SPECIFIC TIME CONTENT AVAIDS TEACHERS LEARNERS EVALUATION

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Introduce the 2 mts INTRODUCTION : Introducing the Listening
topic topic
Central venous catheters (CVC) are an integral
part of patient treatment in the intensive care
unit (ICU). One of the disadvantages of CVCs is that
they are a deeply invasive medical device that incurs a
significantly higher risk of infection than peripheral
catheters . A primary route of CVC bacterial
contamination is the intraluminal route, where
contamination occurs from breaches in aseptic
technique when accessing the CVC, contaminated caps
and connectors, and contaminated infusates

Define central 3 mts CENTRAL VENOUS CATHETER :

venous catheter A central venous catheter, also called a chart Defining the Listening What is central
central venous venous catheter ?
central line or CVC, is a device that helps you receive catheter
treatments for various medical conditions. It’s made of
a long, thin, flexible tube that enters your body
through a vein. The tube travels through one or more
veins until the tip reaches the large vein that empties
into your heart (vena cava).
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Name the purpose 2 mts PURPOSES : Leaflet Listing the Listening What are the
of central venous purposes of purposes of central
catheter central venous venous catheter ?
 Percutaneously inserted non-tunnelled central
catheter
venous catheter
 Peripherally inserted central venous catheter
(PICC)
 Tunnelled uncuffed central venous catheter
 Tunnelled cuffed central venous catheter (e.g.
Hickman)
 Implantable vascular device (e.g. PortaCath)
 Percutaneous and tunnelled
apheresis/haemodialysis type catheter (e.g.
VasCath)

Listening
INDICATIONS OF CENTRAL VENOUS
List the 3 mts Pamphlet Listing the Name the
CATHETER :
indications of indications of indications for
central venous central venous central venous
 Administration of medications that require
catheter catheter catheter.
central access e.g. amiodarone, inotropes, high
concentration electrolytes
 Fluid balance monitoring with CVP
 Intravenous access (long term )
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Mention the 3 mts Contraindications to central line (central Pamphlet Mentioning the Listening Mention the contra
contra indications venous catheter) insertion contra indications of the
of central venous indications of central venous
catheter.  Coagulopathy central venous catheter.
catheter
 Local infection
 Avoid in raised intracranial pressure- aim for a
femoral approach if required
 Patient non-compliance

Equipment required for central line (central Listening

Enlist the 4 mts venous catheter) insertion Leaflet Enlisting the Enlist the
equipments equipments equipments
required for  Ultrasound and sterile ultrasound sheath required for the required for central
central venous  Sterile trolley central venous venous catheter.
catheter. catheter.
 Sterile field, gloves, gown and mask
 Seldinger central line kit
 Saline flush
 Chlorhexidine
 Lignocaine (4ml (2 vials) of 2% is reasonable)
 Suture
 Scalpel
 Sterile dressing

Explain the pre 2 mts Pre-procedure PPT Explaining the Listening What are the pre
 SPECIFIC TIME CONTENT AVAIDS TEACHERS LEARNERS EVALUATION
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procedure pre procedure procedural steps ?

 Consent patient if conscious otherwise

document why the procedure is in the patients
best interests

Consent should include:

 Infection, bleeding (arterial puncture,

haematoma, haemothorax), pain, failure,
damage to surrounding structres (including
pneumothorax), thrombosis.
 Set up sterile trolley
 Position patient with head down if they can
tolerate it, with head facing away from side of
insertion
 This ensures maximum venous filling
 Ultrasound area to define anatomy
 Having a nurse or assistant is helpful
Listening
Discuss the 5 mts Procedure for central line (central venous PPT Discussing the Explain the
procedure of catheter) insertion procedure of procedure of
central venous central venous central venous
catheter insertion  Wash hands and don sterile gown and gloves catheter catheter insertion.
 Clean the area and apply sterile field. Make
sure to have some spare gauze swabs ready.
 Apply sterile sheath to the ultrasound probe
 SPECIFIC TIME CONTENT AVAIDS TEACHERS LEARNERS EVALUATION
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 Confirm anatomy
 Under ultrasound guidance insert lignocaine
cutaneously, subcutaneously and around
internal jugular.

 Whilst lignocaine has time to work flush all

lumens of the line and then clamp all lumens
except the Seldinger port
 Ensure caps are available for the lumens
 Under ultrasound guidance take Seldinger
needle attached to syringe and insert into the
internal jugular vein
 When blood is freely aspirated remove syringe
and immediately inset Seldinger wire. This
should pass easily
 Keeping hold of the inserted wire, remove the
needle. Ensure the wire stays in the vein as you
do this
 Use scalpel to make an small incision in the
 SPECIFIC TIME CONTENT AVAIDS TEACHERS LEARNERS EVALUATION
OBJECTIVES ACTIVITY ACTIVITY
skin (approx 3mm). This should be done cutting away
from the wire so as not to damage it

 Pass the dilator over the wire and gently but

firmly dilate a tract through to the internal
jugular.
 At this stage there may be some bleeding so
ensure to have some swabs ready
 Remove the dilator and pass the central line
over the Seldinger wire. Do not advance the
line until you have hold of the end of the wire
 Once the central line is in place, remove the
wire
 Aspirate and flush all lumens and re clamp and
apply lumen caps
 Suture the line to allow 4 points of fixation

 Dress with a clear dressing so the insertion

point can be clearly seen.

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Post-procedure
 Attach central line to pressure bag to allow CVP
monitoring

Nursing staff can shows how to do this or will do it instead

 Run a blood gas to ensure a venous sample

 Chest x-ray to confirm placement and to check for
pneumothorax
 Clear documentation of date of insertion and monitor
for infection
TYPES OF CVC :
 SPECIFIC TIME CONTENT AV AIDS TEACHERS LEARNERS EVALUATION
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Elaborate the 5 mts TYPES OF CATHETER : PPT Elaborating the Listening What are the types
types of catheter Central venous catheters come in many types of of catheter?
forms. These include: catheter

Non tunnelled central venous catheter :

This type of CVC is appropriate for short-
term access to the vein (less than two weeks).
The provider uses a needle puncture to access a
vein in the neck, groin or upper chest.
Peripherally inserted central catheter
(PICC) :
A PICC line is similar to a non-tunneled
CVC. But the physician uses a needle puncture
to access a vein in the upper arm instead of the
neck or chest. The physician threads the
catheter through other veins until its tip reaches
the superior vena cava.
Tunneled central venous catheter:
This type is appropriate for more
than two weeks of access. Physician surgically
inserts the catheter into a vein in the neck or
chest. The catheter “tunnels “under the skin for
8 to 10 centimeters and then exits through the
skin in a different area of the chest. The CVC
are known by its brand name. Common names
are Broviac, Hickman and Groshong.
Subcutaneous (implanted) port:
A port is appropriate for long-term access of
at least three months. This type doesn’t exit
through the skin at all. The physician surgically
implants it so that it’s completely within the
 body. The hub (catheter access point) is very
close to the surface of the skin. So, the
physician can puncture the skin with a needle
to access the hub for the treatment. The
physician may call this type of catheter an
implantable venous port or a Port-a-Cath.

Mention the 2 mts COMMON INSERTION SITES FOR Leaflet Mentioning the Listening List down the
common sites for common sites common sites for
CVC CVC : for CVC CVC.
Three common access points for CVC
placement include :
Internal jugular vein: Located in the neck.
Subclavian vein: Located in the upper chest.
Common femoral vein: Located in the groin.
PICC line access points include the basilic vein
and cephalic vein, both located in the arm.

Guidelines for Central Venous Listening

Brief about the PPT Briefing about Any few guidelines
guidelines for 3 mts Catheter Care the guidelines for CVC?
CVC Nurse must always wash hands carefully for CVC
for 15 seconds before and after working with
the CVC. Anyone who helps them with CVC
care must do the same. This is necessary to
protect the patient from infection. Use liquid
antibacterial soap and paper towels to dry the
hands.

To prevent infection, anything that touches the

exit site of the CVC and anything that goes into
the CVC must be sterile. The nurse will show
how to care for the CVC properly. The
following guidelines are helpful in preventing
infection:

 Do not let the CVC exit site get wet

until it is well healed. The patient can
take shower 72 hours after the catheter
has been inserted. When the patient
bathe or shower, they must cover the
site with waterproof material, such as
household plastic wrap, taped over the
dressing and injection caps.
 Do not submerge the CVC site or caps
below the level of water in a bathtub,
hot tub, or swimming pool.
 Store CVC supplies in a clean, dry place
such as a shelf in a closet or a drawer.
 Always clean the work area with alcohol
and let it to dry completely before
setting up the supplies. Or they can
cover the area with clean paper towels.
 Use only sterile supplies. Open all
packages carefully without touching the
contents. Handle dressings only at the
edges.
 Never touch the open end of the CVC
when the cap has been removed.
 Never touch the end of the needleless
cannula or the end of the open syringe.
If this happens accidentally, use a new
cannula or syringe.
 Never use scissors, pins, or sharp
objects near the CVC or other tubing.
  The catheter could be damaged easily.

If the catheter has a clamp, keep it clamped

when not in use. Some CVCs show where the
clamp must be placed. If the CVC does not
show the clamp location, ask the nurse to show
where to clamp.

Remember to wash hands thoroughly before

and after working with the CVC.

Changing the CVC Dressing

Detail about LCD Detailing about Listening What are the
3 mts The CVC dressing is changed every 7 days if
changing the the changing of supplies needed for
CVC dressing dressing of changing CVC?
you are using a transparent dressing. Change it
CVC
every 48 hours if using gauze or Telfa island
dressing and tape. If the dressing becomes wet
or loose, change it even if it is not the normal
time to change it. A nurse will give specific
instructions to the patient and family about the
type of dressing done for them.
Supplies

 A roll of medical tape (silk, paper, or

transparent)
 A central line dressing change kit that
includes:
 sterile gloves
 ChloraPrep® applicator a transparent
dressing
 skin protectant swab

Steps

1. Set up a clean work surface.

2. Gather supplies and arrange them in the
order to be used.
3. Wash the hands for 15 seconds with
liquid antibacterial soap. Dry the hands
thoroughly using paper towels.
4. If someone else changes the dressing, he
or she should put on sterile gloves.
5. Carefully loosen and remove the old
 dressing. Peel the dressing toward the
site without pulling on the CVC. Never
use scissors or sharp objects near the
CVC.

Inspect the area around the site for any sign of

infection (redness, swelling, drainage,
tenderness, warmth, or odor). Call the doctor or
nurse to see any sign of infection. Also report
dry skin, rash, or irritation from the dressing .

6. Check the entire chest area for new or

prominent veins, rash, change in colour,
or swelling
7. Wash hands again for 15 seconds with
liquid antibacterial soap. Dry the hands
thoroughly with paper towels
8. Open the dressing change kit.
9. Put on sterile gloves.
10. Activate the ChloraPrep® applicator by
pinching the plastic wings.
11. Using the ChloraPrep® applicator,
vigorously cleanse an area 4 x 5 inches
in size. Cleanse for 30 seconds using an
up-and-down or side-to-side motion
Note: the patient may notice some
oozing of blood from the site for several
days after CVC placement. If there is a
lot of blood, or if the site keeps
bleeding,
 call the doctor or nurse right away.

12. Allow this area to dry for about 30

seconds.
13. Swab the edges of the cleaned area with
the skin protectant swab. Allow to dry.
14. Remove backing from the transparent
dressing, and place the dressing over the
site. If possible, alternate skin areas
where the dressing is placed to avoid
skin irritation.Loop and tape the catheter
to skin to prevent the catheter from
dangling.

Describe about Flushing of Catheter With a Clamp LCD Descrbing the Listening How should the
the flushing of 3 mts flushing of catheter be flushed
catheter with a catheter with a with a clamp?
Some CVCs have separate tubes. Each tube is
clamp clamp
called a lumen. Each lumen of the CVC needs
to be flushed regularly to keep it clear of
backed-up blood. If the patient have more than
1 lumen, it is helpful to have a routine for
flushing lumens in the same order each time.
For instance,always flush the red one first, then
the white, then blue. The patient catheter need
to be flushed each lumen of the CVC once a
day using 3 cc of heparin solution (100 units
heparin/cc), unless they have been instructed
differently.

Supplies (Exact supplies may vary.)

Enlist the supplies Leaflet Enlisting the Listening Name the supplies
 1 vial of heparin (100 units/cc) and a 10
used in flushing a supplies used in used for flushing
2 mts
catheter cc syringe for each catheter lumen OR flushing a the catheter
catheter
pre-filled heparin syringe
 Needleless injection cannula (unless
your needleless system does not need
this) for each catheter lumen
 Alcohol swabs
 Needle/syringe disposal box

Steps
Demonstrate the
steps of flushing 1. Wash hands for 15 seconds with liquid demonstrate Demonstrating What are the steps
3 mts
the catheter the steps of Observing of flushing the
antibacterial soap. Dry hands thoroughly flushing the catheter?
with paper towels. catheter
2. Gather all the supplies.
3. Wipe the rubber stopper of the medicine
vial with an alcohol swab for 5 seconds.
4. Remove the syringe cover. Twist on the
needleless injection cannula or needle, if it
is not already attached. Remove the cover
from the needleless cannula or needle.
5. Draw 3 cc of air into the syringe by
pulling back on the plunger.
6. Push the cannula or needle through the
rubber stopper of the vial.
7. Push the syringe plunger to discharge air
into the vial.
8. Turn the vial upside down. Be sure the tip
of the cannula or needle is in the solution.
Draw back on the plunger to draw up 3 cc
of heparin into the syringe.
9. Before removing the cannula or needle
from the vial, check for air bubbles. To
remove air bubbles, gently push the
heparin back into the vial and re-measure
the dose.
10. Remove the cannula or needle from the
vial and replace the cap loosely. Fill other
syringes at this time if more than 1 lumen will
be flushed.

11. Replace the needle with needleless

cannula, if that is what used.
12. Use the alcohol swab to clean the injection
cap of the lumen to be flushed.
13. Rub the cap with an alcohol swab, rubbing
vigorously for 15 seconds, and then allow
it to dry. Hold the end of the catheter so it
does not touch anything. Open the clamp
on the lumen.
14. Remove the cap from the cannula or
needle and insert into injection cap.
15. Slowly inject the entire amount of heparin
into the lumen of catheter. If meet
resistance, check to see if the clamp is
closed. If there is still resistance, do not
flush that lumen. Call the doctor.
 16. If the patient are using a standard cap,
clamp the catheter as they are finishing the
injection. If they are using a positive
pressure cap, remove the syringe and then
clamp the catheter. Then remove the
syringe. Place it into the needle disposal
box.
17. Repeat all of the above steps for each
lumen to be flushed, using a clean syringe
to flush each catheter.
18. Close the syringe disposal box lid and
place the container out of reach of children
and pets.
19. Wash hands for 15 seconds with liquid
antibacterial soap.
20. When the syringe box is full, return it to
home care program or doctor’s office.

Enumerate the 3 mts NURSING MANAGEMENT : LCD Enumerating Listening List the nursing
nursing the nursing management .
management management

The patient should be closely monitored

and the catheter site and the system observed.
The patient’s vital signs should be monitored
and recorded. Any handling of the line should
be kept to a minimum to reduce the risk of
contamination and the line should be securely
fastened to the patient.

The dressing on the central venous site

should be changed in accordance with hospital
policy and procedures. It should always be
changed using aseptic techniques and a
transparent dressing is often used to allow
observation for evidence of redness or
discharge.

The nurse usually removes the catheter

after the medical practitioner has given an

instruction to do so. The patient should be
informed and reassured and the procedure
explained. The patient should lie flat in bed
with the foot of the bed elevated to prevent air
emboli on removal of the catheter. Before
removing the catheter, ask the medical
practitioner if the tip of the catheter should be
kept and sent for microbiological examination.
If the tip is to be sent to the laboratory to be
cultured it should be cut with sterile scissors
and placed in a sterile specimen pot to prevent
further contamination.

The removal procedure is carried out using

an aseptic technique. After removal of the
sutures from around the catheter, a wad of
sterile gauze should be held under pressure over
the site. The catheter is pulled gently until it is
removed, while the nurse continues to apply

pressure to the site for up to five minutes until

 bleeding has stopped. The site is sealed with an
airtight dressing, which should be left in place
for 48 hours, and the patient can be returned to
a comfortable position.

CONCLUSION :
Conclude the Concluding the Listening
topic topic
2 mts The insertion of a central venous catheter is a
highly invasive procedure, so a decision to
insert such a device should take into account the
patient’s condition, symptoms and illness. The
device plays an important part in the patient’s
recovery as it can aid diagnosis and treatment.
At the same time, the use of such devices can
put the patient at risk of the complications
discussed. The nurse has a vital role to play in
helping to safeguard the patient against the
potential risks associated with central venous

lines.

REFERENCES :
BOOK REFERENCES :

1. Brunner & Suddarth’s.Medical-Surgical nursing.10th edition.Lippincott williams & wilkins publication (2004).

2. Hatchett & David thompson.med-surg. nursing.first edition(2002); publish by churchil Livingstone sydney.

3. Shaffer’s.Medical-Surgical.seventh edition. BI publications New Delhi (2002).

4. Richard Lippincott. Manual of nursing practice. Eight edition (2006).

5. Lewis, “ Medical Surgical Nursing”, 2014 edition, New delhi, South asian publication,

6. Smeltzer S.C, Bare B.G. & Hinke J.L (1999). Brunner & Suddarth’s textbook of medical surgical nursing. (9th E.D). Philadelphia: J.B.

7. Lippincott  Linton A.D (2007) Introduction to medical – surgical nursing. (4th ed) Saunders Elsevier.

8. Black M. Joyce “Medical-Surgical Nursing”Ed.6th; Saunders publication; 2007.

9. Lewis LS, Dirksen RS, Heitkemper MM, Bucher L. Lewis’s Medical Surgical Nursing Assessment and management of clinical

problems. Second edition. Volume 1.India: Reed Elsevier; 2015.

10. P. Hariprasad., Text book of cardio vascular and thoracic nursing, Jaypee brothers medical publishers 2016.

11. B.venkatesan ., Text book of cardio thoracic nursing , Jaypee brothers medical publishers 2017.

12. Susan l woods erika s sivarajan froelicher sandra underhill motzer elizabeth j bridges ., Lippincott williams & Wilkins ., Cardiac nursing

2009.
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1. www.slideshare .net

2. www.pubmed.in.net

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5. www.nurseslab.in.net

6. https://www.hopkinsmedicine.org/health

7. https://medlineplus.gov.

8. https://www.webmd.com.

CLINICAL PRESENTATION
 ON
INSERTION OF CVC
SUBMITTED BY SUBMITTED TO

Mrs.M.Saranya, Mrs.T.Rubani,

II- Yr M.Sc Nursing .

SACRED HEART COLLEGE OF NURSING – KUMBAKONAM

SUBMITTED ON