Fundamentals session 5
This is the beginning of test 2 information and is covering the 5th set of slides. The main take away points to focus on were: all central lines end in the superior vena cava, and must have an x-ray to confirm the location before use. Also the reasons that one would need a CVL over a peripheral IV. Never use a Quinton catheter (dialysis catheter) as an access port to push meds or pull labs. Happy studying!
Central lines and IV lines!
why use these lines? hydration, speed, if GI tract is compromised
venous vs arterial lines
- we will talk about it later
- Peripheral catheters are short.
- catheter – flexible tube that is carried by the needle to administer the meds and stay in the line.
Initiating a peripheral access
- prepare pt, and position in way that is helpful to you and the pt.
- selecting a site that is comfortable to you and the pt.
- distal to proximal
- foot can be a bad site due to DM and fall risk
- 18 gauge or bigger (smaller #) to run packed Red blood cells through it
- so if the pt is getting surgery an 18 gauge should be used.
- Need to be changed every three days 72 hours.
- can be overruled by hospital
- avoid joints
- Pain or soreness in the site is NOT normal
- antecubital for emergency settings due to ease of access
- keeping a field stick in may or may not be used due to the nonsterile environment.
Catheter goes around the needle
- bevel up
- insert catheter
- take needle out and leave the catheter in.
- 18 green
- 20 pink
- 22 blue
Midline: not too worried about it, but is longer than a peripheral line and shorter than a central line.
Locked – a fluid that remains in the catheter when it is not in use
- PIV, heparin lock, buff cap, saline lock
Flush – with normal saline to clear out the lock of any medications.
- when in doubt flush
- can take out labs when the IV is fresh
- if it won’t flush change the line because there may be a clot in the line.
- No (very light) force needed to flush
Dressing are clear to be able to see and assess the IV site.
IV assessment –
- peripheral IV – location gauge of needle
Infiltration: when fluid enters the subcutaneous tissue
- Pain, Swelling, pale, slow infusion rate, cool to touch because it is just the fluid.
- take out the IV when this is found
- fluid can leak out of the tissue or IV site
- can cause compartment syndrome
- permanent nerve injury
Phlebitis: inflammation of the vascular endothelial wall
- Thrombophlebitis – blood clot is present with the inflammation
- swelling with HEAT because of the inflammation process
- can lead to Infection
Fluid overload: think first about cardiac patients.
- moderate rate: 125 ml/hr
- happens in the very young and old
- monitor rates and pump closely
- monitor I’s and O’s
Catheter breakage or damage
- assess for tip of catheter
- be aware of blood fling into eye when taking our catheter
discontinuation of IV
- be careful when taking off tape it could pull off skin
Side Note: Correctly written order, Medication, dose, route, frequency
- heparin and insulin are measured in units
- The tip of the catheter sits in the superior vena cava.
4 types of CL
- PICc – peripheral inserted central catheters
- MCC – Multi Lumen central catheter
- TCVC – Tunneled central venous catheter
- Implanted vascular access devices
An extra training and a certification is needed to be able to place a CVL
Verify with an x-ray
- NOTHING can be used with that line until the x-ray is examined
- Always wait for verification
- Checklist for CVL (IHI care bundle) 5 pieces
- Hand hygiene
- Max barrier
- Chlorhexidine skin antisepsis
- Optimal catheter site (subclavian)
- daily assessment of catheter
PICC – starts in antecubital area and goes to the superior vena cava
- median cephalic vein
- much bigger and longer than a peripheral IV
- the dressing is more involved than a peripheral IV
- can have double lumen which allows for 2 drugs (even incompatible) to be given at the same time.
- small gauge high number, poor for blood draws
- placed by nurse so it is less expensive (no OR time)
- Held in by stiches
CVAD – multi lumen catheters
- MD or CRNA can place these
- no RN certification
- Patient does not go home with these in.
- internal jugular(neck), subclavian vein(chest), or femoral(groin)
- shorter than PICC
- Nurses can take out
- two stitches hold it in
- Don’t cut the CVL cut the stitches
Quinton catheter (dialysis catheter)
- Red and blue port
- never use it to access, pull blood or push meds.
- High heparin concentration 5000 units per ml
CVAD: tunneled central venous catheter
- Very long term use (months to years)
- Put in and taken out in the OR
- Dacron cuff is under the skin and anchors the Line
- the port is tunneled under the skin and enters the vein far away from the initial site
- this reduces infection
- between the nipple and the sternum
- Implanted ports are now more used
Implantable port – nothing is hanging out of the skin (meta port)
- Long term as well
- drum sits under the skin
- sits just below the clavicle
- risk of infection is smaller
- Non coring needle – used in under skin ports only
- huber needle
- surgical procedure
- attached to muscle
- can be seen in a skinny person
- common in cancer pts
Assessing for complications
- infection: aseptic technique
- Scrub the hub! before accessing CVL
- Air embolism
- place patient on left side feet above head
- Pneumothorax after CVL the lung may be knicked
- more common in tunneled and metaport
- Catheter breakage or damage
- make sure that the full length is present
- if you meet any resistance STOP
- hold pressure for 5 minutes