Seminar 10 Flashcards
What is the difference between a PICC and a CVAD?
a PICC is inserted through a peripheral vein (basilic, brachial, median cubital, or cephalic vein) and end in the lower third of the superior vena cava.
a CVAD are inserted into either the jugular or subclavian vein and advanced into the vena cava.
If VAD therapy is needed for less than 7-10 days what device should be used?
PVAD short
if VAD therapy is needed for 7 days- 1 month what device should be used?
non-tunneled CVAD
If VAD therapy is needed for more than 1 month but less than 1 year what device should be used?
a PICC
If a VAD is needed for more than 1 year/ long term what device should be used?
implanted venous access device (IVAD) or tunneled CVAD
Where are PICCs inserted
Inserted in the periphery in the cephalic, basilic or median cubital vein above the ACF (antecubital fossa)
Where does the tip of a PICC rest?
in the lower portion of the distal superior vena cava
After insertion of a PICC, what needs to be done?
tip location needs to be verified with a chest x-ray.
A blood pressure can be taken on the side of PICC
TRUE OR FALSE
FALSE
A BP should not be taken on a arm with a PICC
Non-valved PICCs have a a)… to prevent reflux or back flow of fluid contents or blood
a) clamp
the a).. should be avoided for central venous access in adult patients
a) femoral vein
non-tunneled CVADS are inserted into
either the external/internal jugular or subclavian vein or femoral vein (not common/avoid)
Non-tunneled CVADs are used for?
short term and emergent therapy
resuscitation, CVP monitoring
Who inserts a non-tunneled CVAD?
physician
how many days is a non-tunneled CVAD typically left in place for?
less than 7 days due to risk for infection
(used up to 1 month in IH however)
What type of dressing is required for a non-tunneled CVAD?
sterile(:
how are non-tunneled CVAD’s kept in place?
sutures! risk of bleeding if pulled out.
tunneled CVAD’s are used for?
long-term intermittent or continuous access
Where are tunnled CVADS placed?
subclavian or internal jugular vein
the proximal end of a tunneled CVAD is a).. from the insertion site (usually 10-15 cm) and brought out through the skin at an exit site
a) tunneled subcutaneously
What is a Dacron cuff used for?
it is placed under the skin just above the exit site of a tunneled CVAD, in 3-4 weeks, granulation tissue will grow onto the cuff and create a seal.
This helps the catheter from slipping out and acts as a barrier to infection.
Once the site is healed for a tunneled CVAD, is a dressing needed?
NO
Where is a tunneled CVAD inserted?
(for the first time)
surgical incision in the OR or in medical imaging under fluoroscopy
in order to remain patency with a tunneled CVAD, what is required?
Heparin flush solution
Tunneled CVADS are typically used for what length of tmt?
more than one year typically
if no infection, blockagem or thrombosis, tunneled CVAD’s can be
left indefinitely
The IVAD port consists of a
- reservoir,
- a hollow metal disk with a self-sealing membrane,
- and a catheter
The distal end of the IVAD catheter is usually placed in the a)..
distal third of the superior vena cava
what part of the chest is a IVAD inserted and who inserts it?
upper anterior chest by a vascular surgeon into a subcutaneous pocket
IVAD are nice because they have a
decreased risk of infection
Are dressings used for IVADs if it is not being used?
no! but if it is being used it needs a aseptic dressing over huber needle, site and tubing.
Usually transparent dressing.
what are IVAD’s used for?
Used for long-term IV therapy (eg. on-going intermittent medications, chemotherapy, frequent blood samples)
what is required to lock a IVAD line?
Requires Heparin flush solution (usually 5 mL).
what length of treatment are IVADs used for
more than one year
What things should the nurse assess for with a IVAD?
- Dislodging of the catheter tip (neck, ear gurgling sounds, palpitations),
- Dislodging of the port (free movement, swelling, difficulty acesssing the port).
How often is a IVAD flushed and checked for patency if not in use.
every 8 weeks (1-3 months per IH policy)
heparin
When is a hemodialysis catheter used?
when temporary access needed for hemodialysis (ex, in an emergency or waiting for an AV fistula to heal)
Where is a hemodialysis catheter inserted?
internal jugular or subclavian vein and then into the superior vena cava
What are the two types of tunneled catheters and when are they used?
uncuffed and cuffed
uncuffed: used in a emergency or less than 3 months
cuffed: used if longer than 3 months
Who usually puts a hemodialysis catheter in place?
nephrologist, surgeon, radiologist in the X ray department or operating room
What holds a hemodialysis catheter in place, unless it is going to be used permanently?
a stitch, but if permanent the stitch may be removed
Name indications for a CVAD
10
- IV fluids and blood.
- meds
- vesicants (chemotherapy)
- irritant meds (panto and ceftriaxone)
- solutions with extreme pH (vanco).
- hypertonic solutions
- obtain a blood sample
- monitor central venous pressure
- asses for pulmonary artery catheters and transvernous pacemaker
- hemodialysis access
if medications are irritating to peripheral lines, what is a better option
giving the med through a central line
Before and after giving a patient medications through a CVAD, what does the nurse need to ensure
that the line is flushed with NS
What does the nurse always need to ensure before administering a medication through a CVAD
That the VAD is patent
If mutiple medications are being administered through the same line what does the nurse need to ensure?
to flush between each med
What VAD is used for TPN (total parenteral nutrition)
CVAD
What type of filter is required for TPN
in-line
What kind of line does TPN need to be administered through
a dedicated line
typically the white one.
How often does solution/tubing need to be changed for TPN through a CVAD
q24h
Does TPN need to be double checked by another nurse?
yes. ensure solution matches daily doctor order
Why would you use a PICC to draw blood
- if a clients peripheral veins are no longer accessible.
or - clinically significant reasons (risk of hemorrhage, needle phobia, client refusal)
What are concerns/risks of drawing blood from a CVAD (picc)
increased risk of catheter-related infection and CVAD occulsion
Can a good blood sample be obtained when drawn from a PICC
not always, lab results are not as accurate as with direct fresh blood access
When drawing blood from a CVAD, what lumen should be used?
- the largest lumen each time (mutiple-lumen CVAD preferred for blood samples)
- if using a multi-lumwn CVAD, leave the red one for blood.
When is a cap change required if drawing blood from a CVAD
if blood is still present in the needleless cap, or as directed by agency policy
Can student nurses draw blood from a CVAD?
yes, with RN supervision
according the IH’s blood sampling collection protocol, how much blood should be discarded when collecting blood from a CVAD? what about a PVAD-S? what about a PVAD-M
CVAD: 6ml
PVAD-S: 3ml
PVAD-M: none
determined by VAD length (2.5 X internal volume)
The nurse should discard blood prior to sample if collecting a blood culture
true or false
false
If a infusion is running, and the nurse wants to take a blood sample, how long do they need to stop the infusion to blood draw and for what VAD is this indicated
atleast 2 mins,
this is indicated for a PVAD-S and only “if critcally indicated” for a CVAD.
what is central venous pressure
the pressure measured in the vena cava near the right atrium
what is the normal range for CVP
3-8 cm H2O (or 2-6mm Hg)
What does CVP measure
right atrial pressure, and indirectly, right ventricular end diastolic pressure
What indicates central venous pressure monitoring
HoTN refractory to fluid resuscitation and severe sepsis
What is the role of the nurse when caring for a client with a CVAD
- ensure asepsis technique
- assess site for redness, drainage, swelling, pain, tenderness, warmth, numbness and parasthesia
- assess dressing and prevent infection
- ensure patency before use
- follow policy for frequency of patency checks and flushing
- check external length of PICC
if non-tunneled, ensure line is secured with sutures
How often should the nurse assess a site for a CVAD continuous infusion
Q1h
How often should the nurse assess the site of a CVAD if it is saline/heparin locked
Q shift
for intermittent CVAD infusions, what should be done after final flush
lock the line
How often should a patency check and flush be done on a IVAD and what type of needle change
Q shift using a non-coring needle change
what should the nurse do if a CVAD line is not flushing properly or is unable to aspirate.
notify IV team and label the line “do not use”
DO NOT USE a line that is not patent
When locking a tunneled CVAD with heparin, how many mls of 100 units/ml solution should the nurse flush with?
3 ml
When locking a IVAD with heparin, how many mls of 100 units/ml solution should the nurse flush with?
5 ml
How often does a PICC external length need to be measured?
atleast q24h in acute care, with every dressing change, and prn if needed
What external length PICC line cm difference (longer or shorter) from the intial placement, should be reported to the MRP or IV team
if over 2 cm difference
The nurse needs to be sure to check the external length of a CVAD,
True or False
False, they are not usually measured
- are needleless caps necessary for CVAD/PVAD continous primary infusions (open system)?
- how about (closed system) continous system primary infusions (no ports in tubing)
they are reccomended for open system continous primary infusions but not necessary. They are REQUIRED for closed system infusions though
What are some potential CVAD complications
- infection
- air embolism
- occlusions
- phlebitis, thrombophlebitis, infiltration, extravasation
- catheter fracture
- catheter embolism
- PE
- catheter migration
- pneumothorax/hemothorax
- arrhythmia
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- What signs and symptoms will be noticed for a infection/sepsis.
- Dx?
- tmt
local and systemic
- local: redness, tenderness, purulent drainage, warmth, edema at the insertion site
systemic: fever, chills, malaise - dx: altered VS, (incr. T, HR, RR and decr. BP, altered LOC), ab. labs
-Local: warm, moist, compresses and culure of drainage from site, remove catheter if indicated.
systemic: IV fluids, abx, sepsis protocol, removal
Symptoms of sepsis?
S: shivering, fever or very cold
E: extreme pain or general discomfort
P: pale or discoloured skin
S: sleepy or difficult rouse, confused
I: “I feel like I might die”
S: SOB
What is the blood concentration in unstressed patients?
1-1.5mmol/L
What is lactate
- a metabolite of glucose produced by tissues in the body under conditions of insufficient oxygen supply.
- normally cleared by the liver + kidneys
In critically ill patients such as ones suffering from shock or hypoperfusion, what are lactate levels usually?
elevated above 2 mmol/L with levels above 4mmol/L indicating immediates resuscitations and ICU admin
in order to prevent infection, if a client is diaphoretic or the site is bleeding or oozing, what alternative dressing can the nurse apply until these issues resolve
gauze dressing
What two conditions need to be present simultaneously for air to enter the vascular system
there must be a pressure gradient between the vasular space and atmospheric air and there must be a direct line of access to the blood vessel
Signs and symptoms of a air embolism
sudden onset dyspnea, continued coughing, breathlessness, tachypnea, wheezing.
altered mental status, agitation, irritability, impending doom feeling.
shoulder/chest pain
lightheadedness, hypotension
JVD
What is the treatment if a patient has a air embolism
- close, fold or clamp catheter.
- occlude puncture site of catheter that has been removed
- place client in tredenlenburg LEFT lateral decubitus position
- oxygen, VS, … if possible try to aspirate air from line.
- notify MRP
What position should patients be placed during CVC insertion at axillo-subclavian or jugular sites, in order to prevent potential air embolism
trendelenburg
What should the nurse instruct the patient to do post CVC removal
lie flat for 30 minutes
after removal of a CVC, what should the nurse apply to the site and for hwo long
a sterile, occulsive, petroleum based dressing covered with a TSM dressing and leave in place for atleast 24 hours
How should the catheter site be positioned when the nurse is removing a CVC
ensure the catheter exit site is lower than the height of the patients heart
What are 3 types of CVAD occulusions
1) thrombotic
2) chemical
3) mechanical
S+S of a thrombotic occulsion and what would the tmt be
- pain or edema in extremity, shoulder neck or chest.
- engorged peripheral veins in shoulder, neck or chest wall.
TMT: thrombolyis therapy and systemic anti-coagulation with or without CVAD removal.
4 types of catheter thrombosis
1) intraluminal clot
2) fibrin tail
3) mural thrombus
4) fibrin sheath
What is a intraluminal clot
there is resistance upon aspiration and decreased ability to infuse fluids
What is a fibrin tail thrombosis
resistance upon aspiration as the tail gets “sucked back” and no resistance when flushing becuase the tail gets pushed aside by the positive pressure
acts like a one way valve so infusion is allowed by not withdrawal
what is a mural thrombus
- depending where its located, may or may not be symptomatic upon syringe assessment.
- can result in partial or complete occulsions of the vein.
- s+s = swelling, pain, tendernes, engorged vessels
what is a fibrin sheath thrombus
inability to aspirate or difficult to withdraw blood and resistance or inability to infuse fluids.
sheath creates “sock” on catheter.
what is a chemical occulsion and what are some s+s and the tmt
occurs suddenly during admin due to a drug, mineral, or lipid residue precipitate.
S+S= line is sluggish and hard to flush
TMT: depends on policy, consult pharmacist, (may reccomend fibrinlytic or non fibrinolytic agent)
What are three risk factors for chemical occulsions
- recent infusion of incompatible drugs. (heparin, morphine, potassium, erythromycin, and dobutamine)
- medication with high-risk for precipitation (phenytoin and heparin)
- high concentration of calcium and phosphorous in parenteral nutrition solutions
How can the nurse prevent pulmonary embolisms
- NEVER irrigate the catheter if the IV is not flowing.
- Use in-line filters where applicable
- inspect meds and solutions containers for particulate matter
Tmt for PE
place client on strict bed rest in semi-fowlers position, notifiy MRP, monitor vitals and admin O2, assess CVC for patency (emerg drugs), document
what is catheter migration, s+s and tmt
CVAD migrates in or out changing the position of the tip.
s+s: sluggish infusuion or aspiration, edema of the chest or neck during infusion, client complaint of gurgling sound in the ear, dyshythmias
tmt:
STOP infusion, DO not use, reconfirm placement with CXR, consult with trained RN or MRP prior to reassessing.
Pneumothorax/ hemothorax cause and S+S
by accidental puncture of the pleura or lung during CVAD insertion
S+S: resp distress, chest/shoulder pain, unilateral distention of the chest, decreased or absent breath sounds.
what is the tmt for a pneumo or hemothorax
oxygen, elevate HOB, call MRP STAT, prepare for chest tube insertion
What causes arrhythmia/dysrthmia in patients with a CVAD and what are S+S and tmt
if CVAD advances into the right atrium there is a risk of irritating the heart and causing arrhythmias
s+s: arrhythmia on telemetry, abnormal HR and rhythm, palpitations.
tmt: oxygen, remove cause (proper placement) and treat symptoms.
what are hazardous drugs
any drug that causes toxicity in humans, animals, or in vitro systems.
