CVADs Flashcards
what would you do if you were unable to flush/ aspirate a line
suspect occlusion
Check for kinks in tubing
change dressing/ check site for:
- Kinks/ twists under dressing
- Tight sutures
- Obstructing securement device
- Remove end cap/ repeat patency assessment
if still not able to aspirate:
- Check for correct needle position/ replace non-caring needle
- Have pt take deep breath/ cough, change position, raise/ lower arm
- Flush with 1-2mL
- If able to aspirate flush with 20mL
- If not able to aspirate label do not use and notify IV nurse or MRP
while doing the PICC dressing you notice that the catheter is longer than it was documented to be what would you do?
- Suspect catheter malposition
- Stop infusion
- Change dressing
- do not reinsert catheter
- Measure/ document new external length if greater than 2cm difference label do not use and notify IV nurse or MRP
- Consider need for PVAD PRN
- If length measured less than 2cm difference flush with 20mL
What do you do if you removed a line and found the end was not intact?
notify MRP and or IV nurse ASAP
What are the complications related to CVADs during insertion?
- arrhythmia
- Arterial puncture
- Pneumothorax
- Hemothorax
- Hydrothorax
- Injury to brachial nerve plexus
- Cardiac perforation
- Central vein perforation
- Catheter migration/ malposition
- Intolerance reaction
What are the complications related to CVADs post insertion?
- Pulmonary embolism
- Phlebitis
- Infection
- Total occlusion
- partial occlusion
- venous thrombosis
- extravasation
- infiltration
- catheter fracture
What are the complications related to CVADs in regards to the insertion and post-insertion
air embolism
what are infusion-related complications for CVADs ?
- circulatory overload
- speed shock
- allergic reactions
- particulate matter
What are LOCAL signs and symptoms of infections for CVADs?
-redness
- tenderness
- purulent drainage
- warmth
- edema at the insertion site
what are systemic signs and symptoms of infections for CVADs?
- fever
- chills
- malaise
what is used for the diagnosis of complications for CVADs?
- increased temp
- increased HR
- increased RR
- decreased BP
- altered LOC
- abnormal lab values (CBC, blood cultures, lactate)
How do you treat LOCAL infections for CVADs?
- warm moist compresses
- culture of drainage from site
- catheter removal if indicated
How do you treat SYSTEMIC infections for CVADs?
- IV fluids
- antibiotics
- sepsis protocols
- catheter removed if indicated and tip sent to lab for culture
What is the role of the nurse when caring for a patient with a CVAD? What assessments and care are performed?
- assess length
- aspirate/ patency check
- assess for pain
- assess dressing
- assess surrounding skin
What are the steps on how to change a PICC dressing?
- Check VAD care/ maintenance protocol
- Review policy for PICC dressing change
- Wash hands
- Gather supplies
- Introduce self to pt, verify with 2 identifiers
- Explain procedure
- Assess pt comfort level
- Wash hands
- Open dressing tray/ get supplies organized
- Don clean gloves
- Place sterile drape
- Instruct pt to face away from PICC arm
- Pull dressing off starting at the top and working way down and boarders leave translucent part of dressing intact
- Remove securement device
- Cleanse skin
- Secure lumen with new device
- Place securement device on skin
- Remove gloves/ clean hands
- Put on sterile gloves
- Use sterile forceps and remove remainder of dressing
- Assess catheter length/ and site
- Cleanse catheter site and surrounding skin
- Apply dressing
- Prime new needless cap/ replace old one
- Assess all lumens for patency and flush with 10mL NS
- Lock with heparin if required and close clamps
- Clean up and document
What are the steps on how to collect a blood sample from a PICC?
- Obtain verbal consent from client
- Explain procedure/ if no refusal consider this consent
- Gather supplies
- Stop infusion for 2 minutes
- Attach NS flush syringe tp proximal lumen
- Check patency
- Withdraw 5-6mL blood into empty syringe discard
- Attach vacutainer fill to required volume repeat for as many vials as required
- Remove vacutainer connector
- Flush with 20mL NS
- If unable to clear all blood form needless cap complete cap change
What are the steps on how to change a needless cap?
- Gather supplies
- Prep needless cap keeping it sterile
- Attach NS syringe/ prime with NS
- Scrub hub around old needless cap end with alcohol for 30 seconds
- Allow alcohol to dry
- Request client to turn head away from line
- Remove old needless cap
- Replace with primes new one
- Complete patency check/ flush
- Restart infusion
where is the tip of PVAD located?
periphery
where is the tip of CVAD located?
superior vena cava
Where is the location of the insertion site for a PVAD?
hand to elbow - distal veins of the arm or in foot
where is the location of the insertion site for a CVAD?
one of the following arteries:
- jugular
- cephalic
- basilic
- brachial
- subclavian
- femoral
What is the catheter dwell time for a PVAD?
change site Q 72-96hrs or prn
What is the catheter dwell time for CVADs?
PICC - 6 months to 1 year
central line
1. non-tunnelled 1 week
2. tunnelled up to 3 years
3. IVAD up to 5 years of # of punctures
what types of infusions can be done through a PVAD?
short term
what are the indications for a CVAD?
- chemotherapy
- long term
- TPN
- increased osmolality
- decreased pH
- higher irritant
- blood products
- obtain venous blood sample
- monitor central venous pressure
What is the rate of infusion that can be used for PVADs?
depends on medication/ fluid
what is the rate of infusion that can be used for CVADs?
- depends on medications/ fluids
- can take 2-3L/ minutes
Who can insert a PVAD?
- RN
- LPN (in some places)
- doctor
- anesthetist
- IV nurse
Who can insert a CVAD?
PICC - IV nurse
all other forms - surgeon while pt is under anesthetic
can you do blood sampling from a PVAD?
no
can you do blood sampling from a CVAD?
yes
can you do home IV therapy with a PVAD?
no
can you do home IV therapy with a CVAD? What are the types?
yes
- PICC
- IVAD
- hemodialysis line
what are the complication risks for PVADs?
- infection
- phelbitis
- thrombophlebitis
- fluid overload
- arterial puncture
- hemorrhage
- extravasation
what are the complications for CVADs?
same as PVAD plus:
- air/ catheter embolism
- pneumothorax
- hemothorax
- arrhythmia
- horner’s syndrome
When do dressings need to be changed for PVADs?
- prn
- flush once/ shift if not infusing
When do dressings need to changed for CVADs?
- Q7 days
- prn
- flush Q12hrs or Q24hrs at home
where is a PICC inserted?
periphery in the :
- cephalic
- basilic
- median cubital vein
Where does the tip of the PICC rest?
lower portion of the distal superior vena cava
who inserts a PICC and what do they use?
IV nurse by using an ultrasound to insert and must have a chest x-ray after to verify position prior to using
how long can treatment last for a PICC?
1 month - 1 year
what forms can a PICC come in?
- valved
- non-valved
- single, double or triple lumen
Can you take a BP on an arm with a PICC in it?
no
What are CVADs that are non-tunnelled used for?
short term and emergent therapy
how long can treatment with a non-tunnelled CVAD last for?
< 7 days due to infection but could be up to 1 month
where is a non-tunnelled CVAD placed?
jugular or subclavian vein
how is a non-tunnlled CVAD place?
surgically by physician and needs to be verified with chest x-ray prior to use
why is a non-tunnelled CVAD sutured in place?
risk of bleeding if pulled out
what are the potential lumen sizes for a non-tunnelled CVAD?
single, double or triple
How long can a tunnelled CVAD be used for?
long term intermittently or continuously for more than 1 year
How long can a tunnelled CVAD be placed for?
indefinitely if there are no complications
how is a tunnelled CVAD placed?
surgically by physician and needs to be verified with a chest x-ray prior to use
what is the purpose of a Dacron cuff for a tunnelled CVAD?
- placed under skin
- creates seal to keep catheter from slipping out
- creates barrier from infection
How many lumens does a tunnelled CVAD have?
single, double or triple
what does IVAD stand for?
implanted vascular access device
what is another name for an IVAD?
surgically implanted ports or port-a-cath
what is a benefit of an IVAD?
decreased risk of infection for long term use
how long can an IVAD be used for?
long term intermittent or continuous access usually more than 1 year
describe the port on an IVAD
has reservoir with self sealing membrane and a catheter
how is an IVAD inserted?
surgically by vascular physician into SC pocket of chest
does an IVAD require a dressing when not in use?
no
does an IVAD require a dressing when in use?
yes
- aseptic, transparent dressing over Huber needle, side and tubing
who can access an IVAD?
HCP with further education
when accessing an IVAD what are you assessing for?
- site for dislodged port
- dislodging of catheter
if an IVAD port has dislodged what might you find?
- free movement of port
- swelling
- difficulty accessing
if an IVAD catheter tip has moved what might you find?
- neck or ear pain
- palpitations
if an IVAD is not in use how often does it need to be flushed?
at least every 8 weeks
does an IVAD require a heparin flush to maintain patency?
yes
why is it preferred to take a blood sample from a PICC if someone has one instead now?
- peripheral veins are no longer accessible or clinically significant reasons
- needle phobia
- client refusal
- risk of hemorrhage
are there any concerns around collecting a blood sample from a PICC?
- increased risk of catheter related infections
- CVAD occlusion
Which lumen do you use from a PICC when collecting a blood sample?
- largest lumen is best
- in multi lumen red one is for blood
when do you change a cap on a CVAD?
when blood is present in the cap and as per policy
can a student collect a blood sample from a PICC?
yes with RN supervision
How often should you assess a PICC/ CVAD?
- every hour for a continuous infusion
- every shift for saline locked
What would you do if the CVAD/ PICC external length had a 4-9cm length difference?
- stop infusion
- notify IV nurse/ MRP
- order X-ray to verify placement
what are some risks associated to taking blood samples from a PICC?
- hemolysis
inaccurate coagulation studies if line locked with heparin - inaccurate therapeutic drug levels from medication admin
- catheter related blood infection from access
What are some benefits associated to taking blood samples from a PICC?
- decrease risk of hematoma from venipuncture
- vein preservation
- decreased pain/ anxiety from needle phobia
when should you change a PICC dressing?
dressing is:
- damp
- loosened
- visibly soiled
- moisture, drainage or blood present under dressing
When should you change a needless cap?
- Q4-7 days
- when unable to clear blood from cap
- sterility is compromised
- following blood sampling
- cap has been removed
What do you use to clean a PICC dressing site?
2% chlorhexidine with alcohol
What should a PICC dressing be labeled with?
- date
-time - initials of the nurse
when removing a PICC dressing what direction do you do so in?
towards the insertion site
What are some complications of a PICC dressing change?
- migration
- bleeding at site
- introduction of contaminants leading to infection
- accidental removal of PICC
What are the steps for removing a PICC?
- verify physicians orders
- get patient to turn head away from PICC
- grasp catheter at insertion site
- withdraw slowly in 2-3cm increments
- do not apply pressure directly over catheter
- support surrounding tissue with sterile gauze
- place sterile gauze and large transparent dressing over site
What do you do if you feel resistance while removing a PICC?
stop and apply heat for 15 minutes to upper arm and shoulder then try again
What are the steps for removing a jugular or subclavian line?
- verify physician’s orders
- practice val salsa with pt
- position pt in transdelenburg without pillows and have them turn their head away
- both pt and nurse should be wearing a mask
- don sterile gloves
- val salsa while drawing catheter and applying direct pressure over site with sterile gauze
- normal breathing while apply pressure for 5-10 minutes without occluding carotid artery
- place sterile/ large transparent dressing over site
What do you do if you have resistance while removing a jugular or subclavian line?
stop, tape in place and report to MRP
What do you do after post CVAD removal?
- assess site q15 mins for 1hr then hourly for hemorrhage
- monitor resp status q15mins for 1hr for SOB, PE
- minimize pt activity for 1hr, 2hrs for femoral
What do you do if you suspect an infection of the catheter?
cut off 1 inch of tip of catheter with sterile scissors and place in sterile C&S container, label, send to lab
how many people do you need when collecting sample for suspected infection of catheter?
2 people
how long do you hav to wait to remove CVAD dressing after line has been removed?
48hrs if no complications
