Central Venous Access Devices and Management

Case Study: Central Line Complications​ (4)

Central venous access devices (CVADs) may be indicated for several reasons, but they place the client at risk for complications. After recognizing and analyzing important assessment findings, prioritizing, and taking action, it is important to evaluate outcomes. To evaluate, the nurse must consider whether or not the interventions were effective.​ The client's condition is improved with a blood pressure 122/80 and a pulse of 78. The client's condition is declined with confusion, lethargy, respirations 30, and temperature 104.2 °F (40.11 °C).

Analyze Cues and Prioritize Hypotheses: Implanted Port​ The nurse provides discharge teaching for a client with a newly placed implanted port. Complete the sentence.

An implanted port is placed through a surgical incision which can become infected. Should pain, redness, or drainage occur at the insertion site after discharge, the client should notify the healthcare provider. A red streak is indicative of phlebitis with a PICC line. Difficulty breathing when accessing the port is not relevant since the client will not be accessing the port. Implanted ports, like all central lines, are a source of infection risk. The client should be educated on the signs and symptoms.

Case Study: Central Line Complications​ (2)

A loose dressing, an insertion site that is red and hot to the touch, and elevated temperature are all indicative of central venous access device (CVAD) infection and should be addressed immediately. No bowel movement in 3 days is not completely indicative of small bowel obstruction, and more data is needed. Signs of bleeding would include leaking around the IV site, not pain in the lower back. Additionally, CVAD infection risk is a more urgent need and takes priority (infection of CVAD). In the clinical judgment model, "analyze cues" and "prioritize hypothesis" is when you figure out what is going on and prioritize what is most important.

Case Study: Central Line Complications​ (1) A nurse on a medical surgical unit is performing an admission assessment on a client. The client is receiving intravenous fluids and long-term antibiotic therapy of vancomycin through a triple-lumen central venous catheter in the right internal jugular. The dressing is loose, and the insertion site is red and hot to the touch. The client's vital signs are T 100.4 °F (38 °C) oral, P 102, BP 105/78, RR 16, pulse oximetry reading 97% on room air. The client states they have lower back pain 5/10 using a Numerical Rating Scale. The client also reports feeling constipated and has not had a bowel movement in 3 days.

A loose dressing, an insertion site that is red and hot to the touch, an elevated temperature, and a high pulse with low blood pressure are all indicative of central line complications and should be addressed promptly. The reports of constipation, pain in the back, respiratory rate, and pulse oximetry are additional data the nurse can review, but they are not connected to central venous access device complications. In the clinical judgment model, "recognize cues" means identifying relevant and important information. This flows into "analyze cues" and "prioritize hypothesis" as you decide what is happening with the client.

Client Education: Implanted Port A nurse is educating a client with a new implanted port for the administration of chemotherapy. Which statement by the client indicates the need for further instruction?

A mediport is an implanted central venous access device (CVAD) located on the upper chest. This device contains a port underneath the skin that can be accessed and de-accessed between uses with a specialized needle (such as a Huber needle). All connections to the port must be sterile when it is being accessed.​ When the port is not in use, the client can shower without covering the port area since the intact skin is the barrier. The client should always be alert for complications common with CVADs such as infection. Pain and swelling are signs of infection and should be reported immediately.

Nursing Actions: Peripherally Inserted Central Catheter The nurse is caring for a client with a peripherally inserted central catheter. What actions should the nurse take when caring for this client? Select all that apply.

A peripherally inserted central catheter is a central venous access device placed in a large peripheral vein and then advanced until the tip rests in the distal superior vena cava or cavoatrial junction. This type of line may be placed by specially trained nurses. The dressing should be changed every 7 days, per policy, or if it is soiled or loose using sterile (not clean) technique. To reduce the risk of infection, the line should be removed when it is no longer necessary. The access port or hub should be scrubbed with the approved antiseptic prior to each use. It is not removed and replaced every 3 days like a peripheral intravenous line.

Sterile Technique​ For each action, click to specify if the nurse is using the correct sterile technique or incorrect sterile technique.

As nurses, it is essential to demonstrate proper infection control, including how to prepare and maintain a sterile field. Using sterile gloves to grab sterile equipment, dropping a sterile object onto a sterile field less than 6 inches above the field, and avoiding the outside 1-inch border are all correct sterile techniques. Reaching over the sterile field, turning your back on the sterile field, and using a sterile glove that touched the client's gown are all incorrect sterile techniques. Incorrect sterile technique is extremely risky and puts clients at risk for infection, sepsis, or even death.

Prioritize Hypotheses and Take Action: Central Line Removal​ The nurse assists with the removal of a central line. The client develops sudden shortness of breath and anxiety. Complete the sentence.

Based on the nursing assessment, the client is most likely experiencing an air embolus. The priority nursing action for this situation is to place the client in the left lateral decubitus position and provide oxygen. The nurse should anticipate the provider to order a computerized tomography (CT) scan while providing supportive care. Other manifestations of an air embolus include a decrease in blood pressure and chest pain. The nurse must immediately reposition the client and may also apply oxygen. Positioning is extremely important to stop the embolus from traveling to the brain.

Take Action: Preventing Central Line-Associated Bloodstream Infections​ The nurse cares for several clients with central venous access devices. Identify if each action performed prevents or potentiates the risk for central line-associated bloodstream infection (CLABSI).

CLABSI is a preventable situation in most clients with central lines. The best prevention occurs when sterile barriers are used for catheter insertion, a chlorohexidine solution is used for skin preparation and care, and handwashing is performed before and after care. The nurse should also advocate for the removal of the catheter as soon as possible. Dressings should be intact and prevent moisture at the site, so gauze should be avoided. Stringently following agency policies for the care of central venous catheters and early recognition of risks can significantly decrease the development of CLABSI.

Take Action: Care of a Central Line The nurse is caring for a client with a central line. Identify each action as appropriate or inappropriate by the nurse.

Caring for a central line includes flushing with a large volume syringe (typically 10 mL) using a push-pause-push motion. The port should be scrubbed with an antimicrobial solution for at least 30 seconds and allowed to dry to reduce the chance of infection. IV tubing should be secured to the skin so that it prevents pulling on the catheter. Clamping the tubing during cap changes prevents the risk of an air embolism. The dressing should be changed routinely per agency policy and when it becomes soiled. There is a high risk of infection when a client has a central line. The nurse should carefully follow all policies and procedures to provide care.

Peripherally Inserted Central-Line Catheter Complications​ The nurse is preparing to perform a peripherally inserted central-line catheter (PICC) line dressing change on a client, but notices that the catheter appears to be longer than before. What should the nurse do next?

Catheter migration is more likely to occur with peripherally inserted central-line catheter (PICC) lines, which is why they are often attached with stat locks underneath the sterile dressing. If a nurse observes possible catheter migration/movement, they must notify the healthcare provider immediately and not use the PICC line until placement is confirmed by x-ray.​ The nurse should not try to re-advance, continue with a dressing change, or ask the client to bear down.

Central Venous Access Device Complications​ During placement of a central venous catheter in the subclavian vein, the client is at highest risk for pneumothoraxinfectionmigration. A client with this complication would most likely have decreased white blood cellsshortness of breathdressing dry and intact.

One complication of central venous access devices (CVADs) in the subclavian vein, is pneumothorax. A pneumothorax can occur when the placement of the catheter is advanced too far during insertion and the guide needle punctures the pleural space. Symptoms of a pneumothorax depend on the size but include shortness of breath, restlessness, and decreased lung expansion.​ Decreased white blood cells are not related to pneumothorax. A dressing that is dry and intact is an appropriate finding. Infection and migration are both delayed complications that are not observed during placement.

Analyze Cues: Central Line Assessment Findings​ The nurse cares for a client with a newly placed capped, open-ended, single-lumen, left basilic peripherally inserted central catheter (PICC). The site has an antimicrobial disc and transparent dressing. Which findings are concerning? Select all that apply.

Common complications of a PICC catheter include phlebitis, thrombosis, infection, catheter migration, and rupture. The nurse should monitor for redness, swelling, drainage, fever, and pain, as these are signs of phlebitis and infection. An antimicrobial disc should cover the catheter insertion site to prevent infection, the dressing should remain clean, dry, and intact, and the catheter should easily flush with normal saline. For an open-ended catheter, the clamps should remain closed when not in use, and the luer lock caps should be tight. A PICC catheter, like all central lines, has a high risk of developing a central line-associated bloodstream infection (CLABSI). Diligent nursing care can significantly reduce this complication. ​

Analyze Cues: Types of Vascular Access Devices The nurse compares different types of vascular access devices. Select the correct description and care for each type of device.​

Each type of central venous catheter requires different care. The nurse should remain knowledgeable about the different types and care required to prevent complications. Non-Tunneled Percutaneous Central Venous Catheter (CVC): CVC is a short-term catheter that is placed by a provider for acute infusion therapy. They are commonly placed in the subclavian or jugular veins.​ Peripherally Inserted Central Catheter (PICC): PICC catheters are small and more fragile. They are long-term catheters that are placed by specially trained nurses. A 10 mL syringe is recommended to prevent the rupture of the fragile catheter.​ Implanted Port: Implanted ports are long-term catheters surgically placed under the skin. Once the incision has healed, a specially trained nurse can access the site using a non-coring needle. A dressing is not required at the site once it has healed.

Central Venous Access Device Indications​ For each nursing action, click to specify whether using a peripheral intravenous (IV) line or central venous access device is most appropriate.

It is important for nurses to carefully assess whether a central venous access device (CVAD) is indicated since it carries potential risks and complications. Peripheral intravenous (IV) lines are less invasive and are indicated for safe and predictable nursing actions including the administration of routine IV fluids or short-term, non-vesicant (non-irritating) IV medications.​ All other nursing actions are potentially dangerous in peripheral veins and are, therefore, most appropriate for CVADs.

Central Venous Access Device Education​ The nurse is providing discharge education for a client with a central venous access device (CVAD). What information should the nurse include? Select all that apply.

It is important for nurses to educate clients about signs of complications including infection, catheter migration, and thrombosis. Redness, pain, pus, swelling, and discharge are all signs of infection. Swelling, discomfort, pain, heat, and redness to the shoulder, chest, neck, or arm are signs of possible thrombosis. The dressing on a CVAD cannot get wet and will need to be covered during bathing. Scissors should not be used to trim loose or dirty dressings. If the dressing is loose or soiled, it should be changed. CVADs require sterile technique in every setting to avoid bacteria entering the blood.​

Generate Solutions: Use of a Central Venous Access Device The nurse is caring for a client requiring 6 to 9 months of total parenteral nutrition. Review the client's laboratory findings and complete the sentence. ​

The client's lab results indicate a risk of bleeding from a low platelet count. The placement of a CVC or implanted port should not be performed on a client at risk of bleeding. The solution being infused will not impact the decision for catheter type. CVCs are used for short-term infusion only. Understanding the catheter types and the client's needs will guide the nurse in preparing for care and educating the client.

Analyze Cues: Indications for a Central Venous Access Device The certified infusion nurse reviews the intravenous needs of clients in the medical unit. Which clients are identified as those who could benefit from the placement of a central venous access device? Select all that apply. ​

The nurse should assess a client's need for a central venous access device. Common reasons include the infusion of caustic medications (potassium, TPN, and chemotherapy), the inability to initiate or maintain a peripheral IV site, the delivery of large-volume infusions, and long-term IV medication needs. A client getting two units of blood can receive this through a peripheral IV. The client on hospice does not need a central line. For all clients receiving intravenous infusions, the nurse should identify the need for a central venous access device.

Case Study: Central Line Complications​ (3)

When caring for a client with central venous access device (CVAD), the nurse must be alert for any complications as well as how to treat them. Once infection is identified, the nurse must take action to prevent any further harm to the client. The nurse should anticipate initiation of sepsis protocol of antibiotic therapy and IV fluids. Even though the client is already on Vancomycin, it is likely that an infection is still occurring and must be treated promptly. The nurse should anticipate orders for blood cultures from both the CVAD and a peripheral blood culture for comparison, remove catheter if needed, and give antipyretics to control the fever. ​ The nurse should use surgical asepsis (sterile) not medical asepsis (clean) when performing CVAD maintenance care. The nurse should flush with of 0.9% normal saline not D5W.

Analyze Cues: Central Line Dressing Change The nurse mentors a colleague who is completing a central line dressing change. Select the best answer for each group. Only one item will be selected for each group.​

When removing the transparent dressing, the dressing should be pulled in the direction of the catheter. This prevents catheter displacement and skin irritation. Prior to cleaning the insertion site, the nurse should don sterile gloves. It is incorrect to use clean gloves or no gloves at all. It is imperative not to displace the catheter, as this could alter the position of the tip in the superior vena cava. The skill of central line dressing change requires both clean gloves and sterile gloves. Clean gloves are needed to remove the dressing, and then sterile gloves should be applied until the new transparent dressing is in place.