NRSG 301 Midterm EXAM

What are the indications for a CVAD?

Meds, infusion duration, VA availability, CVP, hemodialysis, admin fluids, obtain blood samples

Where is the location of a PVAD?

Between the hand and elbow

Where is the location of a CVAD?

The SVC, jugular vein, sublavian vein

What is the dwell time of PVADs?

For as long as there is no complications

What is the dwell time of CVADs?

Non tunneled.= 14D

Tunneled = long term (chemo, LT abx)

IVAD = long term (chemo)

PICC = 1 year

What are the risks with PVADs?

infection, phlebitis, extravasation

What are the risks with CVADs?

DVT, sepsis, arrhythmias, fractures, pneumothorax

Plus PVAD risks

Can you draw blood from a PVAD?

Yes - preferred this way

Can you draw blood with a CVAD?

Yes but only if needed

Can you do IV therapy with a PVAD?

Yes if it is short term (2 weeks)

Can you do IV therapy with a CVAD?

Yes

What is the timing around a PVAD?

takes about 10 minutes to insert, change dressing every 7 days

What is the timing with a CVAD?

About 60 mins for insertion, change dressing every 7 days

Where is a PICC placed?

In the upper arm, with the tip of the catheter in the CAJ/ distal SVC

How is a PICC inserted?

In about 60 minutes using ultrasound technology — need an order to start using it

What is the dwell time of a PICC?

for therapies greater than 2 weeks and less than 1 year

What are the types of PICCs?

Valved, nonvalved, multiple lumens

What is important to know about a PICC?

Do not take BP on the arm with a PICC, avoid moving heavy items and repetative movements with the arm

What is a power injection PICC?

When you can inject fluids under pressure through the lumen, is usually purple, pressure of 5ml/sec (for CT scan), are 18 gauge

What is a valved PICC?

it has an internal valve, will stay closed when not in use and is a safety mechanism in the line

What is a valved PICC - groshong?

Has pressures to control;

Positive = moves outward, allows you to infuse

Negative = move inward, allow you to aspirate

No pressure = closed

What is a nonvalved PICC?

have clamps on the end of the lines to prevent backflow

If no clamps than have a direct line of access to the patient

Where are percutaneous (nontunneled) CVADs placed?

Femorally (increased risk of CLABSI)

Subclavian/jugular

What is a nontunnel CVAD for?

short term infusions or in emergencies

What is the dwell time of nontunneled CVAD?

less than 14 days — replace with different CVAD if still needing access

How is a nontunnneled CVAD done?

By an MD and confirmed by CXR, is sutured in place and can be multilumen

Where is a hickmann (tunneled) CVAD?

In the subclavian; tunnels through subcutanous tisue

How is a tunneled CVAD done?

through a surgical incision or medical imaging

What is the dwell time of tunneled CVADs?

greater tahn 1 month, for longterm and continuous access

What is the dacron cuff with a tunneled CVAD?

helps hold the catheter in place, creates granulation tissue securement in 3-4 weeks

It is 3 inches from the exit site

What is an IVAD?

it has a port with a reservoir, a self sealing membrane and a catheter; requires access with a Huber needle

Where is an IVAD?

The distal tip should rest in CAJ/SVC

How is an IVAD done?

It is surgically implanted

What is the dwell time of an IVAD?

For as long as required

Why would you need an IVAD?

For longterm intermittenet access, to decrease infection, has no limitations (can go swimming)

What are you assessing with an IVAD?

malposition of the catheter (gurgling sound heard), a dislodged tip, flushing every 30D not in use, heparin locking

What is hemodialysis with a CVAD?

Has blue and red ends, only a hemo RN can use

They are utilized temporarily until a fistula is created for access

What are the types of hemodialysis CVADs?

Cuffed = using for more than 3 months

Non cuffed = using for emergencies or less than 3 months

What do you need to know about CVAD tip position?

should be in the CAJ/SVC

If femoral should be where VC meets the RA

Malposition can increase mortality

Perpendicular tips can cause erosion/extravasation

What are the advantages of multilumen catheters?

Can administer multiple medications and multiple incompatabile medications at the same time

Provide different gauges of catheters to use

**important to note that more lumens increase infection

What is important to know with administering medications through a CVAD?

Check the parenteral manual and compatability of drugs

Check the patency and perform in between and post med flushes

WHat is important to know about adminstering TPN through a CVAD?

Must always be done with a CVAD?

Requires a 1.2 micron in line filter

Need to use a dedicated line

What is CVP monitoring?

Checks the pressure in the VC near the RA

Normal is 3-8 cm (2-6 mm Hg)

RA pressure is detected and indirect RV diastolic pressure

What are the indications for CVP monitoring?

HoTN with fluid rescus, sepsis

*mostly seen in ICU/ER

What is the nurses role with asepsis and a CVAD?

ensure 15 second mechanical scrub and 30 second dry time

What is the nurses role with assessment and a CVAD?

Is the site clean and dry; compare PICC arm to other for swelling (DVT); is the nontunneled PICC sutured; monitor patency and flush; lock the line

What is the nurses role with dressing/caps and a CVAD?

Change the dressing Q7D and PRN; 24 hrs if gauze underneath

Change securement devices and caps Q7D; caps after blood draw or blood remains

What is the nurses role with PICCs and a CVAD?

Assess the external lenght; stop using if moved more than 3 cm

What do you need to know about flushing with a continuous infusion?

Complete at:

• start of shift (before meds/blood/TPN)

• when changing tubing or cap

• if occlusion suspected

What do you need to know about fluhsing with intermittent infusions?

Should be completed:

• when switching from continuous to intermittent

• 10 before, 20 after meds/blood

• with TPN

• if occlusion suspected

• every shift

What are the S/S of CLABSI?

Local = redness, tnederness, warmth, edema

Systemic = fever, chills, decreased BP

What is the diagnosis for CLABSI?

alterened VS (inrcrease T/RR/HR), altered LOC

What is the treatment for CLABSI?

Blood cultures (2) — check time to positivity for source; remove the catheter'; complete a C+S

Systemic = abx, follow sepsis protocol, initiate fluids

What are the uidelines for CLABSI?

HH, aspetic techniques, use minimum number of lumens

What is an air embolism?

2 conditions occur: a pressure gradient and a direct line to.the patient

Severity is absed on volume or air/the route/patient positioning

>50mL considered lethal

What are the S/S of an air embolism?

dyspnea, cough,agitated, impending doom, CP

What is the treatment for an air embolism?

close the catheter, put in trendelenburg L lateral, O2 and VS, MRP

How can you prevent air embolism?

Remove all air from tubes, syyringes

Assess all lines for bubbles

Lie in trendelenburg for insetion

Lay flat for 30 mins post

Complete the valsalva manouever

What are thrombotic occlusion?

Clots blocking the line; make up 58% — intra and DVT

What are intraluminal thrombotic occlusions?

When a clot is created within the lumen

Have difficulty aspirating and flushing

What are mural thrombotic occlusions?

When a clot is formed around the catheter and attaches to vein wall

Can be partial or complete occlusions — can cause swellingW

What are fibrin tail thrombotic occlusions?

When there is a clot on the end of the catheter that can impacts usage

Will have resistance on aspiration (acts like one way valve)

What are fibrin sheath thrombotic occlusions?

When the clot forms a sock around the end of the catheter

Will have an issue with aspirating and flushing

Meds will infuse around the clot — so farther from where it should work if clot moves up the line

What are S/S of thrombotic occlusions?

pain, edema, engorgment of the vessels

What is the tretament for thrombotic occlusions?

TPA (done by MD/NP), systemic coagulation for 3 months

What are chemical occlusions?

When there is medication precipitate or reaction in the line that blocks the flow; causes 42%

What are the risk factors for chemical occlusions?

Incompatible drugs infused, an increased precipitate med infused, a med with a high concentration of calcium and phosphorus

What are the S/S of chemical occlusions?

sluggish infusion to complete obstruction of the line

What is the treatment for chemical occlusions?

Consult the IV team and MRP

What are mechanical occlusions?

Can be an external or internal catheter problem

Get the patient to cough or move their arm

What are examples of mechanical occlusions?

kinked lines or leaks, migrating catheter, closed clamps

What are site complications of a CVAD?

phlebitis, thrombophlebitis, extravasation

Peripheral will only have these if they have a fibrin sheath

What are the S/S of catheter embolisms?

palpitations, arrhythmias, dyspnea

What is the treatment for catheter embolism?

inspect the catheter on removal and save it for testing

Contact MD

How do you prevent catheter embolism?

Dont power inject VADs, flush with appropriate size syringe

What are the S/S of pulmonary embolisms with CVADs?

apprehension, dyspnea, cyanosis, CP

PICC - below site swelling

Tunneled — accessory vessels used (spider)

How do you prevent PEs with CVADs?

Dont forcefully flush the catheters

What are the S/S of catheter migration with CVADs?

slugish infusion, edema, gurgling in the ear, dysrhythmias

What are the treatments for catheter migration with CVADs?

stop infusions, confirm placement with CXR, contact MRP

What is the pneumothorax/hemothorax S/S of insertion complications with CVADs?

respiratory distress, CP, decreased breath sounds, tachycardia

What is the pneumothorax/hemothorax treatments of insertion complications with CVADs?

O2 and VS, raise the HOB

What is the arrhythmia S/S of insertion complications with CVADs?

arrhythmias, abnormal HR/rhythm, palpitations

What is the arrhythmia treatments of insertion complications with CVADs?

Oxygen, remove the cause

Why would you draw a blood samples with CVADs?

if you have poor peripheral access, a clinical reason, preserve veins

What are the concerns with drawing blood from a CVAD?

increased infection risk, clot risks, occlusion

What do you need to know about the lumens and caps when drawing blood through a CVAD?

use the largest lumen, change caps always after blood draw

What is the preferred procedure for drawing blood from a CVAD?

Stop infusion, remove cap, cleanse, use a vacuseal container, pull discard amount and sample

What are two other methods of drawing blood from a CVAD?

1. cleans port, connect vacuseal, pull discard and sample, change the cap

2. stop infusion, cleanse, attach 10mL syringe, pull discard and sample

What are the risks with drawing blood from a CVAD?

hemolysis, coagulation levels are wrong, wrong therapeutic drug levels

What are the benefits of drawing blood from a CVAD?

Decreases hematoma, preserves veins, decreases pain

What to know about PICC dressing changes?

Change when damp, loose, soiled

Change q7D — change cap q4-7 days

Use chlorhexidine to clean (need to wait till its dries or will burn the skin)

What is the procedure for changing a PICC dressing?

use clean technique to pull dressing away from securement device

use aseptic technique to cleans the skin and place a new securement device

use sterile technique for rest of process (keep insertion in the window)

• Uses stat seal for first 7D

• label dressing with time/date/initials

• remove old dressing towards the insertion site

What are complications that occur with PICC dressing changes?

catheter migration, blood, introduce contaminants to infection, accidental removal

What to do with a PICC removal?

Requires an MD order

• remove dressing and cleanse site

• Withdraw 2-3cm at a time

• Do not directly apply pressure to the site

• Get patient to do valsalva manoeuvre for last 5-10cm

• Apply pressure to site for 2 minutes

• Inspect the catheter after removal (ensure all parts are there)

What to do with a jugular/subclavian removal?

Requires an MD order

• Have patient perform Valsalva manoeuvre and be placed in trendelenburg

• Remove dressing with chlorhexidine

• Have patient do normal breathing and apply pressure for 5-10 minutes after removal

• Lay flat for 1 hour post removal

• f there is any resistance — stop procedure

What are the post removal assessment pieces?

• q15 minutes for 1 hour

• Resp assess q15 for 1 hour (any SOB/PE)

• Decrease activity for 1 hour post (2 if femoral)

• If there was an infection cut off the catheter tip for C + S

• Remove cover dressing after 48 hours

What are the contributing factors for difficulty urinating and for a catheter?

male obstruction, female obstruction, infections, neuro impact, postop complication, pregnancy induced, trauma, psych impacts

What is the male obstruction contributing factor for difficulty urinating and for a catheter?

If they have BPH, or prostate cancer

What is the female obstruction contributing factor for difficulty urinating and for a catheter?

if they have pelvic cancer or pelvic organ prolapse

What is the infection contributing factor for difficulty urinating and for a catheter?

If they have prostitis, vulvovaginitis, UTI/STI