CVADs ATI

When you use the syringe method,

vigorously clean the needleless connector and attach a small syringe to the appropriate port. Unclamp the line and then slowly aspirate the appropriate amount of blood from the central line. Only the amount of blood needed for testing should be obtained.

When you use the evacuated collection tube system,

vigorously clean the needleless connector and attach the Vacutainer holder. When you unclamp the line and push the evacuated blood tube inside the tube holder, blood will begin to flow into the tube.

Infusion Nurses Society recommends using the distal port of a multi-lumen catheter for

blood sampling. The distal port is largest (16-gauge) and has a greater flow rate. You might have to use a different port for blood sampling if the distal port is already accessed for an infusion or if it is nonfunctional.

Valved (closed) catheter tips

A valved catheter, such as a Groshong, has a specially designed end. When fluid is introduced, positive pressure pushes the valve open to allow fluid to flow into the bloodstream. The tip also can be opened with the negative pressure created by a syringe. When negative pressure is applied, the valve opens inward, thus allowing the catheter to be used for drawing blood. When no pressure is applied, the valve remains closed. This keeps blood from entering the catheter and forming a clot. In addition, the patient is protected from air emboli because the tip does not transfer the negative pressure in the chest to the catheter's lumen. Unlike open-ended catheters, valved catheters DO NOT require HEPARIN flushes. The catheter is filled with normal saline when not in use. Because no heparin is administered to keep it open, it is safer for patients who should not receive heparin. Also, valved catheters DO NOT REQUIRE CLAMPING when not in use.

Complications of central lines AIR EMBOLISM

Air can enter the circulatory system when a central venous catheter is open to the environment, thus causing air embolism. This can occur during inadvertent disconnection of the central line tubing, catheter rupture, and catheter removal. The patient may develop dyspnea, chest pain, tachycardia, hypotension, anxiety, nausea, dizziness, and confusion. An air embolism may be suspected if, during assessment and auscultation over the pericardium, the nurse hears a churning noise. Frequently check that the catheter is intact and patent. A cracked catheter allows air to enter. Closed/valve-tip catheters, such as the Groshong, can be open to air without risking an embolism. Be sure to keep other catheters clamped, particularly when changing connections and accessing the needleless connector. Whether the needleless connector is a positive-pressure connector or negative-pressure connector will determine whether the clamping occurs after or the syringe is removed or if clamping occurs while pressure is maintained on the syringe plunger. If you suspect an air embolism, clamp the catheter, administer oxygen, and place the patient on his left side in Trendelenburg position. This position helps trap the air in the apex of the right atrium rather than entering the right ventricle and, from there, moving into the pulmonary arterial system. Be sure to stay with the patient while a colleague contacts the provider.

At the time of insertion, what is done to confirm proper location

a chest x-ray is done to confirm proper tip location and catheter position and to make sure that there is no pneumothorax.

Complications of central lines CATHETER RUPTURE

Catheter rupture could occur when the catheter is broken (this could occur when using excessive force with flushing) or separated from the hub or port body (this could inadvertently occur when scissors are used to remove a dressing). It could also occur when a subclavian central venous catheter gets compressed between the clavicle and the first rib, otherwise known as pinch-off syndrome. Signs of catheter rupture include fluid leaking around the site, pain or swelling during an infusion, or the inability to aspirate blood. Cather rupture can be prevented by avoiding excessive force while flushing. And using the appropriate syringe size with flushing. Remember, a syringe size smaller than 10 mL could exert too much pressure, which could cause the catheter to rupture. If catheter rupture is suspected, clamp the catheter above the break if it is visible. Also notify the provider, as the catheter may need to be repaired or replaced.

Complications of central lines CATHETER LUMEN OCCLUSION THROMBOSIS PT 2

Deep vein thrombosis (DVT) is a blood clot (thrombus) in a deep vein, usually in the legs. While this isn't the same as a blood clot which clots inside or around the catheter tip, a DVT is related to lack of movement. Although excessive physical activity, such as heavy lifting, which could cause catheter dislodgement, should be avoided for patients with a PICC line, routine movement and performance of activities of daily living should be continued to prevent the development of deep vein thrombosis. Besides those caused by blood clots, called thrombotic occlusions, catheter occlusions can be nonthrombotic, that is, caused by something other than a clot. An example is a mechanical obstruction or impedance of the passage of fluid or medication through the catheter.

Open ended catheters

Examples include Hickman and Broviac catheters. They differ slightly in lumen construction and size. A Hickman catheter may have single or multiple lumens. It is surgically inserted into the patient's chest and into a central vein. It is tunneled under the chest tissue after it exits from the vein so that the exit site at the skin is a distance from its exit from the vein. Near the exit site, the catheter is surrounded by a Dacron cuff, which allows tissue to grow into the material, forming a seal against microbes and anchoring the catheter to minimize the risk of dislodgment. It takes approximately 3 weeks for the catheter to heal thoroughly into place. The internal diameter of a 9.6-French Hickman catheter is 1.6 mm. This is large enough to allow withdrawal of blood and infusion of fluid into the vein. This type of catheter can be kept open with a continuous infusion or capped and filled with heparin to be used for intermittent access to the vein. A Broviac catheter is a similar single-lumen catheter that is inserted in the same way as a Hickman catheter. The major difference between the two is that a 2.7-French Broviac catheter has a smaller internal diameter of 0.5 mm, so problems with clotting can arise when a catheter this small is used for drawing blood. This type of catheter is usually used for pediatric patients or for adults with small central vessels and generally only for infusing fluids and medications.

Complications of central lines CATHETER LUMEN OCCLUSION THROMBOSIS PT 3 If you cannot flush the catheter, check to make sure it is not clamped or kinked. Sometimes the problem is that the catheter tip rests against the wall of the vein.

Have the patient turn his head and cough. Ask the patient to raise his arms over his head. Place the patient in Trendelenburg position. Have the patient take a deep breath. Have the patient stand up. Have the patient change positions in bed. It may be that the sutures securing the vascular access device are constricting the catheter. If so, obtain an order to remove the sutures and apply a stabilizing device. If the obstruction is with an implantable port, check to make sure the noncoring needle is correctly placed in the port. If it is not correctly placed, remove the needle and replace it with a correctly positioned needle. Follow your facility's policies as well as those of the central venous access device's manufacturer for the volume and frequency of saline flushes and the concentration, volume, and frequency of heparin flushes. Include positive-pressure flushing techniques whenever flushing the line. Use a positive-pressure device whenever possible (as described in the introductory accepted practice section). If you suspect a thrombus, follow your facility's policy for infusing a thrombolytic (clot-busting) agent.

The implanted central access device insertion is performed

In the surgical suite or in the radiology department. The most common site for implanted port placement is the anterior chest, just below the clavicle. Other less common sites for implanted port placement include the upper arm, the abdomen, and the back.

Complications of central lines INFECTION

Infection can develop at the insertion site or along the catheter's path. Common pathogens associated with central line infections are bacteria (such as Staphylococcus aureus), yeast, and fungi. Signs of infection include fever, chills, swelling tenderness, redness or drainage at the insertion/exit site. Infection can develop at the insertion site or along the catheter's path. Common pathogens associated with central line infections are bacteria (such as Staphylococcus aureus), yeast, and fungi. Signs of infection include fever, chills, swelling tenderness, redness or drainage at the insertion/exit site. Since the needleless connector is recognized as potential site of contamination, injection ports should be thoroughly cleaned with chlorhexidine (or another facility-approved antiseptic) and allowed to dry prior to accessing the device. Some facilities may use a single-use access valve disinfection cap (SwabCap) instead of chlorhexidine or alcohol. The disinfection cap contains isopropyl alcohol and is twisted onto the needleless connector. Each time the line is accessed, a new disinfection cap is applied. Strict aseptic technique should be used when hanging solutions and with dressing changes. Additionally, the site should be assessed daily for redness, drainage, swelling, or discomfort at the insertion site. Since Chlorhexidine has been found to reduce the number of CR-BSI, it is the recommended skin disinfectant. Since the risk of infection increases each day the central line is in place, daily assessment for the need of the central line should be completed. To reduce the risk of infection, catheters are often coated with antimicrobial substances. An example is an antimicrobial cuff (trade name, VitaCuff) that works in conjunction with a Dacron cuff. The Dacron cuff is a band around the catheter that anchors the catheter under the skin to reduce the risk of dislodgement. The cuff also creates a barrier that keeps bacteria from entering the bloodstream. The antimicrobial cuff, coated with antibacterial chemicals, sits proximal to the Dacron cuff. The antimicrobial cuff substantially reduces the incidence of catheter-related infection in a newly placed line. Its chemicals dissolve within 3 weeks after placement, however.

Fluid displacement needleless connectors

Negative displacement devices let blood flow back into the catheter's lumen when you disconnect the syringe or administration set. Blood reflux can lead to occlusions.

Complications of central lines PNEUMOTHORAX AND HEMOTHORAX

Pneumothorax (air in the pleural space, that is, outside the lung) and hemothorax (blood in the pleural space) caused by a puncture of the covering of the lung are possible complications of central venous catheterization. Identification of these complications may be delayed for hours or days, sometimes because of minimal symptoms. The usual manifestations are dyspnea, hypoxia, tachycardia, restlessness, cyanosis, chest pain, and decreased breath sounds on the AFFECTED side. The likelihood of hemothorax and pneumothorax during insertion is less with PICCs, however. Monitor the patient's vital signs, administer oxygen, and notify the provider. It might be necessary for the patient to have a chest tube inserted and the central line removed.

Flushing practices for implanted ports:

Prior to each use, aspirate for a blood return to confirm device patency. The port must be flushed with 10 mL 0.9% sodium chloride after each use, and when not accessed monthly flushing is usually sufficient. Prior to removing the Huber needle (called deaccessing), the port should be "locked" with a heparin solution per facility protocol.

General principles for all central lines

SYRINGE---Excessive pressure from the syringe you use to deliver therapy through a central line can rupture the catheter. Therefore, USE ONLY 10-mL OR LARGER SYRINGES and avoid excessive force when flushing the lines or administering medications. FLUSHING--0.9% sodium chloride solution helps ensure and maintain patency of all types of central venous access devices. When flushing a central venous access device catheter, use a PULSING (push - stop - push - stop) flush to create turbulence that helps clear blood and medications from the line. If you meet resistance or cannot aspirate blood, take further steps to assess the catheter's patency before you administer medications and solutions. Do not flush the catheter forcefully. HEPARIN FLUSHING--Valve-tip or closed-end valve catheters such as a Groshong incorporate a valve that opens from positive or negative pressure, as is generated by flushing or aspirating. Otherwise, the valve remains closed to keep blood from entering the catheter. These types of valves require only SALINE flushes. *Flushing with heparin helps ensure and maintain patency of the central venous access device.* CLAMPING--If central lines are not clamped, air might enter the patient's central circulation, causing an AIR EMBOLUS. Keep central catheters clamped when not in use. This includes the time in between syringe changes. Use the small plastic clamp attached to the central line for clamping. A catheter with a valved or closed tip such as a Groshong DOES NOT require clamping.

Complications of central lines SEPSIS

Sepsis is a severe blood infection caused by bacteria, viruses, and fungi. Sepsis is extremely serious and can be life-threatening. Common manifestations include fever, chills, hypotension, tachycardia, and confusion. Follow all precautions for preventing infection. These will help prevent the progression of infection to sepsis.

PICC Ongoing care includes

a dressing change (usually with a transparent semi-permeable dressing) 24 hours post insertion and then on a weekly basis. Assess the site for redness, drainage, swelling, and pain. Follow your facility's policies for flushing. A typical schedule for flushing is every 12 hours when medications or fluids are not being administered. The Infusion Nursing Society's recommendations include 5 mL of heparin (10 units/mL) flush once daily for a PICC not in use. Avoid measuring blood pressure and performing venipuncture in the arm with the PICC. Also, keep scissors, razors, and other sharp objects away from the PICC to prevent damage.

Holes in the catheter purposes

The first hole that sits inside the patient's vein is the proximal port (closest to the entry and farthest from the right atrium). The next hole is the medial opening. The next is the distal (the hole farthest from the site of entry and closest to the right atrium).

What is the goal of heparin flushing with central lines?

The goal is not systemic anticoagulation; it is catheter patency.

Nontunneled caths

These catheters are not commonly used for long-term care. Dwell time (how long the catheter stays in place) is typically less than 6 weeks, though maximum dwell time is not well researched. The patient should be assessed daily for need and removal when no longer needed to reduce the risk of catheter-associated bloodstream infection. The insertion method is percutaneous venipuncture and does not require sedation. The provider may insert the catheter at the patient's bedside or, if necessary, in an emergency setting. *Because a nontunneled catheter protrudes externally and because there is no subcutaneous tunneling, the RISK FOR INFECTION IS GREATER than with other central venous access devices. Also, venipuncture directly above the lungs increases the risk of pneumothorax.*

A single-lumen catheter consists of

a tube or lumen ending in a hub that can either be connected to tubing for a continuous infusion of fluid or medication or capped and used for intermittent infusions. A single-lumen central venous catheter is used for patients who need an infusion into a large, central vein. When a single-lumen catheter is in place for infusing parenteral nutrition, it cannot be used to sample blood or to transfuse blood. This is because blood cells tend to adhere to the lumen and impede the flow of the nutrition solution.

Complications of central lines CATHETER LUMEN OCCLUSION THROMBOSIS

Thrombotic occlusions are caused by clotting inside the lumen or outside around the catheter tip that blocks the catheter's lumen. This can make it impossible to draw blood from the catheter, to flush it, or to use it for infusion. One of the most common complications from PICCs is thrombophlebitis. This causes impaired blood return as the vessel with the thrombosis is at least partially occluded. This results in swelling of the forearm. The lack of blood return or sluggish flow may indicate a catheter lumen occlusion or a malpositioned tip, and further assessment of the line is crucial. Proper catheter care and flushing the central venous access device before and after medication administration and after blood draws will help to maintain catheter patency. If, despite preventive measures, a thrombotic occlusion occurs, a thrombolytic enzyme may be needed to clear the blockage. When those measures do not help, the catheter must be replaced.

Complications of central lines PINCH OFF SYNDROME

When a central catheter is inserted into the subclavian vein, the clavicle and rib can move together and compress the central line catheter, causing pinch-off syndrome. Warning signs include difficulty drawing blood samples and resistance to the infusion of IV fluids. It is imperative to obtain a brisk blood return and to be able to flush the catheter easily before infusing fluids or medications through the catheter. If you cannot flush the catheter or aspirate blood, ask the patient to change the position of his arm on the catheter's side by raising it or by pulling his shoulder backward. If you are able to aspirate blood and flush the catheter after the position change, suspect pinch-off syndrome. Be sure to assess the periclavicular area near the insertion site for redness, swelling, or crepitus (a noise or vibration you can feel).

Complications of central lines DRUG PRECIPITATES

When incompatible medications come in contact with one another, a chemical reaction can result and cause precipitate to form. The provider might order a specific agent to help unblock an occlusion cause by precipitates. Designate and label each lumen for a specific infusion and flush the lumen after use. Follow your facility's policies for the frequency and volume of flushes.

Complications of central lines DYSRHYTHMIAS

abnormal heart pattern indicated on the electrocardiogram. It may occur with catheter malposition or dislodgement. This could occur during the insertion procedure or later during the dwell time. The patient may not experience any clinical manifestations. This is why a chest x-ray is performed upon initial insertion to confirm the catheter tip is located in the correct area. Prior to initial use, the nurse should confirm that radiologic results reveal accurate catheter tip location. In addition to assessing heart rate and rhythm, the patient should be assessed for ear, neck, or back pain, which could also indicate catheter malposition and subsequently dysrhythmia. As the nurse completes routine assessments and dressing changes, the health care provider should be informed if the external catheter length has changed.

PICC Patient education should include

activity limitations, such as avoiding heavy lifting, which could dislodge the catheter. The catheter and insertion site will also need to be kept dry during bathing and showering. Proper care, such as flushing, precautions for preventing infection, and signs and symptoms of complications, should also be taught.

PICCs are indicated for:

administering fluids, blood, and medications, as well as for blood sampling, although blood sampling through a PICC can be difficult, especially with smaller lumen PICCs. After blood sampling, the line is flushed with 20 mL sterile saline. A 10-mL syringe is always used for flushing to avoid the dangers posed by increased pressures from smaller syringes.

Tunneled central venous access devices (CVADs) can be used for

administering fluids, chemotherapy, antibiotics, blood, and parenteral nutrition, as well as for central venous pressure monitoring and blood sampling. The distal catheter tip is advanced into the vessel and is placed in the superior vena cava, while the proximal end is tunneled subcutaneously to an incisional exit site on the patient's trunk. The usual exit sites allow the patient to care for them conveniently, while also making it possible to conceal them under clothing. Tunneled catheters are often referred to by the trade names Hickman, Broviac, Leonard, and Groshong.

An implanted central venous access device, often referred to as

an implanted port or by the popular brand name Port-A-Cath, is a device placed under the skin without any portion of it exiting the skin. It consists of a single or double injection port with a self-sealing silicone septum covering a metal or plastic reservoir called the body. The catheter connects the port and reservoir to a central vein, typically the superior vena cava. An implanted port can be used to administer medication including chemotherapy, to deliver fluids, and to draw blood samples.

Blood samples can be taken from

any port not being used for fluid administration.

It is recommended to temporarily stop all other infusions until

blood drawing has been completed. Remember to resume infusions after blood sampling is completed.

The purpose of withdrawing fluid/blood before obtaining a blood sample is to

clear the catheter of any intravenous fluid or medications that could alter the laboratory test results.

A fairly common MLC configuration is three ports, commonly labeled and used as follows:

distal lumen: Used for the administration of blood or other viscous fluids middle lumen: Used for parenteral nutrition proximal lumen: Used for the administration of medications or blood

A lumen size of 4F or larger is recommended for

drawing blood.

Complications of central lines

dysrhythmias infection sepsis pneumothorax or hemothorax air embolism catheter lumen occlusion drug precipitates pinch off syndrome catheter malposition catheter rupture

A transparent semipermeable membrane dressing is often preferred as it allows

easy visualization of the insertion site. Typically, gauze dressings are not recommended unless there is drainage from the site. Gauze placed under a transparent dressing is not advised as it obscures visualization of the site. A chlorhexidine patch may be considered at the insertion site to reduce the possibility of infection.

Complications of central lines CATHETER MALPOSITION

improper technique when removing a dressing, inadequate securing of a catheter, and physical activity. A central catheter migrates when the tip of the catheter changes without the external catheter changing length. For example, the tip could move from the superior vena cava into the internal jugular vein. Changes in intrathoracic venous pressure (coughing, sneezing, vomiting, heavy lifting) could cause the tip to move. With catheter migration, fluids flow against the direction of blood flow. Remove the dressing from the insertion site carefully to prevent inadvertent dislodgment. Also, instruct your patient about physical activity that could contribute to catheter dislodgment. If the line is pulled out, cover the site with an air-occlusive dressing. Place the patient on his left side in Trendelenburg position. Be sure to stay with the patient while a colleague contacts the provider. To prevent migration, most catheters are sutured in place. If present, the Dacron cuff also serves as an anchor. When you assess the line and the insertion site, measure the external catheter length and check for any discomfort and edema of the chest, neck, shoulder, or accessed extremity.

A multi-lumen catheter (MLC)

increases the advantages of a single-lumen catheter. An MLC has separate color-coded ports to identify the different lumens. Each lumen opens separately from the other lumens at the distal end of the catheter or along various areas of the catheter. This means that solutions do not mix as they travel through the catheter. With a multi-lumen catheter in place, several treatments can be performed via a single central line insertion site. The number of lumens within an MLC varies from two to four. The multiple ports allow for administration of medications, blood infusions, blood sampling, fluid replacement, and pressure monitoring. Any one, any two, or all three may be capped and filled with heparinized saline or saline solution for intermittent use.

Central venous catheters have a special cap on the end where IV tubing or syringes connect into the line. This cap is called the

injection or access cap/needleless connector. The needless connectors should also be changed if blood or debris is visible, upon contamination, or prior to drawing a blood culture. Before attaching the new needleless connector, it should be primed with 0.9% sodium chloride and applied using aseptic technique. A single-use Luer-Lok access cap/connector is also available. The use of this eliminates the need to change the cap and it also eliminates the need to swab or clean the end of the cap with alcohol or chlorhexidine. The single use cap (Swab Cap) contains isopropyl alcohol and is twisted over and onto the needleless connector prior to each use and left in place until the next use. At the time of the next use, the single use cap is removed and replaced with a new one. In addition to site care and cap changes, your ongoing care includes assessing the insertion site for redness, drainage, inflammation, swelling, tenderness, and warmth. As part of the evidenced-based interventions to reduce catheter-related bloodstream infections, documentation should also include criteria supporting the continued need for the central venous access device.

The tip of a central venous catheter is generally threaded into the

internal or external jugular veins or into the lower third of the vena cava (superior or inferior) that leads to an area just above the right atrium.

A lumen

is a hollow channel within a tube. Some central catheters have just one lumen while others have multiple lumens.

A peripherally inserted central catheter (PICC) is a

long central catheter that is inserted into the basilic (preferred) or cephalic vein in the arm (thus the term peripheral). The end of the catheter rests in the superior vena cava just above the right atrium. A PICC can have single or multiple lumens. PICC lines are intended for patients who require therapy for several days to months.

Tunneled central venous access devices (CVADs) are designed for

long-term use (months to years) as they are designed to reduce infection without compromising mobility. A Dacron cuff lies within a subcutaneous tunnel created between the insertion site of the dermis and the site where the catheter enters the bloodstream. Tissue granulates around the cuff, anchoring the catheter and acting as a barrier to the spread of organisms from the skin to the bloodstream. Some cuffs contain antibiotics to further prevent infection.

The number of lumens does not define its type, either, only that it allows

multiple uses

To access the implanted port, use a

noncoring, non-barbed (Huber) needle. Noncoring needles have a deflected point that helps avoid septal injury by slicing through the septum without coring out a tiny piece of it each time the port is accessed. Additionally, the septum is made of self-sealing silicone, which allows it to be accessed many times without damaging the septum. Most facilities' policies allow access to the implanted port with the same needle for 7 days.

A central line is indicated for patients who need:

parenteral nutrition chemotherapy or other vesicant or irritating solutions blood products antibiotics IV medications or solutions (when peripheral access is limited) central venous pressure monitoring hemodialysis

When using a device with a needle-free positive fluid-displacement injection cap, do not use

positive pressure flushing techniques. Disconnecting the administration set or syringe forces the reserved fluid into the catheter's lumen. In this case, using a positive pressure flushing technique will cause BLOOD REFLUX. Flush these devices only with SALINE and DO NOT clamp the line.

When using a negative displacement device, it is important to use a

positive-pressure flushing technique: Withdraw the syringe from the injection cap as you flush the last 0.5 mL of flush solution into the catheter. Or, flush all fluid into the catheter, maintain pressure on the syringe plunger, clamp the tubing between the catheter hub and the patient, then disconnect the syringe. Use a pressure flushing technique unless the device has a positive fluid displacement needleless cap. This device withholds a small amount of fluid to overcome blood reflux

A dressing at the insertion site of a central line acts as a protective covering to

prevent infection and also helps stabilize the catheter to prevent migration. How often you change the dressing varies with the type of dressing (gauze versus transparent) and the appearance of the dressing (soiled or damp versus clean and dry). Always use surgical asepsis (sterile technique) when changing the dressing. The Centers for Disease Control and Prevention recommends changing a dressing when it is damp, loosened, or soiled. The Infusion Nurses Society recommends changing gauze dressings every 48 hours and transparent dressings 3 to 7 days or whenever they are no longer intact.

Unlike peripheral catheters, a central line, depending on the type, can remain in place for

several weeks to years. Central lines are especially beneficial for patients who have chronic diseases and require long-term intravenous therapy.

Implanted ports are available with

single or double lumens. A double-lumen port has two noncommunicating reservoirs. Advantages of implanted ports are that they are cosmetically appealing, they have the lowest risk of infection of all chest-accessed central lines, they allow patients to carry on virtually all activities including bathing and swimming when it is not in use, and they do not require exit-site care. Some implanted ports are considered power-injectable and can handle 5 mL/second infusions at high pressure, which is needed during contrast enhanced computed tomography. The patient with this type of implanted port may carry an identification card that includes information regarding power-injection capability of the implanted port. Others may wear a wrist band identifying the presence of the power injection port. Special power-injection rated needles should be used to access the port. Implanted ports may be open-ended or valved. Open-ended ports require heparin flushing while valved ports do not require heparin. When an implanted port is not accessed, monthly flushing is usually sufficient.

Flushing with larger syringes creates less pressure;

smaller syringes create more pressure.

Nontunneled percutaneous central catheters are sometimes called

subclavian, percutaneous, acute-care, or short-term catheters. This type of catheter is usually inserted into the internal jugular or subclavian vein, with the catheter tip resting in the superior vena cava just above the right atrium. Nontunneled catheters most often have multiple lumens. Indications for placement of this type of catheter include intravenous therapy, blood sampling, and central venous pressure monitoring. The femoral vein may be used if necessary. This site is not preferred, and the catheter should be removed as soon as possible due to high risk of infection.

PICC placement can be done at

the bedside by a physician or, in some facilities, by a specially certified RN. If the PICC is not placed under fluoroscopy, an x-ray must verify the position of the distal tip. PICCs can be sutured in place, but this practice is no longer recommended because suture sites create additional breaks in the skin that can become inflamed, thus increasing the risk of bacterial colonization at the exit site. Most PICCs are secured with wound closure strips (such as Steri-strips) or a securing device (such as StatLock) to prevent catheter migration and damage. Your assessment includes measuring the patient's upper arm circumference to establish baseline data. For standardization, it is best to measure at the level of the top of the axilla. This serves as a reference point to determine with later measurements the presence of swelling or edema. Also, be sure to measure and document the length of the external portion of the catheter from the insertion site to the hub of the access cap. Later, you'll compare the length of the external catheter to the previously documented length to detect catheter dislodgement from the insertion site. If the new measurement differs, contact the provider.

Chlorhexidine gluconate is the preferred agent to clean

the insertion site, but some use alcohol and povidone-iodine. The age of the patient is also a consideration when choosing an antiseptic. For example, the INS does not recommend using isopropyl alcohol or chlorhexidine for neonates. Povidone-iodine can be used but must be removed completely with sterile water or saline to prevent product absorption. Povidone-iodine ointment and topical antibiotics are no longer recommended as they can promote the colonization of fungi. When using chlorhexidine, use a back-and-forth motion. Cleanse the site for 30 seconds. With this or povidone-iodine and alcohol, be sure to cleanse the skin well beyond the dressing area. Povidone-iodine requires contact with the skin for a minimum of two minutes in order for it to be effective.