Advanced Skills Exam 2
Air Embolism Interventions
-Clamp, fold, or close the existing catheter or occlude the insertion site immediately -Place the patient in a left Trendelenberg's position if not contraindicated by other conditions -Call HCP -Administer oxygen.
Non-tunneled central line
-short term use line that can be put into your neck, chest, or groin -temporary, attached to the skin but not covered up unless you can see if an infection is occuring -normally placed for 2 weeks or less
Tunneled CVC Broviac
-smaller lumen that is used for children -dont bandage it (cover it), want to be able to see sight and if it is infected or not
Accessing Implantable Port
-sterile technique -stabilize septum (palpate, hold between fingers, cover with dressing) -aspirate and flush system maintaining system integrity -secure with transparent dressing -watch for signs fo swelling or problems with site or infusion
Volume Depletion
-sunken eyes -poor skin turgor -Dry mucous membranes -flattened neck veins -VS changes -decreased urine output -confusion
WHy is fluid sample obtained/discarded before blood is drawn?
-to aspirate Heparin solution, prevents diluted solution
Complications from blood draw
-very rare -high risk for thrombosis and/or occlusion resulting in line removal and/or replacement (not able to be used again, need to replace) Complications: fainting, dizziness, bruising at the puncture site (hematoma), nerve injury, and arterial puncture or laceration
implantable port removal
- sterile procedure - flush - assess skin/cath integrity - pinch port to determine location - remove transparent dressing - grasp needle with non-dominant hand and remove needle - engage needle safety mechanism and dispose in sharps container - apply sterile gauze dressing if bleeding occurs
Dressing Changes (supplies)
-Central line dressing kit -Sterile gloves - include one extra pair (not necessary sterile, but cleaner than other gloves) -Antiseptic (chlorhexidine preferred;2 tincture of iodine, povidone-iodine, or alcohol if the patient is sensitive to chlorhexidine) -Sterile transparent semipermeable dressing or sterile 4" × 4" (10-cm × 10-cm) gauze pad -Sterile tape -Sterile drape -Skin barrier solution -Mask -Label
safety priority when administering meds through an implanted port?
assess patency and non-coring needle placement before medication administratioin
CVP
the pressure within the right atrium of the heart, measures the pre-load
Trendelenberg Syringe
plunger is UP -want bubble at top so air doesn't go into catheter
Hydrothorax
serous fluid leaking into pleural cavity
what do you do when you are flushing a patients port with NS and they complain of pain?
stop and assess
What must you do as the nurse before collecting a blood sample from a central or PICC line?
stop any infusions that are running
What vein used in central line?
subclavian or jugular
s/s of air embolism
sudden onset of dyspnea, continued coughing, breathlessness, chest pain, hypotension, jugular vein distention, tachyarrhythmias, wheezing, tachypnea, altered mental status, altered speech, changes in facial appearance, numbness, and paralysis
Why would a patient need a central line?
-long term IV therapy/TPN/lipids -chemotherapy (cant give peripherally) -dialysis -advanced hemodynamic monitoring (CVP: the pressure within the right atrium of the heart, measures the pre-load)
Why should the cap be removed before drawing a blood sample from a central line?
-maintain cell integrity -cells are being pulled through membrane -VAMP system: pull/waste 5-10ml and you can return the wasted blood
Disadvantages for central lines
-central IV lines also carry higher risks of bleeding, becteremia, and gas embolism
Documentation of Central Line Removal
-date/time of removal -description of exit site -length of catheter -tip intact -client response
Dressing Changes (why?)
-direct route to circulatory system -need to prevent infection *REQUIRES STERILE TECHNIQUE
PICC Line Catheter
-double lumen or single lumen -from outside, a single lumen -PICC resembles a peripheral IV except that the tubing is slightly wider -sterile dressing is needed
Complications of implanted port
-easing the pain -no blood return (SASH) -infiltration or extravasation (normally due to port misplacement) -local/systemic infection (fever, tenderness, redness, remove dressing and assess site)
Advantages of PICC lines
-easy to insert -poses a relatively low risk of bleeding -externally unobtrusive -can be left in place for months to years
Fluid overload
-edema -bounding pulses -distended neck veins -crackles or rhonchi in the lungs -change in VS or LOC *check orders, how much fluid can they get?
A client reports chest pain, dyspnea, and decreased breath sounds after central line was placed a few days ago, what do you do?
-give O2
Air Embolism Signs/Symptoms
-hypotension, tachycardia, anxiety, confusion, SOB *get all air out of tubing!
implanted port complications
- localized/systemic infection - skin breakdown at the site
What are the clinical indicators that a nurse expects when an IV line has infiltrated. Select all that apply. A. heat B. pallor C. edema D. decreased flow rate E. increased blood pressure
B, C, D
pt has onset of pallor, cyanosis, dyspnea, coughing, tachycardia. what would you expect is going on?
air embolism
What do you do before removing a non-coring needle from a port?
hand hygiene and ID patient
implanted port uses
- deliver intermittent infusions of med, parenteral nutrition, chemo, blood products
Obtaining a blood sample from a central line
-must have MD order -line must be patent with blood return (lab will be in room with you) -critical IV fluid infusion not able to be paused prior and during blood draw (if chemo/heparin, not always able to stop it..might have to get a peripheral sample) -highly valuable access for patient management plan
Disadvantage of PICC line
-must travel through a relatively small peripheral vein -therefore limited in diameter -somewhat vulnerable to occlusion or damage from movement or squeezing of the arm *dont lift heavy things! *measure everyday, if bigger, infiltration or infection could have occured
Implantable Port
-often referred to by brand name -central venous line that DOES NOT have an external connector -has a small reservoir implanted under the skin -medication is administered intermittently by placing a small needle though the skin into the reservoir -less inconvenience and have lower risk of infection than PICCs -commonly used for patients on long-term intermittent treatments (chemo)
4 nursing strategies to prevent catheter related bloodstream infection
1. maintaining strict sterile no-touch technique 2. CVC sampling should not be performed using the same catheter lumen that is used for drug infusions 3. group multiple blood draws together to decrease the # of times the system is accessed and thereby decreasing risk of infection 4. use great hand hygiene and vigorously scrub any needleless connectors and using end caps during all procedures
What size syringe should be used when obtaining a blood sample from a catheter?
10mL -insert NS and then pull out waste blood (4-5mL) -then take out as much blood as needed for the lab -change needleless connector when done
After abdominal surgery a client returns to the unit with an NG tube set to intermittent wall suction. The primary healthcare provider prescribes an antiemetic as needed every 6 hours needed for nausea. When the client complains of nausea, what should the nurse do? A. check for correct placement of NG tube B. administer the prescribed antiemetic C. irrigate the NG tube with normal saline D. notify the primary healthcare provider immediately
A. nausea may indicate tube displacement or obstruction.
A nurse inserts an NG tube into a preterm infants esophagus for feedings. Which assessment findings signify correct placement of the tube? select all that apply A. the infant cries without sound B. aspiration produces a quantity of light-yellow or light-green liquid C. the tube is inserted to a depth from the ear to the tip of the nose to the sternum D. a whooshing sound is auscultated in the epigastric area when air is introduced into the tube E. testing of the aspirate with pH strips reveal the gastric fluid is acidic
B,E
Thromboembolism Signs/Symptoms
Edema at puncture site Erythema Ipsilateral swelling of arm, neck, and face Pain along vein Fever Malaise Chest pain Dyspnea Cyanosis
Who is responsible for the insertion of central lines?
MD, provider -in the OR or at bedside
Pneumothorax
air leaking into pleural cavity
PICC got tangled up and came out, what would determine a catheter embolus has occured?
assess PICC line and tubing
What vein used in a PICC line?
basilic vein
What should you do when there is blood in the connector?
change it
Thrombosis
clot forms in the vein at the end of the catheter, if the clot dislodges, can lead to a PE or Right Atrial MAss
When should you, as the nurse, label blood products?
in the presence of the patient
How would a nurse clean a patients skin from dressing change (has sticky residue on it)?
use a non-acetone adhesive remover
How far should the nurse insert a non-coring needle into a port?
when the tip comes in contact with the back of the port
How to verify placement of a central line or PICC line?
x-ray -you need an x-ray to be able to use any line that has been placed, if not and a medication needs to be administered stat, may need to use an IM
Air Embolism Prevention
*secure catheter connections *clamp catheter when not in use *instruction patient in Valsalva Maneuver (bear down during tubing and cap changes) *use air-eliminating filters *position pt so that insertion site is at or below heart level when changing administration sets or needless connectors
PICC removal special considerations
- Change the PICC site dressing and assess the site every 24 hours until healing occurs - Monitor for signs and symptoms of air embolism
implanted port special considerations
- always use smallest needle necessary - change transparent dressing and needle every 5-7 days - change gauze dressings every 48 hours - change dressing immediately if integrity is compromised - assess catheter before each use (lack of blood return, resistance with flushing, edema, patient reports hearing gurgling, flow stream sounds with flushing, paresthesia, neuro effects) - trace tubing and catheter from patient to point of origin before connecting to any device/suction
if resistance is met during PICC removal
- Stop the removal procedure. - Cover the catheter site with a sterile dressing. - Perform interventions, such as applying a warm compress above the exit site, having the patient perform relaxation techniques, and elevating the limb. - Reattempt removal after 15 to 30 minutes. - Consult with the practitioner to discuss interventions for successful removal
implanted port patient teaching
- Stress the importance of pushing the needle into the port until the patient feels the needle bevel touch the back of the port; many patients tend to stop short of the back of the port, leaving the needle bevel in the rubber septum - If the patient is receiving an infusion at home, teach the patient and family about checking the dressing daily - teach the patient how to dress and undress to avoid pulling at the needle site; how to protect the site during bathing; to immediately report pain, burning, stinging, or soreness at the site; and to stop the infusion and report wetness, leaking, or swelling at the site
PICC removal complications
- air embolism - venospasm - thrombosis - Cath breakage - with venospasm and thrombosis, you'll feel resistance during removal
implanted port removal documentation
- assessment findings (appearance of site) - Document noncoring needle removal or change - Note the type and amount of flush solution that you used, the presence or absence of blood return, any resistance to flushing and, if you met resistance, your interventions and the patient's response to the interventions - dressing changes, the status of the implanted port site after the flush infusion, the type of locking solution used - teaching provided to pt/family
implanted port documentation
- assessment findings (location and site appearance) - Record the needle gauge and length you used to access the site, the appearance of a blood return, the number of attempts, and any unexpected outcomes, your interventions, and the patient's response to the interventions - include the type, amount, and rate of the infusion - teaching provided to pt/family
PICC removal documentation
- date and time of removal, the condition of the insertion site, the condition and length of the catheter, the reason you removed the device, and the patient's tolerance of the procedure - type of petroleum-based ointment and dressing you applied to the site - teaching provided to pt/family
implanted port resistance to flush interventions
- examine for external obstruction - move pt arm/head - verify correct needle length and placement
implanted port
- is a type of central venous access device that is surgically implanted by a surgeon - the practitioner places the catheter/reservoir in a subq pocket in teh upper anterior chest wall - Alternative locations for reservoir placement include the upper arm, abdomen, side, back, and lower extremity - used for long term IV access (longer than 6 months) - may be uncomfortable for first 72 hours after placement - have decreased risk if infection, minimal maintenance and higher patient acceptance (d/t discrete design)
PICC removal
- necessary when s/s of complication occur, when infusions d/c, or when PICC is no longer needed - catheter must be measured and inspected after removal to ensure that it's intact - need Emergency equipment (code cart with emergency medications, defibrillator, handheld resuscitation bag with mask, intubation equipment - Place the patient in a supine flat or Trendelenburg position - d/c or stop infusion - Teach the patient how to perform the Valsalva maneuver during removal - after removal, apply manual pressure to the site with a sterile gauze pad for a minimum of 30 seconds - assess integrity of removed catheter - Instruct the patient to remain in a flat or reclining position for at least 30 minutes after device removal to reduce the risk of air embolism
implanted port infiltration/extravasation interventions
- stop infusion immediately - Assess for a dislodged catheter, a dislodged noncoring needle, or a rupture or leak from the external catheter - Aspirate for blood; don't attempt to flush - Assess the extent of infiltration or extravasation - Estimate the volume of fluid that has escaped into the tissue(based on infusion rate) - Remove the noncoring needle; do not attempt reaccess until problem is treated/swelling resolves - ask provide whether to use warm or cold compress - If necessary, administer the appropriate antidote as prescribed -
implanted port access
- uses noncoring needle - has deflected point that slices port's septum - requires sterile technique
Pneumothorax, hemothorax, chylothorax, or hydrothorax (Signs and symptoms)
-Decreased breath sounds on affected side -With hemothorax, decreased hemoglobin level because of blood pooling -Abnormal chest X-ray
Thromboembolism Prevention
-Encourage early mobilization of the affected extremity -Maintain a steady flow rate with an infusion pump or flush the catheter at regular intervals. -Use a catheter made of less thrombogenic material to prevent thrombosis. -Dilute irritating solutions. -Use a 0.2-micron filter for infusions
Infection Causes
-Failure to maintain sterile technique during catheter insertion or care -Failure to comply with dressing change protocol -Wet or soiled dressing remaining on site -Immunosuppression -Irritated suture line -Contaminated catheter or solution -Frequent opening of catheter or long-term use of single IV access site
Central Line
-IV catheter inserted into a large central vein like the subclavian, internal jugular, or femoral vein -catheter terminating in or near the atrium -larger vein so central lines can deliver a higher volume of fluid and can have multiple lumens *meds go straight into the heart *good for long term medical access *several lumens, not as invasive
Air Embolism Causes
-Intake of air into the central venous system during catheter insertion or tubing changes *IV tubing disconnected -Inadvertent opening, cutting, or breaking of catheter, FORGETTING TO CLAMP *saline not flushed well
Infection Prevention
-Maintain sterile technique -Use sterile gloves, masks, and gowns when appropriate -Observe dressing-change protocols. -Change a wet, soiled, or loosened dressing immediately -Examine solutions for cloudiness and turbidity before infusion; check fluid containers for leaks. -Use a 0.2-micron filter (or a 1.2-micron filter for 3-in-1 total parenteral nutrition solutions). -Keep the system closed as much as possible
Why should the tip of the catheter be inspected after removal?
-Make sure it remains intact -some organizations require the tip of the catheter to be sent for culturing (systemic infection)
Infection Nursing Interventions
-Monitor temperature frequently. -Monitor vital signs closely. -Culture the site. -Redress using sterile technique. -Treat systemically with antibiotics or antifungals, depending on culture results. -Remove the catheter, if indicated. -Collect peripheral blood cultures, if indicated (recommended) -If the catheter is removed, culture its tip
Pneumothorax, hemothorax, chylothorax, or hydrothorax (Prevention)
-Position the patient head down with a rolled towel between the scapulae to dilate and expose the internal jugular or subclavian vein as much as possible during catheter insertion -Assess for early signs of fluid infiltration, such as swelling in the shoulder, neck, chest, and arm -Ensure that the patient is immobilized and prepared for insertion -Active patients may need to be sedated or taken to an operating room
Discontinuing PICC lines (why?)
-REMOVE GENTLY to prevent emboli and vasospasm
Infection signs/symptoms (serious complication, CAN BE FATAL!)
-Redness, warmth, tenderness, or swelling at insertion or exit site -Possible exudate of purulent material -Local rash or pustules -Fever -Chills -Malaise -Leukocytosis -Nausea -Vomiting
Thromboembolism Nursing Interventions
-Remove the catheter, if indicated. -Prescribe anticoagulant therapy -Verify thrombosis with diagnostic studies. -Apply warm, wet compresses locally. -Don't use the limb on the affected side for subsequent venipuncture
Pneumothorax, hemothorax, chylothorax, or hydrothorax (Nursing Interventions)
-Remove the catheter, if necessary. -Administer oxygen. -Put in a chest tube
Pneumothorax, hemothorax, chylothorax, or hydrothorax (possible causes)
-Repeated or long-term use of same vein -Preexisting cardiovascular disease -Lung puncture by catheter during insertion or exchange over a guidewire -Large blood vessel puncture with bleeding inside or outside the lung -Lymph node puncture with leakage of lymph fluid -Infusion of solution into chest area through infiltrated catheter
Thromboembolism Causes
-Sluggish flow rate -Composition of catheter material (polyvinyl chloride catheters are more thrombogenic) -Hematopoietic status of patient -Preexisting limb edema -Infusion of irritating solutions
Central Venous Catheter
-a catheter placed into a large vein in the neck (internal jugular vein), chest (subclavian vein or axillary vein) or groin (femoral vein)
Advantages of Central Lines
-access to central (larger) veins for medication and fluid administration (more rapid administration) -more comfortable for client -avoid frequent venipuncture -measure central venous pressure (CVP) -long term placement ranges from months-years *medication reaches heart immediately to disperse medication!
Accessing Implanted Port
-also known as a vascular access device or vascular access port -long term IV therapy (chemo) -one or two lumens -used immediately after placement (or in a couple days if tender/sore) -decreased risk of infection, require minimal maintenance, have a more discrete design, resulting in a high level of patient acceptance (not as invasive) -Heuber needle (90º, very sharp) -sterile tecnique
4 pre-procedural assessments for central line dressing change
-assess the catheter skin junction, and surrounding skin for bleeding, redness, swelling, tenderness -inspect the catheter for cracks, leakage, kinking, pinching, and mechanical problems -measure patients arm to see if it is larger (sign of infection or infiltration) -confirm pt identity using 2 identifiers
PICC Line
-inserted into a peripheral vein, usually in the arm, and then advanced until the catheter is in the superior vena cava or the right atrium -inserted in AC region, a big catheter -X-Ray is used to verify placement that the tip is in the correct spot
Tunneled CVC (Hickman)
-inserted into the target vein and then "tunneled" under the skin to emerge a short distance away (come out by pectoral) -reduces risk of infection (bacteria from skin surface are not able to travel directly into the vein) -made of materials that resist infection and clotting
When are caps changed?
-no more than every 96 hours but at least every 7 days
Dressing Changes (when?)
-per institution policy & procedure *ALWAYS ASSESS INTEGRITY OF SKIN FOR SIGNS OF INFECTION/BLEEDING -whenever dressing becomes soiled or pulls away, loosens, dislodges -not done daily, increases risk for infection -Transparent semipermeable dressings should be changed every 5 to 7 days, and gauze dressings should be changed every 2 days
what do you do when an air embolism occurs in a patient with a central line?
-put them in left trendlenbergs *prevents air embolism into lungs/brain *want head down
NG tube irrigations are prescribed for a client after abdominal surgery. The nurse instills 30mL of saline solution, and 10mL is returned. How should the nurse proceed? A. record 20mL as intake B. increase the amount of suction C. reposition the NG tube D. irrigate the NG tube more frequently
A
A client begins to have difficulty breathing 30 minutes after the insertion of a subclavian central line. What should the nurse do first? A. raise the head of the bed B. apply O2 C. assess breath sounds D. call the primary healthcare provider
A -raising the head of the bed is less invasive and should be the first thing done to help increase RR
Types of Central Lines
1. peripherally inserted central catheter (PICC) 2. central venous catheter (CVC) -tunneled: hickman, Broviac -non-tunneled: subclavian, jugular 3. implantable ports
Obtaining Blood Sample Steps
1. turn infusion off for one minute 2. aseptic NOT sterile technique 3. CLOSE CLAMP!!! 4. removal of cap and cleanse per policy 5. remove waste per policy (avg. 5-10 mls) 6. CLOSE CLAMP!! 7. cleanser per policy, remove blood and CLAMP 8.**cleanse and use NS flush and Heparin per policy (always clamp, clean and flush)**
Twelve hours after a subtotal gastrectomy, a nurse identifies large amounts of bloody drainage from the clients NG tube. Which action should the nurse take? A. obtain vital signs B. clamp the NG tube C. instill 30 Ml of iced NS into the NG tube D. record the observations and continue monitoring the client
A Large amounts of blood or excessive drainage 12 hours post op may indicate hemorrhaging. Vital signs should be taken.
A primary health care provide prescribes 1000 mL total parental nutrition (TPN) to be infused over 12 hours via a central venous access device. What is most important for the nurse to obtain when preparing the equipment A. an infusion pump B. a steady IV pole C. an infusion set delivering 60 gtts/mL D. a set of hemostats to be taped at the bedside
A infusion pump
A nurse is assisting a primary healthcare provider with insertion of a central venous access catheter. Which equipment will the nurse plan to have in the room to help prepare the skin? select all that apply A. mask B. gown C. betadine D. checklist E. sterile gloves
A,B,D,E
What should the nurse do if they have trouble aspirating blood from a central line or PICC?
Assess for external causes
A nurse assesses a client IV site. What clinical finding, unique to infiltration, leads the nurse to conclude that the IV site has infiltrated, rather than become inflamed? A. pain B. coolness C. localized swelling D. cessation in flow of solution
B
To begin the administration of TPN, a client has a right subclavian central venous access device inserted. Immediately after insertion of the catheter, what is the priority nursing action? A. obtain a chest x-ray to determine placement B. auscultate the lungs to evaluate breath sounds C. draw a blood sample to assess blood glucose D. assess the upper right extremity for neurologic deficits
B Common cause is pneumothorax, auscultate lungs
A nurse identifies that a client's IV site is warm, red, tender. What does the nurse conclude is the most likely cause of this finding? A. rapid delivery of the infusion B. chemical irritation to the tissues C. allergic response to the infusion D. catheter infiltration into the tissues
B Irritation
A nurse administers medication via the central venous access device (CVAD) and forgets to monitor the client at the required intervals. The client then develops phlebitis. What charges may the nurse face for this action? A. battery B. malpractice C. false imprisonment D. defamation of character
B The nurse may face malpractice charges due to the failure to monitor the client in a timely manner after medication through a central venous access device (CVAD)
The nurse administers and IV solution that is piggybacked into a primary IV line using gravity flow tubing; the nurse hangs the secondary infusion bag higher than the primary infusion bag. After completion of the infusion, the client expresses concern about air in the piggyback tubing. The client asks fi that means an air embolism is probably. What is the nurses best response? A. "air in the tubing, even if it got into the vein, would not be fatal unless it is a large amount" B. " The antibiotic and now the air are flowing into the primary IV bag, not the venous system directly" C. "The solution from the large IV bag begins to flow when the solution from the smaller bag ceases to flow" D. " the clamps on the tubing leading from both bags will be closed for a few minutes to prevent air from entering the vein"
C
The nurse is caring for a client who has an implanted port and is receiving intravenous fluids. To decrease the risk of infection, the nurse should change the noncoring needle how often? A. every 3 days B. every 5 days C. every 7 days D. every 9 days
C change once a week
A client has surgery for the insertion of an implanted infusion port for chemotherapy. The client asks, "The doctor said after my chemo is finished, the port will stay in , but it needs to be flushed routinely. How often does this have to be done?" What should the nurse tell the client about how often the port will most likely need to be flushed when not in use? A. once a day B. once a week C. every month D. twice a year
C every month flushes are usually adequate to keep an implanted infusion port from clotting
A primary health care provide prescribes TPN for a client with cancer of the pancreas. A central venous access device is inserted. What does the nurse identify as the MOST important reason for using this type of access? A. infection is uncommon B. it permits free use of the hands C. the chance of infusion infiltrating is decreased D. the amount of blood in a major vein helps dilute the solution.
D The major veins help dilute the solutions
A client with esophageal cancer is to receive TPN. A right subclavian catheter is inserted. What is the primary reason TPB is infused through a central line rather than a peripheral line? A. prevents development of infection B. there is less chance of this infusion infiltrating C. it is more convenient so clients can use their hands D. the large amount of blood helps dilute the concentrated solution.
D Blood is a huge dilutent
Insertion Complications
Pneumothorax: air leaking into pleural cavity Chylothorax: lymphatic fluid leaking into pleural cavity Hemothorax: blood leaking into pleural cavity Hydrothorax: serous fluid leaking into pleural cavity
Cap changes
WHEN: varies according to institution policy and how often they are used USE STRICT ASEPTIC TECHNIQUE: be as clean as possible (both wear mask to decrease risk of infection) Flush cap per policy Side Clamp needs to stay closed SASH method
Hemothorax
blood leaking into pleural cavity
what to do when an antibiotic has been ordered for a patient with a newly placed PICC line (not confirmed) and who already has a central line?
connect antibiotic to peripheral line (it had x-ray placement)
Most common complication of a central line dressing change?
infection
Chylothorax
lymphatic fluid leaking into pleural cavity
