NUR 342: Vascular Access – Flashcards

Cease use of catheter. Clamp with nonserrated instrument between the broken area and the exit site. Cover the broken part with sterile gauze and tape securely. Notify health care provider. Health care provider may attempt to repair catheter with kit or CVAD may require removal.

Stop infusion. Consult pharmacist for antidote. Notify health care provider.

Reposition patient, raise patient's arm; if unsuccessful, notify health care provider; health care provider may order bolus of IV fluid, may administer thrombolytics, obtain chest x-ray, or remove catheter.

Notify health care provider. Catheter is likely to be removed by health care provider and culture obtained; health care provider may order antibiotic.

The initial specimen is discarded to avoid dilution of the blood sample with normal saline.

These patients are at risk for developing an infection and have the added factor of an invasive device. Development of phlebitis or infiltration requires prompt removal of the catheter.

Patient is able to demonstrate dressing change and skin care of device by discharge.

Chlorhexidine reduces the skin surface bacteria. Allowing it to dry completely promotes maximum bactericidal effectiveness.

Sterile technique is required to apply a new dressing to reduce the risk of infection.

This prevents pulling the catheter out of place. The previous dressing should be removed carefully, because patients frequently have alterations in skin integrity.

Infection Clotting (occlusion)

A tunneled central vascular access device is inserted by a health care provider with the patient in the operating room under local anesthesia. It is inserted through the subcutaneous tissue and then into a large vein and threaded into the superior vena cava. It is held in place by a Dacron cuff under the skin of the chest wall. Because the subcutaneous tunnel creates space between the end of the catheter and the actual vein, the risk of infection is lower. The catheter tip lies in the superior vena cava. These catheters have single, double, or triple lumens that allow simultaneous administration of several infusions. A percutaneous central venous catheter is inserted directly into a large vein. A PICC line is inserted through a large vein in the antecubital fossa and threaded into the tip of the superior vena cava. A PICC line may be inserted by a specially trained nurse. The catheter tip of an MLC lies in the larger vessels of the upper arm.

Vascular access devices are used to administer IV fluids, chemotherapy, and parenteral nutrition, to infuse medications and blood products, and to obtain blood samples. Enteral nutrition refers to using the GI tract as a pathway for supplemental nutrients, rather than an application of a vascular access device. Although repeated heparinization may reduce the patient's clotting time, this is an unacceptable reason for inserting a vascular access device.

Potential complications of a PICC include air embolism, thrombosis, occlusion, infection (systemic or local), phlebitis, and catheter migration. A fat embolism is unlikely. Immunosuppression may occur because of the administration of chemotherapy but fails to be a result of the insertion of a PICC.

A CVAD can remain in place for a longer period of time; therefore, the patient is able to receive long-term therapy with repeated access to the venous system without frequent venipuncture.

The large vessel lumen minimizes the risk of complications related to vessel irritation, inflammation, or sclerosis.

An implanted infusion port and a external tunneled CVAD require surgical placement. A percutaneous CVAD may be inserted at the patient's bedside. All other statements are true. An advantage of a multi-lumen CVAD is that it may be used to infuse incompatible solutions or medications.

The new nurse requires further teaching regarding the amount of fluid to discard; only 4-5 mL is necessary to avoid dilution of the blood sample. The new nurse should also be aware that the port is flushed with saline both before and after obtaining blood samples, and if the port is a noncontinuous infusion, it is heparinized. The new nurse is correct in stating that the site should be cleansed with alcohol swabs, then chlorhexidine swabs, and allowed to dry to promote maximum bactericidal effectiveness. The Huber needle is inserted through the skin at a 90-degree angle and pushed firmly down until the needle penetrates the silicone septum and hits the bottom of the portal chamber. Sterile gloves are necessary to palpate the port septum to locate the entry site.

The distal port

The nurse should perform hand hygiene. Gloves are unnecessary to open the sterile package. Sterile gloves will be worn for insertion of the Huber needle into the port septum. If the patient does not wear a mask, the patient's head should be turned away from the port site to prevent spread of airborne microorganisms while needle insertion site is exposed. The site should be cleaned in a horizontal plane, then a vertical plane, followed by a circular motion. This pattern allows penetration of the antiseptic solution into the cracks and fissures of the epidermal layer of the skin. Rigorous skin preparation is necessary to prevent introducing bacteria into system.

A 3-mL syringe is unacceptable for flushing a CVAD because it exerts too high a psi pressure and could damage the catheter. Avoid using a syringe less than 10 mL. Heparin flush solution is acceptable to flush a CVAD to prevent clot formation in the catheter. Follow agency protocol. To maintain patency, all three ports should be flushed.

10 mL syringes Avoid using a syringe less than 10 mL as it exerts too high a psi pressure. A 60 mL syringe is too large.

Every 5-7 days and as needed

Redness and tenderness at the site are symptoms of a local infection and should be reported. If the patient had a fever, this may indicate the infection had become systemic as well. A small amount of dried blood is a normal finding and should be cleaned, but does not require reporting. When not in use, each port should be clamped. The expected outcome is an absence of symptoms of infection, such as exudate, swelling, or redness at the placement site.

Occlusion and infection

In the case of an occlusion, the nurse can attempt several measures, such as having the patient cough and deep breathe, repositioning the patient, having the patient raise his/her arm, and making sure the tubing is kink free or unclamped. The nurse may then attempt to aspirate and flush the catheter again. If unsuccessful, notify the health care provider. Infusing the fluids by gravity would be unsuccessful if there is an occlusion. It is inappropriate to administer a thrombolytic without a health care provider's order. The nurse should never use a syringe smaller than 5 mL, as the psi pressure is too great and can damage the catheter or cause catheter migration. The patient is placed in the Trendelenburg's position if experiencing an air embolism. The nurse should avoid flushing the catheter forcefully, as this could dislodge a thrombus.

If extravasation occurs, the nurse should first stop the infusion. The nurse may administer the antidote per protocol for the vesicant drug, and notify the health care provider. Warm compresses may also be applied to the site, and emotional support provided to the patient. The PICC line should remain in place until the health care provider is notified, and then only qualified staff should remove the PICC line if ordered. Blood cultures are unnecessary; they are performed if infection is suspected. The patient may be informed of the purpose of the alarm on the infusion pump; scolding the patient is inappropriate.

The patient has symptoms of a localized and systemic infection. The nurse needs to contact the health care provider for further orders. These may include obtaining blood cultures and administering antibiotics. Removal of the catheter by the health care provider is a possibility. An antidote is inappropriate in this circumstance. An x-ray is unnecessary, as symptoms of displacement are absent. Even though percutaneous CVADs are at greater risk for developing an infection, these symptoms require intervention. The patient is at increased risk for infection because of immunosuppression from parenteral nutrition.

Indications for a vascular access device include IV therapy anticipated for longer than 7 days, including transfusions, TPN administration, long-term antibiotics, or continuous infusions such as opioids; infusion of vesicants or irritants, such as in chemotherapy; poor peripheral venous circulation; and frequent long-term phlebotomy. The patient in the emergency room with a leg injury, a child undergoing tonsillectomy, and a pregnant woman with nausea and vomiting would most likely only require short-term IV therapy, and therefore a long-term vascular access device would be unnecessary.

sterile and clean gloves, antimicrobial swabs, transparent occlusive dressing or sterile gauze dressing/tape, and mask(s).

The nurse used a 3-mL syringe during the catheter flushing. The nurse should avoid using a syringe less than 10 mL to minimize pressure during injection. A 3-mL syringe exerts too high a psi pressure. If continuous infusion is not indicated, the nurse should heparinize the port to prevent thrombus formation by flushing with 5 mL heparin (100 units per mL or institution policy).

To reduce the incidence of clot formation at the catheter tip

Hand hygiene is performed to reduce transmission of microorganisms. The patient and nurse are masked, or the patient turns his/her head away from the port site to prevent spread of airborne microorganisms while needle insertion site is exposed. The sterile field is prepared and sterile supplies are opened to provide a work space for use of sterile items. Alcohol is used to prepare the patient's skin overlying the port septum, swabbing the insertion site in a horizontal plane, then a vertical plane, followed by a circular motion (from the middle outward). This pattern allows penetration of the antiseptic solutions into the cracks and fissures of the epidermal layer of the skin. This is allowed to dry for 60 seconds. In the same manner, chlorhexidine swabs are used to cleanse the skin overlying the port septum, and skin is allowed to dry for 2 minutes. The nurse should have someone hold the vial of saline to draw it into the syringe and maintain sterility of gloves. The extension tubing and Huber needle should be primed with saline solution. The Huber needle should be inserted at a 90-degree angle. Proper placement is checked by attempting to withdraw blood by aspirating with the attached syringe; if a good blood return is present, the tubing is flushed with the remaining saline in the syringe. Five milliliters of fluid is aspirated and discarded into a biohazard container (avoids dilution of sample). The necessary blood for each sample is withdrawn by using two 10-mL syringes equal to the total volume withdrawn to eliminate the need to repeatedly puncture the infusion port for sampling. The port is flushed with 10 mL normal saline (any fluid other than normal saline has potential for clotting blood or precipitating in catheter). If a continuous infusion was not started, the port should be heparinized. The Huber needle is secured with Steri-Strips to prevent accidental dislodging of the needle at the insertion site. The Huber needle and insertion site are covered with a transparent dressing. If the Huber needle fails to sit flush on the skin, a folded 2-by-2 gauze is placed under the hub and then covered with the transparent dressing. The IV infusion tubing is connected to the Huber needle (IV tubing should already be flushed with IV fluids to prevent introduction of air), and the IV is regulated according to orders to maintain desired fluid intake and patency of the catheter. The blood is injected into sampling tubes for the lab. Lab requisitions are completed; the specimen is labeled and sent to the lab in a biohazard bag. All soiled supplies are discarded. Gloves are removed, hand hygiene is performed (to reduce spread of microorganisms), and the procedure is documented

Inserted in antecubital space with distal end advanced into the central circulation

Inserted first through subcutaneous tissue, then into a large vein and threaded into the distal end of the superior vena cava

Inserted directly through the skin into a large vein

Requires a Huber needle to access device

Assess site frequently for signs of infiltration.

Avoid trauma, avoid placement near site of local disease

Always clamp when not in use; never leave catheter open to air

Follow routine flushing with positive pressure, flush between medications

Use strict hand hygiene and aseptic technique

Use needleless system to access port

Administer low-dose oral anticoagulant therapy; avoid using excessive force when flushing a catheter

If an air embolism is suspected, place patient on left side with head down. This will help keep the air trapped in the right atrium so that it will not move in to the pulmonary circulation or the right side of the heart.

"The patient will be taken to surgery to have a PICC line inserted by the health care provider." A PICC line may be inserted by specially trained nurses in the patient's room. The arm in which a PICC or MLC is in place should be avoided when assessing blood pressure. Placement of a central vascular access device must be verified prior to use. A PICC line is ideal when the patient requires intermediate-length venous access (greater than 7 days to several months).

"The dressing of a central vascular access device should be changed when loose, soiled, or damp, but at least every 7 days since it is a transparent occlusive dressing." The dressing of a vascular access device should be changed when loose, soiled, or damp, but at least every 48 hours if it is gauze dressing and every 7 days if it is a transparent occlusive dressing. Band-Aids should not be used as they are not occlusive and thereby increase the risk for infection at the insertion site of the catheter.

Clamp the catheter near insertion site and place sterile gauze over break or hole.

The nurse clamps the port, inserts a syringe, unclamps and aspirates 5 mL of blood and sends it to the lab in a biohazard bag. The nurse flushes the port with 10 mL of normal saline and leaves the port clamped Blood cultures are often obtained both peripherally and from the vascular access device in the occurrence of a local or systemic infection. Do not flush before drawing blood for blood cultures. If blood cultures have been ordered, do not discard any blood. Use initial specimen for blood cultures. Blood cultures should be obtained prior to the initiation of antibiotic therapy. Changing the dressing using aseptic technique is a preventive measure, but not an appropriate intervention at this time.

Have the patient deep breathe and cough.

Reposition under fluoroscopy as ordered.

Potential for infection

Flush with 10 mL heparin flush solution. Regulate IV infusion. Dispose of soiled equipment. Remove gloves and document.

"I should avoid touching the Dacron cuff in a subcutaneous tunnel as this may cause dislodgement."

Stop chemotherapy administration. Administer antidote per protocol. Apply cold/warm compress.

Reposition the patient and have her raise her hand above her head; reattempt.