DONEskills exam 2- central lines Flashcards
What is a Central Venous Assess Device (CVAD)?
tube
ends up where
Tube passed through a vein to end up in the vena cava or in the right atrium.
Why would a patient need CVAD
long
needs
monitoring of
T
self
__peripheral veins
limited
Long-term IV therapy
Need frequent access (blood samples)
CVP monitoring
TPN
Self-Administration of IV therapy
Sclerosed peripheral veins
Limited peripheral access
Hickman, Broviac:
open
what’s used
Central Lines (single of multiple lumens
CVAD: Types
Open ended devices with a catheter tip that is open like a “straw”.
Heparin used
Groshong
what type of catheter
pressure /prevents
use of
Central Lines (single of multiple lumens
CVAD: Types
: Valve ended catheter
; pressure activated valve that prevents blood reflux.
(use ns)
what inserted catheter
where inserted
what’s used
PICC (single or multiple lumens):
CVAD: Types
Peripherally inserted catheter;
basilic or cephalic vein
Heparin used
Implanted port (also called Powerport or Mediport
where put
what maintains patency
CVAD: Types
Surgically implanted under skin in subcutaneous pocket on chest
Heparin/0.9% NS utilized to maintain patency
What should I know?
is it
how many
is the
is the
where does
is it
where does
when was
Is it implanted or external?
How many ports/lumens does it have?
Is the tip open or valved?
Is the external tunneled or non-tunneled?
Where does the tip end?
Is it designed for dialysis or not?
Where does the tip come out?
When was the catheter placed?
Last dressing/cap change? Last flush?
where does central line enter venous system
x4
Subclavian Vein
Internal Jugular Vein
External Jugular Vein
Femoral Vein
where does picc enter venous system
Basilic Vein
Cephalic Vein
when will it end if using femoral vein
inferior vena cava
subclavian
is itdesirable
why
not desirable
Why?High incidence of complications
where will these normally end up-
best is-
true-
Superior Vena Cava
Best is at right atrial junction
True CL placement
what do you need to do before using central line
can rn read X-ray
what need before using
All central lines must be confirmed with X-ray before use!
Rn cannot read the xray- but need the xray to confirm its correct before usage
RN Responsibilities include
monitor what
use what
change dressing how often
assess before what
respond
assisting with
who can insert pics
Monitor & Assess CVL, PICC, and implanted ports
Use STERILE technique! (sterile gloves)
Change dressings(q7days), change caps (q7days or after blood draw), and flush per protocols
Access CVL, PICC and implanted ports for medication administration, blood draw, and IV infusions
Respond to any adverse situations related to these devices
Assisting with placing CVL and implanted ports (surgical)
PICC certified nurses can insert PICCs under Ultrsound guided!
Assessment of the CVAD includes:
trace where
assess
monitor
assess what
asses for any
always do what
Trace line(s)-bag to pump to line
Assess site, dressing, caps
Monitor for any s/s infection
Assess patency
Assess for any potential complications
Always look at patient! How do they look?
Central Line Dressing Change
how often
patient lays how-wears what as well
with gloves do what
put on what
cleanse w/
cover w/
might have
Usually changed 5-7days (per agency policy)
Patient should lay on back and turn head away (can wear mask)
With clean gloves, remove old drsg
Put on Sterile gloves
Cleanse with chloraprep for at least 30 seconds
Cover with sterile dressing and biopatch, depending on agency policy
Might have small gauze if recently inserted.
Infusion via Central lines
the hub
attach
__lumen
aspirate
instill//maintain
do what before removing syringe
the hub again
connect
__lumen
pump
remember
Scrub the hub
Attach 10 ml saline syringe
Unclamp lumen
Aspirate for blood return
Instill saline slowly, approximately 5 ml-Maintain positive pressure!
Clamp catheter before removing syringe
Scrub the hub again
Connect IV fluids, unclamp lumen, set pump.
Remember to trace your line.
Administration of medications via central lines
same as what
except need(x2)
Same procedure
except you always need at least a 10ml syringe and you may need to use the SASH method:
SASH method
saline
administration
saline
heparin
why always use a 10 ml syringe
always use a 10 ml or larger syrnge when apritating- anything smaller may collapse catheter
Managing Ports
brown
red
white
Brown (usually largest) – Use for blood administration
Red – use for blood draw
White – TPN or IV fluids
what to do with a port when withdrawing blood
Stop all infusions when withdrawing blood becayse it may scew results
PICC: Assisting in insertion
put patient in what
place what//turn where
maintain
watch what for what
Patient in Trendelenburg
Place mask on pt and turn pt’s head away from side of venipuncture.
Maintain sterility.
Nurse watches the ecg to make sure pt doesn’t go into lethal rythmm
why put the patient in trendelenerg
(to prevent air embolism and help distend subclavian and jugular veins).
What should you do when a PICC pulls out even a small amount?
do not
notify
what again
Do NOT push a PICC line back in
Notify physician
x-ray again to verify
PICC line removal
verify
put pt where
hh/ppe
remove
sterile
hold //to
what do they do//what you do
what type of motion
apply
inspect
remain for how ling
Verify order
Supine flat or 10 degree
Hand hygiene, PPE
Remove old dressing
Sterile gloves, sterile dressing kit and suture removal supplies
Hold 4x4 gauze to site-sterile
Deep breath (them)and Valsalva maneuver as catheter is removed
Smooth, continuous motion, immediate pressure at site
Apply sterile occlusive dressing
Inspect tip intactness and length
Remain in supine position for 30 minutes
Implanted port (Mediport or Portacath)
placed where
enters
accessed with//remains for how long
newer ports are
used for
Surgically placed under skin in SQ pocket
Attached catheter enters superior vena cava
Accessed with special needle, non-cored (Huber) which can remain in place for 7 days
Newer ports are MRI/CT compatible (POWERPORTS)
Used for long-term (Chemotherapy
Implanted port (Mediport or Portacath)
__site
attach__
__device
insert
withdraw
f
close
flush w/
Scrub site,
Attach 10 ml saline syringe to Huber needle,
flush device
Insert needle,
withdraw blood,
flush
Close clamp
, flush with heparin or attach to fluids
Air embolism:
what position-turn where-does what
adminsister
call/put
monitor for
Potential Complications with CVAD
Trendelenburg position, turned to left(in suspected and confirmed)(prevents air from rising to brain)
Administer 02 via non-rebreather at 15 ml
Call rapid response immediately-put patient in hyperbaric chamber
Monitor for Respiratory Distress, BP, Pulse
air embolism prevention
always have
c and use
no what should ever be in
Always have pt. perform Valsalva’s maneuver;
clamp and use positive pressure
-no air should ever be in anything that you are pushing in catheter
Infection:
prevention:
keep clients
can shower but
Potential Complications with CVAD
Prevention: Wash hands, maintain sterile technique!-use sterile awlays
Keep clients head turned away when accessing or changing dressing
Can shower but need to cover appropraitly
Dysrhythmia:
assess for
if Cath is rubbing-causes
watch
Potential Complications with CVAD
Assess patient for any palpitations/chest pain
If cath is in right place but rubbing against the wall it can cause life threatening dysrhythmias
Watch monitor always
Catheter dislodgement –
stop
notify
get
Potential Complications with CVAD
stop all infusions,
notify md,
get xray
Catheter occlusion:
prevention-use
if not working use
Potential Complications with CVAD
Prevention: Use Push-Pause and flush protocols
Might be able to use Alteplase (ATP) if not working
hypertonic solution contains
a
c
g
v
e
w
others-
Amino acids
Carbohydrates—10-35%
glucose
Vitamins
Electrolytes
Water
Others: insulin
Special Solutions: TPN
must have
store until
ensure
change every
ensure proper rate to prevent
monitor
must have a CVAD
Store in fridge until 30 minutes before use
Ensure patency of central line
Change tubing, filter, and solution every 24 hrs
Ensure proper rate to prevent complications (seizure, coma)
Monitor Blood Glucose
Monitoring TPN
last resort when
how much weight gain
monitor levels of 2
monitor blood
monitor tests
use what for infusion
Given as a last resort when patients cannot tolerate food and need it through iv
Weight gain 1-2 pounds/week expected
Monitor electrolyte and protein levels
Monitor Blood glucose
Monitor kidney and liver blood tests
Use filter for infusion—check policy
Complications: TPN
4
Air embolism
Hyperglycemia
Hypoglycemia
Catheter related infection
Lipids
may-use
change how often
baseline what
start
% of solution
what’s required
May piggyback into TPN: use closest port to client below tubing filter
Change tubing and solution every 24 hours (per agency protocol)
Baseline VS in case of rxn
Start slow at first 1mL/minute for adults
10%-20% solution
Special tubing required
side effects of lipids
c
fx2
dx2
Chills
Fever
Flushing
Diaphoresis
Dyspnea
cvad dressing change
determine
e/p/c/2
gather wash
put on
remove while
inspect
remove
open
put on
akin
apply
apply
apply
label w/
d/d
determine need for dressing change
explain, privacy, culture, 2 identifiers ,
gather equipment and wash hands
put on mask on you and pt and gloves
remove old dressing while stabilizing
insepct site for complications
remove gloves
open chad kit and maintain sterile technique
put on sterile gloves
skin antisepsis
apply skin prep
apply bio patch
apply sterile tegaderm
label with date, time , initials
dispose/ document
cvad blood draw
verify
I/e/p/c
pause
perform
clean port-1st
clean port2nd
use
clean port 3rd
clean port 4th
prime/attach
verify amount with lab
identify/expain/ provacy/ cultural
pause the pump
perform hand hygiene and gloves
clean port you are using/connect empty 10 ml syringe and aspirate 4-5ml/ clamp Cath, remove syringe, discard
scurb for 15/ attach 10 ml syringe - unclamp, withdraw blood , clamp, remove syringe
use transfer device and label each device
scrub for 15 seconds- attach 10 ml normal saline, flush 3-5, push pause and clamp
scrub for 15- flush with heparin, push pause, clamp,
prime new lumen cap with ns and replace cap ///attach lumen and take off ns
managing chest tube drainage systems
safety precautions-
select
prepare according
assess and maintain by
safety precautions-orders/alergies/ wash hands / apply ppe/ assess vs/ meds/hh/privacy cultural needs
select- equipment, supplies and material
prepare according- assess system needed- either water seal or waterless seal
assess and maintain by-assesing vs, assessing pain, clean gloves, checking surrounding, check drainagie tubing, keep drainage system upright, secure w/ tape, maintain suction control
assisting with removal of chest tube-
hh and what
assist w/
what to patient
put pt where
hand hygiene and time out
assist with health care provider as they remove tube
support paitent and put into upright poition.
autotransfusion of chest tube drainage
hh
system set up-acording to
prepare
reinfuse
help pt
-hand hygiene
system set up- according to the steps to keep sterility, make sure its tight and clamps are open
prepare chest drainage for infusion
reinfuse chest drainage
help patient in comfortable position
infuse iv meds where when giving parenteral
can you interrupt parenteral
infuse iv meds in alterntive site when giving parenteral nutrition
Do not interrupt cpn for anything and make sure it does not exceed rate
Administer parenteral nutrition-
h/h
bag//check
identify
clean__
__solution
scrub
flush
remove
connect
hand hygiene,
check/inspect cpn bag and check iv solution,
identify patient usinf indefiiers,
clean gloves,
prime solution
, scrub alchohol swab,
normal saline flush,
remove syninge
connect CPN,
Repsitory system in shock-
impaired oxygen delivery causes a drop in blood volume
o2 carrying RBCs.
GI/gu in shock-
causes what
during shock
long term
cuases gastric ulcers 2-10 days after shock.
During shock, motility is impaired and paralytic ileus
if long term- necrosis of organs
Nuerologic system in shock-
change in mental status and orientation
Renal system in shock-
urine output is reduced
Effects on Skin,
Temperature,
Thirst-
shock
changes in skin color,
body temp decreases,
decreases in metabolism
Pleura
what kind of membrane
covers what
2 layers do what//creates
double layered membrane
covers lungs and inside of thoracic cavities
2 layers cling together hold lungs to thoracic wall and creates negative pressure in pleural space
pleura functions
provides
allows
provides serous fluid
allows lungs to move easily over thoracic wall during breathing
Bronchioles-
air
during inspiration
during expiration
Air moves into air sacs-
During inspiration air enters through bronchus and moves to smaller passageways of lungs to alveoli,
CO2 expelled on expiration
Alveoli
exchange of what
contains what
gas exchange,
contain a surfactant
what is surfancant
fluid
decreases//so
fluid to keep moist
decrease surface tension so lungs don’t collapse)
Tidal volume
-amount of air moved in and out of lungs with each normal breath
Pleural Effusion
collection of what where
from what
Collection of excess fluid in pleural space,
from systemic or local disease (CHF)
Empyema
Pleural Effusion
-pus in pleural cavity
Hemorrhagic
Pleural Effusion
-mix blood and pleural fluid
what does Large Pleural effusion do
and what does it cause
compresses lung tissue
(dyspnea
Pneumothorax
air where
___pressure
what’s impaired
natural recoil causes what
Air in pleural space
equalizes pressure,
lung expansion impaired
natural recoil tendency of the lung causes it to collapse
Spontaneous pneumothorax-
when what ruptures
allows
air does what
when air filled bleb (blister) on lung surface ruptures
Allows air from airways to enter pleural space
Air accumulates until pressures are equalized
Primary spontaneous pneumo
occurs when
cause is
- occurs in previously healthy people, tall slender men ages 16-24,
cause unknown
Secondary spotaneous pneumo
over
more
usually d/t
over distention and rupture of an alveolus,
more serious or life threatening
(usually d/t lung condition)
s/s of spontaneous pneumo-
what pain
what at rest
what increased
chest wall
pleuritic chest pain
, sob at rest,
RR and HR increased,
chest wall movement asymmetrical (less movement on affected side than on unaffected)
Placement of a closed-chest catheter
allows
must be
prevents//creating
allow lung to re-expand
must be sealed if used to remove air/fliud
prevents air from also entering the tube and creating an open pneumothorax
chest tube sealed with what
or connected to what
CT sealed with heimlich valve (one-way)
or connected to a closed drainage system with water seal
water seal prevents what
and what else
Water seal prevents air from entering chest cavity during inspiration
air to escape during expiration
why Low level of suction to system
helps
what occurs
helps to re-establish negative pressure in pleural space
(re-expansion occurs)
Chest Tubes placement
who does it
what is rn responsible for
By MD in Emergency situation or in surgical area
RN responsible for equipment working and ready, assessment of system and site, and assisting with insertion as MD requests
Chest tube Usually placed due to
p
h
f c
p c
t p
Pneumothorax
Hemothorax
Flail chest
Pulmonary contusion
Tension pneumothorax
Purpose of Chest Tubes
allows
drains
Allows for re-expansion of lungs
Drains blood or other fluids
multiple tubes chest tubes
why place in upper/medial
why place in lower lobe
Surgery might place a tube in the upper or medial lobe(s) for re-expansion
in the lower lobes for drainage
rn during insertion
c
s
p
Consent/
Supplies/
Position
Rn after procedure of chest tube
assess how often
have pt do what//nurse do what as well
check system why
Assess respiration status every 4 hrs,
have patient take deep breathes (if painful pre-medicate)
check the system to ensure that drainage is patent and that the tubing is free of dependent loops or kinks
after procedure
maintain
tape why
keep what where
dressing
Maintain closed system
Tape all connections and ensure they are secure with each assessment
Keep collection apparatus below level of chest (drains d/t gravity)
Dressing change depending on agency policy
rn role with chest tube
checking
check what
assist with what
Check for kinks
Check water seal frequently
Assist with applying sterile occlusive dressing (most MDs use petroleum jelly based, but research doesn’t indicate this is necessary)
drainage should not exceed how much in 24 hrs
Drainage should not exceed 500 cc in first 24 hours
When assisting with removal
pt do what
nurse do what
Pt to exhale and bear down;
place sterile dressing immediately over site
what’s in first collection chamber
this is connected to what
which is connected to what
Chest Tube drainage
connected to a water seal chamber,
connected to the suction control chamber
Chamber 1
type of system
used for
collects
Closed system
Used for restoring intrapleural pressure to reinflate lung
Collects fluid from the patient
Chamber 2
what seal
must be
prevents/allows
Water seal
Must be filled at appropriate level with sterile water
Prevents air from entering chest cavity during inspiration and allows air to exit on expiration
chamber 2:
should have
not what
during set up:
if not bubbling-
Should have intermittent bubbling;
not large amount of bubbling
, during set up adjust suction until bubbling in the suction control chamber is noted
If not bubbling check for kinks in tubing.
Chamber 3
what control
set
wants different about this and 2
Suction control
Set to prescribed setting
Same as 2 system setup only with suction being third chamber
Is there extreme bubbling in the water chamber
check for
check what
do what
if so check for leaks…
Check insertion site, tubing and drainage system
pinching at each level to see if bubbling stops. IF stops this is where the leak is
Milk tubing when
what does
ONLY with MD order.
Can increase negative pressure in intrapleural space
what does it mean when there is no fluctuating is water seal chamber
something is obstructing tubing check for kinks
Dressings and clamps
what dressing
what in emergency
Sterile Vaseline dressing
Padded clamps at bedside for emergency
Positioning of tubes and collection device
what allows drainange
secure system where//does what
have what at bedside
what prevents dislodgment
Minimum to no coiling to allow for drainage
Secure system below patient to prevent tipping and adequate drainage
Have emergency backup system and sterile water at beside
TAPE ALL CONNECTIONS to prevent dislodgement
Assess system
how often
should remain
avoid
Assess every 2-4 hours
Should remain patent and intact (sterile)
Avoid tension on tube with positioning
Respiratory Status
every when
water seal
what should not be present
Q 4 hrs
Water seal should fluctuate with respiratory effort
Subcutaneous air should NOT be present=palpate around site
Drainage-keep
when is it removed
Keep tubing free of kinks
Removed usually when drainage is less than 50-100ml in 24 hours
Bubbling with suction
Can be intermittent or continuous (not excessive
If chest tube dislodges
do what immediately
while pt does what
lung
call
Cover with sterile Vaseline/Petrolatum gauze (nonporous) IMMEDIATELY
while you have the patient exhale
Auscultate lung sounds
Call physician and anticipate the need for a stat X-ray
If the drainage system is disconnected from the patient
do what to tube
place
lungs
call
Clamp tube near insertion site
Place end of tube in sterile water
Auscultate lung sounds
Call physician and anticipate the need for a stat X-ray
When is it time to Discontinue a Chest Tube?
if for drainage-
if for tension pneumo-
, physician will consider removing when drainage is minimal (i.e. a patient with a hemothorax)
when the x-ray shows the lung re-inflated
