p&P CVAD Flashcards
where is CVAD tip of catheter terminate
in lower thrd of superior vena cava and junction of R atrium
where does tip of catheter terminate when inserted from femoral region
inferior vena cava above diaphragm
is an open ended or closed ended CVAD more likley to have complication
open ended
how do you maint patency of implanted venous port
- Implanted venous ports are located within the reservoir pocket and there are therefore no external lumens to which to attach admin sets or flush syringes
- Flush implanted venous ports monthly w 3-5ml of heparin to maint patency
which CVADs are short term
long term
nontunneled percutaneous
PICCS
long term: external tunneled (Hickman, Broviac, Groshong)
implanted venous ports
nontunneled percutaneous
Length of dwell
Insertion site
Insertion technique
Nontunneled percutaneous
length of dwell:Days to several weeks
Insertion site: Subclavian, int/ext jugular, femoral
Insertion technique: Not sx. Bedside. Directly punctures intended vein without passing through subcut tissue
external tunneled
Length of dwell
Insertion site
Insertion technique
External tunnelled (Hickman, Broviac, Groshong) length of dwell:permanent
Insertion site: Chest region via sublvian or jugular vein
insertion techniqueSx: tunnelling of the proximal end subcut from insertion site and bringing it out through skin at an exit site
PICC
length of dwell
insertion site
insertion technique
PICC
length of dwell:Until complic dev or no longer fx well
Insertion site: Antecubital fossa or upper arm (basilica or cephalic vein) and advanced until catheter tip reaches superior vena cava
Insertion technique: Can be inserted at bedside or home, radiology
implanted venous port
length of dwell
insertion site
insertion technique
Implanted venous port
length of dwell: permanent
Insertion site:Chest, abd, inner aspect of forearm
Insertion technique: Sx: placed via subclavian or jugular vein and attached to reservoir located within a subcutaneous pocket
assessment for CVAD insertion
.• Order, med etc,
-hydration, i/o,
-surgical procedures of upper chest or anatomic irreg of proposed insertion site,
-skin of area
-consent
• Allergy to: iodine, lidocaine, latex chlorhexidine
• Type of Cvad intended for placement. Read manufacturers directions
• If CVAD already in assess the fx of the CVAD; integrity of catheter, ability to flush or infuse fluid, ability to aspirate blood
• Need to flush? Drsg change?
• Pt knowledge?
(marilyn adds VS q30min x 2)
how should pt be positioned for PICC/midline
or other CVC drsg change/site care
• If PICC or midline device pos pt w arm extended. If other type have pt comfy w head elevated
i think that they should be facing away from the device when site is exposed so they dont cough on it etc
cvad gauze drsg vs transparent drsg. how long should you wait between drsg changes
• If using transparent drsg give care every 5-7 days and as needed
if gauze q48hrs and prn
what to assess CVAD for when about to do drsg change
• If CVAD already in assess the fx of the CVAD; Measure before and after doing everything ,integrity of catheter, ability to flush or infuse fluid, ability to aspirate blood.
primary complication assoc w CVADs
usually referred to as central line assoc bloodstream infections (CLABSIs) d/t contaminationfrom the skin of pt or from poor infection prevention during insetion or care
pt postion for insertion of nontunnedled device (Ins of ND)
rationale
dr and nurse put pt in Trendelenburg.
or supine pos for jugular or subclavian plcement
place rolled towel bet pt shoulder blades, rotate them slightly to 10 degree angle
-turn pt head away from insetion site
-head down below heart enc max filling and distension with inc in diameter of subclavian vein
catheter insertion: nontunneled device
maybe not nec since we dont insert them but we may have o help… coursepack says “ understand assessment of pt prior to CVAD insertion. and care after CVAD insertion”
-position pt • Hand hygiene w antiseptic soap 60 sec • Use clippers if nec • Drape under area to be cannulated • Scrub pt w chlorhexidine for 30 sec then • Hysician preps her equipment • Nurse preps IVbag, primes et • Wipe lidocine so surgeon can inject it it will now be inserted. What should be done by pt during/bfore insertion?
who is trendelenburg contra for
pt with inc ICP, head injury, some spinal injuries and resp issues
what to do just before time of insertion
ask pt to hold breath and strain (valsalva maneuver which inc CVP and prevents air entry into catheter)
what to do if pre insettion of nontunneled CVAD te pt wont do their valsalva maneuver
if this doesnt work pt may hum and hold breath
if unbale to do either, compress the pts abdomen gently
pt is holding their breath for insertion of nontunneled device
steps of insertion and nurses role
what must happen before the nurse can perform his role and why
- Dr inserts IV, determines patency, may suture it in or secure it with manufactured stabilization device
- Nurse adjusts IV infusion to prescribed rate and connects it AFTER XRAY (theres inc risk of pneumothorax w insertion. dont want to put high flow fluids through)
whats neessary before removal of catheter stablization device
when would this be removed
alcohol
for insertion site care and drsg change
INSERTION SITE CARE AND DRSG CHANGE assessments before doing
Order, med etc, hydration, i/o, surgical procedures of upper chest or anatomic irreg of proposed insertion site, skin of area
• Allergy to: iodine, lidocaine, latex, chlorhexidine
insertion site care and drsg change procedure
Implementation of insertion site care and drsg change
• If PICC or midline device pos pt w arm extended. If other type have pt comfy w head elevated
• If using transparent drsg give care every 5-7 days and as needed if gauze q48hrs and prn
• w gloves remove old drsg (in direction of catheter insertion, pull it that way)
• Inspect insertion and surrounding skin
• Meas mid arm circumference above insertion site. (youre looking for thrombosis)
• Measure length of catheter
• Set up sterile field for CVAD drsg kitSterile gloves
• Cleanse w chlorhexidine. Vertical then opp 30 sec. Dry 30 sec.
• Skin protectant to whole area. Let dry.
• Use chlorhexidine impregnated drsg for short term CVADs
• Apply new securement device if not sutured
• Apply transparent semipermb drsg or gaue drsg over site (these msut be sterile)
• Label w drsg, date, time, initials
when to change injection cap
• Usually changed min q7 days or if blood present, when integrity compromised, w each admin set change
CHANGING INJECTION CAP PROCEDURE
Changing injection cap
• Usually changed min q7 days or if blood present, when integrity compromised, w each admin set change
• Wash hands
• Prep caps clean septum of cap w antiseptic soln using friction.
o Keep protective cap on tip of injection cap
o : prime w 0.9% ns. Keep syringe attached
• Clamp catheter lumens one at a time to prevent air entry 0r have pts do valsalva manuver during cap change
• Take off old injection caps using aseptic technique
• W gloves cleanse catheter hub and connect new injection cap on catheter hub
• Flush w 10ml!! Psi is nec. NaCl 0.9% then heparin
flushing a positive pressure device
Flusing positive pressure device
• Prep syringe, prime through device by attaching prefilled saline syringe. Prime through device ad leave syringe attached
• Clamp catheter if nec and remove injection cap and discard
• Flush like normal. Reclamp when exerting pressure on syringe
• (it doesn’t say add another injection cap but I assume we do.
what to do if nurse is trying to add extension set to flush
this doesnt work for positive pressure action of the valve. cant use this
d/c PICC or nontunneled catheter
not sure how much we have to know. advanced practice RNs can do this. I started pg 732 at step O.
- apply petroleum ointment to site
- sterile occlusive drsg/gauze drsg
- label drsg w date time initials
- inspect catheter integrity and dispose
- return pt to comfortable position. Be sure that short peripheral IV or midline is infusing at correct rate
after nontunneled catheter or PICC removal how often do you change drsg
q24h until healed
what to assess after CVAD insertion
Eval
• Is line still nec? (do this every day)
• Complic indicative of pneumothorax: pain, SOB, absent breath sounds
• Monitor for bleeding or swelling at insertion site or neck and occlusiveness of drsg (this indicates infiltration into subcut tissue
• I/O, electrolyte balance,
• VS (infect?),
• site,
• catheter connection points, tubing for kinks, obstr, cracked hubs
• clot filtration in catheter, air embolism, catheter migration
• pt understanding
• Look at xray if avail
how to document pt CVAD removal
pt position -appearance of site -length of catheter removed -integrity of catheter removed drsg applied -pt tolerance bleeding? monitor q15min for 1hr -probems during removal
how can you stabilize a short peripheral IV drsg
• Can stabilize w: manuf stabilization device, sterile tapes, sx strips, cover w TSM or gauze
how often to change gauze drsg of peripheral IV
q48hr and immed if compromised
assess before changing peripheral IV drsg
-IV assessment
-pt for signs of infection
when was it changed last
CHANGING SHORT PERIPHERAL IV DRSG procedure
• Remove TSM w stretch technique by pulling laterally and stabilizing catheter. repeat on other side
• Ig gauze remove one layer at a time
- prep your new sterile tape for securement
• In both cases leave tape that secures VAD to skin in place during removal of the drsg then remove w chlorhexidine swab vertical then horizontal then from insertion site outward w a third swab. Allow to dry
-apply drsg
-(i assume we add tape here but i couldnt see where we should do this0
• Record time change, reason, type of drsg material used, patency of system, description of venipuncture site
consideration for placement of drsg over IV
the connection between the administration set and hub needs to be uncovered to facilitate changing tubing if nec
where should tape not go when periph IV drsg change
dont put it over the transparent drsg (i guess we put it under then??)
pilliteri
how does a dacron cuff stay in place
what type of CVAD would this be found on
it is a wrinkle resistant fabric that adheres to the subcut tissue
found on external tunneled eg HIckman, broviac, groshong
disadvantage from piliteri regarding external tunneled catheter
it could get pulled out and the kid could lose lots of blood
which type of device is likely to be well accepted by children and why
what is a drawback of this type of CVAD
implanted port-can have full range of activities eg swimming, no external drsg, not as visible
it requires puncture with access
where are PICCS well suited (what general population)
good for home care because they only need to be changed every 4 months
where would a midline insertion rest according to piliteri
the tip rests close to the head of the clavicle
do parents prefer PICCs or other CVCs and why
PICCs because they look more like regular IVs
