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Central lines- RN

slide notes

QuestionAnswer
Why a Central Line? Multiple access ports and can be used long term
Central line insertion not a nursing responsibility but will often be present during
What is a Central Line (CVAD- central venous access device)? venous access device in which tip of catheter is in superior vena cava via subclavian, jugular, axillary or brachiocephalic vein.
The tips of Central venous catheters are located in a central vessel (i.e. the thoracic vena cava)
types of CVCs include: central line, tunelled catheters, subq ports, PICC lines
Central line insertion: Who and Where? PICC line: in patient room by MD or trained RN IJ or femoral: in patient room by MD Subclavian, tunneled, implanted: Interventional radiology by MD
What is the role of the RN during insertion? obtain equipment, meds as ordered; add items to sterile field if requested
What are some central line complications? Infections, Thrombosis, Mechanical Occlusion, and air emoblus
What does CLABSI stand for? Central Line associated Blood stream infection
What does the central line bundle to prevent infection include? Hand hygiene Maximal sterile barriers Chlorhexidine skin antisepsis Daily assessment for line necessity
The majority of CLABSIs come from: Skin organisms (60% of CLABSIs)
The second most common cause of CLABSIs are: Contaminated catheter hub (12%)
The third most common cause of CLABSIs are: Contaminated infusate (<1%) and the rest 28% are unknown
What are some signs of CLABSI? Intravascular line in place (or recently in place) Inflammation or purulence at site Abrupt onset, with shock Dramatic improvement after removal of device
What are some symptoms of CLABSI? Fever, Chills, rigors, Hypotension, shock Hyperventilation,Gastrointestinal,abdominal pain, vomiting, Diarrhea, Neurologic Confusion, seizures
The central line should be cleaned for atleast: 15 seconds
The maximal sterile barriers used during catheter insertion should be: cap – should cover all hair mask – should cover nose and mouth tightly sterile gown & sterile gloves Patient covered head to toe with a large sterile full body drape
The optimal site for placement is: the Subclavian
Sites to avoid placement: Avoid: Internal Jugular (more occlusions, infections) Really Avoid: Femoral vein (5x greater rate of infection plus more occlusions)
For optimal skin aspesis, what should be used? 2% chlorhexidine-gluconate is preferred
What is the procedure for skin aspesis? Disinfect skin before catheter insertion and during dressing changes and Evidence favors overall scrub, not circular rub.
For optimal dressing care, it should be changed: when the catheter-site dressing when it becomes damp, loosened, or soiled. Also, dressings used on short-term CVC sites every 2 days for gauze dressings and at least every 7 days for transparent dressings, except in pediatric patients where the risk for d
Line necessity should be checked : Daily! - All physicians are expected to do this
When dealing with thrombosis occlusion you should never : Force catheter insertion
If thrombosis is occluding, you can : check patency and request order for de-clotting per policy (Alteplase; may require IV team
For a mechanical occlusion, you should: per policy, obtain order for chest x-ray (before or after attempting de-clotting)
To prevent air embolus you should always remember to: Prime the line
The greatest risk for air embolus is during insertion and removal of central line
How much air is fatal to a patient? about 20 ml of air
You should expect an air emoblism if : There is sudden dyspnea and confusion at which point you immediately check for break in line and position patient on Left side, Trendelenberg
For safe use of a central line remember: Only an RN may access, scrub the line for 15 seconds vigourously, change tubing per policy, and cover when showering
The size of syringe on catheter should be: 10ml or larger as the smaller the diameter, the more pressure you are putting on catheter
TPN is a dedicated access port because: Certain meds coat catheter; you should label so no labs drawn from that port
If drawing blood from central line you should: Stop infusion if running,scrub the Hub!, Flush with 10 ml NS, Discard first 5 ml blood, Withdraw and fill blood tubes Flush, change cap,Restart infusion or clamp line
For discharge teaching, what should you tell patient about central line? No swimming (except w/port) Monitor for redness, pain or discharge Demonstrate/return demonstrate flushes and dressing change Provide emergency contact numbers
What does VAD mean? Venous access device
What does IVAD mean? intravenous access device
What does PICC mean (peripherally inserted central catheter)
What does Midline mean? (peripherally inserted, 20cm in length, not a central line).
What does VAE mean? (venous air embolism)
What is the purpose of CVADs? For long term vascular access needed to administer fluids, TPN, blood, medications, measure central venous pressures, and draw blood.
What are the advantages of CVADs? only one IV site to care for, access to a large vein, less problems with phlebitis and infection.
CVADs Basic single lumen catheters are how long? 8-12 inches long
What are CVADs with multiple lumens used for? different activities such as blood draw, inserting/infusing more than one solution, measuring central venous pressure
What are the only CVADs nurses can insert? Specially trained nurses may insert PICC lines. The rest are inserted by physicians because they require surgical placement.
How is proper placement of peripheral line insertion confirmed? X-ray
How long are peripheral lines and how long can they be used for? Length about 16-24 inches. Most are single lumen, though some double. Can be in for weeks to months. Many people have at home. Very small and have guide wire to keep catheter stiff while inserting
Where are the PICC inserted? Inserted into axillary, subclavian, or brachiocephalic vein or in superior vena cava via antecubital space.
What is the advantages of PICC over ordinary peripheral lines? less risk of infiltration, vein-wasting, phlebitis than ordinary peripheral lines. Have less risk of pneumothorax, hemothorax, or air embolism than caths inserted directly into subclavian or internal jugular veins.
What are the newer Newer ports called Power Ports used for? –used for CT scans and more caustic drugs.
What is another name for “Purple Power Port”. High Pressure Injections Port
Non-Tunneled Catheters (central venous catheter lines) used for: Inserted through the skin into the jugular, subclavian, and occasionally femoral veins. Man be used for central venous pressure monitoring, have multiple lumens, and can be used for blood draws.
How long are non-tunneled catheters used for? Sutured in place and are often referred to as single, double or multi/quad lumens (depends on how many ports). Intended for shorter use -- days to weeks. May cause pneumothorax. After insertion immediate chest x-ray is completed.
What are Tunneled catheters? Central insertion. Tunneled or inserted through subcutaneous tissue. Go through the chest wall or abdominal wall to the subclavian or jugular vein. Long term use.
What is a Hickman tunneled catheter? silicone with single or multilumen, with one or two Dacron cuffs around catheter in subcutaneous tissue where tissue adheres to it, preventing infection and keeping in place. Skin heals around exit site. Requires flushing with heparin
What is a Broviac tunneled catheter? used with children. Has one Dacron cuff and otherwise same as Hickman. Requires flushing with heparin
Which tunneled catheter will maintain patency without heparin? Groshong: Uses normal saline flush weekly or after use. Has internal valve preventing backflow of blood.
What is an imported catheter? Commonly called Port-a-cath. implanted into subclavian or jugular and the end is stabilized in a pocket under the clavicle or sometimes forearm. For repeated access for IVP injections, drugs, blood, fluids, blood sampling. No tubes or chance of pulling
What is the procedure for dressing changes? Strict sterile procedure requiring sterile gloves. Some hospitals require client to mask and nurse to gown & mask when site exposed.
What equipment is needed for dressing changes? Equipment: clear dressing, Biopatch, or chemicals and ointments specific to sites, tape, sterile gloves, 2 x 2s, swabs, masks.
What is the protocol for removing dressing? Remove old dressing TOWARD insertion site to avoid pulling out line. Observe for signs of infection.Culture if necessary. Don sterile gloves. Wipe inside-out or back and forth 4-6 inches with CHEMICAL OF UNIT SPECIFIC PROTOCOL and allow dry to dry. Appl
For catheter insertion: place in Trendelenburg position to increase pressure, perform valsalva maneuver or hold breath
For Tubing change of catheter: close slide clamp distal to open line
For catheter removal: have client lie down, apply valsalva, apply airtight dressing
Meds used to treat occlusions often seen with PICC line: use urokinase/retavase which dissolves clots
To prevent tip migration: Watch for S/S and always check tip of catheter when it is removed. Chest x-ray needed to verify placement
symptoms of Phlebitis: warmth, discomfort, erythema, drainage, edema, dark streak up arm
Created by: UARN85