sterile gauze over insertion site and then place large transparent semi - permeable dressing (TSM) over gauze

What is happening:

You assess your patient's PICC line. The insertion site looks great - no leaking, no swelling and no discomfort. The dressing is dry and intact. The patient's arm is slightly swollen.

possible thromus

What do you do?

You assess your patient's PICC line. The insertion site looks great - no leaking, no swelling and no discomfort. The dressing is dry and intact. The patient's arm is slightly swollen.

stop using the line and call MRP

The previous patient with a venous thrombosis has now had the PICC line removed and a new one inserted into the other arm. You have to take your patient's vitals.

Where do you take the BP?

the leg

If the central line is infusing with a compatible solution are you able to administer the medication independently if you and your instructor feel you are competent at the skill?

NO its a CVAD and a high alert med

What are the main indications for inserting a catheter?

Urinary Retention

Incontinence

what can urinary retention be caused by?

Surgery - bladder decompression during or following perioperative period

Urethral trauma

Obstruction- between kidney and bladder or bladder and urethra

Urinary retention - chronic or acute

HOUDINI protocol

Haematuria

Obstruction

Urology surgery/abdo surg/ gynecologic surg

Decubitus ulcer

Input and output measures needed

Nursing end of life care

Immobility/bedbound

2 key sings of urinary retention

1.Bladder distension

2.Absence of urine output over several hours

Signs and symptoms of urinary retention

3.Severe pain (or feeling of pressure in a patient who has had an epidural or spinal anaesthetic) in the pelvic area usually non localized

4. Restlessness

5. Diaphoresis

6. Overflow (voiding small amounts, 25-60 mL several times an hour).

key signs of incontinence

1.Inability to control the release of urine (determination of type and cause).

●

Incontinence alone is not a

good reason to catheterize

long term.

●

How do you assess bladder distention

-Palpate just above symphysis pubis for rounded bladder

-The patient can often feel the distention and is exacerbated with pressure to the area

-Sometimes they cannot feel any difference because of neuro causes (eg. Spinal /epidural)

Percuss down from umbilicus

Change to dull sound indicates bladder

-bladder scan

Variance of bladder distention

grossly distended, distended, and empty bladder

contributing factors for urinary retention for men

•Benign prostatic hyperplasia (BPH)

•Prostate cancer

•Phimosis- anatomical: foreskin cannot be pulled back

•Paraphimosis- anatomical: foreskin is trapped behind and cannot be reduced

phimosis

narrowing of the opening of the prepuce over the glans penis

paraphimosis

condition in which a retracted foreskin cannot be pulled forward to cover the glans

urinary obstructive causes in women

•Pelvic organ prolapse- anatomical changes

•Cancer

Urinary Retention- Contributing Factors for both men and women

•Urethral strictures (shrinking)

•Stones

Foreign bodies

Postoperative complications

•Pain

•Traumatic instrumentation of the bladder

•Bladder over distension during surgery

•Medications

Trauma to urethra genitalia or bladder

Anxiety

medications

Medications that Cause Urinary Retention

•Anticholinergics (eg. Atropine)

•Antipsychotics (eg. Haloperidol)

•Antihistamines

(eg. Diphenhydramine)

•Muscle relaxants (eg. Diazepam)

•Morphine and all opioids (eg. fentanyl, hydromorphone)

•Anesthetic agents

Risks of Catheterization

infection, trauma

CAUTI

catheter associated urinary tract infection)- UTIs are the most common healthcare associated infection (HAI) in acute and residential

Care. UTIs are usually related to instrumentation of the urinary tract, the most frequently implicated being bladder catheterization.

-Occur more often with indwelling than with intermittent (in and out) catheters

-Wash hands before and after contact with catheter

-Cleanse connections with alcohol prior to or after any break in this closed system

-Increased risk anytime closed system is opened (ie. Emptying bag), changing from leg bag to night bag