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Flashcards in CVC's and PN Deck (55)
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1

What is central venous therapy?

- Vascular access device inserted (under sterile conditions) into a peripheral or central vein with the tip lying in the Cavo-Atrial Junction
- Achieved using one of the four devices: centrally inserted catheters, peripherally inserted catheters, centrally inserted ports and peripherally inserted devices

2

What are the major indications for central therapy?

- Inadequate peripheral access (esp. pt's who are frequent flyers)
- Complex treatment regimes (e.g. chemotherapy)
- Hyperosmolar infusions
- Infusions of irritating or vesicant drugs

3

What are other indications for central therapy?

- Rapid absorption, and rapid blood and tissue perfusion
- Long-term IV therapy
- Patient preference

4

What are considerations when placing a central line?

- Patient condition
- Underlying disease processes
- Anatomical structural deviations or pathologies (e.g. throat and neck cancers)
- IVDU (drug users; less likely to have access to peripheral veins)
- Confused
- Potential need for dialysis (permanent catheter?))

5

What are some risks and complications?

- Advantages far outweigh the disadvantages, but potential for risks/complications must always be considered
- Can be divided into insertion and long-term complications (e.g. what damage is happening to the vessels themselves?)
- Big insertion risk is infection, as it has potential to spread systemically rapidly

6

What are typical insertion pathways and placements for central lines?

- Usual sites are subclavian vein, internal or external jugulars (e.g. neck placements)
- Femoral access (less frequent)
- Peripheral access: basilic, cephalic and median cubital

7

What are the different types of short-term CVC's?

- Percutaenous (non-tunneled, non-cuffed)
- Midline **

8

What are the different types of long-term CVC's?

- Tunneled
- Implanted vascular access devices
- PICC lines

9

What are the dwelling times for CVC's?

As long as device is required, functional and not a source of infection

10

What is the difference between single vs multi-lumen catheters?

- Single, double, triple and quadruple lumen catheters are available
- Each lumen must be treated as a separate catheter
- Incompatible meds can be infused simultaneously via separate lumens (technically meet in bloodstream, but because vessel is large and quickly dispersed in blood stream it is not a problem)
- Exit ports are approximately 2 cm apart along the catheter stem

11

Describe the suggested uses of lumens in a multi-lumen port design:

PROXIMAL: longest externally, 18 gauge; medication administration

MEDIAL: middle port, 18 gauge; TPN, med or fluid administration

DISTAL: shortest externally, 16 gauge; blood administration, high volume fluids, medication, CVP monitoring and blood sampling

12

What are open-ended CVC's?

- Catheter is open at the distal end, so clamps are usually present
- Clamping required before entry into system
- Requires saline (used to use low-dose heparin to keep patent, but saline is just as effective)
- Any type of CVC can be open ended
- Some have proximal valves in the proximal end of the catheter, meaning that a clamp is not required

13

What are closed-ended CVC's?

- Valve is present at tip or hub of catheter
- Valve stays closed except when aspirating of infusing
- Clamping not required
- May be present on tunneled CVC's, IVAD's and PICC's

14

What are advantages of short-term catheters?

- All types of therapies can be administered
- Multiple lumens, large diameters of lumens
- Economical
- Preserves peripheral veins

15

What are disadvantages of short-term catheters?

- Highest risk of infection and post-insertion complications
- Not for home therapy use or long-term use (complications like bleeding-out can turn bad very quickly, so requires immediate care!)
- Can be easily dislodged

16

Describe long-term catheters:

- Surgically inserted via percutaneous cut-down (AND surgically removed! Cannot come out without surgery!)
- Generally a tunneled or implanted device/port
- Made of soft, medical grade silicone
- Dacron cuff near exit site
- Can be single or multi-lumen
- Can be open ended or closed
- Portion is tunneled through SC tissue from exit site to insertion site
- Dacron cuff (little raised section on tubing) positioned in the SC tissue to minimize risk of infection and promote securement of catheter

17

What are implanted ports?

- A type of long-term catheter
- Consists of a portal body, septum, reservoir and catheter
- Can be open-ended or valved (closed) ended
- Surgically inserted
- Accessed aseptically using a non-coring needle
- Septum can withstand up to 2000 punctures!
- Can be implanted into a vessel, organ or cavity

18

What are advantages to implanted ports?

- All types of therapies can be administered
- Can be single or double port
- No activity restrictions when not accessed
- Body image intact
- Monthly flushing when not in use

19

What are dis-advantages of implanted ports?

- Surgical procedure to insert
- Requires weekly needle access when in use

20

What are PICC's?

- Inserted into peripheral vein and threaded into superior vena cave
- Single or double lumen/triple lumen
- Open ended or valved (closed) ended
- May be sutured or steri-stripped in situ
- Extension tubing attached at insertion remains for the life of the catheter, if a repair is needed and tubing is removed, the extension tubing must be changed weekly with the dressing change
- Inserted by specially trained RN

21

What are the advantages of a PICC?

- All types of therapies can be administered
- Soft, flexible
- Less potential for insertion complications
- Less expensive

22

What are dis-advantages of a PICC?

- Not appropriate for high volume or rapid infusions, pre-existing skin conditions, trauma or burns
- May not be able to withdraw blood samples
- Increased possibility of activity restrictions

23

Describe insertion protocol:

BEFORE:
- Pt preparation
- Who's responsible for what

INSERTION:
- Position
- Site choice
- Local anesthetic
- Insert large bore needle
- Needle removed-guidewire
- Catheter threaded over guidewire, guidewire removed
- Sutured and dressed

24

What are complications of lines being inserted?

- Cardiac dysrhythmias
- Pneumothorax
- Bleeding (normal for some; indicates it is in vessel)
- Hematoma
- Hemothorax
- Catheter mal-position
- Venous thrombosis

25

What are nursing responsibilities related to CVC's?

- Documentation
- Care and maintenance
- Pt teaching

26

Describe the daily assessment of CVC's:

- Done on admission, beginning of shift, and q4h and PRN checks
- Dressing is secure and dry
- Condition of site (inflammation, drainage, edema, bleeding, bruising)
- Palpate site (infiltration, SC emphysema)
- Check system (luer locked, catheter intact and secure, correct solution and rate, no migration/rotation of port)
- Measurement of external segment of minimum of daily CVC

27

Describe site preparation of a CVC:

- Chlorhexidine Gluconate 2% in 70% alcohol used as skin preparation solution, allow to dry completely
- Cleanse an area larger than the dressing
- Cleanse from insertion site outward using friction scrub
- Skin prep solution used once CHG dry; avoid area where CGH pad (on dressing) will occupy

28

Describe dressings used for CVC's:

- Cleanse work area prior to procedure
- Applied using sterile aspectic technique
- Dressing protects the site and stabilizes device
- Upon insertion, a CHG impregnated TSM dressing is applied (change initial dressing in 6-7 days and PRN; subsequent dressings may be non-CHG)
- Dressing must cover the insertion site and extension tubing attachment
- Applied to tunneled CVC's while in acute care

29

Why are clamps important for open-ended CVC's?

- Must be used when accessing and de-accessing to prevent air-embolism or blood back flow
- If not clamp present, have the patient perform the valsava manoeuvre whenever system is open
- Clamps are not used on valved CVC's
- Do not use a hemostat or sharp-edged clamp that may damage CVC

30

Describe infusions and CVC's:

- Commercially prepared IV solutions and medications (e.g. RL, NS, heparin) are changed minimum q96 hours
- IV solutions and medications prepared by pharmacy (e.g. Travesol) will be changed minimum q24 hours
- IV solutions and medications prepared by nursing (e.g. toradol, pantoprazole) are changed minimum q24 hours
- Infusion control device (e.g. IV pump) used for all infusions via a CVC
- All connections to be luer locked