308 week 1 (5/24) Chapter 13: Peripheral and Central IV therapy

Which statement made by the nurse about IV peripheral catheters needs correction?

"Small gauge peripheral catheters pose an increased risk of phlebitis."

The student nurse is teaching about the activities of daily life (ADLs) for a patient with a peripherally inserted central catheter. Which teachings made by the student nurse would need a correction?

"You can walk for exercise."

Older Adult Care considerations for cathorters (3)

1) Skin care - fragile 2) Vein and catheter selection - b/c fluid distribution is different, need to asses 3) Cardiac and renal changes - look @ hx, and remember that cardiac and kidneys change

Which gauge of peripheral intravenous (IV) catheter would the nurse use for rapid fluid resuscitation in a patient with severe blood loss following a motor vehicle accident?

14-gauge

What point should the nurse keep in mind to ensure skin antisepsis prior to venipuncture in older adults?

Apply chlorhexidine for maximum antiseptic action.

A client is admitted to the cardiothoracic surgical intensive care unit after cardiac bypass surgery. The client is still sedated on a ventilator and has an arterial catheter in the right wrist. *What assessment does the nurse make to determine patency of the client's arterial line?* A) Blood pressure B) Capillary refill and pulse C) Neurologic function D) Questioning the client about the pain level at the site

B) Capillary refill and pulse

The nurse is inserting a peripherally inserted central catheter (PICC) into a patient. When identifying the insertion site, which site is the nurse most likely to use?

Basilic vein in the upper arm

Which detail is the least important factor to be considered for a patient who is prescribed peripherally inserted central catheters (PICC) for peripheral infusion therapy?

Gender of the patient

Femoral Central Venous Catheter risks

High area of kinking, also high infection rate

What are indications for placing a nontunneled percutaneous central venous catheter (CVC) in a patient? Select all that apply.

Impending surgery Trauma situations Administration of IV fluids

What is a rare complication of peripherally inserted central catheter (PICC)?

Infiltration

Which central catheter insertion requires the patient to be in the Trendelenburg position for catheter insertion?

Nontunneled percutaneous central venous catheter Insertion of a nontunneled percutaneous central venous catheter requires the Trendelenburg position. This is a position in which the patient's head is low and the body and legs are in the inclined plane which helps ensure that the catheter exit site is at or below the heart

A physician is planning to insert a nontunneled percutaneous central venous catheter into a patient in preparation for surgery. The nurse has been asked to provide patient education about the insertion procedure. During the patient teaching session, the nurse should include information about which of the following positions?

Trendelenburg position

CLABSI/CRBSI

central line associated blood stream infection central line related blood stream infection

Huber needle

needle that has an opening on the side of the shaft instead of the tip Implanted Port( Port a Cath)

Temporary Dialysis Venous Access Catheter

not commonly used for other access - unless order stating you can use it Need to keep it clean/safe for its Dialysis needs

The registered nurse (RN) is training a student nurse on the use of peripheral vascular access devices (VADs). The RN states that one patient is receiving IV antibiotics to treat a lower respiratory infection, but because he has severe lower extremity edema, they are administering the antibiotics intermittently. Which statement by the student nurse indicates an understanding of peripheral VADs?

"That means that the VAD should have a saline lock on it."

A patient is admitted to the emergency department with severe injuries to the neck and upper body from a motor vehicle accident. The physician has ordered the registered nurse to insert a catheter to infuse fluids and antibiotics. The student nurse who is trailing the registered nurse suggests inserting a nontunneled percutaneous central venous catheter (CVC). What should the registered nurse tell the student nurse?

"The CVC is not appropriate for this patient because trauma to the neck or chest prohibits the use of these devices due to injury of the insertion site."

A patient with severe traumatic brain injury enters the hospital in a coma. Because of the severity and location of the injury, the physician suspects that the patient may never recover from the coma. However, the patient's family insists on full medical treatment. Therefore, the physician orders insertion of a tunneled central venous catheter to support long-term total parenteral nutrition. A family member approaches the nurse with concerns that long-term catheter insertion will cause an infection that may speed the patient's death. How should the nurse respond?

"Tunneled central venous catheters have a low rate of infection and are the best catheters to use for long-term intravenous treatment."

A student nurse notes that a patient who has just been admitted to the hospital has a hemodialysis catheter. The physician asks the registered nurse who is supervising the student nurse to draw some blood and start an IV antibiotic. Which statement by the student nurse indicates that additional teaching is needed about the use of hemodialysis catheters?

"We can draw blood and inject the drugs through the hemodialysis catheter to avoid additional needle sticks for the patient."

Central Venous Catheters Non tunneled Most common used vessel is *"x"*

"use the veien close to our intended site" Most common used *vessel is subclavian vein* Steps: 1) The patient is placed in supine position 2) site is cleansed (chlorhexidine) 3) skin is anesthetized 4) *a large bore needle is inserted beneath the clavicle. 5) The catheter is advanced over a guidewire. 6) The catheter is sutured. 7) A sterile transparent dressing is applied.

A tunneled CVT is placed inside the *"x"* tunnel. A nontunneled percutaneous central venous catheter is placed in a *"x"* vein of the chest or an internal *"x"*vein in the neck. A peripherally inserted central catheter is inserted through a vein of *"x"* or the middle of the *"x"*.

*A tunneled CVT* is placed inside the *subcutaneous* tunnel. It is used in the *venous* systems *A nontunneled percutaneous central venous catheter* is placed in a subclavian vein of the chest or an internal jugular vein in the neck. *A peripherally inserted central catheter* is inserted through a vein of *antecubital fossa* or the middle of the *upper arm.*

What assessment does the nurse make to determine patency of the patient's arterial line? (2)

*Capillary refill and pulse* should be assessed to ensure that the arterial line is not occluding the artery

How long can you use: *Midline catheters* *PICCs* *Short peripheral catheters*

*Midline catheters* are used for therapies lasting from 1-4 weeks. *PICCs* are typically used when IV therapy is expected to last for* months.* *Short peripheral catheters* are allowed to dwell (stay in) for *72-96 hours*, but they then require removal and insertion at another venous site.

In what order should the nurse prepare the skin for insertion of a peripheral venous catheter?

1) All nursing interventions should begin with appropriate hand-washing techniques. 2) Once the nurse's hands are clean, the insertion site should be identified by palpating to locate a good vein. 3) When the insertion site has been located, hair should be clipped if needed and 4) the area should be cleaned with soap and water if dirty. 5) Once the site is clear and clean, the nurse should put on gloves before 6) cleansing the skin with antiseptic. The nurse should not touch the insertion site again once it has been cleaned with antiseptic.

CVC Management: Assess

1) Assess insertion site for s/s infection, pain 2) Assess for blood return 3) Assess and prevent complications: * During insertion: * 1) Pneumothorax 2) Arterial puncture 3) Arrythmias Post Insertion: 1) Infection-sterile dressing change 2) *Dislodgement 3) Occlusion 4) Air embolus Removal Considerations = discuss with doctor

Remember ... Interventions to reduce infection risk

1) Clean needleless system connections before use with antimicrobial for *30 seconds* 2) Do not tape connections between tubing sets 3) Use evidence-based hand hygiene guidelines from CDC and OSHA

What are the causes of phlebitis after the venous puncture? (3)

1) Improper antiseptic technique 2) Improper catheter securement devices 3) Osmolarity and pH of the medication use 1) Improper antiseptic technique may lead to phlebitis because of bacterial growth at the site of catheter placement. 2) Improper catheter securement devices may lead to phlebitis since it leads to improper insertion techniques. 3) The medications whose pH range is below 5 and above 9 and osmolarity of above 500 mOsm/L, when infused through peripheral veins, lead to phlebitis.

Which parameters of intravenous (IV) therapy should the nurse document? (3)

1) Vein that was used for insertion 2) Date and time of the vascular access device insertion 3) Name of the nurse who inserted the vascular access device - The vein that was used is documented so that the nurse can assess the correct spot for IV patency, as well as to keep a history of site use. - Date and time of device insertion are important to document so that the device can be changed as is appropriate, based on institution policy. - The name of the nurse who inserted the vascular access device should also be documented.

Assessment of Patients -Intravenous Therapy 6 steps

1) Verify MD orders- Solution and rate D5NS infuse at 100ml/hr 2) Verify right patient 3) Calculate infusion rate: gtts/min or *pump* needs to be programed correctly [double check the pre-programed settings] 4) Intake/Output 5) Site assessment- infiltration, phlebitis, infection (fever) 6) Monitor for complications of therapy-fluid overload (edema, *pulmonary crackles* - can double concentrate dose to reduce volume) , electrolyte therapy (access what is in nutrition)

A patient with a history of cancer is prescribed an intravenous (IV) infusion of chemotherapeutic agents through a peripherally inserted central catheter (PICC). The primary health care provider instructs the nurse to flush the catheter before and after medication administration. What solution should be used for flushing?

10 mL of sterile saline

A patient was admitted to the hospital after a motor vehicle accident. The primary health care provider instructed the nurse to provide *rapid* infusion of fluids peripherally. What could be the possible size of the catheter used for infusion?

16 gauge A 14- to 16-gauge needle is used for trauma and surgical patients requiring *rapid* fluid resuscitation.

Which gauge (g) size of peripheral catheter is preferred for a patient undergoing a routine *surgical* procedure? Why?

18-g An 18-gauge needle is the preferred size for *surgery*, but a large vein is necessary to accommodate the catheter. *why?:* This gauge of catheter allows for faster flow rates of fluids and blood administration if necessary.

A 22-year-old patient is seen in the emergency department (ED) with acute right lower quadrant abdominal pain, nausea, and rebound tenderness. It appears that surgery is imminent. What gauge catheter does the ED nurse choose when starting this patient's intravenous (IV) solution?

18g

The nurse is preparing a child for a tonsillectomy. Which peripheral catheter does the nurse anticipate the anesthesiologist will use?

20-gauge A 20-gauge needle which is 1-1¼ inch length, with an approximate flow rate of 65 mL/min, is adequate for most solutions for a child or an adult with small veins. Anesthesiologists do not prefer to use needles smaller than a 20-gauge size.

A patient with anemia is admitted to the hospital. The primary health care provider instructs the nurse to arrange for a blood transfusion using peripheral catheters. What is the most appropriate catheter size and approximate rate of flow?

22 gauge with 2280 mL/hr

What is the maximum flow rate of contrast injection for a "Power peripherally inserted central catheter" ("Power PICC")? Record your answer using a whole number. ___ mL/sec

5 A "Power PICC" can be used for contrast injection at a maximum flow rate of 5 mL/sec and a maximum pressure of 300 psi. They can also be used in the monitoring of central venous pressure.

A patient with renal failure has to use a hemodialysis catheter. What concentration of heparin is used to lock the catheter?

5000 units/mL

A 24-gauge needle is used for *"x"* and *"x"* children; it is not ideal for *"x"* solutions.

A 24-gauge needle is used for infants and small children; it is not ideal for viscous solutions.

A physician has ordered that a patient be infused with a hypertonic solution to correct fluid and electrolyte imbalances. The solution will be infused through a peripheral IV line. Which solution does the nurse administer to this patient?

A solution that has an osmolarity of 400 mOsm/L

The nurse is starting a peripheral IV catheter on a recently admitted patient. What actions does the nurse perform before insertion of the line? Select all that apply.

Apply povidone-iodine to clean skin, dry for 2 minutes. Clean the skin around the site. Prepare the skin with 70% alcohol or chlorhexidine.

Catheter Complications**** Bleeding/drainage from the site Difficulty advancing the catheter Catheter malposition Catheter migration Nerve damage

Catheter Complications Bleeding/drainage from the site - look @ colagualtion site *Difficulty advancing the catheter* - Look @ valve - need a new site Catheter malposition Catheter migration - further than intended Nerve damage - can happen anywhere *wrist is high risk

Catheter Complications Catheter sepsis Phlebitis/Cellulitis Cardiac associated problems Catheter or air emboli

Catheter sepsis - infected Phlebitis/Cellulitis - *Catheter or air emboli * - you didn't push fluid first, air goes in before fluid... flush line. - pump -

CVC Distal lumen-infuse *"x"* or *"x"* Middle lumen- reserved for *"x"* Proximal lumen- infuse meds or *"x"*

Distal lumen-infuse *blood or fluids* Middle lumen- *reserved for PN* Proximal lumen- *infuse meds or fluids* Recommended for short term treatment

Dressing Changes documentation

Document complete assessment - dry, clean, inclusize Sterile technique Prep solutions Type of dressing Change of add-on device External length of the catheter t

Arrange the steps of aseptic skin preparation for peripheral intravenous (IV) therapy chronologically.

First, the nurse should wash his or her hands before aseptic skin preparation for peripheral intravenous (IV) therapy. Next, wash the skin with soap and water if the skin is dirty. Then, the nurse should wear gloves. Finally, the skin should be cleaned with antiseptics.

Which central venous access device (CVAD) is indicated in patients who require IV therapy for more than a year?

Implanted ports

Which central vascular access device (CVAD) is placed in arteries, epidural space, and the peritoneal cavity?

Implanted ports [Catheters may also be placed in arteries, epidural spaces, and the peritoneal cavities but catheters are central venous catheters (CVCs)]

A nurse has been asked to insert a short peripheral venous catheter in an older adult patient. The patient is right handed and has had a mastectomy and lymph nodes removed on her left side. Where is the best site for the nurse to insert the catheter?

In the median vein of the right arm

Which condition indicates infiltration?

Leakage of nonvesicant intravenous (IV) solution into extravascular fluids

Implanted Port( Port a Cath)

Long term use-Home therapy - Subcutaneous port placed under subcutaneous pocket, requires accessing- Huber needle Minimal care @ usually

A patient admitted to the intensive care unit (ICU) is expected to remain for 3 weeks. The nurse has orders to start an IV. Which vascular access device is best for this patient?

Midline catheter Midline catheters are used for therapies lasting from 1-4 weeks. PICCs are typically used when IV therapy is expected to last for months. Short peripheral catheters are allowed to dwell (stay in) for 72-96 hours, but they then require removal and insertion at another venous site. Tunneled central catheters must be inserted by a health care provider; the nurse typically is not qualified to start this type of IV.

Which catheter type is usually chosen for intravenous therapy in older adults? which catheter type is risky?

Midline catheters Older adults exhibit a reduced skin turgor, limited venous sites, and fragile, tortuous, or hard veins. A midline catheter or peripherally inserted central catheter (PICC) is commonly placed in the upper extremity of older adults where venous distention techniques can be used. [⚠ Using nontunneled percutaneous central catheters in older adults is quite risky and a challenging process. ]

A chemotherapy nurse is planning to give a patient their next dose of chemotherapeutic agent through their implanted BARD PowerPort. What technique will the nurse use to identify the location of the port and the site for puncture?

Palpate three bumps that indicate the location of the septum.

The nurse is documenting peripheral venous catheter insertion for a patient. What does the nurse include in the note? Select all that apply.

Patient's response to the insertion Date and time inserted Type and size of device Type of dressing applied Vein used for insertion

A nurse has been tasked with administering packed red blood cells to a trauma patient. The nurse has confirmed the patient's identification using two patient identifiers. What else must the nurse do before beginning the blood transfusion process? Select all that apply.

Perform strict evidence-based handwashing techniques for infection control. Receive positive patient identification from a second qualified health care professional.

if your peripheral line is not working, NI? IF Central line not working? NI

Peripheral = put in new one Central line = call dx and get new one

A patient with severe pneumonia has been admitted to the hospital, and the physician ordered ciprofloxacin to be administered by IV infusion. Because the patient is frail and immunocompromised due to chemotherapy treatments, the entire 10-day course of antibiotics will be administered parenterally. Which type of infusion system would be best for this patient?

Peripherally inserted central catheter

The novice nurse is inserting a short peripheral catheter into a patient's median vein. The nurse is having trouble finding the vein, and when he pulls the catheter and needle out, he accidentally sticks the needle into his fingertip. What is the nurse required to do to report this incident?

Record the incident in the sharps injury log.

A patient reports pain at the intravenous (IV) therapy site, and the nurse finds redness at the site and inflammation along the length of the vein. Which nursing interventions relieve the patient's pain? Select all that apply. Removing the catheter Providing antimicrobial therapy Using warm compresses to relieve pain Informing the primary health care provider Reinserting a new catheter in opposite extremity

Removing the catheter Using warm compresses to relieve pain Reinserting a new catheter in opposite the patient is suffering from phlebitis; it is an inflammation of the vein due to infusion therapy. -The catheter should be removed at the first sign of the phlebitis *or it may lead to septic phlebitis* - Warm compresses may be used to relieve the pain associated with phlebitis. - Reinsertion of a new catheter in the opposite extremity is recommended if the patient needs continued IV therapy.

Which nursing interventions will bring relief to a patient reporting tingling, feeling pins and needles in the extremities, and numbness during vein puncture? Select all that apply.

Removing the catheter Choosing a new site for the catheter insertion Stopping the intravenous insertion procedure immediately

A patient reports pain at the intravenous (IV) therapy site, and the nurse finds redness at the site and inflammation along the length of the vein. Which nursing interventions relieve the patient's pain? Select all that apply.

Removing the catheter Using warm compresses to relieve pain Reinserting a new catheter in opposite extremity

Infusion Nurses Society (INS) infiltration scale

The clinical criteria for INS grades *1 and 2* is an infiltration site with or without pain that is cool to the touch. Edema that occurs 1-6 in in any direction meets grade 2 infiltration criteria. a grade 4 infiltration is skin that is tight and leaking at the site of infiltration.

A patient on intravenous (IV) therapy reports shortness of breath and cough. The nurse finds that the patient has elevated blood pressure, puffiness around eyes, and distended neck veins. What does the nurse infer about the patient's condition?

The patient is showing signs of circulatory overload.

The nurse is providing discharge instructions for a patient who is being sent home with an ambulatory pump that will dispense regulated amounts of pain medication. What is a teaching point the nurse should include that may not apply to other types of IV pumps?

The patient will need to be taught how to replace or recharge the battery.

Based on the Infusion Nurses Society (INS) infiltration scale, which piece of clinical criteria is associated with a grade 4 infiltration?

The skin is tight and leaking at the infiltration site.

Which devices allow the visualization of a vein for a patient who is prescribed infusion therapy? Select all that apply.

Transilluminator Laser beam Infrared

Traumatic vein puncture is one of the causes of the *"x"*. Obstruction of blood flow at the site of infusion is the common cause of *"x"*and *"x"*.

Traumatic vein puncture is one of the causes of the thrombosis. Obstruction of blood flow at the site of infusion is the common cause of infiltration and extravasation.

The nurse is attending to a patient with a peripherally inserted central catheter (PICC). What action does the nurse take to maintain patency of the PICC?

Use 10-mL barrel syringes to flush all PICC lines.

The health care provider has placed a peripherally inserted central catheter (PICC) in a patient. Which technique is used to confirm the location of the catheter tip?

X-ray

• Inserting peripheral IV is a X techinque

clean