Download AHS - CVAD Learning Module

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Central Venous Access Devices
A Learning Module
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CVAD Education Requirements
1. Attend CVAD clinical skills session in PCH
2. Review the self- study module that is available in the library or check with your
manager
3. Complete the CVAD competency exam. Your manager can check exam answers.
4. If borrowed from the QEII library, please return booklet to the library
5. Arrange practical opportunities on your unit with a skilled staff nurse or your manager
6. Use the PCH CVAD skill check list to guide your learning plan and have it signed by
the staff who witness you practice drawing blood from a CVAD
7. Save a copy of this sheet for your competency profile and hand a copy in to your
manager.
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Table of Contents
1.
2.
3.
4.
5.
6.
7.
8.
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10.
11.
12.
13.
14.
15.
Topic
Purpose of this Learning Module
Objectives
Vascular Anatomy Review
Indications for a CVAD/ types of CVADS
PICC lines
Short-term venous access devices
Long-term venous access devices
Implanted ports
Characteristics of the Various Devices
Review I
Care of CVADS
Review II
Managing common problems and complications
Review III
Pediatric Considerations
Page
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5
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Purpose of this Learning Module
The central venous access device (CVAD) learning program has been developed to assist
staff in acquiring the knowledge and skills necessary to care for clients who have a CVAD.
The module will provide the learner with information specific to vascular anatomy,
indications for a CVAD, the various types of devices, potential complications and a review of
specific procedures involved in caring for the client with a CVAD.
All staff whose scope of practice allows them to care for a client with a CVAD are first
required to complete the IV competency program and then the CVAD competency program
may be started.
The program involves the completion of the following:
a) Reading the self-study module
b) Successful completion of the examination with a minimum score of 80%
c) Successful demonstration of blood withdrawal from a minimum of 2 CVADS
d) Successful demonstration of the de-clotting of a central line. (Because de-clotting is
not always successful, proper technique and rationale described to the witness is
sufficient for successful completion of the skills checklist)
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Objectives
Upon completion of this module, the skilled practitioner shall be able to:
1. Identify the major vessels which are used for central venous catheterization
2. Identify 5 major indications for a CVAD
3. List 3 advantages and 3 disadvantages of a short-term CVAD
4. List 3 advantages and 3 disadvantages of a long-term CVAD
5. List 3 advantages and 3 disadvantages for the use of a PICC line
6. Differentiate between the types of CVADS
7. Identify the priorities of care following insertion of a CVAD
8. Describe the dressing procedures for the CVAD
9. State the flush requirements for the various devices and the frequency of injection cap
changes
10. List the steps in blood withdrawal from a CVAD
11. State the frequency of tubing changes with CVADS
12. Identify common complications and appropriate interventions for the client with a
CVAD.
13. Describe the steps in de-clotting a CVAD
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Central Venous Access Devices
CVADS have become a preferred route of venous access for many clients. Due to the
challenging nature of this procedure and the numerous types of CVADS, it is necessary for
the practitioner to be very familiar with all aspects when caring for these clients.
Vascular Anatomy Review
A basic understanding of the vascular anatomy will give the caregiver an advantage when
caring for the client with a CVAD. This understanding will enable the practitioner to make more
accurate client assessments that could possibly avert serious complications.
1.
The External Jugular Vein: easily visible on the side of the neck. It follows a
descending inward path to join the subclavian vein along the middle of the clavicle.
2.
The Internal Jugular Vein: Descends first behind and then to the outer side of the
internal and common carotid arteries. The internal jugular vein joins the subclavian
vein at the root of the neck.
3.
The Right Innominate Vein: Is about 2.5 cm in length. It passes almost vertically
downward and joins the left innominate vein just below the cartilage of the 1st rib.
4.
The Superior Vena Cava: Receives all blood from the upper half of the body.
Comprised of a short trunk ranging from about 6-7.5 cm in length. It begins below
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the 1st rib close to the sternum on the right side, descends vertically slightly to the
right and empties into the right atrium of the heart.
5.
The Left Innominate Vein: This vein is about 6 cm in length and larger than the right.
It passes from left to right in a downward slant across the upper front area of the
chest. It joins the right innominate vein to form the superior vena cava.
6.
Subclavian Vein: A continuation of the axillary vein, it extends from the outer edge of
the 1st rib to the inner end of the clavicle where it unites with the internal jugular to
form the innominate vein. Valves are present in the venous system until
approximately 2.5 cm before the formation of the innominate vein.
7.
Cephalic Vein: ascends along the outer border of the biceps muscle to the upper 3rd
of the arm. It terminates in the axillary vein with a descending curve just below the
clavicle.
8.
Axillary Vein: This vein continues upward as an extension of the basilic vein,
increasing in size as it ascends. It receives the cephalic vein and terminates
immediately beneath the clavicle as the outer border of the 1st rib. At this point it
becomes the subclavian vein.
9.
Basilic Vein: This is larger than the cephalic vein. It passes upward in a smooth path
along the inner side of the biceps muscle and terminates in the axillary vein.
10.
The Right Atrium: Is larger than the left atrium and its walls are very thin. It receives
blood from the upper body via the superior vena cava and from the lower body via
the inferior vena cava.
Indications
CVADS are inserted for a variety of reasons and have varied uses. Such as:
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a) Long-term IV therapy. Use of a CVAD preserves the peripheral vascular system and
saves the client from painful and repeated attempts at IV access. (i.e.; Clients going
home and placed on a home parenteral therapy program)
b) Infusion of vesicant or irritant medications or nutritional solutions such as:
i. TPN
ii. Chemotherapeutic agents
iii. Medications that can cause necrosis of surrounding tissues if they
where to go interstitial (i.e.: Dopamine, Norepinephrine).
iv. Specific antibiotics
c) Hemodynamic monitoring.
d) Insertion of internal pacemaker wires.
e) Rapid infusion of large volumes of fluid in an emergency situation.
f)
Frequent venous blood sampling and or blood product administration
Types of CVADS
CVADS can be placed in one of three of the following categories:
i.
ii.
iii.
Peripherally inserted CVAD
Short term CVAD
Long –term CVAD
Peripherally Inserted CVADS (PICC line): PICC lines are a reliable form of long-term
central venous access. To be termed a PICC, it must be inserted into the peripheral
vasculature. A vein in the arm is the most common insertion point. To meet the definition,
the distal tip must terminate in the superior vena cava, the inferior vena cava or the
proximal right atrium. If the termination point is not into the central circulation, it is then
considered a peripheral line.
Insertion Methods: There are different insertion methods for PICC lines. Some centers
employ specially trained staff that insert the lines at the bedside, other centers insert the
lines using guided imagery in a diagnostic imaging department. Currently PICC lines
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inserted in the PCH region are inserted in the diagnostic imaging department at the QEII
hospital.
a) Peel-away cannula technique: Access is established by inserting the cannula and
stylet, much like a regular IV cannula into a palpable peripheral vein in or near the
antecubital fossa. The stylet is removed and the catheter is inserted through the
cannula. The cannula is then pulled back and peeled away from the catheter. This
technique requires accessible veins at or near the antecubital fossa.
b) Modified- Seldinger Technique: A vein is accessed with a hypodermic needle, an IV
cannula or an echogenic needle. A guide wire is threaded into the needle or cannula
several centimetres, and then the needle or cannula is removed, leaving the guide wire
in place. An introducer sheath with dilator is inserted over the guide wire, the guide
wire and dilator are removed and the catheter is advanced through the introducer
sheath which is then pulled back and peeled away (Bowe-Geddes, L. & Nichols, H.,
2005).
PICCS are available in 3 Fr, 4 Fr and 5 Fr Sizes. (Equivalent to 20, 18 and 16 gauge
IV’s respectively). They are available in a variety of lengths and can be trimmed at the time
of insertion depending on the anatomy and size of the patient.
Types of PICC Lines:
1. Open –ended or non-Groshong: This type of PICC line has a blunt open end and must
be heparinized or have a positive pressure valve in place to maintain patency. There
are also clamps in place on this line. Due to the open end, blood can sit in the end ,
clot and occlude the valve. Heparin or positive pressure valves are used to prevent
this.
2. Closed-ended or Groshong: This type of PICC has a rounded, closed end with a side
slit that closes like a valve when not in use. Saline flushes are used to maintain
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patency. There are no clamps on these lines. Clamping can cause damage to the
catheter itself.
PICC Line Valves:
Closed –ended (Groshong):
Aspiration
Infusion
Open-ended (non-Groshong):
Peripherally Inserted Catheter: (With Clamp)
Peripherally Inserted Catheter: (Without Clamp)
Closed
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Short Term Central Venous Access Devices:
Short term CVADS can be defined as catheters that are intended for short-term use.
(4-6 weeks). The vein is entered approximately 2.5 cm from the insertion site and is
untunneled. These lines may have single or multiple lumens. They can be inserted in
various vessels including the vessels of the thorax or the femoral veins. The tip rests in the
superior or inferior vena cava. The multi-lumen catheter is made up of 2 or 3 polyurethane
catheters encased in one outer shell. Exit points are staggered and rotated to avoid mixing
infusions.
Arrow short- term CVAD
Short-term central lines are inserted in various clinical settings- at the bedside on any
unit in acute care, but most commonly in the ICU, OR or emergency departments.
Bedside insertion requires staff to assist with this procedure by gathering the
appropriate equipment, setting up the sterile fields, handing items to physicians and
heparinizing the lumens. Close assessment of the client post is insertion is warranted as
per PCH policy and procedure.
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Long-Term CVADS:
When central venous therapy will last longer than 4-6 weeks, a surgeon will insert the
catheter under sterile conditions in an OR setting. The patient is placed under general
anaesthesia for this procedure.
Long- term CVADS can either be “tunnelled” under the skin so that a part of the
catheter is buried in the subcutaneous tissue or they can be “implanted” entirely under the
skin and sutured to underlying fascia.
Tunnelled Catheters:
Tunnelled catheters are placed so that a portion of the catheter lies within a subcutaneous
pocket or tunnel before it exits the skin. The catheter is usually inserted into the upper chest
and threaded through the internal jugular or subclavian vein, however the femoral vein may be
used if chest access is not available. The catheter is then advanced until the tip lies either in
the superior vena cava, proximal to the junction
with the right atrium or directly in the right atrium.
A permanent cuff enables the catheter to be
imbedded into the subcutaneous tissue, allowing
for stabilization of the catheter and inhibition of
ascending bacteria. Long-term tunnelled catheters
are made of soft silicone rubber with one or more
Dacron cuffs for anchoring.
Tunnelled CVAD
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Tunnelled catheters are often described by brand names such as the Broviac™,
Hickman™ or Leonard™catheters. Sizes of catheters vary depending on brand name and
purpose.
Implanted Catheters:
Implanted catheters are an excellent option when having an external catheter is not
appropriate either due to client preference, age (pediatric client) or condition (altered mental
status). An implanted catheter or port is a small reservoir or “portal” attached to a small
catheter. In the center of the portal is a self-sealing silicone septum. The entire device is
implanted under the skin. It must be inserted in an OR setting. Once the chest tissue is
opened, the port is secured in a subcutaneous tissue pocket and the catheter exiting the port
is threaded into the subclavian vein. The chest tissue is then sutured closed over the port and
the catheter so that the access device is totally hidden beneath the skin. These devices are
also referred to as “Implanted venous access devices” or IVADS. The portals themselves can
be made of either plastic or metal and can be either single or double lumen. Common brand
names include Portacath™, Infuse-a-Port™, and Mediport™
IVAD sites may vary. The most common site is the
right or left upper chest. IVADS can also be inserted using
the veins in the upper arm. The distal tip still remains in the
superior vena cava close to the right atrium.
.
Assorted Implantable ports (above). Possible IVAD sites (right)
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Accessing an IVAD requires specific needles designed for this purpose. Using standard
needles can cause coring of the silicone septum and lead to leaking and malfunction.
Huber™Sets
Gripper™Set
Characteristics of the Various Devices:
Catheter Type
Peripherally inserted
central catheter
(PICC)
Location
Inserted through a
small incision in the
antecubital area,
usually at the basilic
or cephalic vein, &
then advanced
upward into the
central circulation.
Tip is located in the
distal superior vena
cava above the right
atrium
Function
Can be used to
infuse hypertonic and
vesicant solutions/
medications. Can be
used to draw blood
samples. BARD®
recommends blood
draw only if larger
than 4 Fr
Tunnelled external
catheter (i.e.:
Hickman™,
Broviac™)
Usually placed in
the upper chest; the
catheter which is
designed with a cuff,
is inserted through
the skin & into a
vein of the chest or
neck. It is then
threaded through a
vein to a point just
above the right
atrium.
Can be used to
infuse hypertonic or
vesicant
solutions/medications
& can be used to
draw blood samples
Advantages
 Does not need to
be inserted in the
OR
 Reliable long-term
access for up to 2
years
 Decreased
insertion risks- i.e.:
pneumothorax/
venous perforation
 Decreased risk of
catheter- related
sepsis
 Cost/Time efficient
 Lower
complication rates
 Easy removal
 Increased patient
comfort; better
access if self-care
required
 Low infection rates
due to the exit site
being distant from
the vessel & the
bacterial barrier
provided by the
cuff.
 Reliable long term
access- can be in
place for 2-3 years
 Increased patient
comfort; easy
access if self-care
Disadvantages
 Fragile catheternarrow and
delicate; easily
occluded and can
rupture easily
 Possible alteration
in body image with
external protrusion
of catheter
 Limitation of
physical activities
such as swimming
 May be difficult to
find and access a
large enough vein
 Easy to remove
 Costly due to the
need to insert in
the OR
 More invasive;
greater risk as far
as general
anaesthetic is
required
 Removal more
difficult and can be
painful
 Possible alteration
in body image due
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required
 Cuff makes
accidental removal
less likely
Implanted venous
access devices
Surgically implanted
under the upper
chest wall in a
subcutaneous
pocket & the
catheter exiting the
port is threaded into
the subclavian vein
skin and tissue; the
chest wall is then
closed over the port
and catheter
Can be used to
infuse hypertonic &
vesicant fluids or
medications.
Moderate success
with drawing blood,
can be used
 Less chance of
infection than with
external catheters
 Minimal limitations
with activities; can
bathe and shower
 Reliable long-term
access for 2-3
years
 Less alteration in
body image
Short Term central
venous access
devices
Percutaneously
inserted directly into,
usually the
subclavian or
femoral veins.
Catheter is then
advanced down
toward the vena
cava and sits above
the right atrium.
Can be used to
infuse hypertonic or
vesicant IV solutions
or medications
(preferred)
 Easily and quickly
inserted At the
bedside for critical
patients
 Reliable access for
blood draw, rapid
fluid administration
& vesicant
medication
administration
 Easy to remove at
the bedside
to external
protrusion of
catheter
 Limitation of
physical activities
such as swimming
 Insertion must be
done by a physician
 Requires
insertion of a
needle through the
skin wall to access
the port; may cause
discomfort
 More skill
required to access
the port due to the
fact that it is
implanted under the
skin
 Repetitive motion
upper body
activities such as
swimming or golf
can cause catheter
rupture as it can
lodge between the
clavicle and 1st rib
 Higher chance of
infection
 Catheter requires
changing every 3-4
weeks
 Higher incidence of
complications due
to “blind” insertion
technique
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Review I
1.
Identify the following vessels:
2.
Identify 5 major indications for CVAD use.
a.
b.
c.
d.
e.
3.
Explain the major difference between a PICC line and a tunnelled long-term CVAD.
4.
List three advantages of a PICC line.
a.
b.
c.
5.
Explain the difference between a closed -ended and open- ended PICC line?
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6.
What is the rationale for using saline only and no clamp for the closed ended PICC line?
7.
List three advantages of long-term CVADS.
a.
b.
c.
8.
List three disadvantages of short-term CVADS.
a.
b.
c.
9.
Match the device to the listed characteristic.
1.
Device
Open-ended PICC line
2.
Closed -ended PICC line
3.
Implanted venous access device
B.
4.
Long-term tunnelled CVAD
C. This device does not require a clamp
5.
Short –term CVAD
D. Also known as a non-Groshong™line
A.
Characteristic
Must be accessed with a special noncoring needle
E.
Can be inserted quickly at the bedside
Inserted in the OR, this device has a
cuff that assists in securing it in the
subcutaneous space
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Nursing Care of CVADS
A. Sterile Technique:
Infection is the most common complication seen when it comes to central lines. This must
always be considered by staff who are caring for clients who have these lines, regardless
of the type of line. The principles of sterility must be strictly adhered to when caring for
clients with CVADS. The tip of a CVAD is located in the central circulation at or near the
heart. The introduction of pathogens can severely compromise a client who is already
compromised due to illness or injury.
B. CVAD Insertion:
1. PICC Lines: PICC lines may be inserted at the bedside in some facilities or
using fluoroscopy in the diagnostic imaging department. The latter is the case
in Peace Country Health. Because the insertion is done in a diagnostic imaging
department, a CXR is not required. Immediate post-insertion assessment
includes assessment of the site for excessive oozing- (it is wise to know if the
patient has any bleeding disorders or is on anticoagulants prior to the
procedure). A pressure dressing can be applied distal to the site and the limb
elevated. Cold packs applied below the site can also help reduce bleeding after
insertion.
2. Short-term CVADS: Short term CVADS are often inserted in the ICU, OR or
emergency room for critical patients requiring large fluid volumes or
administration of vesicant medications. Short term CVADS may also be
inserted on a medical or surgical floor. Regardless of location, a physician must
insert CVADS. The role of staff includes having a thorough understanding of
the necessity for the line as well as preparing the client for the procedure.
Client teaching should include the following:
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
Purpose for inserting the catheter and where it I likely to be located on
the chest area and what the catheter will look like

Explain that they will feel cold antiseptic on their skin & a stinging
sensation from the injection of local anaesthesia (ensure there are no
allergies to local anaesthetics)

Instruct the client to tell the physician if they experience pain during
the procedure

Explain that there will be sterile drapes placed over the chest and face
area and that they may be placed in a “head-down” position

Explain that there may also be a CXR completed following to confirm
placement

The physician is to obtain written consent if the condition of the client
allows for this (refer to consent policy # A-V- 353).

It is the responsibility of the individual inserting the CVAD to discuss
possible complications to the client
The most common complications associated with insertion of a short –term
device include air embolism and pneumothorax.
Air Embolism: This occurs when air is allowed to enter an unclamped catheter.
Signs and symptoms include: sudden onset of pallor, cyanosis, dyspnea,
coughing, tachycardia and shock. If the healthcare provider suspects air
embolism, immediately place the client on the left side in Trendelenberg
position, administer oxygen and call the physician.
Pneumothorax: A pneumothorax or “collapsed lung” can result from
accidental puncture of the pleura of the lung while trying to access the
blood vessel. Symptoms include: shortness of breath, chest pain,
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tachycardia and diminished or absent lung sounds on the affected side.
Immediate care involves administration of high flow oxygen, monitoring
of vital signs and calling the physician. A chest x-ray may be required to
diagnose pneumothorax.
3. Tunnelled/ Implanted CVADS: Placement of these devices is a surgical
procedure done in the OR with the patient under a general anaesthetic.
Catheter tip placement is verified by CXR before the client leaves the OR.
Immediate priorities for nursing care include assessment of bleeding
particularly from the exit site and pain. Check dressings frequently for oozing.
This should stop within the first few hours. Excessive bleeding should be
reported to the physician.
Tunnelled: Bruising and pain along the course of the tunnel are not uncommon.
The extent of bruising and degree of pain should be assessed using
appropriate pain scales, recorded and analgesics or other comfort measures
provided as necessary.
Sutures at the entrance site (at the neck) are removed in approximately one
week (physician to order). Sutures at the exit site (on the chest) are usually
removed 14 days to 1 month post-insertion (physician to order).
A suture at the exit site holds the catheter in place until the cuff becomes
completely imbedded in the subcutaneous tissue (approximately 2-3 weeks).
The first 2 weeks after insertion carry the greatest risk of dislodgementgenerally from too much pull on the catheter or from the patient using upper
chest muscles. To avoid traction on the tubing, coil it once and then tape it to
the chest (If not attached to IV tubing). If the line is connected to IV tubing,
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wrap a piece of tape around the IV tubing in book-fashion and pin to the
patient’s gown. NEVER tape and pin directly to the catheter.
Implanted Devices: During surgery, the tip of the catheter is positioned in the
superior vena cava. A subcutaneous pocket over a bony prominence is then
prepared for the port. The proximal end of the catheter is then routed and
connected to the port site, which is sutured to the underlying fascia. The port
site will initially be tender and sore for a few days following, but should resolve
within a few days. Pain assessment tools should be used during this time and
pain management techniques provided accordingly. Immediate post op
complications are uncommon; observation for external bleeding and breathing
difficulties are similar to the other types of devices.
Specific information concerning care and maintenance of CVADS is outlined in
the policy and procedure at the end of this learning module. Please refer to the
policy and procedure when answering the following questions.
Review II
1. Why is it essential to maintain sterility when working with a client’s CVAD?
2. Mrs. Smith, age 53 is about to have a short-term CVAD inserted. What would
you tell her about the procedure and what to expect?
3. Mr. Edwards, age 33 requires insertion of a long-term, tunnelled CVAD. What
will you tell him about the procedure and what to expect?
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4. List the differences in flushing for a short-term CVAD and a long-term
implanted CVAD (IVAD)?
5. Mr. Jones has a double-lumen open-ended PICC line. He has TPN running
through one lumen and an IV of 2/3 1/3 for medications running through the
other. How often are the tubings changed?
Managing Common problems and Complications
Regardless of the type of CVAD, managing these devices successfully requires troubleshooting skills. The following chart will assist you in recognizing and managing some
common problems and complications.
Complication
Catheter becomes
disconnected
Assessment
 Bleeding from catheter/
tubing connection
 Signs of air embolismcough, chest pain,
dyspnea, cyanosis of lips
and nailbeds
 Signs of shock- may be
hypovolemic due to
excessive blood loss or
obstructive due to air
embolism
Prevention
 Ensure that the
catheter is clamped
when opened ( if a
clamp required for the
device)
 Ensure catheter is
securely connected to
tubing- connections
may be taped using
tape applied in “bookfashion” for easy
removal
Intervention
If air has entered the
catheter:
 Clamp the catheter
 Assist client to lay flat
on left side in
Trendelenberg
position so air can be
trapped in right atrium
and removed
 Notify the physician
immediately
If blood is coming from
the catheter:
 Apply the catheter
clamp
 Clean outside of the
catheter hub with
alcohol, betadine or
chlorhexidine
 Apply a saline lock
device or syringe to
the catheter until a
new tubing can be
attached
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 Restart infusion
 Notify physician
Catheter damage;
breakage
 Observe for pinholes,
leaks and tears each shift
 Assess for potential fluid
leakage with flushing and
during infusion
Dislodgement of
CVAD
 Assess catheter length
daily
 Inform client of possible
catheter dislodgement
 Assess for edema at exit
site and tunnel for coiling
 Assess for distented neck
veins
 Assess for blood return
 Inability to infuse
 Inability to
aspirate blood
 Assess equipment
 If IVAD, re-access and
verify needle placement
 Assess clamping devices
 Note any discomfort or
pain in shoulder, neck,
arm or insertion site
 Neck or shoulder edema
 Ensure sutures not
restricting
Occlusion thrombus,
precipitation,
malposition
Pneumothorax or
hemothorax
 Assess for signs of
respiratory distress, chest
pain, dyspnea, cyanosis,
decreased breath sounds
on affected side, tracheal
deviation, low SPO2
 Signs and symptoms of
shock
 Abnormal CXR
Air Embolism
 Assess for respiratory
distress, unequal breath
sounds, weak pulse,
 Follow proper clamping
procedure.
 Use only approved
clamps for the device
being used.
 Avoid using sharp
objects near the
catheter
 Do not use needles to
flush.
 Use only needless
injection caps on all
CVADS
 Use nothing smaller
than a 10 mL syringe to
flush all CVADS
 Loop and tape the
catheter securely
 Use an occlusive
dressing
 Avoid pulling on CVAD
 Avoid manipulation of
implanted ports and
external catheters
 Follow appropriate
flushing procedure
 Use positive pressure
and turbulent flow
technique
 Avoid using excessive
force
 Flush between drugs to
avoid incompatibility
 Flush vigorously after
viscous solutions
 Avoid kinking catheter
 Proper client position
during insertion ( rolled
towel under shoulder,
trendelenberg position
with head turned to
opposite side)
 Assess for early signs
of fluid infiltration such
as swelling in the
shoulder, neck, chest
and arm area
 Immobilize client during
insertion procedure
 Flush all air from tubing
prior to attaching
 Perform Valsalva
 Check c;ient for signs
of distress
 Stop infusion and
clamp catheter close to
the client’s chest
 Notify physician
 Obtain repair kit from
stores for the physician
 Provide client
instructions re: how to
avoid manipulating the
catheter
 Assist physician as
required for insertion of
a new catheter
 Reposition client
 Have client cough, take
deep breaths
 Raise clients arms
above head
 Remove dressingobserve for kinks &
displacement
 Assess infusion system
tubing and all clamps
 Attempt to aspirate
blood
 If unsuccessful with all
interventions, notify
physician- possible
CXR and de-clotting of
line
 Notify physician
 Assist with removal of
catheter ( competent
staff may remove a
short term CVAD)
 Administer oxygen as
required
 Monitor vital signs
including pulse
oximetry
 Assist with chest tube
insertion
 Clamp catheter
immediately
 Turn patient on left
Central Lines 23
hypotension (signs of
shock), JVD, churning
murmur over precordium,
cyanosis, pallor, dyspnea,
coughing, decreased LOC
during tubing and cap
changes or anytime the
end is open to air
 Use infusion pump with
air-in-line alarm
 Tape all connections
 Clamp catheter when
not in use


Local infection
Systemic infection
Skin erosion,
hematomas, cuff
extrusion, scar tissue
formation over port
Infiltration,
 Assess insertion or exit
site for redness, warmth,
drainage edema or
tenderness
 Assess vital signs
 Monitor labs
 There may be some mild
redness at the PICC
insertions site as the
mechanical motion of the
limb causes irritation. Note
the redness parameters
and any increase in size
 Strict hand washing
 Use of sterile technique
 Adhere to
recommended dressing
change procedure
 Occlusive dressing
over exit site
 PICC lines may require
elevation of the limb,
mild exercise and
warm moist heat to
resolve the edema

 Assess for fever, rigors
 Leukocytosis
 Nausea, vomiting and
general malaise
 Elevated serum or urine
glucose level
 Positive blood cultures
 Tachypnea, diaphoresis
 If septic, look for signs and
symptoms of septic shock
 Examine IV solutions_
check expiry dates,
look for clouding or
sediment
 Assess tubings and
solutions for leaks
 Monitor serum and
urine glucose levels- a
sudden elevation may
be an early sign of
sepsis
 Use sterile technique
when adding solutions
and changing tubings
 Keep system closed as
much as possible
 Provide client with
instructions re: sterile
technique and the
importance of
adherence
 Change tubings,
solutions and injection
caps as per
recommendations
 Maintain nutritional
status
 Minimize edema with
cold packs or
compresses
 Avoid pressure or
trauma
 Rotate site with each
port access
 Do not administer

 Loss of viable tissue over
implanted port
 Separation of exit site
edges
 Drainage at exit site
 Redness
 Edema, contusions
 Tunnelled portion of
catheter exposed
 Pain








side, head down, so air
can be trapped in the
right atrium then
removed. Maintain this
position for 20-30
minutes
Do not allow client to
take deep breaths (a
large air intake would
worsen the problem
Notify physican
immediately
Monitor vital signs as
required
Culture site if
drainage noted
Apply sterile dressing
Blood cultures may be
ordered both
peripherally and from
the line
Assist with removal as
required
Send catheter tip only
if signs of infection
present
Draw central and
peripheral blood
cultures as ordered, if
the same organism is
found in both, the
catheter is probably the
primary source of the
sepsis
Culture catheter tip if
removed and signs of
infection are present
Administer antibiotics
as ordered
Monitor vital signs
closely
 Assist physician to
remove CVAD
 Improve nutrition
 Provide appropriate
skin care
 Observe site
frequently
 Warm compresses
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extravasion
Incorrect placement,
catheter tip migration
Phlebitis (most
common PICC line
complication)




Erythema
Edema
Spongy feeling
Labored breathing







Cardiac arrhythmias
Hypotension
Neck distension
Narrow pulse pressure
Inadequate blood
withdrawal
 Back-up of blood in
catheter
 Referred pain in jaw, teeth
or ear






Pain
Erythema
Induration
Palpable venous cord




vesicants without a
blood return
Astute assessment
skills
Frequent visualization
of exit site
Obtain an x-ray
following placement
Assist physician to
reposition the catheter
or attempt patient
repositioning
Factors that greatly
increase intrathoracic
pressure such as
protracted vomiting or
coughing can cause
catheter tip migration
Usually occurs in the
1st 48-72 hurs post
insertion
Smaller gauge
catheters have a lower
risk
Can be caused by
difficult or traumatic
insertions
 Emotional support
 X-ray for placement
as ordered
 Use antidotes as
required (i.e.:
phentolamine)
 Obtain an x-ray and
ECG as ordered
 Discontinue all fluid
administration
 Assist physician to
reposition the catheter
 Administer
appropriate
medications as ordered
 Warm moist
compresses between
shoulder and insertion
site for 20 minutes QID
 Elevate extremity;
keep it warm
 Remove PICC if
painful, patient is febrile
or there is questionable
drainage from site
Review III
1. Miss White, an 80 –year-old confused patient, has a multi-lumen short-term CVAD
through which she has been receiving TPN and medications. You walk into her room
to discover that the IV tubing has been disconnected from one of the lumens and there
is blood leaking from it. What are you priority actions?
2. If you suspect your client has an air embolism, what are your priority actions?
3. You are attempting to withdraw blood from a central line with a vacutainer but there is
not blood return. What are your priority treatment actions and in what order?
Central Lines 25
4. What types of things can you do and teach the client to prevent damage to a CVAD?
5. When flushing a CVAD, What should you do to help prevent an occlusion at the end of
the catheter?
Pediatric Considerations:
General Considerations:
 Blood withdrawal: 3-5mL for discard. Flush with 5 mL’s normal saline first
 Post blood withdrawal, flush with 5-10 mL’s normal saline using positive pressure
technique.
 All lines are locked with heparin 10u/mL, with a volume of 1-3 mL, except IVAD’s
(see below).
 Competent professionals who have met the competency requirements and whose
College allows this within their Scope of Practice may remove short-term nontunnelled devices and PICC lines.
 For infants less than 10 kg use heparin without preservative.
PICC Lines:
 Usually inserted via the femoral, antecubital or temporal region.
Short-term Non-tunnelled Lines:
 Flush every 12 hours using positive pressure technique.
Long-term Tunnelled Lines:
 For catheters 7fr and smaller, flush 3 times per week if not in use
 For catheters larger than 7fr, flush once a week if not in use.
Central Lines 26
IVAD’s:
 You may use EMLA™ cream over the injection site for IVAD until scar tissue
develops to prevent discomfort for the child.
 EMLA™ cream must be applied 1 hour before injecting the gripped needle.
 Parents must advise daycare or school of child having device implanted and child
should carry card with all info on device.
 Locking solution: 4-5mLs heparin 10u/mL, using positive pressure technique.