CVAD's Flashcards
What is a CVAD ?
it is an indwelling catheter inserted into the vein of the central vascular system (Central Venous Access Device)
Where is a CVAD inserted ?
Internal/External Jugular Vein
Subclavian Vein
Basilica/Brachial Vein
How far does a CVAD catheter go into the body ?
The tip of the catheter is usually located in the lower third of the Superior Vena Cava or into the junction of the Right Atrium
What are the 4 types of CVAD’s ?
- Non-tunnelled Percutaneous Catheter (CVC)
- Externally tunnelled Catheter (Hickman)
- Peripherally Inserted Central Catheter (PICC)
- Implanted Venous Access Device (IVAD)
What are CVAD’s used for (8) ?
- Administer IV fluids and blood products
- Administer IV meds and multiple incompatible meds at once
- Administer hypertonic solutions (TPN, Chemo, Vesicant meds, Irritants, Extreme pH meds)
- Obtain blood samples
- Provide LT IV access/therapy
- Venous access in when peripheral access is difficult
- Hemodialysis access
- Monitor central venous pressure in ill patients
Where is a Non-Tunnelled Percutaneous CVAD inserted ?
Subclavian, Jugular or Femoral Vein
Is a Non-Tunnelled CVAD LT or ST ?
Short term therapy (days to weeks)
How many lumens can a Non-tunnelled CVAD be ?
1 - 3 lumens (based on patient and therapy)
T or F: A Non-Tunnelled CVAD is surgically implanted
F, It is not
How is a Non-Tunnelled CVAD held in place ?
Sutures
Manufactured Securement Device
Why is it called a Non-Tunnelled CVAD ?
It is externally clamped and not valved
What is an example of a Non-Tunnelled CVAD ?
CVC
Where is a Externally Tunnelled CVAD inserted ?
Chest region:
Subclavian Vein
Jugular Vein
Is an Externally Tunnelled CVAD LT or ST?
Long-term therapy
- often referred to as permanent
T or F: An Externally Tunnelled CVAD is surgically implanted
True
How is an Externally Tunnelled CVAD held in place ?
Dacron cuff coated in antimicrobial solution
What is an example of an Externally Tunnelled CVAD ?
Hickman/Permacath
Where is a Peripherally Inserted Central Catheter inserted ?
anywhere from the Antecubital fossa to the upper arm (basillic/cephalic)
How far is the Peripherally Inserted Central Catheter inserted into the body ?
It is fed up to the Superior Vena Cava
Is the PICC LT or ST
Long-term therapy (days - months)
How many lumens can the PICC line have ?
1 - 3 lumens depending on patient and therapy
Most PICC lines have a specialized one-way valve in them. What is it called and why is there/what does it prevent?
- Groshong Valve
- negates need for heparinization/prevents clots forming in line
T or F: The PICC line is surgically inserted
F, it is not
How is the PICC line held in place ?
Sutures
Manufactured Securement Device
Where is the IVAD inserted ?
Chest, Abdomen, Inner aspect of arm
Subclavian/Jugular Vein are most common
Are IVAD’s used for LT or ST ?
Long-term Therapy
T or F: IVAD’s are surgically inserted
True
Where is the IVAD attached to on the body ?
attached to a reservoir in the subcutaneous pocket above the vein
How lumens can the IVAD have ?
none
How do you access the IVAD ?
with a special non-coring needle using sterile technique
What is an example of an IVAD ?
Port-a-cath
What are some CVAD assessments (5)?
Assess for redness, swelling, drainage, discomfort
Check the connections are secure
Assess dressing (dry & occlusive)
Measure external segment and compare with care plan on insertion
What do you use to flush a PICC line ?
Preservative-free NS in pre-filled syringes
When should you flush a PICC line ?
Routine care Pre/Post Med Admin Blood draw Between incompatible medication admin **as per the care plan
What volume syringe do you use to flush a PICC line?
10ml syringe or greater
How do you flush a PICC line ?
two (2) common techniques
- Push-Pause method
2. end with positive pressure
What do you do if you flush one lumen with a CVAD ?
FLUSH ALL
What are the steps in changing an Injection Cap on a PICC/CVC ?
- Assess need to change
- Adhere to care plan
- Prepare a new injection cap (prime and maintain asepsis)
- Ensure all clamps are engaged
- Instruct patient to perform Valsalva maneuver during cap change
- Flush
What are the steps in drawing blood from a PICC/CVC for blood withdrawal ? (not blood culture)
- Stop infusion (if running) 5 minutes prior
- Scrub cap for 15 seconds
- Flush 5ml of NS and withdrawal 6 ml of blood (discard)
- Scrub cap for 15 seconds
- Attach a new (empty) 10 ml syringe and draw desired amount of blood for testing
- Scrub cap for 15 seconds
- Flush post draw with 20ml of NS
What are the steps in drawing blood from a PICC/CVC for blood culture ? (not blood withdrawal)
- Stop infusion (if running) 5 minutes prior
- Aseptically prime a new cap with 10ml syringe (keep it attached
- Clamp lumen (if applicable) and take off cap
- Scrub port for 15 seconds (not the top of port, only the sides)
- Attach empty 10ml syringe to the now cap-less port
- *DO NOT ASPIRATE OR DISCARD BLOOD**
- unclamp line (if applicable)
- Aspirate amount of blood required for culture
- clamp line (if applicable)
- remove blood filled syringe
- Scrub port for 15 seconds
- Attach primed cap with 10ml syringe
- Flush line with 2 x 10ml syringes
- Flush one; Flush all (10ml NS)
What are the complications for CVAD’s (12)?
- Occlusions
- Infection/Sepsis
- Phlebitis
- Venous Thrombosis
- Catheter migration
- Catheter fracture
- Air embolus
- Skin erosion
- Hematoma
- Infiltration/Extravasation
- Pneumothorax/Hemothorax/Hydrothorax
- Incorrect placement
What are the 3 ways catheter dysfunction can cause occlusions in CVAD’s ?
Mechanical occlusion
Chemical occlusion
Thrombotic occlusion
What are the 3 types of catheter occlusions ?
Partial occlusion
Withdrawal occlusion
Complete occlusion
What are mechanical occlusions ?
internal or external problems with the catheter itself
What are chemical occlusions ?
medication or drug precipitate formed in catheter
What is a thrombotic occlusion ?
coagulation of blood in the CVAD line or around the CVAD vein creating a thrombus
What is a partial occlusion ?
resistance on flushing and aspiration with sluggish flow and blood return
What is a withdrawal occlusion ?
inability to aspirate blood without resistance
What is a complete occlusion ?
inability to infuse any fluids or aspirate blood
What are some patient related risk factors for Infection & Sepsis with CVAD’s (10) ?
- Immune suppressed
- Neutropenia
- Poor nutrition
- Renal failure
- Chronic infection
- Diabetes
- Short-bowel syndrome
- Self-care deficit
- Poor hygiene
- inability to manage own care
What are some institutional related risk factors for Infection & Sepsis with CVAD’s ?
- Lack of hand hygiene
- Lack of aseptic technique
- Catheter material
- Increased number of lumens
- Inadequate port scrubbing
- Poor maintenance & care
- Improper flushing
- Not changing wet dressings
- Blocked/occluded lumens left un treated
- Catheters in-situ when they shouldn’t be
- Sludge accumulation within lumen or needleless port
What is biofilm ?
a biologically active and bacterial sustaining coating that forms on the interior and exterior of CVAD’s
If a patient has a BSI, What treatment must be done before they get a new CVAD ?
antibiotic treatment 24 - 48 hours prior to insertion
What is the definition of Phlebitis ?
inflammation of one or all three layers of the vein wall
What are the 3 categories of Phlebitis ?
- Mechanical
- Chemical
- Bacterial
PICC lines are most likely to be affected by what kind of phlebitis & why ?
Mechanical
- insertion site (trying to move along smaller veins and movement of upper arm muscles)
What is a Venous Thrombosis ?
the result of a normal physiological response to a foreign body entering the vein which leads to the aggregation of platelets and the accumulation of fibrin
Why is a Venous Thrombus a severe complication ?
The thrombus are formed outside of the CVAD, putting pressure on the vein, restricting bloodflow
What is Virchow’s Triad ?
What are the components of Virchow’s Triad ?
- 3 factors affecting the development of a thrombus
- Vessel wall damage/injury; Altered bloodflow; Hypercoagulation
Describe each component of Virchow’s Triad and give examples (3) ?
- Vessel wall damage:
- Trauma from CVAD insertion
- Friction from CVAD movement in vein
- Irritating solutions - Alteration in bloodflow:
- Venous stasis d/t immobility
- Obstruction of veins
- Compression of veins
- Heart failure - Hypercoagulation:
- Decreased coagulation factors
- Pregnancy
- Malignancy
- Post-op states
What are the manifestations of a Venous Thrombosis ?
- Edema of hand; arm; shoulder; neck on side of cath
- Distended jugular veins
- Appearance of dilated co-lateral veins over chest; upper arm; abdomen
- Pain around catheter insertion site
- Difficult breathing
- Discolouration of the skin in upper body
- Cyanosis of the hand and arm
How do you treat a Venous Thrombosis ?
- Contact physician and inform about S&S
- A venogram/US
- Anticoagulation therapy
- Remove line
What constitutes Catheter Migration ?
The internal tip of catheter moves its position with/without external movement
What can Catheter Migration cause ?
infusion of fluids to go against the direction of bloodflow
Why are NT-CVC’s at a lesser risk of Catheter Migration ?
Catheters are stiff & large
What could cause a Catheter to Migrate ?
- Vomiting
- Sneezing
- Coughing
- Heavy Lifting
- HF
- Present tumours
- Mechanical ventilation
- Securement dressing or device is not intact (wet/loose)
What are the S&S of Catheter Migration ?
- External segments moves > 5cm
- Leaking of fluid at insertion site
- Swelling/redness/pain in chest or at insertion site
- Patients hears a swishing or flushing sound in their ear as the line is flushed
- Inability to flush or aspirate the line
- Arrhythmias
- Visible coiling of catheter in vein
What is a Catheter Fracture ?
a break or tear in the catheter
What can cause a Catheter Fracture ?
Forceful flushing
Pinch-off syndrome
accidental cutting of catheter
What is an Air Embolus ?
presence of air in the circulatory system that creates an intra-cardiac air lock at the pulmonic valve
What causes an Air Embolus ?
- Catheter Fracture
- Not applying clamps when removing needle-free caps
- Not covering the exit site with appropriate dressings
What are the S&S of an Air Embolus ?
- Hypoxia
- Rapid onset of SOB
- Coughing
- Anxiety
- Hypotension
- Cyanosis
- Palpitations or arrhythmia’s
- Weak, rapid pulses
- Chest and shoulder pain
- LOC
What is Infiltration ?
Misdirection of IV fluid or med from the vein into the interstitial tissue
What is Extravasation ?
The inadvertent infiltration of a irritant/vesicant solution or med into surrounding tissues
What is an irritant drug ?
a drug or solution with the pH value of <5 or >9
OR
an osmolarity of >500mOsmol/L
What is a vesicant drug ?
a drug or solution that has the potential to cause blisters and tissue injury
What are the manifestations of Infiltration & Extravasation ?
- Erythema
- Edema
- Spongy feeling
- Swelling around IV site and at Catheter tip
- Increased WOB
- Aspiration of fluid/blood
- Pain with infusion of meds/solutions
What are some Advantages to IV med admin ?
- Quick therapeutic effect
- When meds are too irritant for other med routes
- Better control of how much you control of the med
What are some Disadvantages to IV med admin ?
- Rapid and severe reaction to med
- Fluid overload
- IV site complication
- Allergic reaction
- Speed Shock
What are the three prodromal manifestations of Anaphylaxis with IV med admin ?
- Anxiety
- Uneasiness
- Impending doom
What are the 5 early signs associated with the integument system with Anaphylaxis in IV med admin ?
- Erythema
- Urticaria
- Pruritus
- Angioedema (eyelids, lips, tongue)
- Feeling of warmth
What are the 5 early signs associated with the respiratory system with Anaphylaxis in IV med admin ?
- “Lump in throat”
- Hoarseness
- Coughing or sneezing
- Dyspnea
- Stridor
What are the Late S&S of anaphylaxis in IV med admin ?
- *2 RESP
- *7 CARDIO
- 4 GI
RESP 1. No breathing (obstruction) 2. Laryngeal spasms/edema CARDIO 1. Hypotension 2. Fluid shift 3. Tachycardia 4. Bradycardia 5. Ischemia d/t vascular dilation 6. Cardiac arrest 7. Coma GI 1. Nausea 2. Vomiting 3. Cramps 4. Diarrhea
How can you prevent Anaphylaxis in IV med admin ?
- Avoidance
- Screening for allergies
- Drug awareness & antidote
- Appropriate documentation
- Teaching
- Diligent checking on pt
- Thorough questioning
- Frequent assessment for early detection
How do you manage Anaphylaxis in IV med admin ?
- Remove allergen/STOP infusion
- Stay with pt
- Call for help/Call a code
- Apply O2
- Vitals ASAP –> Assess ABCDE
- Keep Vein open
- Provide emotional support
What is Speed Shock ?
Medication administered too quickly
Can Speed Shock happen with both IV direct and Intermittent IV admin ?
Yes
What are your nursing assessments for someone who is experiencing Speed Shock ?
- Dizziness
- Facial Flushing
- Headaches
- Irregular Heart Rate
- Sudden onset of symptoms associated with Med admin
How do you prevent Speed Shock ?
- Infuse @ correct rate
- Use infusion devices if applicable
How do you treat Speed Shock ?
- Stop infusion immediately
- Maintain vascular access
- Contact physician
- Provide supportive care
- Monitor vitals closely
What does CATS PRRR represent and what is it used for ?
- Compatibility
- Allergies
- Tubing
- Site
- Pump
- Rate
- Release clamps
- Return and Reassess
- ** CATS PRRR is used for IV med admin and assessment
What are some indications for IV Insulin ?
- Emergency treatment for Diabetic Coma
- Diabetic Ketoacidosis (DKA)
- Hyperkalemia
- Hyperosmolar Hyperglycemic State (HHS)
- Hyperglycemia during critical illness
- Insulin dependant diabetic patients –> Surgery
- Dose finding strategy before converting patients to SC insulin
What are the S&S of HYPERglycemia ?
- Very Thirsty
- Dry Skin
- Sleepy
- Hungry
- Blurry Vision
- Slow Healing
- Frequent Urination
What are the S&S of HYPOglycemia ?
- Headachy
- Dizzy
- Grumpy
- Confused
- Hungry
- Sweaty
- Shaky
