IV Therapy

Types of Central Venous Catheters

100

This type of catheter consists of soft silicone and is inserted into the subclavian vein in the upper chest. It is a non-tunneled catheter, and it is designed for short term use to give medications and IV fluids.

What is a Hohn Catheter?

200

This type of catheter consists of soft silicone and is "tunneled" which means it enters the vein at a different point than it exits the skin. It is inserted into the upper chest into the internal jugular vein.

What is a Hickman Catheter?

300

This is a reservoir that has a silicone bubble called a septum with a catheter attached. The device is surgically inserted under the skin in the upper chest or in the arm and appears as a bump under the skin. The port is surgically inserted into the IJ or subclavian vein.

A medport. The septum is made of a special self- sealing silicone rubber. It can be punctured hundreds of times before it weakens. The port is accessed using a non-coring Huber needle.

400

This central venous catheter is a long, slender, flexible tube that is inserted into a vein in the upper arm. The tip is located in the superior vena cava just before the entrance to the heart.

PICC (peripherally inserted central catheter). The PICC line may have one, two, or three access ports. Usually inserted at the patient's bedside using ultrasound or by interventional radiology using ultrasound and fluoroscopy.

500

These catheters are used to determine hemodynamic status in critically ill patients. The hemodynamic information obtained is used to guide therapy in the critically compromised patient, including IV fluid administration, diuretics, and titration of vasoactive medications.

A pulmonary artery catheter. (Swanz Ganz catheter)

Flushing Central Venous Catheters

100

The patency of a line should be checked: A. Every day B. Twice a shift C. Once a shift D. Once every three days

To assure patency a line peripheral or central should be assessed at least every shift. There should be a brisk, free flowing blood return. The line should flush easily. If no blood return, consult PICC nurse or nursing supervisor as soon as possible.

200

What does the acryonm S.A.S.H stand for?

S.A.S.H. – Saline – Administration – Saline – Heparin. It is not necessary to withdraw the heparin from ports prior to its next use.

300

TRUE or FALSE: Central venous catheters should be flushed with normal saline followed by heparin after each use, if not contraindicated.

TRUE Central venous catheters should be flushed with normal saline followed by heparin after each use, if not contraindicated. Normal heparin dose for flushing catheters is 100units/mL. Use 1 mL heparin per port, after flushing with saline. Heparin dosage is different for oncology patients with Medports, please see nursing policy.

400

TRUE or FALSE: Activase or CathFlo is a low dose t-PA that is used to restore patency and blood return to central lines, PICCs, and Medports.

TRUE: Activase or CathFlo is a low dose t-PA that is used to restore patency and blood return to central lines, PICCs, and Medports.

500

TRUE or FALSE: A poorly functioning catheter can lead to an infected catheter and must be addressed as soon as possible.

TRUE: A potential complication of long-term catheters, is that the catheter becomes encased in a fibrotic sheath (biofilm), which may harbor bacteria and make it difficult to withdraw blood from the line. A poorly functioning catheter can lead to an infected catheter and must be addressed as soon as possible. Things to consider: Does the catheter flush well, but have no blood return? Are you encountering resistance when flushing? Is the catheter totally occluded and can’t be flushed or provide a blood return? Activase or CathFlo is a low dose t-PA that is used to restore patency and blood return to central lines, PICCs, and Medports.

Drawing Labs from Central Venous Catheters

100

TRUE or FALSE: An RN may draw blood from a central line with an order?

TRUE RNs are NOT allowed to draw labs from a central order without an order from the provider.

200

To prevent the introduction of bacteria through a central venous line, what must a nurse do prior to injecting or using a central venous device access port?

The central venous device port must be scrubbed for at least 15 seconds with a 70% alcohol pad. "Juicing an orange"

300

Your patient has an order for a H/H lab draw at 1400. You have a previous order from a provider that states it is okay to use the PICC line for lab draws, however, your patient currently has TPN and lipids infusing. What should be done to obtain a lab specimen?

The nurse can NOT obtain a blood sample through a central line that has TPN/lipids running and must instead obtain a peripheral blood sample. The TPN and lipids may impact the accuracy of the lab results if there is residual left behind in the tubing.

400

TRUE or FALSE: Nurses can obtain blood samples from a hemodialysis catheter?

FALSE: only specialized staff should draw blood from a hemodialysis catheter

500

When drawing a blood sample from a central venous line, how much, if any blood should be wasted?

4 - 5 ml of blood should be discarded.

Assessing

100

At the beginning of your shift you assess the patient's PICC line. You note redness, warmth, and purulent drainage around the device. You suspect a localized infection. What are your next actions?

First, the provider should be notified. Next, anticipate that a bacterial and/or fungal culture may be ordered.

200

An internal catheter infection is suspected, resulting from a central venous catheter. The provider was notified, and has ordered that the catheter be removed. Prior to removing the catheter what must be done first?

Prior to removing the catheter, the insertion site will be cleansed with chloraprep. Following removal of the catheter, if ordered, 1-2 inches of the tip will be cut with sterile scissors and deposited into a sterile cup and sent to the lab for culture.

300

A peripheral IV is ordered on a patient. How often should it be removed and replaced? A. Every day B. Every shift C. Every 3 days D. Every 5 days

C. Every 3 days

400

You are assessing your patient to determine if they would be an appropriate patient to place a peripheral IV in. What are some reasons/contraindications to inserting a peripheral IV.

Contraindications to peripheral IV are related to cases of risk of harm to the patient including; sclerotic veins, arteriovenous fistula, massive edema, burns or injury, cellulitis/infection, thrombosis, phlebitis, or mastectomy. NOTE: (r/t mastectomy) The issue is not the mastectomy itself, but the lymph node dissection. When lymph nodes are removed, there exists the potential of decreasing the body's ability to drain fluid from the arm, armpit and chest. For the vast majority of people, the remaining lymph nodes and veins can handle the removal of fluid without difficulty. However, for some, the lymphatic system can become overloaded, resulting in swelling. Lymphedema can occur anytime after lymph node dissection (LND). Therefore, anyone receiving a LND should understand and follow lymphedema precautions, which include avoiding any trauma to the arm. Trauma can include blood pressures, IV's, sunburn or cuts.

500

The provider has ordered that an IV be inserted on a patient that is a new admission. The patient turns out to be a difficult IV start. What are some techniques/tips that can assist with inserting an IV?

Tips for difficult starts: Position arm below heart level Open and close fist several times Gently rub/stroke patient’s arm Cover arm with warm blankets for 5 to 10 minutes or warm moist towel Use illuminating device - vein light Blood pressure cuff

Infection Prevention

100

TRUE or FALSE: Your patient has just had a PICC line placed and you have received confirmation of placement and the okay to use it. You have discontinued your peripheral IV. Prior to infusing through the PICC line you must first obtain a new IV infusion set.

TRUE: Always use a new IV infusion set with all new central line placements. Do not use a syringe smaller than 10mL. Do not plug end of IV tubing into nearest Y-Port. This is not safe practice. Instead, always use a new sterile cap when capping off IV tubing between infusions.

200

TRUE or FALSE: It is not necessary to clean the rubber stopper underneath the dust cap because it is sterile.

FALSE: The rubber stopper underneath the dust cap is not sterile and must be wiped with alcohol before accessing a vial.

300

TRUE or FALSE: Most insurance companies and third party payers are paying for medical cost related to catheter associated blood stream infections.

FALSE

400

TRUE or FALSE: Catheter related blood stream infections are associated with increased costs and length of stay.

TRUE: The CDC estimates that there are approximately 92,011 incidents of Catheter Related Bloodstream Infections (CRBSIs) annually in the United States. They are associated with increased LOS and higher costs, which can range from $3,700 to $29,000. Between $300 million and $2.3 billion in costs per year have been attributable to these infections. Most insurance companies and third party payers are no longer paying for medical costs related to CRBSIs. CVCs caused approximately 80,000 CRBSIs and 28,000 deaths in ICU patients Mortality is estimated at 12% to 25% in vascular catheter related bacteremia among critically ill patients in the US. This is why it is so important to scrub the hub for 15 seconds with alcohol to help prevent infection.

500

TRUE or FALSE: When accessing a central line it is necessary to clean the port for 10 seconds.

FALSE- When central venous device ports are accessed. It is extremely important to "scrub the hub" top and sides for 15 seconds with a 70% alcohol pad. "Juicing an orange"