Exam #2 Flashcards
Access to CVA circulation
- lower 1/3 superior vena at contral junction
pediatric catheter insertion sites
different than adults are: - temportal - posterior auricular others: - subclavian, jugular, basilic
Classification of CVA catheters
1) Central venous catheters: non tunneled and tunneled
2) ports
3) peripherally inserted central catheters PICC
Nontunneled catheters
- flushed daily
- subclavian catheter: shrot term catheter
- jugular
- epidural: do not use alcohol to clean, complications of loss of b/b and loss of sensation, used for pain management, non-permanent catheter
Tunneled catheters
- goes up through muscle and then into subclavian vein; more protection from infection when tunneled through muscle first
- flushed daily
1) hickman: can stay in long term, years, velcrow cuff grows with skin to secure it in place, openended catheter, must be flushed daily, must be clamped
2) broviac: size of lumen in body is smaller than hickman; used more for women or peds
3) groshong: closed end with valves
3 way groshong valve
- remains closed when not in use
- opens outward for infusion (positive pressure)
- opens inward for aspiration (negative pressure)
- maintain with good flushing every 7 days
ports
- for: kids, breast cancer patients, colon cance pts, meds q 4-6 weeks
- use a huber needle to access it
- can be accessed ~ 1000 times before replacement
- single and double lumen available
- only accessed and flushed q 4-6 weeks
- sutured to ribs to stay in place
power port
- bard’s
- power injections
- can be fiven for CT/MRIs
if there are issues with a port
- huber needle may be bent
- needle may be dislodged or clotted
- deaccess and reaccess making sure you are at a 90 degree angle to port and feel back of port
- if you cannot easily withdraw 3-5ml of blood then catheter is not patent
PICC/Midclavicular/midline catheters
- 90% of CVAs
- midline catheter is not a CVA
- midclavicular, scar tissue can form
- the right side is always the best place to place a CVA for better insertion
PICC lines
- placed with ultrasound
- basilic vein: the preferred vein
- cephalic vein: tortorous vein, more fifficult to threat
- brachial vein: more diff to access and very close to artery (risk of hitting artery)
nerves
- always document if you hit a vein and how the patient reacted
vein anatomy
- endothelium: internal lining of vein
- damage = scarring
flushing PICC lines
- flush with 10ml of saline after meds
- if concern for mixing incompatable meds then flush with 20ml between both meds
- flushing promotes and maintains patency
- reduces incidence of cather related blood stream infection by preventing or reducing the development of biofilm
- pulsating flush
- always should be able to get 3-5 ml
flushing technique
1) scrub the hub
2) flush the catheter
3) clamp the line
4) remove the syringe
catheter securement
- gregory schears
- secures catheter in place
- recommends use of statlocks for catheter securement for PICC, and non-tunneled CVAs
biopatch
- releases CHG for 7 full days
- acts to extend the life of the CHG used to clean the site
- biopatch can hold up to times its weight in fluid
- change q 7 days
IV complications
- local: at or near the insertion site or as a result of mechanical failure
- systemic: occur within the vascular system, remote from the IV site, can be serious and life threatening, more life threatening, more common in CVA pts
local IV complications
- occur as adverse rxn or trauama to the surrounding veinipuncture site
- assessing and monitoring are key components to early intervention
- good veinipuncture technique is the main factor related to prevention of most local complications
- complications include: hematoma, thrombosis, phlebitis, postinfusion phlembitis, thrombophlembitis, infiltration, extravasation, local infection, venospasm, trauama
hematoma
- formations resulting from infiltration of blood into tissues at veinipuncture site
- SQ hematoma is the most common cx
- can be a starting pt for other cx: thrombophlebitis and infection
- R/T: too big canula, no pressure when disconnecting, tournequet applied too tightly above a previously attempted venipuncture site
- pts on anticoags and long term steroids
- S/S: discoloration of skin, site swelling and discomfort, inability to advance the cannula all the way into the vein during insertion
- resistence to positive pressure during the lock flushing procedure
- prevention: indirect method, apply tournequet right before IV insert, use small needle with elderly or skin that is very skin and fragile, gentle
- TX: apply light direct pressure 2-3 minutes after removal, elevate extremity, apply ice, document!
occluded catheters
- 1 out of 4 CVAs get occluded
- thrombotic: 58%, clot or thrombus within/around device in surrounding vessel
- nonthrombotic: 42%, mechanical, malpositioned tip, infusate precipitates or residue
- DX: no blood return, increased pressure or tension when flushing, fluctuating flow with patient positioning, abrupt cessation of flow
- what can happen if occluded? - delayed therapies, decreased good IV sites to use, infection
Thrombosis
- catheter-related obstructions can be mechanical or non mechanical
- trauma to endothelial cells of the venous wall causes RBCs to adhere to the vein wall, form clot or thrombosis
- drip rate slows, line does not flush easily, resistance is felt
- NEVER focibly flush a catheter
4 types of thrombotic occlusions
1) intraluminal thrombus: clot inside of catheter
2) fibrin tail: grows out of inside and pokes out. Cant draw back, if pt moves you may get bood
3) fibrin sheath: can grow entire length of catheter, may cause backflow up to other end of sheath, may come out into SQ skin or out the entrance
4) mural thrombosus: trauma to vein wall in insertion of catheter. Fibrin grows and attaches catheter to vein wall
biofilm
- can cause catheter issues, structured community of microorganisms. Occurs on all VADs. protective bacterial lining around things that are foreign to body
- thrombus/fibrin tail can attach to biofilm and grow
cathflow
- treat clots and fibrin growths
- attaches to clot and breaks down fibrin
infiltration/extravasation
- infiltration: leakage of nonvesicant solution into surrounding tissue
- extravasation: leakage of vesicant solution into surrounding tissue; takes a long time to heal
thrombus
- R/T: HTN, low flow rate, location of IV canula, compresion of IV line for exteneded period of time, trauma to wall of vein
- S/S: fever, malaise, slow infuson rate
- prevention: use pumps to control flow rate, micro drip for
Phlebitis
- inflammation of vein wall
- mechanical: too large catheter, moving catheter around
- chemical: vein become inflammed by irritating or vesicant solutions or medications; too rapid infusion, slower the rate of infusion the less irritating
- S/S: redness at site, warm, swelling, increased basil temp
- prevention: used larger veins, central lines for infusions lasting longer than 5 days
bacterial phlebitis
- AKA septic phlebitis, less common
- inflammation of intima of the vein
- contributing factors: poor aspetic technique, failure to detect breaks in integrity of equipment, poor insertion technique, inadequate stabalization, failure to perform site assessment, aseptic preparation of solutions, hand washing and preparing the skin
postinfusion phlebitis
- inflamm of the vein 48-96 hrs after discontinued
- factors that contribute: insertion technique, condition of vein used, solution used, gauge/size/length/material, dwell time, infrequent dressing change
phlebitis scale
0 - no clinical symptoms
1 - redness with or without pain
2 - pain at site with red and edema
3 - pain, red, edema, streak formation, palpable cord
4 - pain, red, edema, streak, cord, prulent drainage, cord > 1 inch
* apply heat to site
* treat if able to save line
* watch for 24 hours and mark site to see if worse
* take out stage 4
thrombophlebitis
- thrombosis w/ inflammation
- R/T using veins in lower extremities
- S/S: edema in limbs, warm, visible line above IV site, mottling, cyanosis of extremity
- prevention: use forearm veins, avoid joints, access q 1-4 hrs, q2 in children, smallest catheter possible
infiltration
- nonvesicant solution into surrounding tissues, isotonic, mild solutions
- R/T: puncture of vein wall, high delivery rate
- S/S: coolness of skin, fluid in tissues, taught skin, absence of blood return, infusion rate slows
- tx: stop line
- complications: necrosis of tissue, compartment syndrome, complex regional pain syndrome
extravasation
- vesicant into surrounding tissues
- tissue necrosis
- R/T: vesicants - phenergan, dilantin, KCL, calcium gluconate, amphotericin, dopamine, nipride, above 5% dextrose
- S/S: pain, burning, swelling, coolness, damp/wet dressing, slow/stopped infusion
- pain = closed/bad IV
- prevention: know drug, access veins, 3-5ml blood return, free flow IV, access blood return
plastic IV set
- made of PVC
- closed system
- does not contain a vacuum, must be flexible and collapsible
baxter’s mini bag system
- bottle attached to piggyback in which antibiotic is mixed with formula
basic components of administration sets
- spike
- drop orfice
- drip chamber
- tubing: primary tubing length 66-100 inches, secondary tubing length 32-42 inches
- clamp
- macrodrip: 10-20gtt/ml
- microdrip: 60 gtt/ml
- formula for IV flow rate:
ml/hr x DF
————– = gtt/min
minutes
advantages of Peripherl IVs
1) provides a route for immediate availability to the systemic circulation without regard to GI functioning
2) drug absorptoon is more predictable
3) blood levels of the drug can be maintained for even distribution and titrated according to patient’s needs
4) provides a reliable route for emergency conditions
5) ideal for drugs that cannot be given orally due to poor absorption
6) often only available route for unconscious pts
7) ideal for patients who are nauseated
8) site can be accessed for 72 hours or more
disadvantages of peripheral IVs
1) greater possibility of a serious allergic rxn occuring becayse of rapid delivery to the systemic circulation
2) once administered an IV drug cannot be retrieved
3) is error is made the potential for danger is magnified
4) infection or sepsis possibilities
5) pain associated with IV start
6) impaired mobility due to IV placement
7) potential for nerve or vessel damage
8) pain associated with administration of irritating drugs
9) tissue damage can occur
10) always potential for phlebitis, thrombophlebitis, embolization
documenting an IV
1) date and time
2) brand and style
3) size and length
4) condition of extremity
5) location and vein
6) # of attempts
7) pt response
8) fluid and ml/hr
9) pump vs. gravity
10) signature
