Fundamentals session 5: IV and Central lines

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!

-Peter

 

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

 

IV devices

  • 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

Common sites

  • 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.
  • Hand
  • Forearm

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
  • condition

 

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

 

CENTRAL LINE

 

  • 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
  • Discontinuation
    • if you meet any resistance STOP
    • hold pressure for 5 minutes

 

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