Central Venous Access Devices (CVAD)
Catheter Occlusions
- Intraluminal thrombus - Inability to flush or aspirate blood from catheter - Never force flush when meeting resistance - Follow protocol for declotting catheter - Use a "clot buster" ex., Alteplase * Per agency protocol only*
Complication Table
#1 = blood infection
Administering Medication *S.A.S.H Method*
*"Scrub hub" - antiseptic solution (15 - 20 seconds) each* & every time you access *S aline* - sterile normal saline *10 ml* syringe *A dminister* - IV medication - using 6 rights & 3 checks! *S aline* - flush with 10 ml saline after IV medication *H eparin* - only if indicated **per protocol** **heparin may be used as last flush to prevent thrombus forming, low concentration 100u/mL or 10u/mL** - only if giving med, aspirate enough to see blood
Removal of CVADs
*** According to agency policy *** - RNs that have demonstrated competency - Remove dressing, sutures, stabilization device - Ask patient to perform the Valsalva maneuver, take deep breath & hold it - Remove catheter with smooth continuous motion - Inspect tip of catheter; ? send tip for culture - Apply pressure to insertion site - Apply dressing- petroleum-based occlusive dressing antibiotic ointment - Measure tip of catheter, PICC
Needle free cap/hub connector
*SCRUB EACH & EVERY TIME YOU ACCESS* - decrease risk of infection and blood sepsis
Port-A-Cath
*Surgically* implanted port *subcutaneously*, accessed with Huber needle; *flushed with heparin*
Dressing Change
- *Apply sterile transparent dressing (no wrinkles* - *Position so insertion site is in center of dressing* - If CHG gel pad dressing center it over insertion site - Apply securement tape or device if indicated - Label dressing - date, time & initials - Wash hands - Document View demonstration: http://www.youtube.com/watch?v=ud8EWOQYqP0&feature=relmfu
Preventing CLABSI
- *I*nstitute for *H*ealthcare *I*mprovement - The *Central line bundle* is a set of 5 interventions: 1. Hand hygiene 2. Maximal barrier on insertion 3. Chlorhexidine skin antisepsis 4. Site selection 5. Daily review for need with prompt removal of unnecessary lines - Use of disinfectant caps
Flushing the CVAD
- *To maintain patency* - Wash hands apply non-sterile gloves - Flush with 10mls of sterile *normal saline* (20 mls following blood draw) - Use *10 ml* pre-filled saline syringe expel all air bubbles - *Scrub hub* - twist alcohol wipe for 15 -30 seconds & allow to dry - *Push-Pause* technique - Flush *ALL* lumens not being used for infusions - Clamp unused ports if indicated per protocol - smaller syringe = more pressure → catheter rupture - *10 mL syringe or larger for any CVAD*
Nontunneled CVC
- 1 to 4 lumens - Flush with normal saline - May flush with low concentration heparin (100 units/ml) - Femoral access possible but not first choice, →increase risk of infection - *Risk:* pneumothorax - most use low dose heparin to prevent clots and keep line patent. - subclavian preferable
Nursing Management of CVADS
- Assist MD/HCP with insertion - *Confirm placement* before using catheter - Assessment and maintenance is RN responsibility - Maintain patency - Maintain sterile technique - Apply dressing and cap changes per protocol - Administer IV fluids & medications .- Prevent complications - *infection* *ALWAYS PER HOSPITAL PROTOCOL* - dressing q 7 days
Cap Change
- Change Caps per agency protocol - Prime cap with sterile normal saline - *Clamp catheter* - Using aseptic technique twist off old cap - Scrub the end (threads) of catheter 15 to 30 seconds with alcohol - Attach new cap twist completely - Unclamp & Flush catheter - Apply disinfectant cap - clean gloves
Push-Pause Technique
- Creates positive pressure & turbulence to keep catheter patent - Push 1 -2 mls, pause, push 1-2 mls pause, continue until all 10 ml instilled but *END with positive pressure* - Alternate pushing & pausing on syringe plunger - apply a steady gentle pressure - squeeze catheter when finished
Flushing Procedure`
- Don non-sterile gloves - *"scrub hub"* with alcohol or chloraprep - Allow to dry - Expel air bubbles from *10 mL pre-filled saline* syringe - Attach saline flush to catheter hub, twist on - Inject saline using push-pause technique (positive pressure) - End with pressure on plunger while removing syringe - Apply disinfectant cap *IF Heparin flush indicated per protocol:* - Scrub hub again for 15 seconds - Attach heparin filled syringe (100u or 10u per mL) - Instill correct amount of Heparin per hospital protocol - Apply disinfectant cap
Nursing Interventions
- Draw blood samples - discard 3-5 mLs first, draw blood samples then flush with 20 mL NS - Measure length of catheter (PICC & Hickman) - Measure circumference of arm (PICC) - Apply securement device - Assess insertion site for signs of infection *Document- assessment, dressing & cap change* - Patient teaching for home care - Care of CVAD can not be delegated
Tunneled Catheter
- Examples: Groshong, Hickman - Has a valve that reduces risk of blood reflux and clotting >> no need for Heparin Pressure opens and closes valve
*CVAD Dressing Change*
- Gauze dressing for first 24 hours then..... - Transparent dressing - Wash site with antiseptic solution (chlorhexidine) for *30 seconds* - Chloraprep applicator - break ampule release antiseptic into sponge - allow time to air dry - Apply stabilization device - label dressing - Usually every 7 days & PRN - Measure catheter length
Implanted Subcutaneous Port
- Long term use (oncology patients) - Sites: chest, abdomen, inner arm "hidden" under the skin, when not accessed nothing external - No dressing change once healed, Tunneled catheter - Single or double port - Access with a 90 degree non-coring safety needle (Huber)
PICC
- No venipunctures or blood pressures in arm - Assess for catheter migration by measuring external catheter length from hub to insertion site - Held in place with sutures or securement device - Power PICC: larger lumen, withstand more pressure *NEVER use a syringe smaller than 10mL * - A mid-line catheter is shorter (8-10 inches), not the same
Administering Medication via CVAD
- Perform the 3 checks & 5 rights of medication gloves - Scrub hub & allow to dry - Attach prefilled 10 mL saline syringe - *Pull back plunger slightly to aspirate small amount blood* - Inject saline using push-pause and remove syringe -clean gloves
Administering Medication continued
- Scrub hub again - Connect IV tubing with medication & set IV pump to infuse at correct rate (ml/hr) - When infusion complete - Disconnect IV tubing, put a sterile cap on end of IV tubing - scrub hub and flush (push-pause) with 10 mLs of saline - *If* using Heparin > scrub hub again and administer Heparin as prescribed per hospital protocol - Apply disinfectant cap - Clamp CVC if indicated
Tunneled Central Venous Catheter
- Site: chest, subclavian - Inserted in OR or IR - Held in place Dacron cuff - Long term use - tunneled subcutaneously to exit site on chest - one way valve (usually don't need heparin) eliminates back flow of blood, decreases risk of infection - can stay in longer, more secure -barrier from microorganisms entering through skin
Nontunneled Central Venous Catheter
- Site: subclavian, jugular or femoral vein - Inserted at bedside - Prior to use placement confirmed with X-ray (no pneumothorax present) - Held in place with sutures or securement device - Short term therapy - 3 lumen- own independent catheter, can infuse multiple drugs that are not compatible - hubs help to separate - slide clamp so blood does not come out/ no air in to prevent bleeding or air embolism
Assessment
- Type of catheter - Date inserted, date of last dressing and cap change - Skin integrity → insertion site & surrounding area- redness, *edema*, pain, drainage, leaking - Assess patency of catheter - Assess for signs or complications - Assess patient's knowledge & learning needs
Review & Validate
- View demonstration of PICC flush: - Mosby's Skills, Advanced Skill - Vascular Access https://www.youtube.com/watch?v=_wXJkuS5OmM - View demonstration of dressing change: https://www.youtube.com/watch?v=ud8EWOQYqP0 - http://quizlet.com/5543086/central-vascular-access-devices-flash-cards/ - Attend a CVAD practice session in the lab - Review validation forms (available on Blackboard) - Validate with your clinical instructor - *NEVER* flush a CVAD, administer medication or perform dressing or cap change without your Clinical instructor present
Dressing Change Procedure
- Wash hands - Open sterile dressing kit - Don *mask* & nonsterile gloves - Remove old dressing with clean gloves - Inspect insertion site (redness, drainage, edema) - Don Sterile gloves - *Wash site - with chlorhexidine for 30 seconds using repeated back & forth strokes, entire area under dressing, gentle back & forth friction* - Allow to air dry -pull toward insertion site
Advantages
- access to central circulatory system - provide access for IV medications, vasoactive vesicants - decrease need for frequent venipunctures - decrease extravasation and phlebitis - patients with limited peripheral veins - long term IV therapy
PICC - Double Lumen
- clamp squeeze to click close - caps adapter essential for closed system - holding catheter & syringe
Disadvantage
- invasive line - procedure to insert - systemic infection - sepsis - complications air or thrombus embolism, pneumothorax
Central Line Dressing Kit
- mask - gloves - chloraprep - transparent dressing - tape - gauze - label -mask for pt, self, instructor - sterile gloves http://www.carefusion.com/medical-products/infection-prevention/skin-preparation/chloraprep-1ml-applicator.aspx
What is it?
-Central venous access device (CVADS) are *catheters placed in large veins*, usually the subclavian vein (preferred) or jugular vein or femoral to *deliver intravenous therapy* * tip is located in the superior vena cava above right atrium * *Access sites:* internal jugular, subclavian, cephalic, brachial, basilic or femoral vein - femoral access- tip in inferior vena cava
4 Types of CVADs
1. Nontunneled - Central venous Catheters (CVC) Ex. Triple Lumen 2. Tunneled Catheters Ex. Hickman, Broviac 3. Peripherally Inserted - Central Catheters - PICCs 4. Implanted Port - Port-A-Cath
Implanted Port
Huber needle - sterile procedure to access it
*P*eripherally *I*nserted *C*entral *C*atheter
single or double lumen -upper arm above antecubital space -basilica/cephalic vein with tip in superior vena cava -two lumens = two separate pathways into vein (multiple medications)
The Purpose....
→ administration of: - IV fluids - blood & blood products - Total parenteral nutrition (TPN) medication - Chemotherapy (vesicants) →obtain blood samples →long term IV therapy - hospital, ECF or home -vasoactive ↓ BP