Peripheral Blood Draw/ CVAD Flashcards
Peripheral Blood Draw Steps
Clean hands
Assess large vein (brachial)
Gloves
Position yourself in front of the vein
Tourniquet (4 inches above draw)
Syringe (let the air out)
Needle attach
Alcohol swab area
Anchor with angle/stick/ and slowly aspirate
With a butterfly - agitate the tubing when pulled out
Always release the tourniquet before removing the needle from vein
Cotton above entry site
Pull out and put pressure on the site
Cover needle
Put the needle into the 18-gauge tubing
- angled to the back wall but not touching
- Fill to label or desired label
Label the tubes before leaving the room
Sharps and trash designation
Peripheral Blood Draw Options
syringe/needle 18 gauge
vacuholder/needle
butterfly with vacuholder
washcloths/alcohol swabs/CHG/blood tubes(red tubes)/tourniquet/2x2/labels/2 hazard bags
CVAD Supplies
- 3 flushes
- empty 10 mL syringe
- blood fill needle
- lots of alcohol wipes
- gloves
- soap
Central Venous Access devices types
Tubing
Nontubing
Picc Line
Subclavian
CVAD Procedure with syringe technique
Wash hands
Towel under the tubing and skin
Access the area
Distal Lumen (Largest) is better to draw blood from
all Flush (purge the air, loosen cap)
wash hands with gloves
Unclamp distal lumen and clean with swab
Aspirate for blood return
-Pulse pause till 9 mL
- draw back 3-4 mL
-swab
- 10 mL syringe slow and steady 3-5 mL
-put blood fill needle into slow and steady blood
-swab
-flush with 19 mL (push pause)
Clean between
- Remove syringe
-Clamp
- Cap
CVAD Procedure with Safety Holder is only used on a
Subclavian or a Intrajugular
Never use a safety holder on a
PICC Line, too much pressure
CVAD Procedure with Safety Holder
- unclamp
- Clean for 15 sec
- dry
- aspirate air and flush
- pulse pause with 9 mL
- blood return of 3-4 mL
- take safety holder off, clean
- attached flush 19 mL (clean between flushes)
- swab cap
All lumens need to be flushed every
shift or 12 hours
Max 0 Needle-less connectors need to be changed every
7 days
-Clean, attached syringe to prime with saline flush ready
If the fluid is in the lumen,
discontinue or hold medications
The PICC line is commonly located in
the basilic or cephalic vein
CLABSI means
Central line-associated bloodstream infection
CVC Dressing Change Procedure
Tear from top
Open on the tearing arrows and open like an envelope
Clean the surface area and wait to dry
While drying = assess the area of the dressing
1) Wash hands and Don sterile gloves
2) Put on masks, and turn pt’s head to the other side, allergies to CHG
3) open alcohol sab to loosen dressing
4) 2nd packet - take out new sterile gloves
5) take the bottom border and unfold the back
6) Don sterile gloves
7) Supplies in order
- Core prep squeeze to clean site and allow to dry
- rapid dry skin barrier (like a painting, not center)
- apply dressing and line up
What is in the CVC Dressing Change Packet?
2 gloves (pt and nurse)
sterile gloves and hand sanitizer
alcohol swab
What is CLAPSI?
serious infection that occurs when germs (usually bacteria or viruses) enter the bloodstream through the central line
What is a CVAD / central line / central venous catheter?
an intravenous catheter (infusion port) that doctors often place in a large vein in the neck, chest, or groin to give medication or fluids or to collect blood for medical tests
Difference between central lines and IVs
central lines access a major vein that is close to the heart and can remain in place for weeks or months and be much more likely to cause serious infection
Central lines are commonly used in intensive care units.
Pts with CLAPSI have
fever
red skin
soreness around central line
What steps are taken to prevent CLAPSI?
o Perform hand hygiene
o Apply appropriate skin antiseptic
o Ensure that the skin prep agent has completely dried before inserting the central line
o Use all five maximal sterile barrier precautions:
Sterile gloves
Sterile gown
Cap
Mask
Large sterile drape
* Once the central line is in place:
o Follow recommended central line maintenance practices
o Wash their hands with soap and water or an alcohol-based handrub before and after touching the line
* Remove a central line as soon as it is no longer needed. The sooner a catheter is removed, the less likely the chance of infection.
What can Pts do to prevent CLAPSI?
- Speak up about any concerns so that healthcare personnel are reminded to follow the best infection prevention practices.
- Ask a healthcare provider if the central line is absolutely necessary. If so, ask them to help you understand the need for it and how long it will be in place.
- Pay attention to the bandage and the area around it. If the bandage comes off or if the bandage or area around it is wet or dirty, tell a healthcare worker right away.
- Don’t get the central line or the central line insertion site wet.
- Tell a healthcare worker if the area around the catheter is sore or red or if the patient has a fever or chills.
- Do not let any visitors touch the catheter or tubing.
- The patient should avoid touching the tubing as much as possible.
- In addition, everyone visiting the patient must wash their hands—before and after they visit.
PICC means
peripherally (vein) inserted central catheter
PICC line is a
radiopaque central venous access device (CVAD) that is usually inserted into the basilic or cephalic vein in the antecubital fossa and threaded up the vein until the tip of the catheter is in the cavoatrial junction
PICC lines are used for
administration of blood products, fluids, total parenteral nutrition and medications, as well as prolonged antibiotic therapy, and chemotherapy.
When working with CVAD always use
aseptic and meticulous hand hygiene
CVAD is designed to
administer meds, nutrients/IV fluids, blood products and other viscous fluids through central vein
The lumens are used for
exits from the body
What is the largest gauge?
Distal
Distal lumen/gauge/exits is used for
Not tested
blood draw, infusions, meds, CVP
Proximal lumen/gauge/exits are used for
Not tested
IV fluids, meds, blood draw
Medial lumen/gauge/exits is used for
Not tested
TPN
Inserted into large veins in central circulation with catheter tip ending in
Superior Vena Cava
_________ Confirmation
Xray
Indications for CVAD
- Peripheral access (arms) not available or contraindicated
- For moderate to long-term use
- Need for multiple intravenous access
- Hemodialysis
- Total Parenteral nutrition (TPN)
- Chemotherapy
- Multiple blood transfusion/blood draws
- Long-term antibiotics/IV medications or solutions (Vancomyosin)
- Central venous pressure monitoring
Long term antibiotics/IV medications/solutions in CVAD
Vancomycin
When preparing the pt, what should you tell them?
Purpose - what will be administered (meds, IVs)
Estimated length of time
What should you teach the pt about the CVAD and its care?
what to avoid and why
- keep dressing dry
- don’t pull or scratch
- replace dressings if wet, peeling, cracking
What do the pt report on CVAD?
pain, tenderness, s/s of infection
When preparing the pt, what is the schedule of care, and how on CVAD?
every 7 days or as needed
describe the process (sterile
What do you tell the pt post removal and care of CVAD?
prepare pt/family when appropriate
CVAD Insertion: Pre/Post Protocols
- Dr’s order and signed consent
- Support for pt and family
Surgical asepsis - Pre/Post VS and assessments
-Trendelenburg position - Standby assist for PICC Team
- X-ray confirmation
- Doc by both parties
Types of CVAD
non-tunneled
tunneled
port-a-cath
Non-tunneled CVAD is inserted directly into
Subclavian (common)
jugular
femoral
peripheral vein (PICC)
Non-tunneled CVAD is secured by
sutures outside insertion site to the skin
Non-tunneled CVAD is used for how long?
acute - moderate to long term
~ 6 weeks
What CVAD device has a higher infection rate?
Why?
non-tunneled
~ more open to outside and air when the dressing is changed
T/F: Nurse can discontinue non-tunneled CVAD.
True
PICC line is inserted in what veins?
basilic or cephalic, if peripheral vein can be accessed
Where is the basilic and cephalic veins located?
Basilic - medial side of arm
Cephalic - lateral side of arm
Who places the PICC line?
PICC team or IR insertion
In the PICC line, no ____________ or _______ _________ in the affected arm.
phlebotomy or blood pressures
PICC lines tend to clot
easier
Tunneled CVAD is installed
surgically tunneled beneath skin
Tunneled CVAD has a ________ cuff on the catheter.
Darcon
The Dacron cuff is secured where?
SQ tissue initially then scar tissue secures itself around the cuff
Secure and prevent infection
Tunneled CVAD common sites
subclavian vein, IJ, femoral vein
How long is a tunneled CVAD typically in place?
chronic, long-term, greater than 6 weeks
How many ports does a tunneled CVAD have?
multiple
distal, medical, proximal
Distal port color and gauge
Brown, 16 g
Medial port color and gauge
Blue, 18 g
Proximal port color and gauge
White, 18g
T/F: Nurses cannot d/c a tunneled CVAD.
True
Mostly be surgically removed bc of Darcon cuff
How many ports does a Hickman/Broviac-Tunneled?
2
Implanted port, Port-a-cath, Infusaport
is implanted where?
the surgically implanted line below the skin-tunneled
Implanted port, Port-a-cath, Infusaport
is implanted where?
surgically implanted line below the skin-tunneled
Implanted ports are where?
external, tunneled through jugular, subclavian, or cephalic/basilic vein
Implanted ports are
expensive
long-term (months to years)
silicone septum, surrounded by titanium, stainless steel, or plastic
single or dual ports
chemotherapy
Huber needle to access - L shaped
less restrictive
What does the nurse assess and evaluate when CVAD is inserted?
- dressing change, med admin, IV fluids, PRN
- Site: red, leaking, sutures intact
- Date
When do you notify the PCP/PICC Team after insertion?
S/S infection, no sutures, displacement
S/S of Infection (CLABSI)
-redness, drainage, swelling, discomfort at the insertion site
- fever, chills, tachycardia, increase WBC
Nursing Interventions to prevent CLABSI
aseptic technique
thorough hand hygiene and gloves
clean injection ports with an alcohol swab before EVERY access
assessments and doc
dressing changes
Pt/family teaching
Pneumothorax
air in the pleural space outside the lung
Collapsed lung
S/S Pneumothorax
dyspnea, hypoxia, tachycardia, restlessness, cyanosis, chest pain, decreased breath sounds
Nursing Interventions Pneumothorax
Monitor vital signs
Administer oxygen
Notify physician, CN, RRT
Prepare for chest tube, if indicated
Air Embolism
air entering the circulatory system
S/S Air Embolism
Dyspnea, chest pain, tachycardia, hypotension, anxiety, nausea
Turn the pt on the left side to
open up the right atrium
Nursing Interventions of Air Embolism
Keep lumens clamped
Administer Oxygen, Monitor VS, Pulse Ox
Place patient on left lateral side in Trendelenburg position
Stay with patient and Notify physician, CN, RRT
Occlusion
lack of blood return or sluggish flow
thrombosis
a clot that blocks the catheter’s lumen
Catheter Rupture
may be caused by excessive force used when flushing
Catheter Migration
displacement or lengthening of catheter
Catheter Occlusion Nursing Interventions
Take deep breaths/cough
Raise arms overhead; reposition arm on the same side as the catheter
Have patient sit-up/stand-up
Change positions in bed
Place in Trendelenburg
Administer Alteplase
CVAD Knowledge and Care - protocol
1) Know which type of CVAD is present
2) Always assess the CVAD site before any intervention(s)
Site/Dressing/Date
Lumens/Clamps
Fluids/Medications
3) Always “scrub the hub” (Max-Zero cap) at least 15 seconds before accessing
4) Always program CVAD infusions to a pump
5) Flush Port/Lumen(s) with Only 10 mL flush syringes
a - every shift
b - after every medication
c - after every blood draw
6) Dressing Change:
a- dressing 24 hours post-insertion & every 7 days or prn
b- Max-Zero caps every 7 days with dressing change and PRN
CVAD Dressing Change
Gather supplies + extra sterile gloves
AIDET and sterile gloving
Assess for allergies & Readiness
Raise bed to level of comfort
Place patient in supine position, HOB 30°, if tolerated
Position and clean Overbed table waist height – Insight always**
Hand Hygiene*
Assess site, lumens, clamps
remove gloves
Open package #1 apply your mask 1st then pt and turn face away (prevent contamination)
HH and sterile gloves
Palpate tenderness, edema/drainage
Remove old dressing and gloves Discard
START STERILE STATE of Consciousness
Open #2 sterile pack, Set sterile gloves aside and unfold sterile field
HH and Don sterile gloves
Know where your hands and field are continuously
Activate Chlorhexidine sponge
Starting with the Insertion Site, Scrub with Friction for 30 seconds (back & forth – ONLY)
Insertion Site > Hub > Lumens
DO NOT RETURN TO THE INSERTION SITE- contamination
Air Dry
Adhesive Bond opt.
Antimicrobial agent and transparent dressing
- covers site
- smooth outward and remove air pockets to seal
Label dressing with initials, date and time
Remove pt’s mask and discard
Doc and 4Ps
Documentation of replacing dressing
Assessment of insertion site, sutures
Site care performed per protocol /policy /sterile
Type of dressing applied
-Concerns/Who was notified
Site labeled with date, time, initials
- School if stdt changes dressing
External catheter length (PICC)
Type of catheter, # lumens
-Flush easily, ports, clamps, antimicrobial caps, etc.
Patient teaching
Supplies/Steps for CVAD Catheter Removal
- Dr’s order, CVAD kit, Suture Removal kit, Petroleum-based gauze
~follow protocol for dressing change - Clip sutures
- Supine position, hold breath & pull line with deliberation
- Hold pressure 5 minutes or until bleeding stops
- Apply petroleum-based gauze or petroleum-based ointment to insertion site
- Cover with occlusion dressing & leave on for 24 hours
- Remain supine at least 30 min post-removal
- Document + Patient Teaching
CVAD Catheter Removal: PICC Line
- Dr’s order, CVAD kit, Suture Removal kit, Petroleum-based gauze
~follow protocol for dsg change - Clip sutures
- Supine position, hold breath & pull line with deliberation
- Hold pressure 5 minutes or until bleeding stops
- Apply petroleum-based gauze or petroleum-based ointment to insertion site
*** - Cover with occlusive dressing & leave on for 48 hrs.
Must add 4x4 folded gauze over occlusive dressing & secure with Coban wrap
** Measure the catheter length of the PICC line & record ** - Remain supine at least 30 min post-removal
- Document + Patient Teaching
Documentation of Catheter Removal
Time and Date
Site condition and appearance
Any indicators of infection
Culture obtained?
Catheter length if indicated
Type of CVAD (# of lumens)
Any fluids infusing
Concerns/What & Who was notified
Patient teaching
Tourniquets are used to
slow the blood flow and blood pull in veins
Equipment for Peripheral and CVAD Blood Draws
Gloves
Tourniquet
Chlorhexidine
Needle holder
Needles
Blood tubes
Syringes
Cotton balls
Band-aid or Coban
Patient labels/Orders
Computer requisitions
Vacu-holder
Tips for Success
Tourniquets need to be tight
Phlebotomy is an art – it takes practice
Phlebotomy is more about FEEL than sight
Hot packs can help make veins more accessible
Position the patient in a fashion that makes for easier access
Anchor the vein before accessing
The bigger your needle
the smaller the number
The bigger the number
the smaller the needle
Needle - Dark green
14 trauma emergency
Needle - amber
15 g
Needle - Brown
16 g
Needle - Light green
18g
Needle - Pink
20g
Needle - Purple
21g
Needle - Blue
22g
Needle - orange
23
Needle - red
25g
Needle - white
27g
Bevel
angles down and goes to the needle
Vacuholder
helps prevent the nurse from getting stuck with the needle
The butterfly can be used for
smaller and more collapsed veins
most likely to hemolysis
When doing venipunctures the bevel faces
up
What veins are options for venipuncture
1st choice: Median cubital is in the inside of the arm (lowest harm of poking other things)
2nd: choice: Cephalic on radial
3rd: Basilic on pinkie side (most risks because close to arteries and bicep tendons and nerves)
IV Considerations
- IF there are no other options only collect blood from an arm with a continuous infusion
- STOP the infusion prior to collection for 2-3 minutes
- Infusions with heparin stopped for 10 minutes prior to blood collection
Venipuncture procedure
Review lab req / labels
AIDET
Hand Hygiene & gloves
Fasting and/or diet restrictions
Assemble Supplies
Position Patient
Apply tourniquet
Cleanse the site & allow it to dry
Assess sites & select supplies
Inform patient
Insert needle
Collect blood specimen(s)
Order of Draw
Release tourniquet, apply gauze, remove needle, pressure
Sharps & label
Evaluate site & bandage
Thank you
How long do you apply pressure with a cotton ball after removing the needle?
till hemostasis has clotted
The higher the angle
the higher risk of harming patient
Angle of entry
15-20 degrees
What blood draw always goes first?
blood cultures (all 4)
Order of Draw
Sterile
Lt. blue
Red
SST
PST
Green
Lavender
Gray
CVAD Blood Draw is what type of procedure?
clean with gloves
Everytime you remove a syringe from a port, what do you do?
clean with alcohol swab
CVAD Blood Draw Considerations
- Stop any infusions beforehand
- Aspirate to verify blood return
- Flush with 9mL with push/pause
- Waste 3-5 mL (waste and sharps) and discard
- Collect sample with dr’s order of mL
~ only 10 mL syringes - Flush with 19 mL
- Clean and cap
Hemolysis
damaged RBC
Prevent Hemolysis
- Problem-free venipuncture
- Use a larger bore needle to draw – **21, 22, or 23 gauge **
- Use larger needles for transferring blood into test tubes – 18g blunt fill works well
- Tilt blood tubes so that the blood washes down the side of the tube
- Aspirate slowly when collecting from veins or catheters
- dry after cleaning
- never draw from damaged skin or hematoma (bruise)
- remove the tourniquet as quickly as possible
- don’t remove the collection tube till full
- never take needle out with tube attached
- never hook up blood culture to a vacuholder
Blood Cultures
-Priority to minimize risk of contamination
-Blood cultures, when ordered, should be collected FIRST
-5-10 mLs of blood should be collected for each sample (2s) = total of 4 vials
-Never attach blood culture bottles directly onto vacu-holders because beads in the culture bottle can be introduced into the patient’s vein
- from 2 different venipuncture sites (right and left)
- wait 15 to 20 mins between sets prior to antibiotics
Troubleshooting if no blood or incomplete collection
Change the position of the needle
Tourniquet too tight – could obstruct blood flow
Change tubes – vacuum could be a problem
Re-anchor the vein – some veins roll
Have patient make a fist to help engorge muscles
Pre-warm area of venipuncture to increase blood flow
Re-hydrate patient
Stacy is a 58 y/o female pt admitted for pneumonia. she has a 20g peripheral IV with fluids running to her Right AC.
Orders for lab draw require a total of 12mL blood samples.
What supplies would the nurse gather for venipuncture?
Where?
gloves, gauze, 21g needle, alcohol pads, tourniquet, 2 10mL syringes, coband
**optional: vacuholder, butterfly
- Venipuncture on left AC
Rob is 72 y/o male pt admitted to the hospital for septic shock. He has an 18g peripheral IV with fluids running to his left AC. He also has a 20g peripheral IV INT in his right hand.
Orders for lab draw require a total of 8mL blood sample.
Supplies and where?
10 mL syringe, tourniquet, gloves, alcohol, gauze, needle vacuholder/butterfly(opt)
Right AC, if does not work, stop infusion for 2-3 min (10 min for heparin), left higher up
- Can only get blood specimen from IV if just pricked it
- Can’t draw blood from the peripheral IV site
