1
Q
Can blood samples be taken from a CVAD?
A
yes but it should only be done as a last resort. (peripheral poke is best)
2
Q
How long should a infusion be stopped prior to a blood draw?
A
at least 2 mins
3
Q
Where is a the location of the catheter tip in a PVAD?
A
the periphery
4
Q
Where is the location of the catheter tip in a CVAD
A
The cavoatrial junction or distal superior vena cava
5
Q
How is the placement of the catheter tip confirmed on a CVAD
A
Chest X-ray or ECC technology
6
Q
What is the location of the insertion site for a PVAD
A
Hand to elbow - distal veins of the arm or foot
7
Q
What is the location of the insertion site for a CVAD
A
jugular, (cephalic, basilic, brachial above the ACF) subclavian, femoral
8
Q
How long can the dwell time for a PVAD be
A
As long as it is free of complications (redness, swelling, heat, pain, leakage and still required)
9
Q
What is the dwell time for non-tunneled IJ, subclavian
A
14 days
10
Q
what is the dwell time for a tunneled CVAD (hickmann)
A
as long as still functioning and required, inserted for use if tmt is required for over one month. Long term intermittent or continuous access greater than a month.
11
Q
What is the dwell time for a IVAD
A
as long as it is still functioning and still required. (many many years)
12
Q
What is the dwell time for a PICC line
A
up to a year- insertion site must be within 3cm of original insertion length
13
Q
what is the dwell time for a hemodialysis catheter?
A
duration depends on if or when patient will get a fistula created.
14
Q
who can assess a hemodialysis catheter?
A
Only hemo nurses. (may have medication port that can be assessed by hemo nurse with continuous IV fluids and than you can access that IV line. (nephrology approval)
15
Q
how many cc can a PVAD handle per hour?
A
no more then 999 cc/hr
16
Q
how many cc can a CVAD handle per min
A
2-3 L/min
17
Q
Who can insert PICC lines?
A
Iv nurses who are trained
18
Q
who can insert CVADS
A
physicians only
19
Q
Can blood sampling be done through a PVAD
A
yes but it is not recommended. This would be last last resort.
20
Q
Can blood samples be taken from a CVAD
A
Yes! but we prefer to do venipuncture or peripheral poke!
21
Q
Can home IV treatment be done with a PVAD
A
yes, if tmt less than 2 weeks
22
Q
Can IV treatment be done at home with a CVAD
A
yes, PICC IVAD and tunneled catheter if pt capable
23
Q
How often a PICC assessed and flushed if at home?
A
Q 24 hours
24
Q
if at home, how often should a IVAD be assessed and flushed if not in use
A
q 30 days
25
What is the vessel that a PICC is inserted into
cephalic, basilic or brachial vein above the ante cubital fossa (1/3 to 2/3 up upper arm)
26
What must be in place before the nurse accesses a PICC line
a written order from the IV nurse saying the PICC is okay to use.
27
What must the nurse be aware of when using a non-valved PICC line? (hickmann)
that the line is open and a direct conduit into the bloodstream. This means air can go into the line as well as blood can come out.
28
what must the nurse be aware of when accessing a valved PICC line (groshong)
If cap advertently comes off, air will not be able to enter the body and blood will not be able to come out
29
What must the nurse ensure not to do when caring for a patient with a PICC line
Do not take BP on the PICC arm and do not have patient use arm crutches on this side. No heavy lifting above 10-15 lbs on that arm and no repetitive movements for an extended period of time.
30
what is the maximum rate for a power picc aswell as the gauge and what are they commonly used for
5ml/sec and 18 gauge, CT contrast
31
Do valved CVADs need to be clamped or heparinized?
no, there is not need for this as the system is closed when not in use to prevent back flow.
32
Explain how a groshong valve works
This is valved catheter. Positive pressure during administration opens valves, negative pressure opens valve inwards for blood draw. (flush with NS)
33
What to do if a Groshong PICC line fractures externally
aeseptically secure the catheter with tegaderm. Call the IV team.
34
what to do if you see ballooning of a groshong PICC line at the hub
stop, call IV team, place tegaderm over PICC and label "do not use"
35
What color is a Groshong catheter
silicone and blue
36
What end is the Groshong catheter trimmed on
the proximal end (external portion)
37
What veins are percutaneous (non-tunneled) CVADS inserted in
internal jugular (IJ) and subclavian and femoral
38
What are femoral CVADS at risk for
CLABSI (central line associated blood stream infections) due to placement
39
When are non tunneled lines (percutaneous) used
short term or emergent therapy (CVP monitoring, resuscitation)
40
where are tunneled catheters (hickmann) typically inserted
inserted most often into the subclavian vein
41
how is a tunneled catheter inserted
by a surgical incision in the OR or in medical imaging under fluoroscopy in which the proximal end is tunneled subcutaneously from the insertion site (10-15 cm) and brought out through the skin at an exit site.
42
what does a tunneled catheter have to keep it in place
A Dacron cuff on the tunneled portion of the catheter that is place under the skin about 3 inches above the exit site. In 3-4 granulation tissue will grow onto the cuff adhering it into place.
43
Where is the tip of a IVAD inserted
into the cavoatrial junction or distal superior vena cava
44
Why are IVAD good
They have a decreased risk of infection due to skin healing over after needle removed. No limitations to getting areas wet.
45
is a dressing required for a IVAD?
no dressing is required when not being used. IF it is being used a sterile dressing over no coring Huber needle, sit and tubing (transparent)
46
What is the port of a IVAD accessed with
a non coring Huber needle with attached extension tubing
47
how often is the non coring Huber needled changed
Q7D
48
What will the patient potentially notice if a IVAD is mispositioned?
neck or ear pain or affected side, pt hears gurgling sounds when line being flushed, palpitations.
49
sign od a dislodged non-coring huber needle?
free movement of the needle hub, swelling, difficulty flushing or getting blood return, pain
50
How often is a IVAD flushed when not in use and what is it flushed with
flushed with heparin ever 30 D
51
What are the two types of tunneled catheters
cuffed: used if longer than 3 months. tissue will adhere to cuff.
uncuffed: used in emergency or for less than 3 months (sutured to secure)
52
who places a hemo line
nephrologist, surgeon or interventional radiologist
53
When can a non hemo nurse use a hemo line
if okayed by nephrology and a hemo RN has come to attach the running IV to it. WE can then use this running IV for access.
54
what color are hemo lined typically
They have blue and red ends
55
Where should the tip of femoral lines be placed
At the cavoatrial junction inferior vena cava meets the right atrium
56
Can you administer incompatible medications through a CVAD with multiple lumens
yes!
57
What is the proximal port typically used for (longest)
blood sampling, medications and blood administration
58
What is the medial port used for
TPN, medications. IF used for TPN use distal port for medications
59
what is the distal port used for (closest to the body)
CVP monitoring, blood admin, high volume or viscous fluids, colloids, medication
60
What catheter is used for TPN
always a CVAD
61
what type of filter is needed for TPN
an 1.2 micron in-line filter
62
what is CVP (central venous pressure)
the pressure measured in the vena cava near the right atrium
63
What is normal CVP
3 to 8 cm H20 or 2-6 mm hg
64
what does CVP measure
right atrial pressure and indirectly right ventricular end-diastolic pressure
65
what are indications for CVP
- hypotension refractory to fluid resuscitation.
- severe sepsis
66
how long should the nurse scrub venous access ports and how long should they let the port dry
scrub for at least 15 seconds and let it dry for at least 30 prior to attaching syringe
67
What is a important thing to access when a patient has a PICC
arm with PICC should be compared to arm without a PICC. The nurse should ensure both arms are the same size.
68
what does noticeable swelling in a arm with a PICC indicate
a DVT, call MRP, have ultrasound done
69
how should the syringe be disconnected when flushing a CVAD
disconnect with positive pressure.
70
what size syringe should be used when flushing or accessing CVADs
10 ml or larger to reduce risk of catheter damage
71
if the PICC placement is ____ cm or more difference from initial measurement the nurse should?
stop the infusions and call the IV team
72
What are local and systemic signs of CLABSI (central line associated blood stream infections)
local: redness, tenderness, purulent drainage, warmth, edema at site.
systemic: fever, chills, malaise, decreased BP
73
If a CLABSI is suspected, what should the nurse do
-get blood cultures both from CVAD and peripheral set.
- get order for catheter removal (tip culture and C+S of drainage from site)
- consider abx and IV fluids if septic
74
how does time to positivity help determine CLABSI?
if positive result comes from line draw, line is source, if positive source comes from peripheral, than source is from somewhere else
75
What vitals sign trend will be seen with a CLABSI
incr temp, HR, RR and decr BP
76
What two conditions need to be present for air to enter the vascular systems
must be a pressure gradient between vascular space and atmospheric air, and there must be a direct line of access to the blood vessel
77
signs and symptoms of a air embolism
- sudden dyspnea, coughing, breathlessness, tachypnea, wheezing,
- altered mental status or impending doom
- shoulder and chest pain
- hypotension or lightheaded
- JVD
78
what should the nurse do if a air embolism is suspected
- close, fold or clamp existing catheter.
- occlude puncture site of a catheter that has been removed.
- Trendelenburg left lateral decubitus (trap air in R ventricle)
- oxygen, vitals, attempt to aspirate air from catheter
- call MRP
79
what should never be used near a CVAD to prevent severing of the catheter
scissors
80
during CVC removal how should the patient be positioned
position patient with catheter exit side lower than the height of the patients heart.
81
what should the patient be instructed to do post CVC removal
remain flat for 30 minutes
82
how long should a occlusive petroleum based dressing be
83
what is a intraluminal clot
there is resistance upon aspiration and decreased ability to infuse fluids
84
what is a fibrin tail
resistance upon aspiration (tail gets sucked back) no resistance when flushing.
85
What is a fibrin sheath
inability to aspirate or infuse fluids. Sock on catheter is formed
85
What is a mural thrombus
can result in partial or complete occlusion, may or may not be symptomatic upon syringe assessment. Will see swelling, pain, tenderness, engorged vessels
86
signs of a thrombotic occlusion
- pain in extremity, shoulder neck or chest.
- edema (unilateral swelling)
- engorged peripheral veins in shoulder, neck or chest well.
87
What should the nurse do if a thrombotic occlusion is suspected
TPA is instilled by IV team and left to dissolve fibrin. Catheter is withdrawn and discarded with hopes to restore catheter patency.
88
signs and symptoms of a catheter embolism
palpitations, arrhythmias, dyspnea, cough or thoracic pain.
89
If a catheter embolism is suspected, what should the nurse be sure to do after removal
inspect all catheters for damage of possible fragmentation, notify MD and treat symptoms. save catheter and report
90
signs of a pulmonary embolism
apprehension, pleuritic discomfort, dyspnea, tachypnea, cyanosis, cough, unexplained hemoptysis, sweating, tachycardia, low grade fever, chest pain radiating to neck and shoulders.
91
what interventions should the nurse take for a pulmonary embolism
- place client on bed rest in semi fowlers.
- monitor vitals
- admin of O2
- assess cvc patency
- notify MRP
92
signs of a pneumo/hemothorax
- resp distress
- chest/shoulder pain
- unilateral distension of chest
- decreased or absence of breath sounds
- tachycardia
93
what should nurse do if a patient is experiencing pneumothorax/hemothorax
- oxygen/monitor VS
- elevate HOB
- prepare for chest tube insertion
94
Why would you use a PICC to draw blood
-peripheral veins are no longer accessible
- clinical significant reason (hemorrhage risk, needle phobia)
95
what are the concerns with drawing blood from a PICC
increased risk for infection, clot formation and PICC occlusion
96
Can a good blood sample be obtained when drawn from a PICC?
not always, blood cells can be damaged during draw and medication precipitant within lumen can all skew results
97
What lumen should be used for a blood draw from a PICC
largest lumen. pick 18g if possible
98
when drawing blood from a PICC, when is the cap changed
ALways change the cap after a blood draw or as directed by policy
99
what is best practice for drawing blood
1. stop infusion (2 mins)
2. remove needleless cap
3. cleanse PICC port
4. attach luer lock vacutainer adaptor to catheter lumen
5. discard 10 CC blood if not BC
6. obtain samples in order
100
if you are obtaining a blood culture do you discard blood?
no
101
coagulation studies should not be drawn from _____
heparinized CVADS
102
What is the acronym for blood draws
Stop Light Red Stay Put Green Light Go
S – Sterile (for blood cultures)
L- Light blue
R- Red
S – SST (Gold but are not used for routine chemistry except b12 and ionized Ca due to clotting time requirements)
P – PST (Light green for chemistry and troponin)
G – Green (Dark green = Lithium Heparin for VBGs)
L – Lavender
G – Gray
103
when using 2% chlorhexidine with alcohol, how long should the nurse wait for the site to dry. What about the green chlorhexidine with no alcohol?
30 seconds at min. green swabs need 2 mins to dry.
104
how often should the needless cap be changed on a PICC dressing
every 4-7 days or if blood is in the cap or if sterility is broken, following blood sampling, or if removed for any reason
105
which way should old PICC dressing be removed?
towards the insertion site
106
if the nurse notices that gauze is present under PICC dressing, what should they do
change dressing in 24 hrs
107
what is the preferred antiseptic for CVAD site care
pink chlorhexidine with alcohol swab sticks
108
When removing a PICC, what is the procedure
1. Need doctor order
2. remove dressing and cleanse site.
3. remove slowly 2-3 cm increments
4. support surrounding tissue
5. have patient valsalva once you get to last 5-10 cm.
6. place sterile gauze and hold for 2 mins. than cover with sterile transparent dressing.
7. leave in place for 48 hours
109
if resistance is felt during PICC removal, what should the nurse do
cover catheter with sterile dressing. Apply warm heat to upper arm for 15 mins and try again. If still resisting, contact IV team.
110
What position should patient be when having a jugular or subclavian CVAD removed
trendelenburg with head turned away
111
how should patient breath during a CVAD removal
Valsalva maneuver until catheter is removed. Than patient can breath normally.
112
how long should the nurse hold pressure after removing a CVAD
5-10 minutes without occluding artery
113
what should the patient be instructed to do post CVAD removal
remain laying flat in bed for a hour.
114
what is the assessment procedure for a patient who has just had a CVAD removed
- assess site Q15 min for 1 hour then hourly for hemorrhage,
- monitor resp status q15 for 1 hour for SOB or PE
115
how long should activity be restricted post CVAD removal
1 hour, 2 hour for femoral.
NRSG 301
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