ATI: Central Venous Access Devices (CVC, PICC)

PICC

Peripherally Inserted Central Catheter

Which of the following statements are false regarding nontunneled catheters? a) Nontunneled catheters most often have a single lumen. b) Indications for placement of this type of catheter include intravenous therapy, blood sampling, and central venous pressure monitoring. c) The femoral vein may be used, if necessary. d) This site is not preferred, and the catheter should be removed as soon as possible due to high risk of infection.

(a) - nontunneled catheters most often have multiple lumens. All other answers are true.

Which of the following statements are true regarding PICC lines? Select all that apply. a) PICCs are indicated for administering fluids, blood, and medications, as well as for blood sampling, although blood sampling through a PICC can be difficult. b) Flushing a PICC line should always be done with a 20-mL syringe. c) PICC placement is a surgical procedure and requires the patient to go under general anesthesia. d) Most PICCs are secured with wound closure strips (such as Steri-strips) or a securing device to prevent catheter migration and damage.

(a) and (d) are TRUE (b) is FALSE - a 10-mL syringe is always used for flushing to avoid the dangers posed by increased pressures from smaller syringes. (c) is FALSE - PICC placement can be done at the bedside and does not requires anesthesia.

Which of the following statements regarding multi-lumen central venous catheters is false? a) With a multi-lumen catheter (MLC), only one treatment can be performed at a time. b) Each lumen in an MLC opens separately from the other lumens at the distal end of the catheter, or along various other areas, so solutions do not mix as they travel through the catheter. c) The multiple ports within an MLC (2-4) allow for administration of medications, blood infusions & sampling, fluid replacement, and pressure monitoring. d) Any one, any two, or all three ports may be capped and filled with heparinized saline or saline solution for intermittent use.

(a) is false: with a multi-lumen catheter in place, several treatments can be performed via a single central line insertion site.

Which of the following statements regarding single-lumen central venous catheters is false? a) A single-lumen catheter consists of a tube 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. b) A single-lumen central venous catheter is used for patients who need an infusion into a large, central vein. c) When a single-lumen catheter is in place for infusing parenteral nutrition, it can also be used to sample blood or to transfuse blood. d) A single-lumen catheter, as indicated by its name, consists of just one hollow channel within the tube.

(c) is false: single-lumen CVC's used for infusing parenteral nutrition should not 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.

A nurse is teaching a group of students about how to care for patients with PICC lines. Which of the following students needs further teaching? a) "I will be sure to assess the insertion site for any redness, drainage, swelling, or pain." b) "If my patient has a PICC line, but is not being administered any medications or fluids, I will flush the line with NS every 12 hours, and 5 mL of heparin once daily." c) "I will instruct these patients to avoid heaving lifting and other strenuous activities that may dislodge the catheter." d) "When my patient is performing daily hygiene, I will instruct them to wash the catheter with warm soap and water." e) "I must avoid measuring blood pressure and performing venipuncture in the arm with the PICC."

(d) is false - the catheter and insertion site will need to be kept dry during bathing and showering.

Air can enter the circulatory system when a central venous catheter is open to the environment, thus causing air embolism. Which of the following statements is false regarding an air embolism? a) This can occur during inadvertent disconnection of the central line tubing, catheter rupture, or catheter removal. b) Typical manifestations include dyspnea, chest pain, tachycardia, hypotension, anxiety, nausea, dizziness, and confusion. c) An air embolism may be suspected if the nurse hears a churning noise when auscultating over the pericardium. d) If you suspect an air embolism, clamp the catheter, administer oxygen, and place the patient on their right side in Trendelenburg position.

(d) is false - the patient should be placed on their 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.

What sites are commonly used to place an implanted port device?

*Anterior chest, just below the clavicle Upper arm Abdomen Back

A commonly used multi-lumen catheter has three ports: 1. Distal lumen 2. Middle lumen 3. Proximal lumen What is each port used for?

1. Administration of blood, or other viscous fluids 2. Parenteral nutrition 3. Administration of medications or blood

Infiltration: leakage of IV solution or (non-vesicant) medication, out of the vein, into the surrounding tissue. 1. Signs & Symptoms 2. Interventions

1. Pain, decreased skin temperature, edema, pallor 2. Discontinue the IV line, *elevate the extremity*, apply a warm compress

Phlebitis: inflammation of a vein. 1. Signs & Symptoms 2. Interventions

1. Pain, increased skin temperature, redness 2. Discontinue the IV line, apply a warm compress

Extravasation: IV catheter becomes dislodged and the (vesicant) medication infuses into the surrounding tissues. 1. Signs & Symptoms 2. Interventions

1. Pain, stinging, burning, swelling, redness 2. Discontinue the IV line, apply a cool compress, administer an antidote (if it exists for that medication)

What are the four general principles of all central lines?

1. Syringe size: excessive pressure from the syringe you use can rupture the catheter. Therefore, use only 10-mL or larger syringes and avoid excessive force when flushing the lines or administering medications. Flushing with larger syringes creates less pressure; smaller syringes create more pressure. 2. Flushing: flushing with preservative-free, sterile 0.9% sodium chloride (NS) solution helps ensure and maintain patency of all types of central venous access devices. When flushing a central VAD catheter, use a pulsing (push-stop-push-stop) flush to create turbulence that helps clear blood and medications from the line. 3. Heparin flushing: flushing with heparin helps ensure and maintain patency of the central VAD. The goal is not systemic anticoagulation; it is catheter patency. 4. 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. A catheter with a valved or closed tip, such as a Groshong, does not require clamping.

To access an implanted port, you should use what type of needle?

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.

Groshong catheter

A rounded, closed-ended (valved) tip with a 3-way valve that reduces the risk of blood loss and air embolism when removed. Preferred location is the superior vena cava ~ 2-3 cm above the right atrial junction. Due to the size, fluids are much less caustic (burning) in central veins than in smaller ones.

A nurse is caring for a patient who has just received an implanted port. The patient seems weary about her new device and is concerned about how it will affect her everyday life. As the RN, what could you say to this patient to address her concerns? Select all that apply. a) "Implanted ports have the advantage of being more cosmetically appealing than other central line devices." b) "These devices have the lowest risk of infection of all chest-accessed central lines." c) "You will only need to visit your doctor once a week for exit-site care." d) "Implanted ports allow people to carry on virtually all activities including bathing and swimming, when they are not in use."

ALL are true, except (c) - implanted port devices do not require exit-site care

A tunneled CVAD can be used to administer which of the following? Select all that apply. a) Fluids b) Chemotherapy c) Antibiotics d) Blood e) Parenteral nutrition f) Central venous pressure monitoring and blood sampling

ALL of the above

Which of the following nursing interventions should be performed for a patient with a central line associated dysrhythmia? Select all that apply. a) Confirm that radiologic results reveal accurate catheter tip location. b) Assess the patient's heart rate and rhythm. c) Assess the patient for ear, neck, or back pain. d) Inform the provider of any changes in the external catheter length.

ALL of these interventions are correct

This is a rare complication of tunneled central venous catheters that occurs when the catheter is compressed between the first rib and the clavicle, causing an intermittent mechanical occlusion.

Catheter Pinch-Off (causes Pinch-Off Syndrome)

CR-BSI

Catheter-related bloodstream infections

CVC

Central Venous Catheter

________ is the preferred agent to clean the insertion site of a central line, but some use alcohol and povidone-iodine.

Chlorhexidine gluconate

This is an antibacterial compound with substantial residual activity that is used as a liquid antiseptic and disinfectant.

Chlorhexidine gluconate; trade name ChloraPrep®

This plasma expander is a protein-containing fluid infused intravenously to help restore circulating blood volume.

Colloid solution

When a central catheter is inserted into the subclavian vein, the clavicle & rib can move together and compress the central line catheter, causing pinch-off syndrome. What are some signs that this has occurred?

Difficulty drawing blood samples Resistance to the infusion of IV fluids Redness, swelling, or crepitus

This port of a CVC is the third hole that sits inside the patient's vein and is farthest from the site of entry and closest to the right atrium.

Distal port

This central line associated complication is an abnormal heart pattern indicated on an EKG, and may occur with catheter malposition or dislodgement. This can occur during the insertion procedure or later during the dwell time. The patient may not experience any clinical manifestations, which is why a chest x-ray is performed upon initial insertion to confirm the catheter tip is located in the correct area.

Dysrhythmia

What are common complications associated with central lines?

Dysrhythmias Infection Sepsis Pneumothorax & Hemothorax Air embolism Catheter lumen occlusion Drug precipitates Pinch-off syndrome Catheter malposition Catheter rupture

True or False: Air embolisms are complications that can occur when central line catheters, such as the Groshong, become open to the environment.

False - closed/valve-tip catheters, such as the Groshong, can be open to air without risking an embolism.

Sepsis is a severe blood infection, commonly caused by the introduction of bacteria, viruses, or fungi into a central venous access device. What are some common manifestations of sepsis?

Fever, chills, hypotension, tachycardia, confusion

Catheter rupture could occur when the catheter is broken or separated from the hub or port body. 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. What are common signs of catheter rupture?

Fluid leaking around the site Pain or swelling during an infusion The inability to aspirate blood

Valsalva maneuver

Forceful exhalation against a closed glottis, which increases intrathoracic pressure and thus interferes with the return of venous blood to the heart; performed with central line insertion to create a positive phase in central venous pressure, thus reducing the risk of air being drawn into the central circulation and creating an air embolus.

If you cannot flush the catheter, check to make sure it is not clamped, kinked, or occluded. What strategies can be used to reposition the catheter?

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.

IVADs

Implanted Vascular Access Devices (aka implanted ports)

This is a catheter whose end is attached to a small chamber placed in a subcutaneous pocket (instead of exiting from the skin), usually on the anterior chest wall.

Implanted port

This is a transparent, volatile, colorless liquid used as a solvent and disinfectant and applied topically as an antiseptic.

Isopropyl alcohol

These type of central line catheters are not commonly used for long-term care; dwell time is typically less than 6 weeks. 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.

Nontunneled catheter

CVC's: open-ended vs closed-ended/valved

Open-ended catheters: - The catheter is open at the distal tip - The catheter requires clamping before entry into the system; clamps are usually built-in - Requires periodic flushing (heparin or NS) - Any type of CVC can be open-ended Closed-ended catheters: - A valve is present at the tip of the catheter (Groshong) or at the hub of the catheter (PAS-V) - Clamping is not required as the valve is closed, except during infusion or aspiration - Do not require heparin flushes - The catheter is filled with NS when not in use - May be present on tunneled catheters, implanted ports, and PICCs

Peripheral IV catheters must be changed every 72 to 96 hours while a ________ may remain in place for a year or more, as long as there are no complications with the insertion site or the catheter.

PICC

A central line is usually 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

This is a catheter used for long-term intravenous access and inserted in the basilic or cephalic vein, just above or below the antecubital space, with the tip of the catheter resting in the superior vena cava.

Peripherally Inserted Central Catheter (PICC)

This type of catheter is a long central catheter that is inserted into the basilic or cephalic vein in the arm. It can have single or multiple lumens and is intended for patients who require therapy for several days to months.

Peripherally Inserted Central Catheter (PICC)

________ occurs when there is inflammation of a vein. ________ occurs when there is leakage of IV solution or medication (non-vesicant) into the surrounding tissue. ________ occurs when the IV catheter becomes dislodged and medication (vesicant) infuses into the tissues.

Phlebitis Infiltration Extravasation

A patient you are caring for has a central line and is becoming restless, tachycardic, and hypoxic. He is somewhat cyanotic, is experiencing chest pain & shortness of breath, and has decreased unilateral breath sounds. As the RN, you know that these signs and symptoms are commonly associated with what CVC-related complication?

Pneumothorax / Hemothorax

What considerations should be made when performing a central line dressing change on a neonate?

Povidone-iodine can be used, but must be removed completely with sterile water or saline to prevent product absorption. The use of isopropyl alcohol or chlorhexidine is not recommended for cleaning.

This port of a CVC is the first hole that sits inside the patient's vein and is closest to the entry & farthest from the right atrium.

Proximal port

SASH

Saline, Administer, Saline, Heparin The technique for administering a medication intravenously, involving first flushing with normal saline solution, injecting the medication, flushing with normal saline, then flushing with heparin solution.

Extravasation

Seepage of fluid, such as intravenous fluid, into the tissues surrounding a blood vessel; sometimes used interchangeably with infiltration, but more accurately describes catheter dislodgement with medication infusing into the tissues and causing actual or potential tissue damage.

Dacron cuff

Stabilizes the catheter and decreases incidence of infection

________ cannot be delivered into a peripheral IV line due to its high glucose content. Solutions of 10% dextrose or less may be delivered via a peripheral IV line; more than 10% dextrose requires delivery via a CVAD into a larger vein with more turbulent blood flow.

TPN

True or False: a dressing change at the insertion site of a central line is an aseptic (sterile) procedure.

True

True or False: Incompatible fluids/drugs may be administered simultaneously into a dual-lumen implanted VAD.

True: dual-lumen implant VADs are equipped with two access ports side-by-side which can be accessed separately using two different needles. Each lumen provides independent access to the venous circulation, so that incompatible drugs or fluids can be administered simultaneously.

This type of central line is designed for long-term use (months to years) as they are designed to reduce infection w/o 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.

Tunneled catheter

Tunneled vs Nontunneled Catheter

Tunneled: - Inserted into a central vein of the chest and the remainder is tunneled subcutaneously to a distant exit site - Tunneling helps secure the catheter in place - Lower risk of infection - Surgical procedure - Dwell time: months-years (long-term) Nontunneled: - Inserted directly into a central vein of the chest or neck - Higher risk of infection - Procedure can be done at the bedside - Ideal for emergency situations in patients who require multiple therapies - Dwell time: less than a month (short-term)

This is the intermittent push-stop-push technique of quickly injecting a small amount of flush solution, pausing, then injecting again and repeating until all the flush solution has been injected.

Turbulent flushing

This is the forceful exhalation against a closed glottis, which increases intrathoracic pressure and, thus, interferes with the return of venous blood to the heart. It is performed with central line insertion to create a positive phase in central venous pressure, so as to reduce the risk of air being drawn into central circulation and creating an air embolus.

Valsalva maneuver

VAD

Venous Access Device

When using a negative displacement device, it is important to use a positive-pressure flushing technique; describe how this is done.

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 positive pressure flushing technique, unless the device has a positive fluid displacement needleless cap; these devices are flushed with saline and are not clamped.

Before a newly inserted CVAD can be used for fluid infusions or medication administration, a ________ must be obtained to confirm the tip location and thus verify proper placement.

chest x-ray

When drawing blood samples from a multi-lumen central venous catheter (CVC), it is recommended that the ________ port be used because it is the largest (16-gauge) and has a greater flow rate.

distal

Implanted ports may be open-ended or closed-ended (valved). Open-ended ports require ________ flushing, while valved ports do not.

heparin

This is a device placed under the skin without any portion of it exiting the skin. It can be used to administer medications including chemotherapy, to deliver fluids, and to draw blood samples.

implanted VAD aka implanted port

Phlebitis

inflammation of a vein

Because a ________ 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.

nontunneled

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. When using a negative displacement device, it is important to use a ________ flushing technique to overcome the blood reflux.

positive-pressure

psi

pounds per square inch

This is a topical, anti-infective agent produced by reacting iodine with the polymer povidone to release iodine.

povidone-iodine; trade name Betadine

Use a positive-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. 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; using a positive-pressure flushing technique will cause blood reflux. Flush these devices only with ________ and do not ________ the line.

saline, clamp

The catheter tip position for a properly placed CVAD is in the:

superior vena cava (SVC) This vessel is considered ideal as the SVC is a large vessel and blood flow in this area is turbulent.

One of the most common complications from PICC lines is ________, which 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.

thrombophlebitis

A ________ is a chemical that produces blisters.

vesicant

How is TPN administered?

via a Central Line (CVC), as the concentrated solutions could damage peripheral veins