Competencies vascular access

Catheter technique

**This same technique applies to the protective catheters also, however with protective catheters you must remember to engage the safety devices in order to secure the needle appropriately and safely!

Handwashing

*Always wash hands before and after initiation of infusion therapy/vascular access - this has been proven the number one way to prevent the spread of disease.

Fibrinolytic therapy

-Alteplase (Activase) also known as t-PA - now available as Cathflo Activase -Clinical trials have proven efficacy and safety in clearing central venous catheters

Central line placement

-Central lines are placed in large centrally located veins -CDC recommends using a subclavian site for non-tunneled catheters instead of jugular or femoral in adult patients to minimize infection risk. In fact, they state to avoid using the femoral vein in adult patients for central venous access. -Temporary catheters are usually placed at the bedside by physicians, physician assistants, or advanced nurse practitioners. These providers are assisted by nurses.

Before using a fibrinolytic

-Reposition the patient -Open the clamp -Flush the catheter -Have patient raise arm

What are the types of central lines?

-Subclavian Lines -Triple Lumen -Hickman Catheters -Implantable Ports -Peripherally Inserted Central Catheters (PICC)

Central line dressing change rules

-Wash hands before and after dressing changes -Wear a mask -Remove old dressing -Change dressing using aseptic technique -Needleless connectors changed per hospital policy -Never use scissors!

Timing for peripheral

< 1 week

Arteries vs veins

Arteries pulsate; veins do not!

What are the catheter types?

Non-tunneled Tunneled PICC Implanted Dialysis

What size syringe do you use to flush a central line?

Only use a 10 mL syringe; NEVER use a 3 mL syringe.

What is a Groshong catheter

Special catheter made of silicone rubber and has valve at its tip that prevents blood backflow and clotting - Flush briskly with 5 to 10 mL normal saline

What type of precautions do you use when starting and discontinuing any vascular access site?

Standard precautions

Triple lumen catheters

Temporary catheter placed in at bedside into either subclavian or jugular and tip threaded into the superior vena cava - Flush each port with 5 to 10 mL NS followed by 5 mL of 10 units of heparin each port (if not in use) every 8 to 12 hours depending on employing agency's policy Three ports: White - proximal (longest) - 18 gauge lumen Blue - middle (median) - 18 gauge lumen Brown - distal (shortest) - 16 gauge lumen

Timing for PICC

Up to 1 year

Documentation of VAD

a. Label vascular access site appropriately with date and time of procedure, catheter gauge and length, and your initials - Provide patient education b. Record in patient's record according to your institution's policies such as: Date and time of venipuncture, site location, catheter gauge and length, number of attempts required, IV fluids and flow rate if appropriate, patient's understanding using specific comments related to the procedure and your signature.

Veins most commonly selected for short peripheral catheter placement (SPC)

a. metacarpal veins b. cephalic veins c. basilic veins d. median vein

If a central line becomes clotted:

the physician might order fibrinolytic therapy using a thrombolytic agent or catheter-clearance agent. To treat occlusions, instill the amount of catheter-clearance agent based upon filling capacity of catheter lumen and allow the agent to dwell in the catheter for 20 to 50 minutes, depending upon agent used (INS, 2016). If the occlusion is thrombosis, a thrombolytic agent must be used. Urokinase (Abbokinase) is the most recognized fibrinolytic, however there is an ongoing nationwide shortage due to the FDA blocked shipment of urokinase in December 1998. Streptokinase has too many risk factors and side effects if used for catheter clearance. Alteplase (Activase), also known as t-PA, is now being utilized to declot catheters. It is available for central line use as Cathflo Activase (Alteplase). This is available from Genentech, Inc. Clinical trials have shown t-PA's efficacy and safety in clearing central venous catheters. All fibrinolytic drugs are expensive and should only be utilized when other measures have been done to re-establish proper flow of fluids (opening the closed clamp, repositioning the patient, flushing the catheter with normal saline to re-establish adequate fluid flow, having client to raise his/her arm above their head on the side of the central catheter). Trouble shooting central venous lines should be left to nurses with experience and extensive knowledge in infusion therapy or physicians. Cathflo Activase (Alteplase) is given by registered nurses (RNs) only! This is used usually in long term or permanent lines (not temporary lines).

Informed consent

"Obtain informed consent for all invasive procedures and treatments in accordance with local or state laws and organizational policy." "The clinician confirms that the informed consent process is completed for the defined procedure or treatment." "The patient or surrogate has the right to accept or refuse treatment."

Preparing the patient psychologically

"The clinician educates the patient, caregiver, and/or surrogate about the prescribed infusion therapy and plan of care, including, but not limited to, purpose and expected outcome(s) and/or goals of treatment, infusion therapy administration, infusion device-related care, potential complications, or adverse effects associated with treatment or therapy, and risk and benefits."

Techniques to increase the visibility of difficult to find veins:

*Lightly stroke vein downward to make it more prominent and wipe with alcohol *Warm compresses may be used - place over the arm for 10 to 15 minutes *Transilluminate the vein if your institution has a fiberoptic light source or a vein Doppler device *The use of ultrasound for placement of peripheral intravascular devices is becoming increasingly more popular, evidence supports the use of ultrasound, especially in special patient populations, the use of ultrasound has been associated with greater success

Indications for use of central line therapy

-Administration of IV fluids requiring dilution within the central circulation -Rapid fluid administration (multiple trauma, burns, sepsis, extensive abdominal surgery) -Frequent blood sampling -Central venous pressure monitoring -Administration of incompatible medications -Fluids to chronically ill patients

Other vascular access line

-Aterial lines -Hemodialysis catheters: (usually only dialysis nurses flush these) -Planted imports for dialysis (listen to your patient, they are very educated regarding their ports) -Swan-Gans catheter -Epidural catheter -Intraosseous therapy -Subcutaneous infusions

Sites best to use for central venous access

-Avoid using femoral vein in adult patients -Use a subclavian rather than jugular -Promptly remove any catheter that is no longer exssential

Documentation of vascular access device

-Date, size, initial at site -Size and type of cannula -Name of solution, rate, and pump -Dressing -Number and location of attempts by whom - remember only 2 attempts per person and no more than 4 attempts per patient -Patient responses to procedures

Sites with greatest risk for nerve injury: AVOID

-Distal sensory branches of the radial and ulnar nerves for sites in the dorsal hand -Superficial radial nerve at the cephalic vein of the radial wrist -Median nerve on the volar aspects of the wrists -Median and anterior interosseous nerve at or above the antecubital fossa -Lateral and medial antebrachial nerves for the antecubital fossa -Brachial plexus nerve for subclavian and jugular sites

Timing of central line dressing change

-Every 5 to 7 days if transparent. -Every 2 days (48 hours) if gauze. -Before changing a dressing you must wash your hands. -This is a sterile procedure (asepsis must be maintained)

Steer clear of trouble:

-Nerves lie close to all major veins in the arm.

Triple lumen central lines

-Nontunneled -Temporary VAC, usually <30 days -High rate of infection with longer dwell times -Potential risk of pneumothorax with insertion -Three ports: (White, Blue, Brown) -Common Flushing Practice: 5 to 10 mL NS followed by 5 mL of 10 units/mL heparin (However, remember to check institution's policies)

Points to remember about central line removal

-Not a matter of just holding your breath -Culture tube may be needed

Medication criteria for use in peripheral lines:

-Osmolality must be less than 500 mOsm/liter -The pH must be between 5 and 9 -The medication must not be a vesicant or irritant -IV solution must not exceed 10% dextrose

To insert IV

-Position the needlepoint, bevel-up, parallel to the vein and about 1/2 inch below the site of venipuncture Hold the needle at 10-30 degree angle and pierce skin -Keep your fingers away from the needle

Discontinuing peripheral infusion therapy:

-Sites rotated when clinically indicated -Always wear gloves -c. Carefully remove dressing, stabilizing vascular access device during process, and then quickly remove catheter once all tape has been removed. d. Always inspect catheter after removal to check if it is intact - Remember to chart that catheter was removed intact. e. Apply digital pressure to discontinued access site to control bleeding. f. Observe and document site condition, remember to assess the site before and after cannula is removed. g. Place clean sterile dressing over removal site. h. Document removal in medical chart include: date and time of removal, reason for removal, patient's response, any complication and nursing interventions.

Blood sampling from central venous access device

-When collecting blood from a central venous access device, always refer to your employing agency's policies and procedures. -Usually you are required to withdraw about 3-5 mL of blood to be wasted (remember this blood contains the heparinized solution used to maintain the catheter's patency). -Then the appropriate amount of blood is drawn and placed into the collection containers (again this may be collecting via a syringe - remember at least a 10 mL syringe - or a vacutainer may be used, check your institution's policies). -After the blood specimen is collected, the catheter is flushed with a sufficient amount of normal saline (usually 20 mL) followed by the appropriate amount of heparinized solution (depends on the type of central venous device). -Remember to flush with positive pressure to prevent reflux of blood back into the catheter. If drawing blood from a line that has intravenous solution infusing, the infusion should be stopped prior to blood sampling. -Remember to always wash hands before and after drawing the blood and to always wear gloves!

Peripheral blood sampling

-When completing a blood sampling the recommended site for phlebotomy is the antecubital area. The needle is usually a small gauge (23 or 25) winged needle or a straight needle may be used. -Blood is drawn into a syringe and then transferred into the collection tubes or the blood is drawn into the collection tubes using a vacutainer device. -Apply the tourniquet above the insertion site. Locate and palpate the vein. -ALWAYS wash your hands before and after the phlebotomy draw and -ALWAYS wear gloves! The angle of the needle again depends on the depth of the vein. -The needle should be with the bevel side up and quickly penetrate the vein. -Flashback of blood should be immediate, collect the specimen into the appropriate collection container or syringe then release the tourniquet and quickly withdraw the needle applying pressure to the venipuncture site after the needle has been removed. -Apply a sterile dressing.

Central line Bundle of 5 Care steps:

1) Proper Hand Hygiene. 2) Maximal Barrier Precautions Upon Insertion 3) Chlorhexidine Skin Antisepsis 4) Optimal Catheter Site Selection, with Avoidance of the Femoral Vein for Central Venous Access in Adult Patients 5) Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines

Aseptic technique of venipuncture:

1. Do not touch the prepared area after the site has been cleaned 2. Inspect cannula before insertion Cannula should be inserted bevel end up at a 10 - 30 degree angle, (remember your angle depends on the depth of the vein - a very superficial vein may need a 10 - 15 degree angle while a deeper vein may require a 20 to 30 degree angle) *If you accidentally touch the catheter before or during insertion - discard the contaminated catheter and start again

Tips for Starting Short peripheral access lines in pediatric patients

1. Introduce yourself to child and parents 2. Explain the procedure 3. It is usually best to take the child to the treatment room or some place other than his/her assigned room 4. Always have help - you may ask the parents if they would like to stay, sometimes it is best if parents are not present 5. Wash hands and gather equipment - make preparations to draw blood, if physician has ordered blood work. This is easier on the staff, child, and parent; in addition, less traumatic if everything can be completed at one time. 6. Take your time in assessing veins, look at veins in the hands, forearms, and upper arm below axilla, avoid antecubital area due to high failure rate, may consider scalp veins in infants, also may consider foot if infant is not walking Also, consider mobility and hand dominance when considering a peripheral vascular access site - Avoid joints if possible (the more movement of the area with the vascular access device - the greater the risk for infiltration) *Check with your employing agency's policy on the use of scalp veins and remember to always ask parents for permission to use the scalp. These veins are utilized on infants because scalp veins are usually more accessible in this age group. Scalp vascular access sites must be monitored closely for signs of complications. 7. Sometimes it is easier to access the vein if the extremity that is being used is secured to a padded armboard 8. Wear gloves and prep the skin per policy 9. Use small gauge catheter usually #24 for infants and #24 or #22 for toddlers on up 10. Access the vein quickly and carefully - keeping in mind that blood flashback may be slow due to venous spasm or collapse 11. Secure the catheter using an external catheter securement device; there are commercially available vascular access site covers/protectors to help protect the vascular access site in active children 12. Make sure child's extremity is taped securely to armboard 13. Tell parents to watch vascular access site closely and explain signs and symptoms of vascular access complications . Pediatric infusion must be delivered via an electronic infusion device (controller) because children are more prone to fluid overload than adults - many medications are given via syringe pumps especially to young children *Remember all of the electronic infusion devices must have alarms and tamper- proof / locking mechanisms 15. Pediatric IV sites must be monitored closely and frequently for signs of complications - Document hourly checks for continuous IV infusions and before, during and after intermittent infusions 16. Remember the intraosseous route (into the bone) is used during emergency situations when immediate vascular access is needed in infants and children - short-term use only

Physical characteristics of veins

1. Outer layer - tunica adventitia 2. Middle layer - tunica media 3. Inner layer - tunica intima

When selecting a SPC site:

1. Take your time when assessing veins 2. Assess patient who is going to receive infusion therapy - consider age, diagnosis, length and type of therapy prescribed, and activity level - do not use peripheral catheters for continuous vesicant therapy, parenteral nutrition, or infusates with osmolarity greater than 900 mOsm/L (INS Standards of Practice, 2016). 3. Discuss arm preference with patient - avoiding the dominant arm usually promotes better outcomes 4. Avoid operative side on dialysis patients and mastectomy patients, avoid arms with compromised circulation (this includes patient's with CVAs) 5. Avoid sites that are located near joints. Movement at joints leads to irritation, inflammation, and even infection. 6. Avoid the use of the lower extremities in adult patients - veins of the lower extremities should not be used routinely in the adult population due to risk of tissue damage, thrombophlebitis, and ulceration (INS, 2016). 7. Avoid bruised areas, areas of inflammation, and sites of previous infiltration 8. Avoid the lateral side (surface) of the wrist for about 4-5 inches due to the potential risk for nerve damage. 9. Avoid the ventral surface (inside wrist) of the wrist due to pain upon insertion and the potential of damage to the radial nerve.

Tips for starting short peripheral access lines in geriatric patients

1. Wash your hands and collect your supplies 2. Remember to select the smallest gauge catheter that will deliver the prescribed therapy 3. Introduce self to patient - remember to speak slowly and clearly - Explain what you are going to be doing - starting a peripheral vascular access line 4. Remember to take your time when assessing for an appropriate venipuncture site - Use good lighting 5. Examine with and without tourniquet - If using a tourniquet, place a washcloth on the patient's skin to prevent the tourniquet from being directly upon the skin, in elderly patients, the skin is very sensitive and fragile 6. Remember elderly clients have very fragile veins and bruising occurs easily 7. Select a site in the patient's non-dominant arm, remembering that elderly patients have lost skin elasticity and subcutaneous tissue; the preferred site will be the forearm of the non-dominant arm. 8. Clean site appropriately according to your employing agency's policies 9. Always wear gloves when starting a peripheral vascular access device 10. Try to stabilize the vein with other hand - It may be necessary to seek help with some elderly patients 11. Insert catheter quickly and carefully in order to avoid a hematoma 12. Secure catheter per employing agency's protocol

Timing for Midline

2-4 weeks

Sizing:

20- to 24- gauge - for most infusion therapies - evidence supports peripheral catheters larger than 20 gauge have a greater chance of causing phlebitis. 22- to 24- gauge - for neonates, pediatric patients, and elderly population to decrease insertion related trauma 16- to 20- gauge - for rapid infusion (when fast fluid replacement is needed) such as trauma 20- to 24- gauge - for blood transfusion, when rapid infusion is needed use a larger gauge catheter

Venipuncture technique

3. Quickly puncture the skin and anterior vein wall, observe for blood return - blood should fill the catheter and/or the flashback chamber of the catheter if insertion is successful 4. Once flashback has been observed you have penetrated the vein - lower the catheter almost flush with skin and advance the cannula slightly (about 1/16 of an inch - do not continue at an angle) this technique will help ensure you are in the vein lumen and not the vein walls 5. Once this has been accomplished - loosen the stylet and use the push-off tab to separate the catheter from the needle stylet, continue to hold skin taut and use the push-off tab advance the catheter slowing into the vein by pushing the catheter hub directly against the skin. This can be accomplished using the one-hand method or two-hand method. DO NOT reinsert the stylet once it has been loosen and slightly retracted. *Never reinsert the stylet into the cannula once it has been separated - this could lead to cannula shearing

After venipuncture

6. Release tourniquet - releasing the tourniquet prior to removing the stylet from the catheter prevents the formation of a hematoma at the site 7. Apply pressure well above the catheter tip to prevent backflow of blood - (remember do not apply pressure on skin that has been cleaned and will be under the sterile dressing) Carefully remove the stylet and connect the IV extension tubing (INT) to hub of catheter being careful not to allow the male luer lock of the extension set to touch the skin of the patient. *Some of the new short peripheral catheters on the market have a back valve in place that prevents blood from exiting out the end of the catheter hub thereby eliminating the need to compress the vein to stop blood flow 8. Aspirate for blood return and flush with 3-5 mL normal saline maintaining positive pressure to prevent reflux of blood back into the extension tubing and catheter. The catheter should flush easily with no resistance, no swelling noted, and no complaints of pain from patient; then your venipuncture has been successful .

Statistics for complications

90% of catheter-related bloodstream infections occur with central lines 14,000 deaths occur annually due to central line infections (some estimate a figure as high as 28,000 deaths per year Cost per bloodstream infection are estimated between $3,700 to $29,000 Prolongs hospitalization 7 days

Central line dressing change nursing role

A competent trained nurse should be performing all VADs site care and dressing changes. According to the new 2011 CDC guidelines institutions should designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters. -Remember a sterile dressing should be applied and maintained on these devices.

Cathflo Activase

A fibrinolytic that can be injected into the external opening of a CVAD to target fibrin (a substance that helps clots form) and dissolve the blood clot, restoring blood flow to the catheter line

Appropriate selection of VAD (vascular access device)

Always choose the smallest gauge catheter (smallest outer diameter) with the fewest number of lumens and the least invasive device to meet the patient's prescribed therapy (INS, 2016) Catheter sizes (length may vary - usually the smaller the catheter the shorter): Example: 24 gauge may be ½" in length and 20 gauge may be 1" in length

Rewarding children

Always remember to reward children with something - stickers are a great idea! Pediatric peripheral vascular access devices are not routinely changed; they remain in place until a problem is identified or the therapy is completed. Remember to keep in mind growth and development concepts when working with pediatric patients. Infants need to feel loved and secure. Toddlers need to understand the procedure in terms they will see, feel, and hear. Preschoolers like to have choices (if possible and if reasonable). School age children are able to understand and comprehend concretely, let them talk about what is going on and share what is on their minds. Adolescents have a tendency to focus a lot of time on their own thoughts and changes in their own body and they believe that others are focused on those things as well. They should be able to think abstractly. Review growth and development for all age groups.

Tourniquets:

Both your text and INS recommend removing tourniquet after site has been selected to allow for the preparation of the insertion site (which includes cleaning area with antiseptic soap and water if visibly soiled; clipping excess hair is needed, and administering local anesthesia if needed). NOTE: Shaving excess hair with a razor at the intended venipuncture site is not recommended. INS (2016) recommends clipping the excess hair with scissors or clippers (make sure they have a disposable head for single-patient use). The use of a razor on excess hair causes the potential for microabrasions putting the patient at an increased risk of infection. After skin preparation, perform hand hygiene and don gloves!

Complications from central lines

Cardiac Arrhythmias - usually related to over insertion of guidewire Artery puncture Pneumothorax - puncture of lung tissue Air embolism Cardiac Tamponade - due to perforation of structures Infection Thrombosis-all catheters are thrombogenic

Common flushing practices

Central implantable ports are flushed once each month with 10 mLs saline followed by 3-5 mLs 10 to 100 units of heparin. Peripheral implantable ports are flushed once a month with 5 to 10 mLs saline followed by 3 to 5 mLs 10 to 100units of heparin. (Remember to check institution's policies)

Central vascular access placement

Central lines, with the exception of Peripherally Inserted Central Catheters (PICCs), are usually placed by physicians, advanced registered nurse practitioners, or physician assistants. A temporary central line is usually placed at the bedside with the patient awake and alert. This is a sterile procedure with staff wearing gowns, masks, and gloves. (Sometimes a mask is placed on the patient also.) When accessing the subclavian or jugular vein, the provider will place patient in a Trendelenburg (head down) position with a rolled towel or sheet under the shoulder of the proposed side. This position tends to distend the veins and decreases the risk for pneumothorax. Permanent lines are usually placed in surgery under general anesthesia.

What do you do if a central line becomes disconnected?

Clamp the catheter!

Positive pressure

Created by closing the clamp while flushing the final milliliter (mL) of the solution and keeping your finger on the plunger of the syringe until the clamp is securely closed.

Documentation of catheter removal

Date and time of removal - remember to include that the catheter was removed intact Reason for removal Any complications and interventions Patient's response to procedure **Follow institution's policies and procedures related to vascular access removal

CDC guidelines

Educate healthcare personnel regarding the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections. Periodically assess knowledge of and adherence to guidelines for all personnel involved in the insertion and maintenance of intravascular catheters. Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral and central intravascular catheters.

Groshong catheter

Has a patented 3-way valve at the end of the catheter that prevents reflux of blood back into the catheter. Normal Saline flush only - does not need heparin

Heparin and removal of access needles

Heparin lock solution of 100 units/mL is used before removal of an access needle from an implanted port and/or for periodic access and flushing. Hemodialysis catheters are locked with heparin lock solution 1000 units/ml after each use. When using heparin lock solutions greater than 100 units/mL (higher concentrations are used in hemodialysis lines) you must remember to aspirate and discard prior to using the catheter line. Occasionally you may see central venous catheters flushed with an antimicrobial solutions for therapeutic and prophylactic purposes. If an antimicrobial solution is being used it must be aspirated and discarded prior to using the line. Also, there are anti-infective central vascular access devices are now available on the market and how shown a decrease in colonization and/or catheter-related bloodstream infections. These devices are coated or impregnated with chlorhexidine and silver sulfadiazine, minocycline and rifampin, and silver ion. Remember these devices should not be used in patients with allergies to silver, chlorhexidine, silver sulfadiazine, rifampin, or tetracyclines.

Taping/securing catheter and dressing

It is important to remember short peripheral catheters (SPCs) may by secured using securement devices or transparent dressing, however the use of some type of catheter securement devices is highly recommended. Catheter securement devices lead to better stabilization and securement; these devices prevent vascular access device movement/motion which leads to complications such as phlebitis, infiltration, infection, and catheter migration. The use of an external stabilization device with SPCs represents a significant change in infusion therapy. Both the CDC and INS recommend use of catheter stabilization devices (CDC recommends a sutureless device). Also, remember it is important to loop and secure tubing independent of the catheter.

Timing for CVC?

Long-term

Timing for PORT?

Long-term

Hickman catheter:

Long-term (several months to years) catheter placed surgically under general anesthesia into subclavian and catheter tip threaded into superior vena cava, remaining catheter is tunneled underneath skin in chest wall with exit site just below nipple area - Aspirate exiting heparin - Flush with 10mL NS followed by 5 mL of 10 units heparin once a day (if not in use) - Single or dual lines

Midline catheter use:

Midline Catheters are becoming increasingly more popular. Midline Catheters are peripherally inserted catheters, they are longer (up to 8 inches approximately) and are place in peripheral veins generally above the antecubital fossa. The catheter is usually inserted via basilic, cephalic, or brachial vein and the tip is generally located below the axillary line.

Needleless connectors

Needleless connectors are removed or changed if there is blood or debris within the needleless connector; prior to drawing blood culture sample from the catheter; upon contamination; or according to the organizational policies, procedures, and/or practice guidelines; or per the manufacturer's directions for use. According to INS the optimal time frame for changing needleless connectors has not been determined. All needleless connectors should be consistently and thoroughly disinfected using alcohol, tincture or iodine, or chlorhexidine gluconate/alcohol combination prior to each access. According to INS the optimal techniques or disinfection time frame has not been identified. However the technique of using friction and a scrubbing motion is recommended and allow the needleless connector to dry completely before accessing.

Helpful hints for successful venipuncture:

Patient should be relaxed and in a comfortable position with the arm lowered. You may ask Patient to open and close his/her hand to distend the veins. You must appear calm and confident in your skills in for your patient to be calm and relaxed.

Catheter Attempts:

Remember only one catheter per attempt! INS (2016) recommends no more than two (2) attempts of a short peripheral catheter by one individual and no more than four (4) attempts per patient. Peripheral vascular catheter insertion should only be attempted if venous access is considered to be adequate (INS, 2016). You must also be aware of your employing agency's policies concerning number of attempts made by each person.

Remember to education patient:

Remember to educate your patient about their infusion therapy and tell them how to protect the vascular access site. Inform them to report any complications immediately such as: pain, swelling, redness, blood in the tubing, moisture on the IV dressing, or infusion devices alarms. Also, tell your patient about your institutions policies on how often the IV sites are rotated - The current recommended frequency for site rotation of short peripheral catheters is based on clinical indications, not a specific time frame. Clinical indications include: assessment of patient's condition and access site, skin and vein integrity, length and type of prescribed therapy, venue of care, as well as integrity and patency of the catheter. Also short peripheral access site care and dressing changes are performed when the dressing the integrity of the dressing is compromised (no longer occlusive, etc.)

Rolling veins

Remember to keep the vein from rolling, and to ease needle insertion apply skin stabilization - Use your nondominant hand to stabilize the vein, pull the distal skin away from the point of insertion Warn the patient of stick before you before venipuncture

Central venous vascular access

Remember: A central line is when the catheter tip is placed into the superior vena cave (SVC) near its junction with the right atrium. This is designed for long-term therapy. A chest X-ray is usually performed to confirm proper placement of the catheter tip unless IV ECG technology is utilized when placing line. When using IV ECG technology, the practitioner is monitoring ECG and watching for the change in the p-wave (this is discussed in more detail under the section TYPES OF CATHETERS - Peripheral inserted central lines).

Selection of appropriate supplies for VAD

Short peripheral catheter Dressing materials including stabilization device (check employing agency's policies) Gloves - nonsterile Latex free tourniquet and antiseptic solution to clean insertion site Short extension set with needless connector and prefilled saline for priming (Some institutions have IV start kits with many of the supplies needed packed together)

Antimicrobial cuffs

Some physicians are placing an antimicrobial cuff (Vitacuff) on the central lines that are being inserted. The cuff has two layers: an inner layer of silicone elastomer that secures the cuff to the catheter and an outer layer of biodegradable bovine collagen that contains silver ions. These ions are released slowly and provide antimicrobial activity for 4 to 6 weeks. This cuff can be placed on single and multiple lumen catheters and also comes preattached top some long-term catheters. This cuff's purpose is to act as a barrier to microorganisms that may occur along the subcutaneous catheter tract. When the catheter is inserted, this cuff is placed subcutaneously. As mentioned previously some anti-infective central vascular access devices are now available on the market and how shown a decrease in colonization and/or catheter-related bloodstream infections. These devices are coated or impregnated with chlorhexidine and silver sulfadiazine, minocycline and rifampin, and silver ion.

Starting Short peripheral access lines in pediatric patients

Sometimes a topical anesthetic, such as ELA-Max and EMLA cream, can be applied to potential vascular access sites prior to the procedure. Both of these require time for the cream to be effective which can be a problem if access is needed immediately. Two other devices on the market: Zingo (uses compressed helium gas to inject lidocaine subcutaneously) and J-Tip Needleless Injection System (uses carbon dioxide to inject lidocaine subcutaneously). Both to the preceding numb the injection area quickly, however they make a loud noise which sometimes frightens children. Numby Stuff is also available. INS recommends consideration and use of anesthetic agents with children. Also, the use of chlorhexidine preparations are not recommended in infants less than 2 months (check agency's policies and procedures if working with neonates in intensive care or have infants under age 2 months).

Central line removal

Temporary central lines placed at the bedside are removed at the bedside usually by a registered nurse. After washing hands and doning clean gloves, the dressing is carefully removed. A sterile dressing tray is opened and sterile gloves applied. The site needs to be cleaned aseptically and the sutures clipped (if sutures are in place). The patient is usually in a supine position - flat. Have the patient to perform the Valsalva's technique (forceful attempt at expiration with mouth and nostrils closed - bearing down after a deep inspiration) to prevent air embolism while gently removing the catheter. Apply a sterile dressing to the site then label the dressing with the time and date of removal. Apply pressure for a minimum of 30 seconds, or until hemostasis is achieved. The Infusion Nurses Society (INS) recommends applying a petroleum-based ointment and a sterile dressing to the access site to seal the skin-to-vein tract and decrease the risk of air embolus. Be sure to check the institution's policies and procedures if performing the task of removing a central line. Also if resistance is encountered when the catheter is being removed, remember do not try to forcibly remove the catheter, notify the provider and discuss the appropriate interventions for successful removal. The patient should remain flat for a short period (approximately 30 minutes) after the removal of the line. Monitor the patient frequently for signs of complications including bleeding at the site. Monitor vital signs according to employing agency's protocols. Usually the site is sealed within 72 hours and the dressing may be removed, the risk of an air embolism has past by this time. INS recommends changing the site dressing every 24 hours until the exit site has healed, however be sure to check your institution's policies and procedures. Remember to document the removal and the patient's response in the chart. Sometimes the physician orders for a culture to be done on the tip of the central line catheter - when doing this remember to clip the tip of the catheter with sterile scissors and allow the tip to drop into a sterile container. Label the container and send to the lab. Document that a culture was ordered and sent.

PICC lines

Temporary long-term catheter placed percutaneously through cephalic or basilic vein by specially trained registered nurses - Catheter is threaded with a stylet or guide wire via the subclavian into the superior vena cava; catheter tip is placed into the superior vena cave (SVC) near its junction with the right atrium. Tip placement is confirmed before use - either by X-ray or if using IV ECG tracing (which may be the most reliable method to precisely locate the catheter tip placement) the nurse is monitoring ECG as PICC is being threaded, when the catheter tip passes the sinoatrial node, the P wave increases with an upward spike to let the nurse know the catheter tip is in the correct location. PICC lines are flushed with 5 to 10 mL NS followed by 5 mL of 10 units of heparin every 8 to 12 hours if not in use - single, dual, or triple lines - these lines are used for several weeks to months (not to exceed one year) Many institutions are using Power Injection PICCS - these products allow utilization of central vascular device for injection of contrast using high infusion rates over short period of time. These products are designed to sustain the pressure and high infusion rates generated by power injectors. Power PICCS are usually purple - they require flushing before and after infusion with saline and do not require use of heparin. They require weekly flushing when not in use.

Stay away from:

The "snuff box" (radial artery area with a lot of nerves)

Heparin and flushing

The amount and concentration of heparin utilized as well as the frequency of flushing these lines depends on each institution's policies and procedures. The amount of heparinized solution used is usually equal to the filling volume of the catheter. The current recommendation from INS (2016) is lock central vascular access devices with either heparin 10 units per mL or preservative-free 0.9% sodium chloride, this should be done according to the manufacturers guidelines for use and the needleless connector Also remember these lines should be flushed and central lines heparinized (if required) after an infusion. When flushing central lines you must use a positive pressure technique to prevent reflux of blood back into the catheter. Positive pressure is created by closing the clamp while flushing with the final milliliter (mL) of solution and keeping your finger on the plunger of the syringe until the clamp is securely closed. You may also consider using pulsate flushing technique (push - pause - push - pause). Studies has shown using 10 short boluses of 1 mL interrupted by brief pauses may be effective in removing solid deposits when compared to a continuous low-flow method (INS). If you notice blood backing up into the line then positive pressure was not maintained. Blood not only harbors microorganisms but also can form a clot in the line preventing its further use.

Competency requirements

The clinician is responsible and accountable for attaining and maintaining competence with infusion therapy administration and VAD (vascular access device) insertion and/or management within her or his scope of practice. Competency assessment and validation is performed initially and on an ongoing basis Competency validation is documented in accordance with organization policy.

Phlebotomy techniques

The principle of phlebotomy is to collect blood and other specimens for diagnostic purposes. As mentioned previously in this study guide, the nurse will often collect the blood specimen at the time of the venipuncture for infusion therapy. It is important the nurse be aware to the correct collection tubes and to ensure the specimens are handled properly and correctly prior to be sent to the lab for evaluation. The equipment used to perform phlebotomy differs depending upon the method utilized. All needles used for phlebotomy are safety needles; we will discuss in class and practice with some of the equipment available to us during lab.

Flushing rules

USE a 10mL syringe when flushing vascular access devices especially central vascular access catheters. NEVER USE a 3mL SYRINGE! (For adult patients) DO not force anything to flush. Should flush easily without problems. The use of a prefilled syringe has shown to save nurse time and may reduce risk of infection. If a multiple dose vial must be used, then the vial must be designated for single patient use (INS, 2016). Also, please remember these prefilled saline syringes should not be used for the dilution of medications. INS reports some of the concerns as: differences in gradation markings, an unchangeable label on prefilled syringes, partial loss of the medication, and possible contamination increase the risk of serious medication errors. Prior to any infusion or use, all vascular access devices are flushed and aspirated for blood. This is to assess the catheter function as well as prevent complications or possibly detect complications. A brisk blood return should always be noted from a central vascular access device. After administering an IV direct push medication flush the vascular access device with prefilled 0.9% sodium chloride at the same rate of injection as the medication. Use an adequate amount of flush solution to clear the medication from the line (INS).

Competency and validation

Use a standardized approach to competency assessment and validation . . . Validate clinician competency by documenting the knowledge, skills, behaviors, and ability to perform . . Employ multiple methods to deliver education (eg, lecture, reading materials, simulations, self-study) repeated over time and combined with outcome monitoring and feedback to increase their impact on professional behavior.

FLushing procedure

Vascular access devices should be flushed before and after each infusion with preservative-free 0.9% sodium chloride solutions. For normal saline, use the minimum volume equal to twice the internal volume of the catheter device and add-on devices. Recommended flushing of 10 mL of saline for central lines may remove more fibrin deposits, drug precipitate and other debris from the lumens (INS, 2016). INS (2016) states the following factors should be considered when choosing the flush volume for devices: the type and size of catheter, age of patient, and type of infusion therapy being administered. When blood products, parenteral nutrition, contrast media, and other viscous solutions are being used, your vascular access devices may require larger flush volumes. Always refer to your institution's policies and procedures regarding flush recommendations. Central venous vascular access devices should be heparin locked after the completion of the final flush solution to decrease the risk of occlusion. The recommended and preferred heparin lock solution is 10 units/mL (INS and CDC). *Remember to follow policies and procedures for employing agency. Always clean injection ports with alcohol or other antiseptic solution prior to accessing. Use friction and a scrubbing motion allowing the needleless connector to dry completely

Changing central line dressing rules:

Wash hands. Explain procedure to patient. Wear a disposable surgical mask. Remove old dressing with clean-gloved hands and discard appropriately. Remember to assess the insertion site for signs and symptoms of complications. Palpate lightly for any local tenderness. Notify provider if site complications are present. Remove stabilization device if present; be careful not to dislodge catheter. Change dressing using aseptic technique. Perform hand hygiene. Place on sterile gloves; cleanse skin per protocol (most institutions are using chlorhexidine gluconate (ChloraPrep) to clean the site; however some institutions may continue to use alcohol (70%) and povidone-iodine (Betadine). INS and CDC recommend the use of chlorhexidine solution for all patients over the age of 2 months. When using ChloraPrep to cleanse the site, remember to rub back and forth using friction for at least 30 seconds to clean the area working from the center to the outer area. If using alcohol and Betadine - use alcohol first, allow to dry, then Betadine - if not allergic to Betadine - and allow to dry completely - (if allergic to Betadine clean with alcohol only) remembering to work in a circular motion from center to outer areas; it must remain on the skin for at least 2 minutes or longer to dry completely for adequate antisepsis. Continue to inspect site while cleaning to observe for erythema, edema, or drainage. Also assess for pain or tenderness at the site. Notify physician if any of these complications mentioned are present. Place sterile gauze dressing or transparent dressing over insertion site. Label the dressing with date, time and your initials.

Encouraging patients to take an active role

Watch hospital staff to make sure they wash their hands. Do not be afraid to remind them. Ask the doctors and nurses lots of questions: (e.g.) How will you clean the skin before the line goes in? Make sure doctors and nurses check the line every day.

When are short peripheral catheters rotated?

When clinically indicated.

Blood sampling from central venous access device

When collecting blood from a central venous access device, always refer to your employing agency's policies and procedures. Usually you are required to withdraw about 3-5 mL of blood to be wasted (remember this blood contains the heparinized solution used to maintain the catheter's patency). Some institutions may recommend the push-pull or mixing method instead of the discarding method when drawing blood from a central vascular access device. The push-pull or mixing method does offer some good results for measuring certain laboratory values, check with the lab and physician prior to using this method. When employing push-pull or mixing method the recommended cycles of push-pull is five (5); however there studies are inconsistent with establishing an exact consensus (INS, 2016). After either method the appropriate amount of blood is drawn and placed into the collection containers (again this may be collecting via a syringe - remember at least a 10 mL syringe - or a vacutainer may be used, check your institution's policies). After the blood specimen is collected, the catheter is flushed with a sufficient amount of normal saline (usually 20 mL) followed by the appropriate amount of heparinized solution (depends on the type of central venous device). Remember to flush with positive pressure to prevent reflux of blood back into the catheter. If drawing blood from a line that has intravenous solution infusing, the infusion should be stopped prior to blood sampling. Remember to always wash hands before and after drawing the blood and to always wear gloves!

Central line dressing changes:

a. A sterile dressing should be over the insertion site either sterile gauze or a sterile, transparent, semipermeable dressing. Change gauze dressing every 48 hours (2 days) and transparent dressings every 5 -7 days - this is the NEW current recommendation for short- term (temporary) central venous catheters from both the Infusion Nurses Society (INS) and the Center of Disease Control (CDC). Both INS and CDC recommend using gauze dressings on patients who are diaphoretic, or if the site is oozing or bleeding. Also placement of a gauze dressing under a transparent dressing is considered a gauze dressing and should be changed every 2 days (48 hours). A transparent dressing should be used on all long-term tunneled catheters and implanted ports and should be changed once a week (every 7 days). Remember all dressings must be occlusive on all lines - central and peripheral, so if the dressing becomes unocclusive - loose, damp or soiled; it should be changed immediately. Therefore some central line dressings as well as peripheral line dressings are changed more frequently then recommended because they are no longer occlusive and do not provide the protective barrier needed to prevent infection.

Insertion site preparation:

a. Aseptic technique *Chlorhexidine solution is preferred - apply using a back & forth motion with friction for at least 30 seconds. Clean an area 2-3 inches in diameter and allow drying completely. Other antimicrobial solutions such as alcohol and povidone-iodine are applied in a circular motion - start with intended site and work outward using friction and remaining on skin for at least 2 minutes or longer to completely dry for adequate antisepsis. BE sure to check for allergies, especially to iodine. What are some of the questions you would ask for iodine allergy? Allergic to shellfish, IV dye, etc. What kind of reaction? b. Approved skin prep per employing institutions policies Chlorhexidine solution (CloraPrep) is recommended to clean peripheral IV sites by Infusion Nurses Society (INS) and Center of Disease Control (CDC). Reapply the tourniquet if it has been removed for site preparation - remember you cannot touch the site after application of skin antiseptic, if vein palpation is needed you must apply sterile gloves

Site selection for SPC venipuncture

a. Assess patient's skin condition looking for previous sites of venipuncture or complications, avoid those areas if noted b. Assess vein for size, location, and condition *Avoid areas of joint flexion this includes surface areas of hand, all surfaces of wrist and antecubital area. Choose an insertion site in the forearm (this allows the patient to continue self-care if appropriate, does not interfere with mobility devices if utilized; also this location helps to increase dwell time and decrease complications). c. Palpation of vein Sometimes the most visible veins are not always the right choice; feel the prominent veins and learn to recognize the soft, spongy and bouncy characteristic of veins (like a rubber band) - this will help in learning to feel for the deep veins that are not visible. *This should be done with gloves on!

Two options for peripheral catheter stabilization:

a. INS (2016) recommends two options for peripheral catheter stabilization: an integrated stabilization feature on the SPC hub combined with a bordered polyurethane securement dressing or the standard round SPC hub in combination with an external stabilization device. Other method for SPCs taping and dressing - apply sterile transparent dressing, catheter hub may be secured with sterile tape or sterile surgical strips, never apply tape directly over catheter-skin junction site. Sometimes all you see securing the SPC is a transparent dressing. Some institutions may apply sterile gauze over IV sites. Band-aids should not be used. The use of a semi-permeable transparent dressing is recommended, however they do not stick well to diaphoretic patients. b. Remember to refer to employing institutions policies and procedures c. Some institutions recommend the use of joint stabilization devices such as arm boards when vascular access devices are placed in the antecubital fossa or other areas of flexion, however remember to check the institution's policies because arm boards can be described as "restraints" . Remember to periodically remove joint stabilization device to assess for circulation status, range of motion and skin integrity. The use of arm boards is very common and acceptable in the pediatric setting.

Rotation of peripheral infusion therapy

a. Sites should be rotated when clinically indicated. The CDC suggest rotating peripheral vascular access sites every 72-96 hours to reduce infection and phlebitis in adult patients and replacing peripheral catheters in children only when clinically necessary. INS states short term peripheral catheters should be rotated when clinically indicated and should not be routinely rotated in adult or pediatric patients - only change peripheral vascular access site when clinically indicated according to INS. Clinical indicators include frequent assessment of the patient's condition and access site, skin and vein integrity, the type and length of infusion therapy, the location of care the patient is receiving, as well as the integrity and patency of the catheter. There is evidence that supports dwell time of catheters of 96 hours was not significantly different from dwell time of 72 hours and extended dwell time did not lead to significantly higher rates of phlebitis. The evidence however evolves around the utilization of infusion teams and reports when infusion specialists insert and evaluate catheters, catheter dwell time may be extended and complications are decreased. INS continues to recommend that short term peripheral catheters that are placed in emergencies situations where asepsis was possibly compromised should be replaced as soon as possible or at least in 48 hours. Many institutions have policies in place that any peripheral catheter placed outside of the institution should be removed and replaced in 24 hours. Remember to check your institutions policies and also remember there are always exceptions INS and CDC recommend removing any vascular access device that is no longer

Techniques for vein dilation

a. Tourniquet placed 4 to 6 inches above selected site *Remember do not cut off arterial flow (need to restrict venous return only) Tourniquets should be single-use and latex-free. (In some cases the use of hand-pressure to create vein distention is appropriate especially if your patient is thin, frail and elderly, poorly nourished - this allows for better pressure control and it's safer on the patient's skin/circulation) b. Fist clenching - instruct patient to open and close fist several times c. Lowering extremity below level of heart for several minutes d. Lightly stroke vein downward - do not tap vein e. Heat application - when using heat the maximum amount of time to leave it in place is 10-15 minutes this promotes vein relaxation and dilation. Remember do not leave patient unattended during heat application.

Blood sampling from peripheral access

a. When completing a blood sampling the same principles applies, however the recommended site for phlebotomy is the antecubital area. The needle is usually a small gauge (23 or 25) winged needle or a straight needle may be used. The blood is drawn into a syringe and then transferred into the collection tubes or the blood is drawn into the collection tubes using a vacutainer device. Apply the tourniquet above the insertion site. Locate and palpate the vein. Remember to wash your hands before and after the phlebotomy draw. Always wear gloves! The angle of the needle again depends on the depth of the vein. Always have the needle with the bevel side up and quickly penetrate the vein. Flashback of blood should be immediate, collect the specimen into the appropriate collection container or syringe then release the tourniquet and quickly withdraw the needle applying pressure to the venipuncture site. Apply a sterile dressing. HINT: Blood sampling may be done at the same time of the peripheral vascular access venipuncture especially with pediatric patients. Just have a syringe and collection device available at the time and withdraw the appropriate amount of blood needed, release the tourniquet and then connect the INT extension tubing.

Central line dressings

c. Some institutions are placing a Biopatch™ around the insertion site of the central line. Biopatch™ is a small circular pad that has been impregnated with chlorhexidine to help provide extra protection from infections. Both INS and CDC recommend the use of a chlorhexidine-impregnated sponge for temporary short term catheters on all patients over the age of 2 months. This provides an additional catheter-related bloodstream infection prevention measure. d. Dressing changes should be documented along with site condition and patient's response according to employing agency's policies and procedures. e. When a line is not being used, it must stay clamped. Stays clamped when you hook the saline on, unclamp to aspirate for blood return, flush, reclamp using positive pressure when you take syringe off. Only unclamped when being accessed for something. If it is accessed and there is infusion going through and it becomes disconnected, first thing to do is clamp the catheter to prevent blood from coming out.

If no peripheral venous access sites are noted through visualization and palpation:

consider using visible light devices (most units have these devices available for nurses). Also ultrasound technology is being utilized more often for difficult venipunctures and patients with multiple unsuccessful attempts. In fact, INS (2016) recommends the use of ultrasonography (US) for short peripheral catheter placement in both adult and pediatric population with difficult venous access and/or after failed attempts. Clinicians using ultrasound should be taught proper technique, no one should attempt use of ultrasound for placing any vascular access device without recommended training.

Implantable ports:

ports placed surgically under general anesthesia for central placement and local anesthesia for peripheral placement - If central, catheter is placed into subclavian and tip threaded into superior vena cava, remaining catheter is tunneled underneath skin in chest wall and port is placed under skin in chest wall, usually above nipple area - If peripheral, catheter is placed into either cephalic or basilic vein and threaded into the subclavian with tip placement in the superior vena cava, remaining catheter is tunneled underneath the skin in either the forearm or upper arm and port placed under the skin in either of those areas - Ports are attached to catheters and sutured into place - Skin in then sutured over port - Once the incision site has healed the skin becomes the natural barrier against infection - These ports are accessed using aseptic technique with Huber needles (non-coring needles) - single or dual ports. Central implantable ports are flushed once a month (if not in use) with 10mL NS followed by 3-5 mL of 10 or 100 units of heparin. Peripheral implantable ports (P.A.S. ports) are flushed once a month (if not in use) with 5 to 10 mL NS followed by 3-5 mL of 10 or 100 units of heparin. These ports stay in place for years without complications

If you remove the stylet and notice no blood flow out of the catheter

remove the catheter and apply pressure to the site. Or if when you flush the catheter and notice swelling at the insertion site, or patient complains of pain of discomfort then remove the catheter. If either of those happen, your venipuncture has been unsuccessful and you must try another insertion attempt at a more proximal site if using the same extremity or preferably switch to the other extremity

Subclavian lines:

single lumen catheter - Temporary catheter placed in at bedside into either subclavian or jugular and tip threaded into the superior vena cava - Flush with 5 to 10 mL NS followed by 5 mL of 10 units heparin every 8 to 12 hours (if not is use) depending on employing agency's policy

Nurse's role in central line placement

supplies, support to the patient, consent may be obtained from the nurse (however the provider should explain the procedure), assist with sedation and positioning the patient. After the placement the nurse is responsible for line maintenance and care this includes ensuring the chest x-ray has been performed if needed and placement confirmed.