Central Venous Access Devices and Nursing Management

disinfect catheter

hubs, needleless connectors, and injection ports before accessing the cath use alcoholic chlorhexidine, 70% alcohol, or povidone-iodine change injection caps at regular intervals use strict sterile technique

Advantages of CVADs

immediate access to the central venous system reduced need for multiple venipunctures decreased risk for extravasation injury

major disadvantages of CVADs

increased risk for systemic infection and the invasiveness of the procedure

CVADs can provide

-a means to perform hemodynamic monitoring and obtain venous blood samples -are useful with patients who have limited peripheral vascular access or have projected need for long-term vascular access -can be used to inject radiopaque contrast media

midline catheters

-do not enter a central vein -peripheral catheters -use and care similar to PICC -specially trained nurse can insert a midline cath -3-8 inches long and have single or double lumens -inserted in the antecubital area through either the basilic or cephalic vein using ultrasound guide -the tip rests right below the axilla, staying below the shoulder joint to reduce the risk for vein irritation from moving the shoulder -can stay in place for up to 4 weeks

CVADs permit

-frequent, continuous, rapid, or intermittent administration of fluids and medications -allow for the administration of drugs that are potential vesicants (agents that can cause tissue damage), blood and blood products, and parenteral nutrition

implanted infusion port advantages

-long-term therapy and have a low risk for infection -hidden port offers the patient cosmetic advantages and overall has less maintenance than other types of CVADs -monitor accessed ports for infiltration that can occur if the needle is not in place or dislodges

implanted infusion port drugs

-placed in the reservoir either by a direct injection or through injection into an established IV line -the reservoir then slowly releases the medicine into the bloodstream

Implanted infusion port

-surgically implanted CVC connected to a reservoir or port -the tip lies in the desired vein -the port lies in a surgically created subcutaneous pocket on the upper chest or arm -titanium or plastic reservoir covered with a self-sealing silicone septum -access the port by using a special noncoring needle with a deflected tip to prevent damage to the septum

centrally inserted catheters CVCs

-the tip rest in the distal end of the superior vena cava near its junction with the right atrium -the other end of the catheter exits through a separate incision on the chest or abdominal wall

flushing technique

-use the push-pause technique when flushing all catheters -this crates turbulence within the catheter lumen, promoting the removal of debris that adheres to the catheter lumen and decreasing the chance of occlusion -this technique involves injecting saline with a rapid alternating push-pause motion instilling 1-2 mL with each push on the syringe plunger

Mr. Johnson's CVAD insertion site is draining purulent drainage; the skin is reddened and warm to touch. Which of the following actions is most appropriate for the nurse to take? a. Do not access the CVAD, complete a physical assessment, and notify the physician. b. Remove the transparent dressing, clean the site and apply gauze dressing to absorb the purulent drainage. c. Flush the catheter with 10 mL normal saline and notify the physician. d. Document in the notes section of Meditech and continue to access site.

A. Do not access the CVAD, complete a physical assessment, and notify the physician.

Valsalva maneuver

Any forced expiratory effort against a closed airway such as when an individual holds his or her breath and tightens his or her muscles in a concerted, strenuous effort to move a heavy object or change positions in bed.

What is the most appropriate action when resistance occurs when flushing a CVAD? a. Obtain an order for a stat chest x-ray. b. Assess for mechanical occlusion. c. Administer alteplase 2 mg and allow dwell time of 60 minutes. d. Flush the CVAD with bacteriostatic saline using a 3 mL syringe.

B. Assess for mechanical occlusion

The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to

have the patient change positions, raise arm, and cough

What is the most appropriate action when there is no blood return when aspirating a CVAD? a. Continue to access the CVAD b. No action is required as blood is never aspirated from a CVAD c. Ask the patient to cough, raise his/her arm, or change position d. Call the physician immediately

C. Ask the patient to cough, raise his/her arm, or change position

3) Complications of CVADs

Catheter occlusion -clamped or kinked catheter -tip against wall of vessel -thrombosis -precipitate buildup in lumen Manifestations -sluggish infusion or aspiration -inability to infuse and/or aspirate Management -have patient change position, raise arm, and cough -assess and alleviate any clamping or kinking -flush with normal saline using a 10mL syringe DO NOT force flush -instill anticoagulant or thrombolytic agent

The registered nurse accesses the patient's implanted vascular access device (IVAD) and observes leaking around the non-corning (Huber) needle. Which of the following actions is most appropriate for the nurse to take? a. Connect IV tubing and proceed with medication administration, continue to monitor site for leaking. b. Document in the notes section of Meditech and continue to access site. c. Remove the non-corning needle; re-insert the non-coring needle, attempt blood aspiration and normal saline flush. d. Notify the physician as leaking from an IVAD is a medical emergency.

C. Remove the non-corning needle; re-insert the non-coring needle, attempt blood aspiration and normal saline flush.

1) Complications of CVADs

Catheter Migration -improper suturing/ sluggish infusion or aspiration -insertion site trauma/edema of chest or neck during infusion -changes in intrathroracic pressure/patient reports gurgling sound in ear -forceful catheter flushing/dysrhythmias -spontaneous/increased external catheter length Management -prepare for fluoroscopy to verify position -assist with removal and new CVAD placement

4) Common indications for CVADs

heart failure; perform ultrafiltration

What is the reason for using a steady positive pressure flush to flush a CVAD? a. This technique helps to prevent adverse effects from certain medications. b. This technique helps to prevent pressure from building up in the line. c. This technique helps to prevent infection. d. This technique helps to prevent catheter occlusion.

D. This technique helps to prevent catheter occlusion

4) Complications of CVADs

Embolism -catheter breaking -dislodgment of thrombus -entry of air into circulation manifestations -chest pain -respiratory distress (dyspnea, hypoxia, cyanosis) -hypotension -tachycardia Management -Apply O2 -clamp catheter -place patient on left side with head down (air emboli) -notify provider

surgically placed tunneled catheters

Hickman, Broviac, Groshong suitable for long term needs

7) Common indications for CVADs

Nutritional replacement; infusion of parenteral nutrition, infusion of high percentage dextrose solutions

5) Complications of CVADs

Pneumothorax -perforation of visceral pleura during insertion Manifestations -decreased or absent breath sounds -respiratory distress (cyanosis, dyspnea, tachypnea) -chest pain -distended unilateral chest Management -apply O2 -Place in semi-Fowler's position -prepare for chest tube insertion

9) Common indications for CVADs

Shock, burns; infusion of high volumes of fluid and electrolyte replacement

5) Common indications for CVADs

hemodynamic monitoring; used to measure central venous pressure to assess fluid balance

PICCs are associated with

an increased risk for deep vein thrombosis and phlebitis -if phlebitis occurs it usually happens 7-10 days after insertion -do not use the arm with the PICC to take a BP reading or draw blood (when the BP cuff is inflated, the PICC can touch the vein wall, increasing the risk for vein damage and thrombosis)

Nursing management: CVADs

assessment, dressing changes, cleaning, injection cap changes, maintenance of catheter patency -assessment: inspect site for redness, edema, warmth, drainage, tenderness, pain observe for misplacement or slippage perform comprehensive pain assessment, particularly noting chest or neck discomfort, arm pain, pain at the insertion site -Do NOT use a newly placed CVAD until the tip position is verified with a chest x-ray -BEFORE manipulating a cath for any reason: HAND hygiene -perform dressing changes and cleanse cath insertion site using striCt steriLe technique

1) Common indications for CVADs

autoimmune disorders; perform plasmapheresis

When should the nurse use a non-coring (Huber) needle? a. To draw blood samples from tunnelled CVADs. b. To access an implanted vascular access device (IVAD). c. To flush the distal lumen of a non-tunnelled CVAD. d. Nurses cannot use a non-coring (Huber) needle.

b. To access an implanted vascular access device (IVAD)

Peripherally inserted central catheter site

basilic or cephalic vein

2) Common indications for CVADs

blood sampling; multiple blood draws for diagnostic tests over time

3) Common indications for CVADs

blood transfusions; infusion of blood or blood products

2) Complications of CVADs

catheter-related infection (local or systemic) -contamination during insertion or use -migration of organisms along catheter -immunosuppressed patient Manifestations: -local: redness, tenderness, purulent drainage, warmth, edema -systemic: fever, chills, malaise Management: Local: -culture drainage from site -apply warm, moist compresses -remove catheter if needed Systemic: -take blood cultures -give antibiotic therapy -give antipyretic therapy -remove catheter if needed

Central venous access devices (CVADs)

catheters placed in large blood vessels (e.g., subclavian vein, jugular vein) of people who require frequent or special access to the vascular system

3 main types of CVADs

centrally inserted catheters peripherally inserted central catheters (PICCs) implanted ports

to prevent reflux of blood back into the catheter

clamp the catheter while maintaining positive pressure while instilling the last 1mL of saline for negative pressure cap or neutral pressure cap

peripherally inserted central catheters (PICC)

inserted into a vein in the arm basilic vein is best bc of it's large diameter other options: cephalic, median, cubital, brachial single, double, triple lumens double lumens are preferred bc they allow for simultaneous uses PICCs are used for patients who need vascular access for 1 week to 6 months, but can be in place for longer periods

if a positive-pressure valve cap is present

it works to prevent the reflux of blood and resultant catheter lumen occlusion -remove the syringe before clamping the catheter to allow the positive pressure valve to work correctly

advantages of a PICC over a CVC

lower infection, fewer insertion-related complications, decreased cost, and ability to insert at the bedside or in an outpatient area

6) Common indications for CVADs

medication administration -cancer; chemotherapy, infusion of irritating or vesicant medications -contrast media; inject radiopaque contrast media for diagnostic testing -infection; long-term administration of antibiotics -pain; long-term administration of pain medication -drugs at risk for causing phlebitis; Epoprostenol (Flolan), Calcium chloride, potassium chloride, Amiodarone

flush with

normal saline solution in a syringe that has a barrel capacity of 10mL or more to avoid excess pressure on the catheter if you feel resistance, do not apply force (this could result in a ruptured catheter or create an embolism if a thrombus is present)

Tunneled insertion site

note tip of catheter in the superior vena cava

CVAD removal

nurses with demonstrated competency can remove PICCs and nontunneled central venous catheters involves removing any sutures and then gently withdrawing the catheter have patient perform Valsalva maneuver as the last 5-10 cm of the cath is withdrawn immediately apply pressure to the site with sterile gauze to prevent air from entering and to control bleeding inspect the catheter tip to determine that it is intact after bleeding has stopped, apply an antiseptic ointment and sterile dressing to the site

nontunneled catheters best for

patients with short-term needs in an acute care setting

8) Common indications for CVADs

renal failure; perform hemodialysis (especially on an acute basis) or continuous renal replacement therapy

CVCs available in

single, double, or triple lumens

Tunneling of the catheter

through the subcutaneous tissue and the synthetic cuff used to anchor the catheter provide stability and decrease risk for infection after the site heals, the catheter does not need a dressing

typical dressings for CVADs

transparent, semipermeable or gauze and tape -if site is bleeding a gauze dressing is preferable otherwise transparent dressings are best (allow observation of the site) Transparent dressings may be left in place for up to 1 week change any dressing at ONCE if it becomes damp, loose, or soiled cleanse skin with friction to prevent infection around the cath with chlorhexidine-based agent allow area to dry completely before applying a new dressing secure the lumen ports to the skin above the dressing site document date and time of the dressing change and initial the dressing

flushing is one of the most effective ways to maintain catheter patency

true

flushing keeps incompatible drugs or fluids from mixing

true

patient teaching CVADs

turn head to opposite side of insertion during cap change if you can not clamp the cath have the patient lie flat in bed and perform the Valsalva maneuver whenever the cath is open to air to prevent air embolism

to avoid contamination and infection

use solution from prefilled syringes or single-dose vials rather than multiple-dose vials when flushing catheters (if you are not using a positive-pressure valve cap, clamp any unused lines after flushing

multilumen catheters

useful in the critically ill patient bc each lumen can be used simultaneously to provide a different therapy ex: incompatible drugs infuse in separate lumens without mixing while a third lumen gives access for blood sampling

nontunneled catheters

usually placed in the subclavian or internal jugular vein, more rarely in the femoral vein