Central Venous Access Devices

When preparing to change the CVAD dressing, you select which of the following cleansing solutions? Please select from the options below. A.0.9% sodium chloride B.Chlorhexidine C.Hydrogen peroxide

.Chlorhexidine B - CORRECTYes. This is the correct choice. Since 2002, the Centers for Disease Control and Prevention has recommended the use of chlorhexidine for cleansing both IV and CVAD sites. Chlorhexidine is effective in reducing the incidence of bloodstream infections.

To administer the first unit of blood over the ordered time frame, how many mL per hour should you set the infusion pump to deliver? Please select from the options below. A.120 B.125 C.130

A.120 A - CORRECTYes. This is the correct choice. Remember that infusion pumps are set to deliver hourly rates. You have a unit of blood that contains 360 mL. You must infuse it over 3 hours (according to the physician's order) 360 mL ÷ 3 hrs = 120 mL per hr

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 nontunneled 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 nontunneled 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 nontunneled in either the chest or the neck. Also, a tunneled catheter is usually placed in a surgical or radiology suite while a nontunneled 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 nontunneled catheter usually has a dwell time of less than a month.

The nurses from the PICC team arrive to explain the insertion procedure, and the patient seems at ease with the need for the line. She gives consent and the team tells her that they will return in a few minutes to perform the insertion. The patient has just one more question for you. The nurse teaching the patient about a newly placed central line should include which of the following? Please select from the options below. A."Cover the non-accessed implanted port with a transparent dressing each time you bathe or shower." B."Advise health care workers that the blood pressure cuff should be placed at least 1 inch above the PICC insertion site." C."Clamp the central line catheter below the level of the break if it is visible and catheter rupture is suspected." D."Refrain from using scissors around the central venous catheter tubing when removing a dressing."

D."Refrain from using scissors around the central venous catheter tubing when removing a dressing." D - CORRECTYes. This is the correct choice. Scissors or sharp objects should not be used to remove the dressing as this could inadvertently cause damage to the catheter line.

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 should I do when I'm unable to obtain blood return from the 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 a noncoring 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 noncoring (Huber) needle so that you can access the septum repeatedly without damage.

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 cathter with 0.9% (normal) saline solution without any evidence of infiltration.

You are aware that the catheter tip position for a properly placed CVAD is in the Please select from the options below. A.pulmonary artery. B.subclavian vein. C.left atrium. D.superior vena cava.

D.superior vena cava. D - CORRECTYes. This is the correct choice. The superior vena cava (SVC) is the vessel that enters the right atrium. Placement of the CVAD with the tip in the SVC is considered ideal as the SVC is a large vessel and blood flow in this area is turbulent.

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 unless the line is placed under fluoroscopy. Newer imaging systems may be able to validate tip placement. 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 usual recommendation for peripheral IV catheters, on the other hand, is to replace them every 72 to 96 hours. The Infusion Nurses Society advises changing short (3/4 to 1¼ inches long) peripheral catheters every 72 hours and immediately when contamination or complications occur. PICCs (18 to 29 inches long) are commonly used for parenteral nutrition, chemotherapy, and any other intravenous therapies that must continue longer than 4 weeks.

You explain that a PICC-certified nurse will give her further instructions about the insertion process. The patient has a question for you. When explaining the advantages of a PICC, which of the following teaching points should you include? Please select all that apply. A.A PICC can be used for the blood sampling you will require while on TPN. B.A PICC does not have to be replaced every few days. C.A PICC can be used for TPN because it is in a larger vein. D.A PICC does not require routine flushing with a saline solution. E.A PICC cannot become occluded.

A.A PICC can be used for the blood sampling you will require while on TPN.A - CORRECTYes. This is a correct choice. In addition to being used to deliver fluids, medications, and TPN, a PICC may be used to obtain blood samples using the appropriate technique to access and flush the line. A patient on TPN requires regular blood sampling, as does a pregnant patient. B.A PICC does not have to be replaced every few days.B - CORRECTYes. This is a correct choice. According to established guidelines, peripheral IV catheters must be changed every 72 to 96 hours while a PICC may remain in place for a year or more, as long as there are no complications with the insertion site or the catheter. C.A PICC can be used for TPN because it is in a larger vein.C - CORRECTYes. This is a correct choice. TPN cannot be delivered into a peripheral IV line due to its high glucose content. Solutions of 10% dextrose or less may be delivered via a peripheral IV line; more than 10% dextrose requires delivery via a CVAD into a larger vein with more turbulent blood flow.

Which immediate complications do you monitor the patient for during the insertion of the CVAD? Please select all that apply. A.Pneumothorax B.Bloodstream infection C.Dysrhythmias D.Lumen occlusion E.Hematoma

A.PneumothoraxA - CORRECTYes. This is a correct choice. A pneumothorax is a collection of air in the pleural space (between the lung and the chest wall.) It may result from the accidental puncture of the pleural covering of the lung by the introducer during insertion of a CVAD via a subclavian approach. With a pneumothorax, chest pain, dyspnea, a drop in oxygen saturation, and diminished chest wall movement on the affected side are likely manifestations. C.DysrhythmiasC - CORRECTYes. This is a correct choice. A dysrhythmia is an abnormal heart pattern indicated on the electrocardiogram. It may occur if the catheter accidently hits an irritable focus in the right atrium. Repositioning the line by a few centimeters often moves the catheter away from the irritable focus. E.HematomaE - CORRECTYes. This is a correct choice. A hematoma could result if the physician must make more than one attempt to access the vein; other sites could bleed leading to hematoma formation at the site. This is especially problematic if the patient has a bleeding disorder or is on anticoagulant therapy. Pressure must be applied to the site to control the bleeding, and a new site or approach may be required.

Based on the patient's diagnosis and history, you anticipate that he will need a blood transfusion. Therefore, to access the port you will use a Please select from the options below. A.a Huber needle. B.an angiocatheter. C.a winged infusion device.

A.a Huber needle. A - CORRECTYes. This is the correct choice. Implanted infusion ports have a reservoir under a self-sealing septum. To access the port for an infusion, a 90° angle noncoring Huber needle (with attached extension tubing) is inserted through the skin into the port reservoir using surgical asepsis. The nurse should choose a 20-gauge or larger Huber needle to administer blood.

You further explain to the patient that the first sign that the presence of the PICC line increases the risk for DVT because of Please select from the options below. A.edema of the forearm. B.loss of blood return from the line. C.bruising at the insertion site.

A.edema of the forearm. A - CORRECTYes. This is the correct choice. DVT formation causes impaired blood return as the vessel with DVT is at least partially occluded. This results in swelling of the arm below the DVT site. The PICC is typically inserted above the antecubital fossa, so if edema does develop as a sign of DVT, it is likely to affect the forearm. The patient should report this sign to the home care nurse for further evaluation.

A triple-lumen CVAD is placed without difficulty in the patient's right subclavian vein. There is a brisk blood return from each lumen and a sterile dressing is applied to the site. The nurse has another question for you. You explain to the nurse that, before using the line, it is essential to Please select from the options below. A.obtain a chest x-ray. B.flush the line with heparin. C.obtain a central venous pressure (CVP) reading.

A.obtain a chest x-ray. A - CORRECTYes. This is the correct choice. Before a newly inserted CVAD can be used for fluid infusions or medication administration, a chest x-ray must be obtained to confirm the tip location and thus verify proper placement. During insertion, it is possible for lines to malposition, for example, by entering the jugular vein, or by being either too short or too long. The chest x-ray is also important for making sure that there is no pneumothorax, since the subclavian approach was used to insert the line.

After instructing the patient about site care for the implanted infusion port, you know that the teaching has been effective when the patient states, Please select from the options below. A."I will keep the site dry when showering." B."I will flush the infusion port once a month." C."I will call my home care nurse if the dressing becomes soiled or loose."

B."I will flush the infusion port once a month." B - CORRECTYes. This is the correct choice. This is a correct statement for a patient being discharged with a deaccessed infusion port. To maintain the patency of his port, the patient must access it and flush it once a month.

Identify the correct sequence of steps you must take to prior to obtaining the blood specimen. Please select from the options below. A.1. Attach a 10-mL syringe and aspirate for a blood return.2. Perform hand hygiene and don gloves.3. Swab the hub of the extension tubing with 70% alcohol.4. Flush with 10 mL of sterile 0.9% sodium chloride and withdraw a discard sample. B.1. Perform hand hygiene and don gloves.2. Attach a 10-mL syringe and aspirate for a blood return.3. Swab the hub of the extension tubing with 70% alcohol.4. Flush with 10 mL of sterile 0.9% sodium chloride and withdraw a discard sample. C.1. Perform hand hygiene and don gloves.2. Swab the hub of the extension tubing with 70% alcohol.3. Attach a 10-mL syringe and aspirate for a blood return.4. Flush with 10 mL of sterile 0.9% sodium chloride and withdraw a discard sample.

C.1. Perform hand hygiene and don gloves.2. Swab the hub of the extension tubing with 70% alcohol.3. Attach a 10-mL syringe and aspirate for a blood return.4. Flush with 10 mL of sterile 0.9% sodium chloride and withdraw a discard sample. C - CORRECTPrior to obtaining the specimen and after identifying the patient as per protocol, perform hand hygiene and don clean gloves. Swab the hub of the extension tubing vigorously with an alcohol pad. Attach a 10-mL syringe to the hub and aspirate for a blood return. After verifying the blood return, flush with 10 mL of sterile 0.9% sodium chloride prior to withdrawing a small amount of blood to discard. Now you are ready to withdraw the required amount of blood for the specimen. Afterwards, flush again with 20 mL 0.9% sodium chloride and label the specimen according to your facility's policy.

When flushing the PICC lumen with heparin, it is appropriate to use a Please select from the options below. A.3-mL syringe. B.5-mL syringe. C.10-mL syringe.

C.10-mL syringe. C - CORRECTYes. This is the correct choice. When flushing central catheters, it is important to remember that smaller syringes generate more pressure than the line can tolerate. Using a syringe smaller than a 10-mL syringe could cause the line to rupture.

It states that the plan is to insert a central venous catheter and give the patient total parenteral nutrition for several weeks. Based on your knowledge of central venous access devices (CVADs), which type would be the appropriate choice for this patient? Please select from the options below. A.A nontunneled percutaneous central catheter B.An implanted infusion port C.A peripherally inserted central catheter (PICC) D.A tunneled central venous access device.

C.A peripherally inserted central catheter (PICC) C - CORRECTYes. This is the correct choice. A physician or a specially certified RN inserts the PICC in the patient's arm, typically at the bedside. It can remain in place for weeks or months, depending on the length of therapy required, and can be used to administer medications and fluids that are most appropriately administered via a central line, such as total parenteral nutrition (TPN).

You tell the nurse that, during the sterile procedure, everyone entering the room is required to wear Please select from the options below. A.a sterile gown. B.sterile gloves. C.a face mask.

C.a face mask. C - CORRECTYes. This is the correct choice. Everyone entering the area where a sterile procedure is being performed is required to don a face mask. Additional personal protective equipment is required for those actually performing the procedure.

After receiving report, you prepare for the admission and read the orders the patient's physician has faxed to the unit from his office. When the patient arrives, you obtain vital signs, including oxygen saturation, and he tells you his pain is an 8 on a scale of 0 to 10. You explain that you must obtain venous access and the patient replies, "I already have an implanted infusion port for venous access." Based on this information from the patient, you expect to find Please select from the options below. A.a catheter tunneled into the chest wall. B.extension tubing protruding from a dressing on the upper arm. C.an object palpable under the subcutaneous tissue in the chest wall.

C.an object palpable under the subcutaneous tissue in the chest wall. C - CORRECTYes. This is the correct choice. This type of central venous access device is typically used for patients who require prolonged therapy and require stable venous access for infusions, medications, and blood sampling. The infusion port is inserted under the chest wall and can easily be palpated under the skin when it is not in use.

What should I teach a patient who is going home with a central line in place?

Include the following in your teaching plan: risk for catheter-related bloodstream infection hand hygiene protecting the device during activities of daily living (keeping line dry, preventing catheter dislodgement) signs/symptoms of complications (catheter dislodgement or rupture; lumen occlusion) special instructions for those receiving home infusions (storage of solution, disposal of equipment) 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)