Chapter 17: CVAD

11. A tunneled catheter's synthetic cuff is located 1. in the superior vena cava. 2. at the nipple. 3. within the subcutaneous tunnel. 4. in a peripheral vein.

3. within the subcutaneous tunnel.

2. Which of the following is not a type of CVAD? 1. PICC 2. non-tunneled central catheter 3. Huber non-coring needle 4. implanted port

3. Huber non-coring needle

27. Absence of a free-flowing blood return from a CVAD signals 1. catheter-related sepsis. 2. catheter positioned in superior vena cava. 3. catheter malfunction. 4. catheter positioned in right atrium.

3. catheter malfunction.

22. If you suspect catheter-related sepsis, you should first 1. remove the catheter. 2. administer an antibiotic. 3. notify the physician. 4. obtain specimens for culture.

3. notify the physician.

31. Signs and symptoms of catheter malposition in the jugular vein include 1. swollen arm on side of catheter. 2. fever spike. 3. sudden earache on side of catheter. 4. sudden increase in heart rate.

3. sudden earache on side of catheter.

What are the flushing policies for non-tunneled catheters

0.9% normal 10ml; flush each port after each use and q12h when not in use

Flushing policies for PICC?

0.9% normal saline 10ml, flush each port after each use and daily when not in use

Flushing policies for tunneled catheters?

0.9% normal saline 10ml; flush each port after each use and daily when not in use

Implanted port flushing policies?

0.9% normal saline 20ml when cannulate, and not in use, and before and after each use

20. Which statement is correct about implanted ports? 1. They may last for 2,000 punctures. 2. They're inappropriate for cyclic therapies. 3. They increase infection risks. 4. They're not suitable for active adults

1. They may last for 2,000 punctures.

8. A non-tunneled catheter may break if you flush it with 1. a small-barrel, high-pressure syringe. 2. a 10-ml syringe. 3. fluid volume that's twice the catheter volume. 4. heparin.

1. a small-barrel, high-pressure syringe.

10. Tunneled catheters are best used for patients who are 1. chronically ill and requiring long-term therapy. 2. receiving emergency care. 3. restricted in their activity. 4. receiving short-term I.V. therapy.

1. chronically ill and requiring long-term therapy.

19. Which CVAD may be painful to access? 1. implanted port 2. PICC 3. Broviac catheter 4. nontunneled catheter

1. implanted port

9. Use the positive-pressure technique to prevent 1. breaking the catheter. 2. blood backflow and occlusion. 3. inaccurate lab results. 4. drug contamination.

2. blood backflow and occlusion.

15. A PICC is inserted in which vein? 1. jugular 2. cephalic 3. subclavian 4. epidural

2. cephalic

16. If you notice a change in a PICC's external length, you should 1. obtain an X-ray. 2. change the dressing. 3. anchor the catheter in place. 4. flush the catheter, using the SASH protocol.

1. obtain an X-ray.

4. Verify correct tip placement by 1. obtaining a radiology report. 2. flushing the catheter. 3. obtaining an "okay to use" physician order. 4. checking for blood backflow.

1. obtaining a radiology report.

28. Which intervention may correct catheter malfunction related to occlusion by a fibrin sheath? 1. starting thrombolytic therapy with t-PA 2. infusing a vesicant drug 3. pulling the catheter back slightly 4. changing the dressing and catheter cap

1. starting thrombolytic therapy with t-PA

23. A damaged implanted port must be 1. surgically removed. 2. palpated. 3. cleaned with alcohol and povidone-iodine. 4. tested for blood return.

1. surgically removed.

5. When assessing a PICC, measure and document 1. the external catheter length. 2. maximum dwell time. 3. catheter hub position. 4. the atrial/caval junction.

1. the external catheter length.

30. Closed-ended catheters should never be 1. flushed with saline. 2. clamped. 3. infused with fluids. 4. attached to extension tubing.

2. clamped.

25. Which of the following methods of organism isolation may be unreliable? 1. swiping the catheter tip across an agar plate 2. cutting the catheter tip into a sterile container 3. drawing blood culture specimens from two sites 4. swabbing drainage around the catheter insertion site

2. cutting the catheter tip into a sterile container

1. In the 1960s, central lines were developed to 1. infuse I.V. medication. 2. infuse I.V. nutrition. 3. infuse I.V. fluid. 4. draw blood.

2. infuse I.V. nutrition.

6. Which CVAD has the highest infection rate? 1. Hickman catheter 2. non-tunneled catheter 3. PICC 4. implanted port

2. non-tunneled catheter

21. Redness and purulent drainage around a CVAD insertion site may indicate 1. catheter malfunction. 2. septicemia. 3. catheter malposition. 4. presence of a fibrin sheath.

2. septicemia.

18. Which statement is correct about removing a PICC? 1. Put on sterile gloves before starting . 2. If you meet resistance, continue pulling firmly. 3. After PICC removal, apply an occlusive dressing. 4. Don't apply ointment to the exit site.

3. After PICC removal, apply an occlusive dressing.

24. Which of the following is correct about catheter-related infection? 1. Tunneled catheters carry the highest risk of catheter-related sepsis. 2. Draw blood culture specimens from two sites and discard the first specimen. 3. Bacteria is likely to be embedded in the fibrin sheath that coats all catheters that have been in place for 5 to 7 days. 4. Infusing antibiotics through the infected catheter is the most effective way to treat catheter-related sepsis.

3. Bacteria is likely to be embedded in the fibrin sheath that coats all catheters that have been in place for 5 to 7 days.

13. Which statement is correct about closed-ended catheters, compared with open-ended catheters? 1. Flush them more frequently with saline. 2. Flush them more frequently with heparin. 3. Flush them less frequently with saline. 4. Flush them less frequently with heparin.

3. Flush them less frequently with saline.

29. Which of the following is correct about changing a CVAD dressing? 1. Povidone-iodine is replacing chlorhexidine as the antiseptic of choice. 2. Wear sterile gloves to remove the old dressing. 3. After cleaning the insertion site, apply antimicrobial ointment to prevent infection. 4. If you're cleaning the skin with alcohol and povidone-iodine, use the alcohol first.

4. If you're cleaning the skin with alcohol and povidone-iodine, use the alcohol first.

17. Obtain blood specimens from a PICC using 1. vacuum blood collection. 2. a Huber needle. 3. a non-coring needle. 4. a 10-ml syringe.

4. a 10-ml syringe.

26. The external portion of your patient's PICC isn't visible and his heart rate is 120 beats/minute. You suspect 1. catheter tip resting in atrial/caval junction. 2. presence of a fibrin sheath. 3. catheter occlusion. 4. catheter tip resting in right atrium.

4. catheter tip resting in right atrium.

7. The SASH method includes all of the following except 1. heparin. 2. saline. 3. drug administration. 4. chlorhexidine.

4. chlorhexidine.

12. When assessing a tunneled catheter, what should you inspect and palpate for signs of infection? 1. synthetic cuff 2. scar tissue 3. internal valve 4. exit site

4. exit site

14. Which portion of a tunneled catheter can be repaired? 1. end caps 2. synthetic cuff 3. portion inside the subcutaneous tunnel 4. external portion

4. external portion

3. Where should a CVAD's tip rest? 1. Right atrium 2. SA node 3. Tricuspid valve 4. superior vena cava

4. superior vena cava

What is the difference between a peripheral IV line and a PICC?

A peripherally inserted central catheter (PICC) is much longer than a peripheral line. A PICC is inserted in the upper arm but its tip goes past the shoulder and ends in the superior vena cava. For this reason, a chest x-ray is done to confirm proper placement. Also, a PICC has less risk of infiltration and phlebitis. It can stay in place for a year or more, as long as there are no complications with the insertion site or the catheter. The Infusion Nurses Society advises changing short [3/4 inch to 1¼ inch long] peripheral catheters every 72 hours and immediately when contamination or complications occur. PICCs are commonly used for parental nutrition, chemotherapy, and any other intravenous therapies that must continue longer than 4 weeks.

Why must I allow the alcohol or chlorhexidine to dry after prepping and before using the access cap?

Alcohol and chlorhexidine must dry completely to allow time to break down the lipoprotein wall of the pathogens and kill them. Do not blow on the site to hasten drying; this contaminates the site.

What are the advantages of an implanted port?

An implanted port is an option for patients who require long-term, intermittent vascular access. It is cosmetically appealing as there is no external portion visible when it is not in use. Because it is completely under the skin, there is no need to cover the device while bathing or showering. In fact, patients can swim without any concerns about keeping the device dry. Another advantage is that the implanted port requires less frequent flushing, typically once a month when not in use.

What is the difference between a tunneled and a non-tunneled catheter?

As the terminology indicates, it's the tunneling. A tunneled catheter is inserted into a central vein and the remainder is tunneled subcutaneously to a distant exit site. Tunneling helps secure the catheter in place and reduces the incidence of infection. A non-tunneled catheter is inserted directly into a central vein and is associated with a higher risk of infection. The location varies as well: A tunneled catheter is inserted in the chest; a non-tunneled in either the chest or the neck. Also, a tunneled catheter is usually placed in a surgical or radiology suite while a non-tunneled catheter can be inserted quickly at the bedside (making it a good choice in an emergency situation). Dwell times vary as well: A tunneled catheter may remain in place for several months to years while a non-tunneled catheter usually has a dwell time of less than a month.

What does CVAD stand for

Central Venous Access Device

Why is saline flushing of a central line so crucial?

Flushing helps confirm the catheter's patency, avoid drug incompatibilities, ensure that the entire drug dose is delivered, and prevent thrombus formation.

What do you do if the tubing isn't patent?

Get HCP prescription to be treated with t-PA (declotting agent) as soon as any of these are identified

What is the difference between Groshong, Hickman, and Broviac catheter?

Groshong catheters need no clamping, Hickman and Broviac are open ended and need clamping. Hickman catheters are stiff. Broviac are small and used in children

What should I teach a patient who is going home with a central line in place? Include the following in your teaching plan:

Hand hygiene How to flush the line How to secure the device Dressing and cap changes Necessary supplies Inspection of the insertion site and surrounding skin for Infection (redness, swelling, drainage, pain, leakage), a Break or hole in the line, and difficulty flushing Emergency actions (applying pressure to site if the catheter is pulled out and clamping the catheter if punctured and then seeking emergency assistance)

What should I do when a blood clot blocks a central venous access device?

If you cannot aspirate a brisk blood return or flush the line, try some troubleshooting strategies before assuming that there is a blood clot. Have the patient cough, stand up, raise his arms over his head, take a deep breath, change positions in bed, or lie in Trendelenburg position. If these strategies fail and the provider determines that there is a thrombotic inclusion, he might prescribe a thrombolytic agent to dissolve the clot without the need for surgery. The medication dwells in the catheter in direct contact with the clot to break it down.

Can a patient shower with a central venous access device in place?

Immediately after a central venous catheter is inserted, the patient should keep any incisions on the chest dry to allow the area to heal (about 7 days). Showering is permitted as long as the site, the catheter, and the connecting devices are covered with an impermeable dressing. An access or injection cap must always be in place at the end of the line, and the dressing should be changed immediately after the shower. The patient should not submerge the exit site in water. That means no immersion in hot tubs, swimming pools, or lakes while the line is in place. With an implanted port, however, the patient is allowed to shower, swim, and soak in a hot tub (if not otherwise contraindicated) when the port is not in use.

Why is positive pressure flushing important?

Positive pressure flushing prevents the aspiration of blood or solution into the lumen, which could occlude the catheter. Positive pressure flushing can be accomplished by withdrawing the syringe from the injection cap as you flush the last 0.5 mL of flush solution into the catheter maintaining pressure on the syringe plunger as you near the end of the flush, clamping the tubing between the catheter hub and the patient, then disconnecting the syringe using a positive displacement device to do the work for you

What is sluggish flow, partial occlusion and complete occlusion in regards to checking patency?

Sluggish flow: early sign of catheter occlusion partial occlusion: fluid will infuse but not aspirate complete occlusion: unable to infuse or aspirate

Where is the tip placement for a CVAD?

Superior vena Cava; if it goes in the right atrium, it can cause arrhythmias

What is a non-coring needle?

Think about the meaning of the word coring. When you core an apple, you remove the innermost portion of the apple (the core). Or, think of coring as a cookie-cutter action: The cookie cutter cores or cuts a shape from the rolled cookie dough. If you use a coring (standard) needle when you access an implanted port, you'd remove a "core" of silicone from the septum, resulting in leaking and an increased risk of infection. So instead, you use a non-coring (Huber) needle so that you can access the septum repeatedly without damage.

What is PICC line, use, description and care?

Use: >1 week-6 months or more. Describe: inserted into peripheral antecubital space (large arm vein). Special IV nurse must insert. Can have Groshong tip. Care: Needs an occlusive dressing, can be removed by an RN, BP cuff, tourniquet and blood draws cannot be done on that arm. BP can be taken distal to catheter location.

What is the time use, description and care on implanted ports?

Use: >6 month-less frequent access Describe: it's a sub-q pocket with a tunneled catheter. Placed and removed in interventional radiology. Power ports are used for power injections (catheters will blow). Huber needles are used: j-shaped, leave a small slit, and slit closes after removal

What is the time use, description, and care of a non-tunneled catheter?

Use: less than 60 days (inpatient) describe: goes into large vein (subclavian or jugular) and to SVC. Inserted by physician. Strict asepsis because they are easily infected. Open ended and needs a clamp. 1-4 lumens. RN can remove. Blood should go into the largest lumen. All lumens can infuse at the same time

What is the use, description and care of a dialysis catheter?

Use: long term Describe: inserted in x-ray by radiologist, very large diameter Care: dressing changes usually done by dialysis nurse; nursing cannot use either lumen without an order

What is the time use, description, and care of a tunneled lumen?

Use: long term (6 weeks-12 months+) Describe: surgically implanted. Tunneled through skin to SVC and exits abd (decreases risk of infection); usually has Dacron cuff so tube adheres to the skin. Surgeon removes or in OR.

How can I be sure I have accessed an implanted port correctly?

You'll find it easy to aspirate a brisk blood return and flush the extension tube, needle, and catheter with normal saline solution without any evidence of infiltration.

What are the Advantages of using a CVAD?

easy access, permits outpatient care, no need for multiple skin punctures (except implanted ports-week/monthly)

Main uses of CVAD

poor peripheral access when repeated IV access is needed, long term admin IV therapy (meds,blood, chemo, PN), blood sampling, hemodynamic monitoring, dialysis