Caring for patients with arrhythmias can challenge your knowledge and skills.

That’s because
some patients with these irregular heart rhythms are not affected by them. But other patients may
lose their lives unless you recognize and treat their arrhythmias promptly.
To do this, you need to know the difference between dangerous arrhythmias and benign ones.
You also must understand how arrhythmias develop and how they can affect other parts of the
body. Consider this patient, who was recently admitted to the stop-down unit after mitral valve
replacement.

When assessing his vital signs, you note that the heart rate is rapid and irregular, and the pulse is
weak and thready. When checking his heart rhythm on the monitor, you recognize the arrhythmia
uncontrolled atrial fibrillation marked by a rapid, irregular ventricular rate, with characteristic
fibrillatory (or F waves) and no discernible P waves.
But do you know how this arrhythmia occurs? Can you predict what complications may result?
And are you confident in intervening swiftly and accurately? After viewing this video, you'll
understand the pathophysiology of various arrhythmias. You'll also gain a full understanding of
how your interventions can prevent an arrhythmia from occurring or stop it in its tracks.

An arrhythmia can occur in any part of the heart's electrical conduction system or in tissue in the
atria or ventricles. Normally, the sinoatrial (or SA) node in the right atrium spontaneously initiates
electrical impulses because it has a property known as automaticity.
The impulses follow pathways that lead to the atrioventricular (or AV) node between the atria and
ventricles. The AV node acts as a gatekeeper for impulses limiting the number that pass through
each minute. Once impulses leave the AV node, they travel through the AV junction to the
common bundle of His, which divides into the right and left bundle branches.
Next, they enter the Purkinje fibers, which conduct impulses to the ventricles' endocardial surface.
Then the impulses travel through the heart's tissue layers, which causes muscular contraction or
systole. Each impulse moves through the conduction system because cells are activated and
deactivated (or depolarized and repolarized).

This process occurs when sodium and potassium are exchanged across cell membranes. When
the body is at rest, 60 to 100 impulses normally form per minute at a regular pace. This makes the
atria and ventricles contract in tandem, which produces a normal sinus rhythm.
When the SA node generates more than 100 beats per minute, sinus tachycardia occurs. This
arrhythmia results from enhanced automaticity in such conditions as stress, infection,
hypovolemia, or hypotension.

When the SA node generates fewer than 60 beats per minute, sinus bradycardia occurs. This
arrhythmia results from delayed or slowed automaticity. It can happen:

 During sleep,
 In healthy athletes,
 After use of a heart-slowing drug, such as a beta-adrenergic blocker, or
 In hypothyroidism and other conditions

When impulse formation or conduction is enhanced, delayed, or blocked, or when impulses come
from outside the SA node, an arrhythmia results.
Atrial fibrillation occurs when ectopic (or abnormal) sites take over the SA node's normal
automaticity. Although this arrhythmia can be chronic and well-tolerated in some patients, the
acute form commonly causes hemodynamic compromise. Acute atrial fibrillation may result from
cardiac surgery or a disorder that leads to atrial inflammation and increased stretching.
Then, ectopic sites in the atria create impulses randomly. This leads to chaotic firing of 400 to 600
impulses per minute. Some of these impulses run into refractory tissue, which doesn't respond to
stimulation. When this happens, the impulses change direction and form a circuit that may
eventually die out. Other impulses collide with one another and weaken.
Even if impulses reach the AV node, they may not reach the ventricles. That's because the AV
node selectively blocks impulses to protect the ventricles. So, only about 150 impulses reach the
ventricles per minute.

If you note acute atrial fibrillation, perform a rapid, focused assessment. Begin by checking your
patient’s vital signs. His blood pressure is likely to be low, because atrial fibrillation reduces
cardiac output in two ways.
First, it prevents atrial kick (or contraction), which reduces cardiac output by about one-third.
Second, it causes a rapid ventricular rate. This shortens the diastolic filling time, which reduces
cardiac output. When the heart ejects less blood each minute, less blood circulates through the
body with less pressure on the arterial walls. And this reduces the blood pressure.
Also expect a rapid heart rate caused by fast ventricular contraction in response to rapid firing of
impulses by the atria. Next, listen to your patients heart sounds. Expect to hear an irregular rhythm
because impulses reach the ventricles in an inconsistent pattern. Also listen for changes in the
intensity of the first heart sound (or S1).

Because the duration of diastole is inconsistent, the amount of blood that moves through the mitral
and tricuspid valves also is inconsistent. When less blood moves through the valve leaflets, they
close slowly and weakly, making S1 sound quieter. When more blood moves through the leaflets,
they close briskly and vigorously, making S1 sound louder.

Next, evaluate the patient's circulation by assessing the color, temperature, and pulses in his arms
and legs. Also look for unilateral weakness and paralysis, as well as decreased level of
consciousness. These signs may point to cerebral ischemia.
Cerebral and peripheral ischemia may result from thromboembolism. This complication occurs
when blood pools in the atria and forms clots. When normal sinus rhythm is restored, the clots
may be ejected into the circulation and eventually lodge in small blood vessels.
Thromboembolism can also occur when inconsistent blood flow causes pressure changes on the
arterial walls. If a patient has an atherosclerotic artery, pressure changes may cause a thrombus
on the atherosclerotic plaque to break off. If the thrombus lodges in a smaller blood vessel, it can
cut off the local blood supply.

Finally, review the results of diagnostic tests, such as a 12-lead ECG. You're likely to see signs of
chaotic atrial impulses, including an irregular pattern of QRS complexes and characteristic F
waves.

When atrial fibrillation is confirmed, prepare to administer treatment. If atrial fibrillation has lasted
more than 48 hours, expect to administer an anticoagulant, such as heparin. By preventing the
conversion of fibrinogen to fibrin, heparin prevents thrombus formation in the atria and ventricles.
This reduces the risk of thromboembolism.

Next, expect to administer a drug to slow the ventricular rate. You may need to use a:

 Cardiac glycoside, such as digoxin,

 Beta-adrenergic blocker, such as propranolol, or
 Calcium channel blocker, such as verapamil

These drugs slow conduction through the AV node and decrease the ventricular depolarization
rate.

If prescribed, administer an antiarrhythmic drug to restore the normal sinus rhythm. Class 1A
antiarrhythmic drugs, such as procainamide, do this by making myocardial cell membranes less
permeable to sodium, which slows depolarization. These drugs also prolong the refractory period
so that myocardial cells can't be stimulated repeatedly.
Class III antiarrhythmic drugs, such as amiodarone and ibutilide, inhibit potassium movement
across the cell membrane. This suppresses impulse formation in ectopic sites. These drugs also
slow conduction through the AV node, slowing the heart rate. Also, administer adenosine, if
needed. This endogenous nucleoside slows conduction through the AV node.
If drugs don’t halt atrial fibrillation, the physician may perform synchronized electrical
cardioversion. In this procedure, a defibrillator delivers electrical current to myocardial cells and
interrupts chaotic depolarization in the atria. After cardioversion, the SA node resumes control of
impulse formation, and normal sinus rhythm is restored.

This patient was transferred to your unit after an inferior wall myocardial infarction (or Ml). When
you first assess his cardiac rhythm on the monitor, you notice that the PR interval is long 0.24
seconds. Suddenly, his rhythm changes and the P waves show no relationship to the QRS
complex. What's more, the heart rate is only 30 beats per minute. You suspect that your patient is
experiencing third-degree AV block. So you work quickly to intervene.
Typically, AV block results from ischemia or scar tissue at or below the level of the AV node. This
tissue damage delays or blocks impulse conduction from the atria to the ventricles. If impulses are
delayed, the time between atrial and ventricular contractions lengthens. If impulses are blocked,
the atria may contract independent of the ventricles. Or the ventricles may not receive any
impulses, causing ventricular standstill.
The degree of change in impulse conduction determines the severity of the AV block. In first-
degree AV block, impulse conduction through the AV node takes more than 0.20 seconds. In
second-degree AV block type I, one or more atrial impulses don’t reach the ventricles.
This condition also is called Wenckebach block. First-degree and second-degree AV block type I
usually don’t affect the patient adversely and therefore, may not require treatment.
However, if impulse conduction to the ventricle is delayed or blocked further, the patient may
develop advanced AV block, which includes second-degree AV block type II and third-degree AV
block. In second-degree AV block type II, SA node impulses are blocked at the bundle of His. If
only half of the impulses reach the ventricles, this type of AV block may cause a dangerously low
heart rate that decreases cardiac output dramatically.
If ischemia or scar tissue completely blocks AV conduction, the patient develops third-degree AV
block. In third-degree AV block, none of the impulses from the SA node reach the ventricles.
Because the ventricles’ cells aren’t receiving stimulation, impulses arise from junctional tissue or
Purkinje fibers, depending on the location of the block.

If junctional tissue creates the impulses, the ventricular rate may reach 60 beats per minute. That’s
because junctional tissue cells can initiate 40 to 60 impulses per minute, creating a junctional
escape rhythm. If the block lies beyond the junctional tissue, Purkinje fibers in the ventricles take
over.
However, Purkinje fibers can only create 20 to 40 impulses per minute, producing a slow heart
rate and a ventricular escape rhythm. When junctional tissue or Purkinje fibers take over impulse
conduction, the atria and ventricles don’t contract in tandem. This makes the cardiac output fall
sharply and may lead to cardiac arrest.

If you note AV block, perform a rapid, focused assessment. First, check your patient's vital signs.
His blood pressure may be low, because advanced AV block reduces cardiac output. This process
begins when the atria and ventricles don’t work together efficiently. This decreases the amount of
blood that fills the ventricles.
As the ventricles eject less blood and contract fewer times each minute, less blood circulates
through the body. The blood also exerts less pressure on the arterial walls. Together, these
actions reduce the blood pressure.
If your patient has advanced AV block, expect a slow heart rate. Depending on the escape rhythm,
the rate may fall as low as 20 beats per minute.

Next, listen to your patient's heart sounds, which are likely to have changes in S 1’s loudness as
well as an irregular rhythm. Irregularity occurs when some atrial impulses reach the ventricle as in
second-degree AV block types I and II.
While listening to heart sounds, look for cannon a waves. You're likely to see these waves in the
jugular vein pulsations just before you hear S1. Cannon a waves occur when the atria contract
during ventricular systole. Because the right atrium contracts against a closed tricuspid valve,
blood can't move forward.

Also check the results of diagnostic tests, such as a 12-lead ECG. In first-degree AV block, the P
waves and QRS complexes follow a regular pattern. However, the PR interval is more than 0.20
seconds long because impulses are delayed from the atria to the ventricles.
In second-degree AV block type I, the PR intervals progressively lengthen, until one QRS complex
drops out, causing a "footstep" pattern on the ECG tracing. This occurs because impulses from
the atria to the ventricles are progressively delayed until one impulse isn’t conducted to the
ventricles.
In second-degree AV block type II, the PR interval is constant, but some QRS complexes are
missing, for example, in every third beat. This occurs because a block in the bundle of His
intermittently prevents atrial impulse from reaching the ventricles.

In third-degree AV block, P waves and QRS complexes occur regularly. However, the P waves
show no relationship to the QRS complexes, indicating that no atrial impulses are conducted to the
ventricles. Also, the atrial rate exceeds the ventricular rate. This occurs because the SA node
generates impulses faster than junctional tissue or Purkinje fibers can.

When AV block is confirmed, prepare to provide treatment if needed. In advanced AV block when
your patient has light-headedness, hypotension, and other symptoms expect to administer
atropine. This drug increases SA node automaticity and promotes impulse conduction through the
AV node. These actions allow the atria to form more impulses and increase the likelihood that the
impulses will reach the ventricles.
If atropine doesn't raise the heart rate, your patient may need a temporary pacemaker, which may
be external or transvenous. A temporary pacemaker works by stimulating cardiac muscle fibers to
contract. If it doesn’t resolve the AV block, the patient may need a permanent pacemaker.
If these treatments are ineffective, expect to administer isoproterenol. This drug stimulates beta 1-
adrenergic receptors, which increases the heart rate and myocardial contractility. However, the
drug also stimulates beta2-adrenergic receptors, which relaxes vascular smooth muscle and can
worsen hypotension.

Now suppose you're caring for this patient, who developed syncope today while gardening. She's
been admitted to your unit for observation. As you take her history, she says that she suddenly
feels palpitations. So you check the cardiac monitor, and see a fast, wide QRS-complex rhythm.
You suspect ventricular tachycardia. As you quickly measure the patient's blood pressure, she
loses consciousness, and her cardiac monitor shows fine fibrillatory waves, which represent
ventricular fibrillation. You immediately call the code team.
Ventricular arrhythmias occur when cells in the ventricles initiate ectopic impulses. If an ectopic
ventricular impulse occurs between normal beats, the patient has premature ventricular
contractions (or PVCs). If three or more ventricular impulses occur in a row and are faster than
100 per minute, the patient has ventricular tachycardia.

In nonsustained ventricular tachycardia, the arrhythmia usually ends suddenly without intervention.
In sustained ventricular tachycardia, the arrhythmia continues until you intervene. Ventricular
arrhythmias can result from:

 Enhanced automaticity,
 Reentry, or
 Triggered activity
Enhanced automaticity usually occurs when ventricular cells become irritable from an electrolyte imbalance or
other cause. Then these irritable cells fire without SA node stimulation.
If a patient has ventricular scar tissue from an Ml, reentry may cause ventricular arrhythmias.
When an impulse runs into scar tissue, it may split and follow two pathways one that's fast and
one that's slow. The fast pathway conducts impulses normally. The slow pathway delays impulses
just enough to let stimulated cells repolarize and be stimulated again. Then slow-pathway
impulses may conduct back up the fast pathway, producing a continuous circuit that leads to
ventricular tachycardia.
Ventricular tachycardia may also stem from triggered activity, which happens when an injured
cardiac cell depolarizes several times. This may occur when a second impulse stimulates the cell
during repolarization. For example, a drug such as quinidine can delay cell repolarization. Then if
a second impulse stimulates the cell, it must depolarize before it’s ready. Ultimately, this may
result in torsades de pointes, which is polymorphic ventricular tachycardia. And this arrhythmia
commonly deteriorates into ventricular fibrillation.

Whatever the cause of the ventricular arrhythmia, work quickly to provide critical care. Support
your patient’s airway, breathing, and circulation. If needed, perform CPR until a defibrillator is
available.
If the patient has ventricular fibrillation or pulseless ventricular tachycardia, prepare to defibrillate
immediately. Defibrillation interrupts multiple, chaotic ventricular depolarizations and lets the SA
node resume its role as the heart's pacemaker. This restores normal sinus rhythm.
When the patient recovers from ventricular fibrillation (or develops ventricular tachycardia with a
pulse), expect to give her an antiarrhythmic drug, such as lidocaine. Lidocaine stabilizes the
cardiac cell membrane, which reduces automaticity and conduction. This suppresses ventricular
arrhythmias and may prevent new ones from forming. If lidocaine isn’t effective, plan to use
another antiarrhythmic drug, such as procainamide or bretylium.

Once your patient is stabilized, perform a general assessment beginning with her vital signs.
When evaluating blood pressure, be alert for hypotension. This occurs because ventricular
arrhythmias reduce cardiac output and stroke volume.
Also, review your patient's diagnostic test results. Check for low potassium and magnesium levels,
which can increase automaticity in irritable cells. Evaluate her 12-lead ECG tracing for signs of
arrhythmias and ischemia. Remember that ischemia can cause ventricular arrhythmias.
If indicated, prepare your patient for electrophysiology studies (or EPS). In EPS, the physician
threads electrode tipped catheters through large veins, such as the femoral vein, and into areas of
the heart, such as the right atrium and right ventricle.

Then the physician uses the electrode to recreate and record the arrhythmia to locate its exact
source. EPS may reveal:

 A defect in the hearts conduction system,

 The type and speed of the arrhythmia caused by the defect,
 The patient's tolerance of the arrhythmia, and
 The ability of drugs, such procainamide, to suppress the arrhythmia
If test results point to a high risk for life-threatening ventricular arrhythmias, your patient may need treatment with
drugs, surgery, or both. Drugs for ventricular arrhythmias usually include:

 Class I antiarrhythmic drugs, such as quinidine, and

 Class III antiarrhythmic drugs, such as amiodarone

These drugs work on cell membranes to make them less permeable to sodium and potassium. This stabilizes
myocardial cells and helps them resist overstimulation by ectopic impulses.
For life-threatening ventricular arrhythmias, surgery involves insertion of an implantable
defibrillator. This device consists of a generator attached to wires that are threaded into the heart.
The wires detect arrhythmias, and the generator interprets them and provides energy for
cardioversion or defibrillation. Then the wires deliver this energy to the ventricles.

When you're caring for a patient with any type of arrhythmia, individualize your interventions based
on her condition and prescribed treatments. But expect to include these general nursing
interventions.
Frequently monitor your patient’s vital signs, noting the:

 Effects of the prescribed drugs on her heart rate and blood pressure,
 Auscultate her heart sounds to detect signs of a recurring arrhythmia,
 Establish and maintain I.V. access, and
 Use the access device to give antiarrhythmic or other drugs, as prescribed
 Administer oxygen if prescribed to help support ischemic cells, and prevent the arrhythmia from
worsening

Before your patient is discharged, teach her the information that she'll need for a full recovery at home. Be sure
to provide instructions about:

 Drugs, including their dose, frequency, and sides effects,

 Signs and symptoms to report to the physician,
 Emergency interventions, and
 Follow-up care

As you've seen, arrhythmias occur when impulse formation or conduction is enhanced, delayed, blocked or
when a site other than the SA node produces impulses.
By understanding the pathophysiology of arrhythmias, you can:

 Accurately distinguish dangerous arrhythmias from benign ones,

 Provide rapid, effective care that limits complications,
 Assess your patients expertly, and
 Provide full and individualized treatment

For your patients with arrhythmias, this knowledge can help you intervene unerringly to stop or
prevent arrhythmias.

LESSON 3
Central Venous Catheter Insertion: Performing (Advanced Practice) - Overview

Overview: Central venous catheters are inserted to measure and obtain (RAP) and CVP
with jugular or subclavian catheter placement. Clinically useful information can be
obtained about right ventricular preload, cardiovascular status, and fluid balance
in patient's who do not require pulmonary artery pressure monitoring. Central
venous catheters also are placed for infusion of vasoactive medications, total
parenteral nutrition, and hemodialysis access. In addition, central venous
catheters are used to administer medication and intravenous (IV) products to
patient's with limited peripheral IV access, as well as to provide access for
pulmonary artery catheters and transvenous pacemakers.
The CVP can be particularly helpful after major surgery and during active
bleeding. It can be helpful in differentiating right ventricular failure from left
ventricular failure. The CVP is commonly elevated during or following right
ventricular failure, ischemia, or infarction because of decreased compliance of
the right ventricle while the pulmonary artery wedge pressure is normal. The CVP
value is low if the patient is hypovolemic; venodilation also decreases CVP. The
CVP provides information regarding right heart filling pressures and right
ventricular function and volume.
The CVP can be measured using a water manometer system or via a
hemodynamic monitoring system. The CVP waveform is identical to the RAP
waveform. Normal CVP value is 2 to 6 mm Hg.
Central venous access may be obtained in a variety of sites [See Table 1]. The
risk for pneumothorax is minimized by using an internal jugular vein. The
preferred site for catheter insertion is the right internal jugular vein. The right
internal jugular vein is a straight shot to the right atrium. The right or left
subclavian veins are also sites for central catheter placement. Placement of a
central catheter through the right subclavian vein is a shorter and more direct
route than the left subclavian vein, because it does not cross the midline of the
thorax. Femoral veins may be accessed but have the strong disadvantage of
forcing the patient to be on bed rest with immobilization of that leg, and there is
an increased risk for infection with placement in the groin.
Individuals who perform this procedure should have the following prerequisite
knowledge:

 Normal anatomy and physiology of the cardiovascular system

 Clinical and technical competence in central line insertion and suturing
 Understanding of principles of sterile technique
 Anatomy and physiology of the vasculature and adjacent structures of the neck,
groin, and arm
 Competence in chest-x-ray interpretation
 Advanced cardiac life support (ACLS) knowledge and skills
 Understanding of a, c, and v waves

Table 1: Sites, Complications, and Success Rates

Access Site Complications Success Rates (%)

 Internal jugular vein Carotid artery puncture 60-90
Carotid artery cannulation
Right subclavian vein Pneumothorax 70-98
Tension pneumothorax
Thoracic duct puncture
Decreased success rate
with inexperience
Left subclavian vein Pneumothorax 70-98
Tension pneumothorax
Thoracic duct puncture
Decreased success rate
with inexperience
Femoral vein Infection 75-99
Arterial puncture
Failure rate during
hypotension and shock
Inability to thread central
catheters

Central Venous Catheter Insertion: Performing (Advanced Practice) - Outcomes

Expected Outcomes  Successful placement of the central venous catheter
 If infusing IV solution, the solution infuses without problems
 The a, c, and v waves identified in hemodynamic monitoring
 CVP measurement determined

Unexpected  Pain or discomfort during the insertion procedure

Outcomes  Pneumothorax, tension pneumothorax, hemothorax, or chylothorax
 Nerve injury
 Sterile thrombophlebitis
 Infection
 Cardiac dysrhythmias
 Misplacement (e.g., carotid artery, subclavian artery)
 Inadvertent lymphatic or thoracic duct perforation
 Hemorrhage
 Hematoma
 Venous air embolism
 Pulmonary embolus
 Cardiac tamponade
 Sepsis
 Heparin-induced thrombocytopenia or thrombosis

Central Venous Catheter Insertion: Performing (Advanced Practice) - Assessment and

Preparation

Preparation  Ensure that the patient and family understand preprocedural teaching. Answer
 questions as they arise, and reinforce information as needed.
 Obtain informed consent.
 Prescribe sedation if needed.
 Place the patient in a supine position, and prepare the area with an antiseptic
solution (e.g., 2% chlorhexidine-based solution).
 If the patient is obese or muscular and the preferred site is the internal jugular
vein or subclavian vein, place a towel posteriorly between the shoulder
blades.
 Place sterile drapes over the prepped area.

Supplies  CVC insertion kit

 Teflon®-coated or antimicrobial/antiseptic impregnated catheter of
choice(single, dual, or triple lumen) usually supplied with insertion needle,
dilator, syringe, guidewire
 Large sterile drapes or towels
 1% lidocaine without epinephrine
 One 25-G 5/8 needle
 Large package of 4 x 4 gauze sponges
 Suture kit (hemostat, scissors, needle holder)
 0 or 4-0 nylon suture with curved needle
 Three-way stopcock
 Syringes: one 10- to 12-ml syringe, two 3- to 5-ml syringes, two 22-G, 1½-inch
needles
 Masks, caps, goggles (shield and mask combination be used), sterile gloves,
and sterile gowns
 Number 11 scalpel
 Skin protectant pad or swab stick
 Roll of 2-inch tape
 Dressing supplies
 Moisture proof underpad
 Antiseptic solution (such as 2% chlorhexidine-preparation)
 Nonsterile gloves
 0.9% sodium chloride, 10 to 30 ml.

Additional equipment as needed includes the following:

 Hemodynamic monitoring system

 IV solution with Luer-Lok administration set for infusion
 Luer-Lok extension tubing
 Bedside monitor and oscilloscope with pulse oximetry
 Supplemental oxygen supplies
 Emergency equipment
 Package of alcohol pads or swabsticks
 Package of povidone-iodine pads or swabsticks
 Heparin flushes
 Needleless caps
 Arm board

Assessment 1. Determine the patient's medical history of pneumothorax/emphysema.

2. Determine the patient's medical history of anomalous veins.
3. Assess the intended insertion site.
 4. Assess the patient's cardiac and pulmonary status.
5. Assess vital signs and pulse oximetry.
6. Assess electrolyte levels.
7. Assess the patient for heparin sensitivity or allergy.
8. Assess coagulopathic status or whether the patient has recently received
anticoagulant or thrombolytic therapy.

Central Venous Catheter Insertion: Performing (Advanced Practice) - Procedure

1. Determine the anatomy of the access site.

Rationale: Helps ensure proper placement of the catheter.

Catheter placement on the right side is preferred to avoid cannulation of the thoracic
duct.

1. Wash hands, and don caps, masks, sterile gowns, goggles or face shields, and gloves for all health
care personnel involved with the procedure.

Rationale: Reduces the transmission of microorganisms and body secretions. Prepares for
sterile technique.

1. Check landmarks again for the intended catheter insertion site.

Rationale: Ensures proper placement of the catheter.

1. Estimate the length of the catheter needed. This can be done by holding the catheter from the
insertion site to the sternal notch.

Rationale: Helps ensure proper placement.

Internal Jugular Vein See Figure 2

1. Locate the carotid artery by palpation.

Rationale: Helps prevent placing the introducer in the carotid artery.

1. Identify the jugular vein, and mark it if necessary.

Rationale: Identifies the intended insertion site.

1. Instruct the patient to turn his or her head away from the insertion site.

Rationale: Helps identify the landmarks.

Turn the patient's head if the patient is unable to.

1. Place the patient in a 15- to 25-degree Trendelenburg position.

Rationale: Helps to decrease the risk for air embolism. Helps engorge the veins to help
identify the correct site.

1. Identify the internal jugular vein from the triangle between the medial aspect of the clavicle, the
medial aspect of the sternal head, and the lateral head of the sternocleidomastoid muscle See
Figure 2.

Rationale: A high entry can be made from a posterior approach, a lateral approach, an
 anterior approach, or a central approach.
The midanterior approach may be preferred in an obese patient. The posterior
approach may present a slightly higher risk.

1. Administer a local anesthetic and locate the internal jugular vein with a small needle 3 to 4 cm
above the medial clavicle and 1 to 2 cm within the lateral border of the sternocleidomastoid muscle.

Rationale: Provides patient comfort and aids in insertion.

1. Attach a 3-ml or 5-ml syringe with 2 or 3 ml of 1% lidocaine (without epinephrine) to the 18-G
needle. Align the needle with the syringe parallel to the medial border of the clavicular head of the
sternocleidomastoid muscle. Aim at a 30-degree angle to the frontal plane over the internal jugular
vein, toward the ipsilateral nipple.

Rationale: Helps to anesthetize below the subcutaneous tissue. If the needle bevel is
directed medially, the bevel aids in directing the guidewire medially.

1. Use the Seldinger technique for placement of the catheter See Figure 3.

Rationale: This technique is the preferred method of central venous catheter placement.
This technique uses a dilator and guidewire.

1. Puncture the skin, and advance the needle while maintaining slight negative pressure until a free
flow of blood is obtained.

Rationale: Slight negative pressure helps to ensure placement into the vein and decreases
the risk for air embolism and pneumothorax.
If a free flow of blood is not obtained, remove and redirect the needle 5 to 10
degrees more laterally.

1. After a free flow of blood is obtained, have the patient hold his or her breath or hum while the
syringe is detached, and insert the soft-tipped guidewire 10 to 15 cm through the needle. Remove
the needle, wipe the guidewire with the sterile 4 x 4 gauze, and instruct the patient to breathe
normally.

Rationale: A free flow of blood indicates the needle is in the vessel. Holding the breath or
humming decreases the risk for air embolus. Wiping the guidewire dry eases manipulation.

1. With a number 11 blade, knife edge up, make a small (2-mm to 3-mm) stab wound at the insertion
site.

Rationale: Eases the insertion of the dilator through the skin.

1. Insert the dilator through the skin, over the guidewire, until 10 to 15 cm of wire extends beyond the
dilator. Remove the dilator.

Rationale: The dilator enlarges the vessel and skin opening, easing the insertion of the
catheter.

1. Insert the catheter over the guidewire until 10 to 15 cm of wire extends beyond the catheter.
Remove the guidewire. Advance the catheter. Note the catheter length at the insertion site.

Rationale: Helps identify the location.

 1. Aspirate and flush the ports with normal saline.

Rationale: Prevents clotting of the catheter

1. Connect to the hemodynamic monitoring system or intravenous fluid.

Rationale: Necessary for pressure monitoring and maintaining catheter patency.

1. Suture the catheter in place.

Rationale: Secures the catheter.

Some institutions use stat locks or a sutureless mechanism for securing the
catheter.

1. Apply an occlusive, sterile dressing.

Rationale: Decreases the risk for infection.

Some institutions use stat locks or a sutureless mechanism for securing the catheter.

1. Return the patient to a neutral or head-up position

Rational: Provide comfort.

1. If monitoring, identify the appropriate waveforms.

Rational: Ensures accurate monitoring of values.

1. Assess lung sounds and obtain a chest x-ray film.

Rational: Confirms placement and assesses for pneumothorax.

The radiograph needs to be read before administration or total parenteral nutrition
or chemotherapeutic agents.

1. Discard supplies, and wash hands.

Rationale: Decreases the risk for transmission of micro organisms; standard precautions.
Subclavian Vein See Figure 4

1. Identify the junction of the middle and medial thirds of the clavicle. The needle insertion should be 1
to 2 cm laterally.

Rationale: Identifies landmarks for catheter placement.

Access from the right side is preferred to avoid inadvertent puncture of the thoracic
duct.

1. Depress the area 1 to 2 cm beneath the junction with the thumb of the nondominant hand and the
index finger 2 cm above the sternal notch.

To avoid the subclavian artery, select a puncture site away from the most lateral
course of the vein, and do not aim too posteriorly.
1. Administer a local anesthetic and locate the vein with a 21- to 25-G needle directed to the index
finger at a 20- to 30-degree angle.

Rationale: Provides patient comfort and assists patient cooperation and ease of insertion.
Extends the vein to ease the location.

1. Instruct the patient to turn his or her head away from the insertion site.

Rationale: Helps identify the landmarks.

Turn the patient's head if he or she is unable to.

1. Place the patient in a 15- to 25-degree Trendelenburg position.

Rationale: Helps to decrease the risk for air embolism. Helps engorge the veins to help
identify the correct site.

1. Insert the needle under the clavicle and "walk down" until it slips below the clavicle into the vein
while maintaining negative pressure within the syringe until free-flowing blood is returned See
Figure 5.

Rationale: Decreases the risk for pneumothorax. Slight negative pressure helps to ensure
placement into the vein and decreases the risk for air embolism and pneumothorax.
Insert at a 45-degree angle to prevent pneumothorax. If it is difficult to depress the
needle down, the needle may be bent to form an arc. For the elderly: the subclavian
vein may be more inferior. Avoiding a too lateral or too deep a needle insertion can
reduce the risk for pneumothorax.

1. When a free flow of blood is returned, turn the bevel to the 3 o'clock position. Once in the vein,
remove the syringe and insert the flexible guidewire after asking the patient to hum or hold his or
her breath.

Rationale: A free flow of blood indicates a vein is entered. Turning the bevel helps the
guidewire advance to the correct position. Holding the breath or humming decreases the
risk for air embolus.

1. Insert the guidewire 10 to 15 cm through the needle. Remove the needle, and wipe the guidewire
with a sterile 4 x 4 gauze.

Rationale: Wiping the guidewire eases the manipulation of the guidewire.

If the guidewire insertion is not smooth, it may be in the internal jugular vein.

1. Advance the dilator over the guidewire with a light twisting motion.

Rationale: This aids dilation of the subcutaneous tissue to ease insertion and prevents the
formation of a false channel.

1. Remove the dilator from the wire.

2. Insert the catheter of choice over the guidewire; then remove the guidewire.
3. Aspirate and flush the ports with normal saline.

Rationale: Ensures blood return, and maintains catheter patency.

 1. Suture the line in place.

Rationale: Secures the catheter.

1. Connect the catheter to the hemodynamic monitoring system or to intravenous fluid.

Rationale: Necessary for pressure monitoring and catheter patency.

1. Apply an occlusive, sterile dressing to the site.

Rationale: Decreases the risk for infection.

1. If monitoring, identify appropriate waveforms.

Rationale: Ensures accurate monitoring of values.

1. Assess lung sounds, and obtain a chest x-ray film.

Rationale: Confirms placement and assesses for pneumothorax.

The radiograph must be read before administration of total parenteral nutrition or
chemotherapeutic agents.

1. Discard supplies, and wash hands.

Rationale: Decreases the risk for transmission of microorganisms; standard precautions.

Femoral Vein See Figure 1

1. Identify the anatomy, including the femoral artery (remember "NAVEL").

Rationale: NAVEL is an acronym for remembering the anatomy (Nerve, Artery, Vein,
Empty space, Ligament; from lateral to medial).

1. Administer a local anesthetic and locate the vein with a 21- to 25-G needle lateral to the femoral
artery. Aim the needle at a 20- to 30-degree angle.

Rationale: Anesthetizes the area to provide patient comfort.

1. Attach a 3- or 5-ml syringe with 2 or 3 ml 1% lidocaine without epinephrine to the 18-G needle.

Rationale: Anesthetizes the area to provide patient comfort.

1. Use the Seldinger technique for placement of the catheter See Figure 3.

Rationale: This technique is the preferred method of central venous catheter placement.
This technique uses a dilator and guidewire.

1. Puncture the skin and advance the needle while maintaining slight negative pressure until a free
flow of blood is obtained.

Rationale: Negative pressure helps to identify a free flow of blood and ensures proper
placement into the vein.
If a free flow of blood is not obtained, remove and redirect the needle 5 to 10
 degrees more laterally.

1. After a free flow of blood is obtained, detach the syringe and insert a soft-tipped guidewire through
the needle 10 to 15 cm. Remove the needle and wipe the guidewire with a sterile 4 x 4 gauze.

Rationale: A free flow of blood indicates that the vessel has been accessed. Wiping the
guidewire eases the manipulation of the guidewire.

1. With a number 11 blade, knife edge up, make a small (2-mm to 3-mm) stab wound at the insertion
site.

Rationale: Eases insertion of the introducer through the skin.

1. Insert the dilator over the guidewire until 10 to 15 cm of wire extends beyond the sheath. Advance
the dilator through the skin.

Rationale: The dilator dilates the vessel and skin to assist in the ease of the catheter
insertion.

1. Remove the dilator.

2. Insert the catheter of choice over the guidewire and into the vein; then remove the guidewire.
3. Aspirate and flush the ports with normal saline.

Rationale: Ensures blood return and maintains catheter patency.

1. Suture the catheter in place.

Rationale: Secures the catheter.

Some institutions use sutureless systems.

1. Connect to the hemodynamic monitoring system or to intravenous fluid.

Rationale: Necessary for pressure monitoring and catheter patency.

1. Apply an occlusive, sterile dressing.

Rationale: Decreases the risk for infection.

May be gauze or transparent, semipermeable sterile dressing.

1. Identify the appropriate waveforms.

Rationale: Ensures the accurate monitoring of values.

1. Discard supplies, and wash hands.

Rationale: Decreases the risk for transmission of microorganisms, standard precautions.

Arm Vein See Figure 6

1. Identify the median basilic vein.

Rationale: Identifies the site for catheter placement.

The basilic vein is deeper and ascends along the ulnar surface of the forearm, joined
 by the median cubital vein in front of the elbow.

1. Further patient preparation includes applying a tourniquet to locate the vein. Abduct the selected
arm 30 to 45 degrees, and secure it on a flat, padded arm board resting on a flat surface.

Rationale: Aids preparation and allows for engorgement of the vessel.

1. Use the Seldinger technique for placement of the catheter See Figure 3.

Rationale: This technique is the preferred method of central venous catheter placement.
This technique uses a dilator and guidewire.

1. Apply a venous tourniquet to the upper arm. Maintain traction on the skin distal to the insertion with
one hand; puncture the vein with the needle bevel up at a 15- to 20-degree angle.

Rationale: Allows better visualization of veins. Helps with insertion, and prevents the
needle from penetrating too deeply.
Do not attempt to place a central venous catheter in a vein that cannot be seen or
palpated.

1. When blood appears in the needle, insert the guidewire into the vein approximately 2 to 4 cm
beyond the tip.

Rationale: Ensures appropriate placement of the catheter.

If resistance is met, do not force the catheter to advance. Withdraw the catheter 2 to
3 cm, rotate it, and readvance it.

1. Release the tourniquet, and advance the guidewire several centimeters. Remove the needle; wipe
the guidewire with a sterile 4 x 4 gauze.

Rationale: Eases manipulation of the guidewire.

1. Insert the catheter of choice over the guidewire. Remove the guidewire. Note the centimeter
marking at the skin.
2. Aspirate and flush the ports with normal saline.

Rationale: Maintains line patency.

1. Suture in place.

Rationale: Secures the line.

1. Connect to intravenous fluid.

Rationale: Maintains line patency.

1. Apply an occlusive, sterile dressing to the insertion site.

Rationale: Reduces the incidence of infection.

1. Immobilize on an arm board.

Rationale: Ensures that minimal movement of the catheter and sheath occurs.
 1. Discard supplies, and wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

Central Venous Catheter Insertion: Performing (Advanced Practice) - Post Procedure and
Variations
Post Procedure 1. Perform cardiovascular, peripheral vascular, and hemodynamic
assessments immediately before and after the procedure and as the
patient's condition necessitates.

Rationale: Assess for signs of adequate perfusion; air embolism

may present with restlessness; patient may present with
decreased level of consciousness if the catheter is advanced into
the carotid artery.
This includes:

1. Level of consciousness

Rationale: Change in pressure may indicate change in

volume status.

1. Vital signs, central venous waveform, central venous pressure

Rationale: Changes in the waveform may indicate change

in right ventricular function or catheter migration.
Change in level of consciousness, changes in vital
signs, or abnormal waveforms or pressures should be
reported if they persist despite nursing interventions.

1. Monitor the site for hematoma and hemorrhage.

Rationale: If the patient is coagulopathic, a pressure dressing

may be required.
Bleeding that does not stop or hematoma and/or expanding
hematoma should be reported if they persist despite nursing
interventions.

1. Assess heart and lung sounds before and after the procedure.

Rationale: Abnormal heart or lung sounds may indicate cardiac

tamponade, pneumothorax, chylothorax, or hemothorax.
Diminished or muffled heart sounds or absent or diminished
breath sounds unilaterally should be reported if they persist
despite nursing interventions.

1. Assess results of chest x-ray film.

Rationale: Ensures adequate placement and identification of

pneumothorax, if present.
Abnormal x-ray film results should be reported if they persist
despite nursing interventions.
 1. Monitor for signs of complications.

Rationale: May decrease mortality and morbidity if recognized

early.
Signs and symptoms of complications should be reported if
they persist despite nursing interventions.

1. Follow institution guidelines for changing CVC.

Rationale: CVCs are changed according to CDC guidelines when

an infection is suspected, when the CVC is placed in the femoral
vein, or when the catheter is placed emergently.
Signs or symptoms of catheter infection should be reported
if they persist despite nursing interventions.
Documentation  Patient and family education
 Signature on informed consent form
 Insertion of central venous catheter
 Insertion site of central venous catheter
 Vein selected and type and size of catheter placed
 Right atrial pressure and CVP waveform
 Central venous pressure values after insertion
 Centimeter marking at the skin
 Patient response to the procedure
 Confirmation of placement (e.g., chest x-ray film)
 Occurrence of unexpected outcomes
 Additional nursing interventions

Patient Education  Explain the need for the CVC insertion, and assess patient and family
understanding of CVP.
 Explain the procedure and the time involved.
 Explain the need for sterile technique and that the patient's face may be
covered.
 Explain the benefits and potential risks for the procedure.

LESSON 5
Changing the Central Venous Dressing - Overview of the Skill
Overview: Because the central venous catheter insertion site is a direct route to the
circulatory system, care must be taken to keep the insertion site clean and
infection-free. The insertion site must be inspected frequently for signs and
symptoms of infection, such as inflammation, heat, or drainage. Regular,
aseptic dressing changes can help decrease the possibility of infection at the
insertion site and systemically. Policies vary from institution to institution
regarding the type of dressing to apply as well as the frequency with which
they are changed. Be aware of the policy at your institution and the rationale
for it. Dressings that have become wet or are pulling loose from the insertion
site must be changed immediately.
Assessment: 1. Assess the need for dressing change by noting the last dressing change
documented in the medical record and standard of care recommended by the
manufacturer and the institution. This decreases the risk of infection by
following the standard of care.
2. Assess the timing of the dressing change as it relates to medication, IV fluid
and transfusion schedules, as well as the time of the client's daily shower or
 bath. This allows the nurse to avoid simultaneous administration of
medication and the need for two dressing changes in one day.
3. Assess the type of central venous access in place in order to obtain the
appropriate supplies.
4. Assess the integrity of the skin at the site for signs of infection or bleeding.
5. Assess the client and caregiver's knowledge of the purpose and care of the
catheter so a teaching plan can be developed.

Diagnosis:  Risk for Infection

 Impaired Skin Integrity
 Deficient Knowledge, related to insertion site care

Planning
Planning Needs: Equipment Needed:

 Povidone-iodine and alcohol swabs

 Four to five syringes (10-ml)
 Vial of normal saline solution
 Vial of heparin solution (heparin flush or heparin 100 U/ml in saline)
 Sterile needle (20 to 22-gauge)
 Sterile Huber needle (20 to 22-gauge)
 Sterile drape
 Sterile gloves, gown, and mask, as needed

Expected 1. The nurse will be able to aspirate blood through the catheter without difficulty.
Outcomes: 2. The nurse will be able to infuse fluid through the catheter without difficulty.
3. The skin at the catheter insertion site and the puncture site will remain intact
and without redness or swelling.
4. The client will have no signs or symptoms of localized or systemic infection.
5. The catheter injection port will remain intact and without leaks.
6. The client and caregiver will be able to explain the purpose of the VAD and
the proper method of maintaining the VAD.
7. The client and caregiver will be able to perform dressing changes and skin
care.
8. The access site will be free of signs or symptoms of infiltration of blood or IV
fluids.

Client Education 1. Teach the client the rationale for flushing the VAD with normal saline and/or
Needed: heparin according to the institution's or manufacturer's guidelines.
2. Instruct the client about the need for aseptic technique.
3. Teach the client and caregiver how to change the dressing at the
insertion/access site of the VAD.
4. Discuss with the client how to care for the VAD.
5. Ask the client or caregiver to demonstrate ability to care for the VAD after
having been taught.

Changing the Central Venous Dressing - Implementation—Action/Rationale

Implementation ACTION RATIONALE
Action/Rational
e
1. Wash hands and put on clean gloves. 1. Reduces the number of
microorganisms.
2. Remove old dressing carefully 2. Skin integrity may be impaired.
(see Figures 8-12-2 and 8-12-3, being
 careful not to dislodge the central
catheter.
3. Note drainage on dressing. 3. Potential for bleeding or infectious
material.
4. Inspect skin at insertion site for redness, 4. Assesses for infection.
tenderness, or swelling (see Figure 8-
12-4).
5. Palpate tunneled catheter for presence 5. Documents proper placement of
of Dacron cuff, using care not to palpate catheter.
close to the exit site.
6. Visually inspect catheter from hub to 6. Checks whether catheter has a
skin. crack or is split or cut.
7. Remove gloves and put on sterile 7. Prevents transmission of
gloves. microorganisms from skin to exit
site.
8. Clean exit site according to institution 8. Eliminates microorganisms by
protocol. Most use alcohol wipes first, chemical and mechanical means.
then povidone- iodine swab beginning at
the catheter and moving out in a circular
manner for 3 cm to maintain aseptic
technique (see Figure 8-12-5).
9. Some institutions use povidone-iodine 9. Reduces growth of bacteria at exit
ointment to exit site (check agency site.
policy).
10 Apply transparent dressing (see Figures 10 Prevents bacteria from entering exit
. 8-12-6, 8-12-7, and 8-12-8). Some . site.
institutions prefer to omit the gauze
dressing to allow visualization of the
site. In this case only the transparent
dressing is applied.
11 Label with date and time of dressing 11 Documents time to plan for next
. change (see Figure 8-12-9). . change.
12 Secure tubing to client's clothing. 12 Prevents accidental displacement.
. .
13 Remove gloves and dispose of all used 13 Reduces transmission of
. materials. . microorganisms.
14 Wash hands. 14 Reduces transmission of
. . microorganisms.

Changing the Central Venous Dressing - Post-Skill

Evaluation:  The client's skin is intact at catheter site, has normal color, and is not
edematous.
 The client has no signs of systemic infection such as fever or malaise.
 The central venous catheter and tubing are intact.
 Client and caregiver are able to perform skin care and dressing change.

Documentation: Nurses' Notes

 The date and time the dressing was changed

 The type of ointment and dressing applied
 The condition of the skin at the site
  The presence of any exudate or bleeding at the site
 The client or caregiver's ability to perform the dressing change

Variations

Geriatric Variations:
 The integrity of the skin of an elderly client may be impaired. Care
should be taken when removing tape and the dressing, which may stick
because of exudate.
 Teaching a geriatric client or caregiver about changing a dressing will
need to be done after assessing his or her willingness and ability to
perform this procedure.

Pediatric Variations:  Children can be taught to help with the dressing change, such as
opening and holding the sterile dressing or holding the tape.
 Children may need an extra means for securing the catheter, such as a
vest to attach the catheter and tubing.

Home Care Variations:  Supplies should be kept in a clean, dry space.

 The nurse can contact the client at home to see if he or she is having
problems with the dressing change.
 Discharge planning should include referral for home health services.
 Client should be given a written list of providers of supplies and
equipment.

Changing the Central Venous Dressing - Common Errors

Possible Errors: You accidentally pull the catheter while removing the dressing that is stuck to the
catheter.

Prevention: Assess the dressing for drainage that may have stuck to the catheter. Be sure gloves
are the correct size so fingers are agile. If this error does occur, assess the area
around the catheter for bleeding. Soak the dressing with sterile normal saline in order
to remove the dressing without further trauma. Proceed with the dressing change.

Possible Errors: The sterile dressing falls on the floor before it is applied to the skin.

Prevention: Have all supplies next to the client. Maintain sterile supplies on a sterile field. Be sure
you do not have to reach over anything to use your equipment. If this does occur,
discard the gauze, obtain another package, put on another pair of sterile gloves, and
continue with the procedure.

Nursing Tips:  Gather extra supplies to have available in case you drop something.
 A cotton-tipped applicator dipped in normal saline may help loosen exudate on
a catheter.
  Have a catheter repair kit available if a leak or hole is seen during the dressing
change.

Critical Thinking Skill

Introduction: Mrs. Bouvier's tunneled central line exits in her upper chest right under her bra strap.
The strap sometimes rubs the dressing at the site.

Possible The skin around the exit site is red and, one day, she noticed a puslike drainage. She
Scenario: cleaned the area as instructed and reported the redness and drainage to her nurse by
phone.

Possible Mrs. Bouvier's nurse told her to continue to cleanse the area as instructed and apply
Outcome: an antibiotic ointment to the site. The nurse planned to come see Mrs. Bouvier within a
day or two and would assess the site then. The nurse was unable to see Mrs. Bouvier
until 3 days after her call. When the nurse did arrive, he noted that the central venous
catheter insertion site was quite reddened and pus was visible around the catheter.
The nurse notified the physician and received an order for IV antibiotics as well as
more frequent dressing changes.

Prevention: The nurse should have talked to Mrs. Bouvier regarding the site and its care. This way,
he would have found out that Mrs. Bouvier's bra strap rubbed against the site and was
quite irritating. The nurse should then have mentioned that perhaps Mrs. Bouvier could
obtain a bra that did not rub on the central line insertion site or she could discontinue
wearing a bra until the insertion site was no longer inflamed. He should have then
recommended that Mrs. Bouvier change the dressings more frequently to assess the
site condition and then seen Mrs. Bouvier the next day to determine if there were any
other steps that could be taken to reduce the irritation to the central line insertion site.

LESSON 7
Changing the Central Venous Tubing - Overview of the Skill

Overview: Central venous catheter tubing is changed frequently to ensure minimal risk of
infection. The frequency of change depends on institutional policy, the status
of the client, and the type of fluid that is being infused. In clients receiving total
parenteral nutrition or those with compromised immune systems, tubing may
be changed daily. Clients who are neutropenic, such as cancer clients
undergoing chemotherapy, also require more frequent central venous catheter
tubing changes. However, if the client is receiving hydration such as normal
saline and has an intact immune system, central venous catheter tubing may
be changed just a few times a week. Central venous catheter tubing should be
changed immediately if it is found to be damaged or contaminated.
Assessment: 1. Verify policy regarding frequency of central venous catheter tubing
changes. This allows the nurse to ensure institution policies are being
followed.
2. Check original fluid or medication orders regarding rate of infusion and
duration. Identification of this information ensures that fluid or
medication is given at the correct rate for the intended amount of time.
3. Assess client's knowledge regarding fluid or medications. Determine need for
fluid or drug education.
4. Assess client's catheter site. Determine need for dressing change and
observe for signs of infection.

Diagnosis:  Impaired Skin Integrity

 Risk for Infection

Planning

Planning Needs: Equipment Needed (see Figure 8-13-1):

 Central venous catheter tubing

 Medication administration record (MAR) or original order containing
documentation of the type and rate of medication or fluids to be administered
 Medication or fluids
 Tag or a piece of tape with the date tubing is due to be changed

Expected 1. Central venous catheter tubing will be changed in accordance with institutional
Outcomes: policy.
2. The client will remain free of infection secondary to the central venous
catheter tubing.
3. The client will remain free of infection secondary to the central venous
catheter tubing change.

Client Education 1. Explain type of medication or fluids.

Needed: 2. Explain action of medication or fluids.
3. Explain use of central venous catheter tubing and why it is changed on a
schedule.
4. If the client is going to be administering medication or fluids at home using an
infusion central venous catheter tubing, have client do a return demonstration
setting up the infusion set independently.
5. Make sure client knows whom to call with questions.
 6. Reinforce verbal teaching with written instructions.

Changing the Central Venous Tubing - Implementation—Action/Rationale

Implementation ACTION RATIONALE

Action/Rational 1. Wash hands. 1. Reduces the transmission of
e microorganisms.
2. Check MAR against health care 2. Ensures accuracy in the administration
provider's written orders. of the fluid or medication.
3. Check for drug allergies. 3. Decreases risk of allergic reaction such
as hives, urticaria, or anaphylactic
shock.
4. Prepare the medication or fluids for 4. Ensures that the right client receives
one client at a time. Decide what type the right medication using the right
of central venous catheter tubing is equipment.
needed and assemble equipment
(see Figure 8-13-2).
5. Check the client's arm band before 5. Ensures right client.
hanging the new central venous fluids
(if appropriate).
6. Identify the fluids for the client and 6. Encourages client cooperation and
their therapeutic purpose. increases client awareness of what to
expect from the medication or fluids.
7. Clamp off new tubing. Spike bag of 7. Prevents air from being infused through
medication or fluids with new tubing. the central venous catheter and
Squeeze drip chamber (if there is causing an air embolus.
one) until it is about half full. Open
clamp on new tubing until medication
or fluids have filled tubing completely.
8. Clamp off the central venous catheter 8. Sterile tips on catheter and tubing must
and old tubing if it is currently be maintained to minimize risk of
hanging. Disconnect old tubing or cap contamination and infection.
from central venous catheter site.
Connect new tubing without letting
the end of the catheter or the needle
become contaminated (see Figures
8-13-3, 8-13-4, and 8-13-5). Secure
the connection (see Figure 8-13-6).
9. Insert tubing into pump if one is being 9. Necessary to ensure proper rate and to
used and unclamp new tubing. Set prevent fluid bolus.
pump or adjust drip rate to infuse at
ordered rate.
10 Put tag on tubing with next date to be 10. Ensures that other nurses will be aware
. changed. Document tubing change in of date the tubing needs to be
client's chart or on MAR if space is changed.
allotted.
11 Wash hands. 11. Reduces the transmission of
. microorganisms.

Changing the Central Venous Tubing - Post-Skill

Evaluation:  The central venous catheter tubing was changed in accordance with
institutional policy.
 The client remains free of infection secondary to the central venous
catheter tubing.
 The client remains free of infection secondary to the central venous
catheter tubing change.

Documentation: Nurses' Notes

 Record any unusual findings.

MAR Flow Sheet

 Record the time and date the tubing and fluids were changed. Sign and
initial the entry.

Variations

Geriatric Variations:  Elderly clients may have compromised immune systems and delicate,
thin skin. Changing the tubing is a good time to assess for signs of
infection and skin breakdown at the insertion site.

Pediatric Variations:  Pediatric clients are very susceptible to small fluid balance changes. Be
sure to use the correct tubing when changing the central line tubing.
Some tubing sizes deliver large drops and some deliver small drops.
You should use a volume control mechanism, such as a pump or
Volutrol, on any pediatric IV.
 Remind the pediatric client that changing the tubing is not painful.

Home Care Variations:  Make sure that you have supplies set up and a clear work field when
changing tubing in the home setting. It can be difficult to replace
contaminated tubing.
 Make sure the home caregiver knows how to work the IV pump and how
to respond to alarms and emergencies.
 Make sure the home caregiver has the correct tubing and equipment for
the pump.

Long-Term Care  Establish a regular schedule for changing tubing.

Variations:  Complications can occur in central lines that have been placed for long
periods of time. Do not become complacent about assessment.
 People who care for the client daily should know what changes to look
for, who to report them to, and how to respond to pump alarms.

LESSON 7
Flushing a Central Venous Catheter - Overview of the Skill
Overview: A central venous line is a safe, convenient, and painless way to infuse fluid,
medications, and blood products or obtain blood samples from clients who
require specific therapy and monitoring. Frequent venipuncture and multiple IV
lines increase the risk of infection and bleeding. Long-term therapy involving
multiple treatments with corrosive medications can cause peripheral venous
hardening or collapse. Central venous catheters, which are inserted through a
large vein into the superior vena cava, can help avoid these problems.

There are several types of venous access devices. This skill deals with
flushing peripherally inserted central catheters (PICCs), tunneled catheters,
and nontunneled catheters.

 The PICC is inserted into a large vein in the antecubital fossa and advanced
to the subclavian vein and finally into the superior vena cava.
 Tunneled central venous catheters are surgically inserted while the client is
under general or local anesthetic in the operating room. They can have one to
three lumens depending on the needs of the client. A tunnel is made through
subcutaneous tissue below the clavicle; then the catheter tip is inserted
through one of the large veins, such as the internal or external jugular, and the
distal end is threaded into the right atrium. The proximal end is pulled out
through the tunnel where it can be anchored.

The patency of a central venous catheter depends on regular flushing with

saline and possibly heparin solution to prevent clots from forming within the
catheter or at the tip. Changing the dressing at the insertion site is detailed in
Skill 8-12.

Assessment: 1. Assess the type of central venous line in place. This allows the nurse to
know how many lumens are available to access.
2. Assess the function and patency of the catheter to ensure minimal
complications during a blood draw or infusion.
3. Assess client's knowledge of the purpose of the central venous line to
determine the need for education.

Diagnosis:  Risk for Infection

 Impaired Skin Integrity
 Deficient Knowledge, related to the procedure

Planning

Planning Needs: Equipment Needed (see Figure 8-14-1):

 Povidone-iodine and alcohol swabs

 Syringes (10 ml)
 Vial or ampule of normal saline solution
 Vial of heparin solution (heparin flush or heparin 100 U/ml in saline) (check
institution policy on heparin solution use)
 Plastic clamp or metal bull-dog clamp
 Sterile needle (20 to 22-gauge)
 Sterile gloves, gown, and mask
Expected 1. The nurse will be able to aspirate blood through the catheter.
Outcomes: 2. The nurse will be able to infuse fluid through the catheter.
3. The client will not exhibit any signs or symptoms of systemic infection.
4. The visible portion of the catheter will be intact without leaks, holes, or tears.

Client Education 1. Teach the client the rationale for flushing the catheter with normal saline
Needed: and/or heparin according to the institution's or manufacturer's guidelines.
2. Instruct the client about the need for aseptic technique.
3. Teach the client and caregiver how to flush the catheter.
4. Teach the client and caregiver what complications to look for and how to react
to them.
5. Ask the client or caregiver to demonstrate their ability to flush the catheter
after they have been taught.

Flushing a Central Venous Catheter - Implementation—Action/Rationale

Implementation
Action/Rational
e ACTION
1 Wash hands. Apply gloves, gown, and
. other protective equipment as needed.
2 Prepare two syringes (see Figure 8-14- 2.
. 2): one with 10 ml normal saline and
one with 5 ml heparin solution.
3 Swab injection cap or catheter hub with 3.
. povidone-iodine and alcohol.
4 Clamp catheter and remove cap.
.
5 Check catheter for patency: 5.
.
 Attach syringe with normal
saline.
 Release clamp.
 Aspirate heparin solution from
catheter (see Figure 8-14-3).
 Observe blood return.
 Flush quickly with normal saline
(see Figure 8-14-4).
 Reclamp.
 Remove empty syringe.
 Attach syringe filled with 5 ml
heparin solution to catheter.
 Release clamp.
 Flush quickly.
 Reclamp.
RATIONALE
1. Reduces transmission of
microorganisms.
Preparing equipment in advance
allows for a smooth procedure.
Prevents introduction of
microorganisms into catheter.
4. Prevents entrance of air into catheter.
Ensures patency of catheter.
 Connects syringe to catheter.
 Opens catheter lumen.
 Removes old heparin solution.
 Verifies patency of catheter.
 Ensures that catheter will be
cleared of any blood so it will
not clot.
 Clamping catheter during
changes of syringes prevents
air from entering catheter.
 Continues procedure.
 Connects syringe to catheter.
 Opens catheter lumen.
 Injects heparin solution into
catheter.
 Closes catheter lumen.

6 Place new cap on end of catheter, tape 6. Maintains sterile seal to catheter.
. all tubing connections, and attach
tubing to client's clothing.
7 Dispose of soiled equipment and used 7. Reduces transmission of
. supplies. microorganisms.
 8 Wash hands. 8. Reduces transmission of
. microorganisms.

Flushing a Central Venous Catheter - Post-Skill

Evaluation:  The nurse was able to aspirate blood through the catheter.
 The nurse was able to infuse fluid through the catheter.
 The client does not exhibit any signs or symptoms of systemic infection.
 The visible portion of the catheter is intact, without leaks, holes, or tears.

Documentation: Nurses' Notes

 Report the condition of the catheter.

 Report the patency of the catheter, including the ability to draw blood
and difficulty of infusing fluids.
 Report occlusions, damage to the catheter, or air embolus to the health
care provider immediately.

Variations

Geriatric Variations:  If the client is fluid compromised, adjust the volume of flushes.

Pediatric Variations:  Be sure to reduce the volume of fluids used to aspirate and to flush the
catheter.

Home Care Variations:  A receptacle for disposing of soiled equipment is needed.

 Be sure the client or caregiver knows the signs and symptoms of
complications and what steps to take if they occur.
Long-Term Care  If the catheter has been indwelling for a long period, be sure to assess
Variations: carefully for cracks, tears, or leaks.

Flushing a Central Venous Catheter - Common Errors

Possible Errors: The catheter was not clamped between changing the saline syringe and the heparin
syringe. When the client took a deep breath, an air embolus formed.

Prevention: Keep one hand near the clamp in order to remember to clamp the catheter between
changing syringes. If this error does occur, clamp the catheter. Attach an empty
syringe and aspirate blood. Observe for air bubbles. Place client on left side with head
slightly elevated. Assess for dyspnea, hypoxia, or tachycardia. Notify the health care
provider immediately.

Nursing Tips:

 Have all the equipment available for the procedure.

 Take advantage of this procedure to assess the client and provide emotional
support.
 Different catheters require different amounts of heparin or no heparin at all.
 Some catheters do not require clamps.
 If maneuvers to aspirate blood are not successful, the health care provider
should be notified so fibrinolytic therapy (urokinase) can be ordered and given
according to institutional policy.

Critical Thinking Skill

Introduction: There are several causes of difficulty in aspirating blood from a central venous
catheter. It could be a thrombus, precipitation from incompatible medications, or
malposition.

Possible The client was lying on his side when the nurse came to check on his central line. He
Scenario: wanted to check on its patency before starting the IV infusion of antibiotics. When he
tried to aspirate blood, nothing happened. He knew the catheter had been patent just 2
hours before.

Possible He asked the client to turn on his other side, then raise his arms and cough. No blood
Outcome: returned into the syringe. Finally, he asked him to perform the Valsalva's (bear down
and attempt to exhale while keeping the nose and mouth closed) maneuver and blood
easily flowed into the syringe.
Prevention: The tip of the catheter can become lodged against the side of the blood vessel.
Knowing how to cause the catheter to return to a good position will re-establish
patency of the catheter.

LESSON 8
Central Venous/Right Atrial Pressure Monitoring - Overview
Overview: CVP/right atrial pressure (RAP) monitoring provides information about the
patients fluid volume status and right ventricular preload. The CVP or the RAP
allows for evaluation of right-sided heart hemodynamics and evaluation of the
patient's response to therapy. CVP and RAP are used interchangeably.
The CVP or RAP is the pressure measured at the tip of a catheter placed within a
central vein near or in the right atrium. CVP influences and is influenced by
venous return and cardiac function. Although the CVP is used as a measure of
changes in the right ventricle, the relationship is not linear. Because the right
ventricle has the ability to expand and alter its compliance, changes in volume
can occur with little change in pressure. Normal CVP is 2 to 6 mm Hg. The CVP
represents right-sided heart preload or the volume of blood found in the right
ventricle at the end of diastole. CVP values can be obtained by using a
hemodynamic monitoring system or a fluid manometer system. Understanding of
a, c, and v waves is necessary. The a wave reflects right atrial contraction. The c
wave reflects closure of the tricuspid valve. The v wave reflects right atrial filling
during ventricular systole. CVP readings can be affected by location of the air-
fluid interface of the monitoring system. CVP values are useful in evaluating
volume status, effect of medication therapy (especially medication that decreases
preload), and cardiac function [See Table 1].
Individuals who perform this procedure should have the following prerequisite
knowledge:

 Normal anatomy and physiology of the cardiovascular system

 Understanding of the principles of aseptic technique and infection control
 Principles of hemodynamic monitoring

Table 1: Central Venous Pressure

Conditions Causing Increased CVP

· Elevated intravascular volume
· Depressed right-sided cardiac function (RV infarct, RV failure)
· Cardiac tamponade
· Constrictive pericarditis
· Pulmonary hypertension
· Chronic left ventricular failure
Conditions Causing Decreased CVP
· Reduced intravascular volume*
· Decreased mean arterial pressure (MAP)
· Venodilation
*Although the measured CVP is low, cardiac function may be depressed, normal or
hyperdynamic when there is reduced vascular volume.

Central Venous/Right Atrial Pressure Monitoring - Outcomes

Expected Outcomes  Accurate CVP/RAP measurements
 Adequate and appropriate waveforms
  CVP/RAP readings that correlate with physical findings

Unexpected  Air embolus or other complication

Outcomes  Inaccurate readings
 CVP readings that do not correlate with physical findings
 Infection/sepsis

Central Venous/Right Atrial Pressure Monitoring - Assessment and Preparation

Preparation  Ensure that the patient and family understand preprocedural teaching. Answer
questions as they arise, and reinforce information as needed.
 Place patient in the supine position.

Supplies  Hemodynamic monitoring system

 Bedside monitor
 Analog recorder
 Carpenter's level or laser level

Additional equipment to have available as needed includes the following:

 Water manometer and IV fluid, normal saline solution

 Indelible marker

Assessment 1. Assess for signs and symptoms of fluid volume deficit, including weakness,
thirst, decreased urine output, increased urine specific gravity, output that is
greater than intake, sudden weight loss or gain, decreased pulmonary artery
wedge pressure, hemoconcentration, hypernatremia, postural hypotension,
tachycardia, decreased skin turgor, dry mucous membranes, decreased pulse
pressure, weak and thready pulse, abnormal paradoxical pulse on the arterial
line waveform, and altered mental status.

2. Assess for signs and symptoms of fluid volume excess, including dyspnea,
orthopnea, anxiety, sudden weight gain, intake greater than output, pulmonary
congestion, abnormal breath sounds (e.g., crackles), S3 heart sound,
dependent edema, pleural effusion, anasarca, tachypnea, dilutional decrease
in hemoglobin and hematocrit, tachycardia, dysrhythmias, increased
pulmonary artery pressure or pulmonary artery wedge pressure, jugular vein
distention, oliguria, decreased urine specific gravity, altered electrolyte levels,
and altered mental status.

3. Assess for signs and symptoms of air embolus, including sucking sound on
inspiration, dyspnea, tachypnea, hypoxia, hypercapnia, wheezing, a bell-
shaped air bubble in the pulmonary outflow tract on a chest x-ray, increased
pulmonary artery pressure, tachycardia, cyanosis, jugular vein distention,
hypotension, increased systemic vascular resistance, substernal chest pain,
ST-segment changes on electrocardiogram (ECG), cor pulmonale, cardiac
arrest, lightheadedness, confusion, anxiety, fear of dying, aphasia, localized
neurologic deficits, hemiplegia, unresponsiveness, and seizures.

4. Assess for signs and symptoms of infection. Potential for infection can occur
with improper catheter care or contamination. Contamination may occur
 during insertion or any time while the catheter is in place.

Central Venous/Right Atrial Pressure Monitoring - Procedure

CVP Measurement Using Water Manometer Method

1. Wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

1. Locate the phlebostatic axis.

Rationale: Ensures accuracy of measurement.

Once the phlebostatic axis has been identified, the nurse should mark the patients
skin with an indelible marker at this level. This will ensure that future readings are
taken at the same location.

1. Place the patient in the supine position with the head of the bed from 0 to 45 degrees.

Rationale: Studies have determined that the right atrial (RA) and pulmonary artery (PA)
pressures are accurate in this position.

1. Attach the water manometer to the CVP tubing system, and flush the tubing with normal saline
solution while the system is off to the patient.

Rationale: Prepares the system.

1. Place the zero level of the water manometer See Figure 1 at the level of the phlebostatic axis See
Figure 2 .

Rationale: Levels the water manometer for accurate measurements. Ensures accuracy in
measurement.
If the water manometer is attached to an IV pole, use a carpenter's level or laser
leveling device to ensure that the zero level of the manometer is level with the
phlebostatic axis.

1. Turn the water manometer stopcock open to the flush solution See Figure 3 System A .

Rationale: Permits fluid to fill the water manometer.

1. Open the IV tubing roller clamp so that fluid flows from the IV fluid solution into the water
manometer.

Rationale: Prepares the water manometer for pressure measurement. If fluid is allowed to
overflow the top of the manometer, contamination can result.

1. Fill the manometer two thirds full or above the level of the expected CVP measurement.

Rationale: Underfilling the water manometer will result in an inaccurate

 measurement.

1. Ensure that there are no air bubbles in the manometer.

2. Close the roller clamp on the IV tubing.

2. Turn the water manometer stopcock open to the patient and closed to the IV solution See Figure 3
System B .

Rationale: Allows fluid to flow into the patient until the fluid column equalizes with the
pressure in the right atrium.

1. Observe the fluid column closely. It should fluctuate with the patients respiratory cycle.

Rationale: The fluid column may fall rapidly. Care should be taken not to allow all of the
fluid to flow out of the manometer.
If the manometer is allowed to empty, air may enter the patient.

1. The fluid column should fall quickly and then fluctuate gently at the point at which the fluid column
equalizes with the RAP. Measure the CVP reading at end-expiration.

Rationale: The pressure within the manometer equalizes with the pressure in the right
atrium. The height of the fluid column reflects the RAP.
The fluid level will fluctuate with the patient's respiratory cycle once the fluid has
equalized. The CVP should be measured at end-expiration.

1. Turn the water manometer stopcock open to the flush solution and the patient, See Figure 3
System C and reestablish the IV fluid infusion.

Rationale: Prevents clotting of the catheter and reestablishes IV flow.

1. Wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

CVP Measurement Using a Hemodynamic Monitoring System

1. Wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

1. Validate the waveform as CVP/RAP on the bedside monitor.

Rationale: Ensures that the catheter is in proper location.

1. Place the patient in the supine position with the head of the bed from 0 to 45 degrees.

Rationale: Studies have determined that the RA and PA pressures are accurate in this
position.
RA and PA pressures may be accurate for patients in the supine position with the
head of the bed elevated up to 60 degrees, but additional studies are needed to
support this. Only one studysupports the accuracy of hemodynamic values for
patients in the lateral positions; other studies do not. The majority of studies
 support the accuracy of hemodynamic monitoring for patients in the prone
position.Two studies demonstrated that prone positioning caused an increase in
hemodynamic values.

1. Prepare the hemodynamic monitoring system.

Rationale: Ensures accuracy in measurement.

1. Level the air-fluid interface of the monitoring system to the phlebostatic axis.

Rationale: Ensures accuracy in measurement.

1. Run a dual-channel strip of the ECG and right atrial waveform See Figure 4.

Rationale: RAP should be determined from the graphic recording so that end-expiration
can be properly identified.
Some monitors have the capability of "freeze framing" waveforms. A cursor can be
used to determine pressure measurements.

1. Measure the CVP or RAP at end-expiration.

Rationale: Measurement is most accurate because the effects of intrathoracic pressure

changes are minimized.

1. Using the dual-channel recorded strip, draw a vertical line from the beginning of the P wave of one
of the ECG complexes down to the RAP waveform. Repeat this with the next ECG complex See
Figure 5.

Rationale: Compares electrical activity with mechanical activity. Usually three waves will be
present on the RAP waveform.
At times, the c wave will not be present.

1. Align the PR interval with the RAP waveform See Figure 4.

Rationale: The a wave correlates with this interval.

1. Identify the a wave See Figure 4.

Rationale: The a wave is seen approximately 80 to 100 ms after the P wave. The c wave
follows the a wave, and the v wave follows the c wave.
The a wave reflects atrial contraction. The c wave reflects closure of the tricuspid
valve. The v wave reflects passive filling of the right atrium.

1. Identify the scale of the RAP tracing.

Rationale: Aids in determining the pressure measurement.

The RAP scale is commonly set at 20 mm Hg.

1. Measure the mean of the a wave to obtain the RAP See Figure 6.

Rationale: The a wave represents atrial contraction and reflects ventricular filling at end-
diastole.
 1. Wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

Central Venous/Right Atrial Pressure Monitoring - Post Procedure and Variations

Post Procedure 1. Monitor the patient's vital signs every 2 hours or more frequently if the
patients condition indicates.

Rationale: Monitoring vital signs will alert the nurse to the

beginning signs and symptoms of complications or infections.
Changes in vital signs should be reported if they persist
despite nursing interventions.

1. Continue monitoring of the CVP waveform if using the hemodynamic

monitoring system.

Rationale: Changes in the waveform may indicate a change in

catheter position or a change in the patient's condition.
Abnormal CVP values or waveforms should be reported if
they persist despite nursing interventions.

1. Measure the CVP every 2 hours and as needed if using the water
manometer method.

Rationale: Indicates changes in patient's condition.

Abnormal CVP values should be reported if they persist
despite nursing interventions.

Documentation  Patient and family education

 Patients tolerance of the procedure
 Cardiopulmonary assessment
 Assessment and labeled CVP waveform, if appropriate
 IV intake, including amount of flush solution
 Assessment of fluid balance
 Confirmation of RA catheter placement with x-ray film or waveforms
 Unexpected outcomes
 Additional interventions

Patient Education  Discuss the purpose of the CVP catheter and monitoring with both the
patient and family.
 Explain the patients expected participation during the procedure.
LESSOn 13
Infusing Total Parenteral Nutrition (TPN) and Fat Emulsion through a Central Venous Catheter - Overview of the Skill

Overview: Total parenteral nutrition (TPN) is the intravenous administration of varying

combinations of hypertonic or isotonic glucose, lipids, amino acids, electrolytes,
vitamins, and trace elements. Although the formulas vary for individual clients, they
are designed to be nutritionally complete and meet the total nutrient needs of the
client. The TPN formulas are used for clients who, because of their disease process or
treatment, are unable to receive adequate nutrition through the gastrointestinal tract.
The following are examples of disease states that require this type of nutritional
intervention:

 Short bowel syndrome

 Inflammatory bowel disease
 Gastrointestinal fistula
 Hypermetabolic state (severe burns)
 Intractable diarrhea
 Serious acute alimentary disease (pseudomembranous colitis)
 Chronic idiopathic intestinal pseudo-obstruction

Total parenteral nutrition can be administered either through a peripheral (PPN) or

central line (CPN). Determination of the type of venous access is based on a number
of factors: the length of the therapy; concentration of the TPN solutions (more
hypertonic solutions require a central line); and client contraindications for line
placement. Table 8-17-1 outlines the comparison between peripheral and central line
administration.

Another component of TPN is the addition of lipid emulsions. Lipid emulsions are a
10% or 20% combination of triglycerides, egg phospholipids, glycerol, and water.
These solutions may be given as a separate infusion; however, more commonly they
are incorporated into a total nutrient admixture or three-in-one emulsion. Fatty acids
are an essential part of a normal diet. Clients at risk for fatty acid deficiency will
exhibit signs and symptoms such as dry skin, sparse hair, impaired wound healing,
liver abnormalities, and decrease in immune system function.
Total parenteral nutrition is administered continuously over 24 hours or may be given
intermittently (cyclic TPN). Cyclic TPN is given over 10 to 12 hours in a 24-hour
period, which allows for easier integration of the therapy into the client's lifestyle and
minimizes adverse effects of TPN. Intermittent therapy is desirable for those clients on
long-term therapy at home.

Total parenteral nutrition may have both physiologic and psychological consequences
for the client. Clients may feel socially isolated if they cannot eat and are unable to
enjoy the usual atmosphere that centers on food. Client and family education and
support become integral components of the treatment plan.
This skill focuses on the administration of TPN through a central line, also known as
central parenteral nutrition (CPN).
Assessment: 1. A nutritional assessment should be performed prior to initiating therapy. There should
also be a plan of care for ongoing nutritional assessment as the client proceeds with
this therapy. Central parenteral nutrition is indicated when a client has been or is
expected to be unable to take adequate oral or enteral nutrition caused by the
inability to ingest, digest, or absorb nutrients.
2. Determine the type of venous access to be utilized for TPN. Anticipate placement of a
central venous line if indicated. Clients who require TPN short-term and have
adequate peripheral assess may be candidates for PPN depending on the
concentration of the solution ordered. If the client needs a central line for access,
that procedure will be scheduled in advance and the nurse may be required to
assist with the line placement.
3. Review the health care provider's orders and the TPN formula. Compare the ordered
solution with the venous access to be utilized. Remember, the concentration of
the TPN solution will determine the need for a central line. For example, a
dextrose solution >10% should be given via central versus peripheral line.
4. Review the client's medical history and rationale for CPN. The nurse should have an
understanding of the disease process, treatment plan, or acute situation (burns,
trauma) that has led to the need for CPN. This knowledge will help the nurse
anticipate the length of time the client may expect to remain on CPN, and he or
she will format the teaching plan for self-care accordingly.
5. Review the client's normal range of vital signs, weight, electrolytes, liver function,
triglyceride levels, glucose levels, and fluid balance. Also check blood counts in
clients who may be at risk of neutropenia, either caused by their disease process or
treatment. Central parenteral nutrition can produce serious complications such as
metabolic changes, fluid and electrolyte imbalance, line maintenance, or sepsis. It
is critical that the nurse understands the client's baseline data and monitor for
complications.
6. If the client is to receive a lipid emulsion, review the client's history of food allergies,
particularly to egg, soybean, or safflower products. Lipid emulsions may contain
these products, and clients may experience adverse side effects such as fever,
chills, or rash during administration.

Diagnosis:  Imbalanced Nutrition, Less Than Body Requirements

 Risk for Infection
 Anxiety, related to the disease process and treatment plan
 Ineffective Coping, related to the disease process and treatment plan
 Deficient Knowledge, related to self-care management

Planning

Planning Needs: Equipment Needed (see Figure 8-17-1):

 Disposable gloves
 IV infusion tubing
 IV infusion pump
 CPN solution
 IV filter (optional: 0.22 mm for dextrose/amino acids; 1.2 mm for three-in-one
solutions)
Expected Outcomes: 1. Client maintains ideal body weight (for those clients on preventative CPN).
2. Client gains 1 to 2 pounds per week to reach ideal body weight as appropriate.
3. Serum glucose levels are less than 200 mg/dl.
4. Venous access site remains patent and free of signs and symptoms of infection.
5. Client masters self-administration of CPN in those situations requiring long-term
nutritional support.

Client Education 1. Explain the rationale for CPN as it relates to the client's disease state.
Needed: 2. Instruct the client to report discomfort around the venous access site during infusion.
3. Teach the client and caregiver catheter care procedures for long-term administration
as appropriate.
4. Instruct the client to report any symptoms of infection or sepsis, such as shaking,
chills, malaise, fever (if not in a monitored setting), and redness or tenderness at
catheter site.
5. Instruct the client to monitor glucose levels and to report any symptoms of
hyperglycemia: thirst, malaise, flushed skin, nausea or vomiting, or polyuria, and
symptoms of hypoglycemia: headache, drowsiness, diaphoresis, dizziness, tremor,
tachycardia, muscle twitching, or seizure activity.
6. Review with the client symptoms related to venous thrombosis-a potential
complication of CPN. These symptoms include edema and pain in neck or shoulder,
leaking of infuscate around catheter site, and inflammation or swelling at insertion
site.
7. Instruct the client to report any symptoms associated with a potential allergic reaction
such as rash, shortness of breath, headache, flushing, pain in chest or back, or chills.
8. Teach the client to report any adverse symptoms.
9. Teach the client emergency measures in the event of problems with the central line
(breakage, disconnection from IV tubing). Include information regarding true
emergencies (and calling 911) versus reporting minor problems to the health care
provider or home care team.
10. In the home care setting, teach the client to call the home care provider with any
questions related to the solution or the infusing device. The home care provider will
usually work with the client over the phone to solve the problem and provide a
nursing visit for those problems that the client cannot resolve by phone.
11. Teach the client to weigh self daily on the same scale and at the same time for more
accurate results. The client may also need to know how to take his or her temperature.
12. Tell the client how long to expect to receive TPN.
13. Ask the client to tell you why he or she is receiving TPN and fat emulsion.
14. Instruct the client to report any symptoms of infection or sepsis, such as shaking,
chills, malaise, fever (if not in a monitored setting), and redness or tenderness at
catheter site.
15. Discuss the need for setting aside a special place for IV fluids at home.

Infusing Total Parenteral Nutrition (TPN) and Fat Emulsion through a Central Venous Catheter - Implementation—
Action/Rationale

Implementation
Action/Rationale
ACTION RATIONALE
1. Remove TPN from refrigerator at least an 1. Some solutions must be refrigerated; this
hour before hanging, if appropriate decreases risk of hypothermia or venous
 (see Figure 8-17-2).
2. Inspect fluid for presence of cracking or for 2.
precipitate or discoloration of solution. If the
solution is a three-in-one solution, check for
a cream layer of separation. Check label
against order and check expiration date.
3. Wash hands and identify client. 3.
4. Using aseptic technique, attach tubing (with 4.
filter) (see Figure 8-17-3) to the CPN bag or
bottle; prime tubing.
5. Attach tubing into volume control infusion 5.
pump (see Figure 8-17-4). Connect the
tubing to the catheter. With some infusion
devices, you may connect the IV tubing first
to the client's catheter and then to the
infusion device.
6. Regulate flow rate based on client's 6.
nutritional and metabolic needs.
7. Check to see that all IV connections are 7.
secured.
8. Recheck flow rate on infusion pump; check 8.
to see that unit is plugged into wall or has
adequate battery reserve (see Figure 8-17-5).
9. Wash hands. 9.
spasm.
The CPN solution should be clear without
clouding. The three-in-one solution should
be uniform without areas of fat separation.
If there is any problem with the solution,
notify pharmacy and receive a new
product.
Reduces the transmission of
microorganisms. Ensures proper client
identification.
Reduces the transmission of
microorganisms. Prevents air embolus.
Note that infusion pumps vary on tubing
requirements, priming, and attachment to
the central line. Review this information
and be familiar with the equipment before
beginning this step.
Flow rate may begin at 40 to 60 ml/hr. The
rate is increased each day toward a target
goal. For example: Begin the infusion flow
rate at one-half the end desired rate for 1
hour, then increase to the end desired rate.
Institute more gradual tapering increments
for pediatric clients.
Prevents disconnection of tubing. Many
facilities tape the connections as an added
measure of security.
Prevents flow rate errors.
Reduces the transmission of
microorganisms.

Infusing Total Parenteral Nutrition (TPN) and Fat Emulsion through a Central Venous Catheter -
Post-Skill

Evaluation:  If this is a new start of therapy, monitor the client's response hourly, assessing
for complications such as allergic reactions, fluid overload, occlusion of the
line, and electrolyte imbalance (mental status changes).
 Monitor blood glucose frequently with initiation of CPN; schedule will vary per
facility routines.
 Monitor electrolytes daily, particularly liver function tests and triglyceride
levels, and assess for the presence of jaundice. Clients on long-term CPN will
require ongoing evaluation of liver function tests (at least monthly).
 Monitor client's weight daily and intake and output; assess for peripheral edema.
 Inspect venous access site for signs of infection and patency.
 Check breath sounds for crackles, indicating fluid overload.
 Table 8-17-2 outlines some of the more common complications of CPN therapy.
The nurse should be familiar with these and incorporate the information into his
or her ongoing assessment of the client.
Documentation: Nurses' Notes

 Document initiation of therapy; record client's preinfusion vital signs.

 On the medication record, document the components of the CPN solution (some
facilities have pretyped labels that the nurse verifies and documents).
 Document client's response to initial flow rate and subsequent increase in rate.
 Document tubing changes and condition of venous access site. Review record
for date that the venous access site dressing was last changed.
 Document client/caregiver education.
 Document results of the physical assessment (e.g., breath sounds) during the
infusion.
 Document glucose levels and pertinent electrolytes, such as the additives.

Variations

Geriatric Variations:  Older adults may have visual or mental impairment, which may interfere with
their ability to perform self-care routines related to the central line dressing or
administration of CPN. Precautions may be needed to protect the central line
site, particularly if the client is disoriented.
 Elderly clients are also at risk for lipid intolerance and hyperglycemia.
 The geriatric client will need to be monitored for fluid overload and cardiac
status when receiving these concentrated IV fluids.

Pediatric Variations:  Central parenteral nutrition may be indicated for infants with gastrochisis,
congenital anomalies of the gastrointestinal system, or short bowel syndrome.
Infants are also more prone to complications such as hepatobiliary dysfunction.
 Care and protection of the central line for infants and young children are
especially important. Young children should be carefully supervised at all times.
Additional extension tubing may be required for children in order to allow them
adequate room to play and move about.
 Glucose levels may be difficult to maintain in children.
 Children will need emotional support with frequent glucose monitoring if done
by needle stick.

Home Care Variations:

 Extensive client and caregiver education is needed to successfully manage this

therapy in the home setting. The therapy administration schedule will need to be
integrated into the client's lifestyle; most of these clients will be on cyclic CPN.
 The client should have written information related to the storage, handling,
preparation, and infusion instructions.
 Care should be taken to ensure that the client has a refrigerator, which can store
the premixed solutions at 2° to 8° C (35.5° to 46.5° F).
  Client and caregiver should be taught aseptic technique for caring for central
venous catheter, tubing, and IV fluids.
 Clients should be taught to record their weight, intake and output, and glucose
levels.

Long-Term Care Long-term care facilities may not be equipped for the management of CPN. Some
Variations: facilities will require pharmacy support from a qualified provider and extensive training
of nursing personnel for the ongoing management of the client on this therapy.

Infusing Total Parenteral Nutrition (TPN) and Fat Emulsion through a Central Venous Catheter -
Common Errors

Possible Errors: Upon removal from the refrigerator, the CPN solution (three-in-one) has a layer of separation,
or "creaming," of the solution.

Prevention: The nurse cannot actually "prevent" solution separation. However, the nurse's role is critical in
inspecting the solution prior to administration for signs of discoloration, precipitation, or
separation.

Possible Errors: The CPN solution is tapered too quickly.

Prevention: Verify the health care provider's orders for the solution composition and for the rate ordered.
Verify that the infusion pump is set for the correct rate and that it is operating properly. If this
error does occur, call the health care provider. The client may exhibit symptoms of
hypoglycemia. The health care provider may order D10W at the previous CPN rate and may also
have the blood glucose checked.

Nursing Tips:

 Prepare several syringes with normal saline to have available for flushing the catheter.
 Have a reference card for drug compatibility to refer to.
 Write a medication schedule to ensure safe administration.
 Have an extra cap and syringes at hand.
 Hyperglycemia is defined as a serum glucose of >160 mg/dl and causes thirst and
increased urination because of a lack of insulin in the bag of TPN.
 Hypoglycemia is defined as a serum glucose of <80 mg/dl and causes the client to be
shaky, dizzy, nervous, and anxious because of an excess of insulin or TPN that is
stopped abruptly.
 Be familiar with the infusion pump. Some pumps can be programmed for a tapering
schedule. Other devices will require manual programming for each change.
 Allow adequate time for client teaching for those clients going home on this therapy.
Always include a caregiver in the teaching session and allow for adequate opportunity
for return demonstration. Provide written instructions and check client's insurance
benefits for home care services.
 It is important that the home environment be reviewed with the client who is self-
administering CPN. Does the client have, for example, adequate refrigeration,
 electricity, water supply, and access to 911?
 Check carefully the prepared CPN solution with the health care provider's orders. The
solution is composed of many types of additives (i.e., trace elements) that are an
important part of the therapy.
 Always use sterile technique when working with the central line because of the
increased risk for septicemia.

Critical Thinking Skill

Introduction: Caring for the client on CPN also means caring for the central line. Prevention of complications
arising from the line placement or line maintenance is key for clients receiving this therapy.

Possible Scenario: Mrs. Bauer had a subclavian catheter placed in anticipation of initiating CPN therapy.
Currently she was only receiving normal saline to maintain the line until the compounding was
completed for her CPN solution. Mrs. Bauer's call light went on. When the nurse entered the
room, Mrs. Bauer was short of breath, very anxious, coughing, and reporting chest pain. The
nurse quickly clamped the central line, placed the client on her left side, in Trendelenburg
position, and immediately called the physician. Upon close inspection of the IV tubing, the
nurse noticed that it was disconnected at the extension tubing site.

Possible Outcome: Most likely the client had received an air embolism from the disconnected central line.

Prevention: Carefully check all connections with each client assessment. Many settings require that the
connection sites be taped together for added security. Teach the client to help monitor the
connections as well; frequently it may be the client that reminds a nurse to tape a tubing
connection.

LESSOn 14
Central Venous Catheters: Removal - Overview

Central venous catheters are removed when therapy is completed, a mechanical

Overview: malfunction has occurred, the catheter has become occluded or malpositioned, or a
catheter-related infection has developed.
The pathogenesis of a nontunneled central venous catheter is the extraluminal
colonization of the catheter originating from the skin, primarily with less common
hematogenous seeding of the catheter tip or intraluminal colonization of the hub and
lumen.
Consider whether a culture tube or agar plate is needed for culturing the tip of the
catheter, because there is poor evidence to support a recommendation for or against this
practice.
 Individuals who perform this procedure should have the following prerequisite
knowledge:

 Normal anatomy and physiology of the cardiovascular system

 Anatomy and physiology of the vasculature and adjacent structures of the neck
 Clinical and technical competence in central line removal
 State nurse practice act

Central Venous Catheters: Removal - Outcomes

 The catheter is removed intact.

Expected Outcomes  Hemostasis is achieved at the catheter site.

 Inability to remove the catheter

Unexpected  Catheter not removed intact
Outcomes  Air embolism
 Pulmonary embolism
 Catheter site infection
 Difficulty attaining hemostasis at the puncture site; formation of
hematom

Central Venous Catheters: Removal - Assessment and Preparation

 Ensure that the patient and family understand preprocedural teaching. Answer
Preparation questions as they arise, and reinforce information as needed.
 Position the patient supine in the Trendelenburg position or with the head of the bed
flat if the Trendelenburg position is contraindicated.
 Start a new peripheral intravenous (IV) line or ensure that an existing peripheral IV is
patent.

 Goggles or face shield mask and nonsterile and sterile gloves

Supplies  Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
 Suture removal kit or sterile scissors
 4 x 4 gauze pads
 2 x 2 gauze pads
 One roll of 2-inch tape

Additional equipment to have as needed includes the following:

 Container for culture

 1. Review the patient's laboratory data for platelet count, prothrombin time, activated
Assessment partial thromboplastin time, and international normalized ratio. Review the patient's
medical history or hospital course for coagulopathy issues.
2. Determine whether the patient is receiving anticoagulant therapy.
3. Assess the patient's vital signs.
4. Observe the catheter site for redness, warmth, tenderness, or presence of drainage.

Central Venous Catheters: Removal - Procedure

1. Wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

2. Open the suture removal kit or sterile scissors and sterile gauze pads.

Rationale: Prepares supplies for use.

3. Turn off the IV infusion.

Rationale: Prevents saturating the bed, patient, or work area with IV solution on catheter removal.

4. Don personal protective equipment (goggles, mask, and nonsterile gloves).

Rationale: Reduces the transmission of microorganisms; standard precautions.

5. Place the patient supine in a slight Trendelenburg position. Have the patient turn his or her head away from
the catheter (if removing an internal jugular or subclavian catheter).

Rationale: Positions the patient for central line removal; decreases the risk of air entry and reduces
the transmission of microorganisms.
Place the patient flat if the Trendelenburg position is contraindicated or cannot tolerated by
the patient.

6. Remove the catheter dressing, and discard it.

Rationale: Exposes the catheter site.

7. Remove the nonsterile gloves, wash hands, and don a pair of sterile gloves.

Rationale: Reduces the transmission of microorganisms; standard precautions.

8. Carefully cut the suture, and pull the suture through the skin.

Rationale: Allows for removal of the catheter.

Ensure that the entire suture is removed. Retained sutures can form epithelialized tracts that
can lead to infection.

9. Instruct the patient to take a deep breath in and hold it (if removing an internal jugular or subclavian
 catheter).

Rationale: Minimizes the likelihood of air being accidentally drawn into the systemic venous
circulation.
If the patient is mechanically ventilated, withdraw the catheter during the inspiratory phase of
the respiratory cycle or while delivering a breath via a bag-valve device.

10. Remove the catheter, following these steps:

a. Grasp the catheter with the dominant hand, and withdraw the catheter in one continuous motion.

Rationale: Withdrawing the catheter with continuous motion decreases trauma to the vein.
The distal end of a multilumen catheter should be removed quickly because the exposed
proximal and medial openings could permit the entry of air.
If there are signs of infection, send the catheter tip to the laboratory for culture and
sensitivity testing, if prescribed.

b. With the nondominant hand, quickly apply pressure over the puncture site with a sterile 4 x 4 gauze
pad.

Rationale: Minimizes the risks of air entry and bleeding.

11. Maintain pressure for 5 minutes until hemostasis has been achieved.

Rationale: Prevents bleeding and hematoma formation.

Pressure may be needed for a longer period if the patient has been receiving anticoagulant
therapy or if results of coagulation studies are abnormal.

12. Once hemostasis has been achieved, apply an occlusive, sterile dressing over the site.

Rationale: Minimizes the risks of air entry and infection at the site.

13. Inspect the catheter after it has been removed.

Rationale: Ensures that the entire catheter has been removed.

14. Reposition the patient after application of the occlusive dressing.

15. Discard used supplies in appropriate waste containers, and wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

Central Venous Catheters: Removal - Post Procedure and Variations

1. Monitor the patient's vital signs, pulse oximetry, and level of consciousness
Post Procedure before and after the central venous catheter is removed.

Rationale: Changes in mental status, heart rate, blood pressure, and

respiratory rate may indicate pulmonary air embolism. If an embolus is
suspected, position the patient on the left side and in the Trendelenburg
position.
Changes in vital signs, persistent shortness of breath or tachypnea,
 cyanosis or decreased oxygen saturation, or changes in mental
status should be reported if they persist despite nursing
interventions.

2. Assess the dressing for indications of bleeding for the first 15 minutes after
catheter removal, then every 15 minutes for the next hour.

Rationale: Assesses for hemostasis and early evidence of bleeding.

Bleeding or hematoma development should be reported if they
persist despite nursing interventions.

3. Assess catheter integrity.

Rationale: Catheter debris could cause further complications, such as

pulmonary embolism.
Altered catheter integrity, changes in vital signs, persistent
shortness of breath or tachypnea, cyanosis, or decreased oxygen
saturation should be reported if they persist despite nursing
interventions.

4. Observe the catheter site daily for signs of infection.

Rationale: Infection of the skin site may occur after removal of the
catheter.
Redness, tenderness, or drainage at the catheter site or elevated
temperature or white blood cell count should be reported if they
persist despite nursing interventions.

5. Remove the dressing, and assess for site closure 24 hours after removal.

Rationale: Verifies healing and closure of the site.

Abnormal healing should be reported if they persist despite nursing
interventions.

 Patient and family education

Documentation  Date and time of catheter removal
 Site assessment
 Culture specimen sent (if appropriate)
 Ease of catheter removal
 Inspection of the catheter
 Length of time pressure was applied to achieve hemostasis
 Application of occlusive dressing
 Patient's tolerance of the procedure
 Unexpected outcomes and interventions

 Explain the procedure for catheter removal to the patient and family.
Patient Education  Instruct the patient to report any signs and symptoms of shortness of breath,
 chest or groin pain, or other changes.

LESSON 15
Peripherally Inserted Central Catheter Care - Overview

Peripherally inserted central catheters (PICCs) provide alternative IV access when the
Overview: patient requires intermediate-length venous access (greater than 7 days to 3 months).
PICCs are inserted through the larger cephalic and basilic veins in the upper arm and
advanced until the tip enters the central venous system (e.g., subclavian vein). In many
states the PICC can be inserted by a registered professional nurse who has received
special training and has demonstrated competency in PICC line insertion (refer to state
Nurse Practice Act).
The nurse caring for patients with PICCs must understand what they are and be aware of
their appropriate care and maintenance. In comparison with centrally placed venous
catheters, PICCs have less risk for creating pneumothorax, hemothorax, and air embolism
and are more cost-effective to maintain. Compared with peripheral IV catheters, PICCs
have less risk for causing infiltration and phlebitis. This allows them to be maintained in
place longer (more than 72 to 96 hours) because IV fluids and medications are diluted in
the greater volume of blood flow present in the larger veins (superior vena cava) where
the catheter tip placement should reside. In fact, PICC lines may remain in place as long
as there are no signs of problems. Complications associated with PICC use include
clotting, leaking, migration, infection, and the breaking of the catheter. For successful
catheter placement, the patient must have a usable cephalic or basilic vein located in the
antecubital fossa or upper arm.
PICCs vary in size from 16 to 24 gauge and in length from 40 to 65 cm (16 to 26 inches).
The length is chosen based on the distance from the proposed insertion site in the patient
to the desired point of tip placement. Catheters can have a single or a double lumen. The
catheter is made of soft materials, which cause minimal irritation to the vein. PICCs can
be used to infuse IV fluids, parenteral nutrition, blood and blood products, and
medications such as antibiotics. The nurse should be aware of the product advantages and
limitations of each device used.

Peripherally Inserted Central Catheter Care - Outcomes

 Site is intact and has no redness or swelling.

Expected Outcomes  Systemic signs of infection (fever, malaise, increased white blood cell count
[WBC]) are absent.
 Fluids, medications, blood products infuse without difficulty.
 Blood can be aspirated from catheter.
 Catheter and connecting tube are intact.
 Catheter tip is correctly placed, as confirmed by x-ray examination.
 Patient and family are able to explain the purpose of PICC therapy and perform
dressing changes and skin care.

 There is blocked or difficult infusion of fluids through catheter, indicating

Unexpected Outcomes occlusion that is either mechanical, nonthrombotic, or thrombotic.
  Patient experiences pain and erythema at insertion site; blood or fluids leak from
PICC insertion site.

Peripherally Inserted Central Catheter Care - Assessment and Preparation

1. Position patient in semi-Fowler position. Position level of bed for easy access to
Preparation patient.
2. Explain procedure and purpose to patient and family. Instruct patient to be still during
procedure.

Blood Drawing
Supplies
 Antimicrobial swabs (i.e., chlorhexidine, povidone-iodine, alcohol)
 Four to five syringes (preferably needleless access)
 Sterile drape
 Saline flush
 Heparin flush (100 units/ml)
 Sterile needleless access
 Blood tubes, labels, requisitions
 Gloves, masks

Dressing Change

 Antimicrobial swabs
 Gloves, mask, gown
 Sterile tape
 Transparent occlusive dressing
 Gauze dressing: 2 x 2 sterile gauze
 Steri-Strips or securement device
 Adhesive remover (if needed)

Heparinization

 Antimicrobial swabs
 Access syringe (5 ml or 10 ml—see institution policy)
 Saline flush
 Heparin flush (100 units/ml)
 Sterile needleless access

1. Assess the stage of the patient's disease and the plan of therapy by reviewing medical
Assessment record.
2. Review physician's order, and assess treatment schedule: times for administration of
fluids, drugs, blood products, nutrition, and blood sampling.
3. Assess type of PICC in place. Review manufacturers directions concerning the
catheter and its maintenance. Each manufacturer publishes guidelines for its specific
catheters.
 4. Assess need to use PICC for blood sampling.

In most situations, several tests can be run from one blood tube sample. For
example, potassium, calcium, and magnesium test results can all be obtained
from one full tube of blood versus three separate tubes. Always anticipate the
need for a blood test (e.g., blood cultures if a patient has developed an elevated
temperature). If your next task is to draw blood for electrolyte results, you could
eliminate reaccessing the PICC at a later time by asking the physician if blood
cultures are to be drawn. Consultation with the laboratory services can provide
and confirm specific instructions.

5. Assess PICC placement site for skin integrity and signs of infection (i.e., redness,
swelling, tenderness, exudate, bleeding).
6. Assess for proper function of PICC before therapy: integrity of catheter, ability to
irrigate or infuse fluid, ability to aspirate blood.
7. Assess need for irrigation and dressing change by referring to medical record, nurse's
notes, institution policies, and manufacturers recommended guidelines for use.
8. Assess patient's acceptance of PICC and teaching needs related to knowledge of
purpose, care, and maintenance. Ask patient to discuss steps in care and to perform
procedure (e.g., catheter site cleansing or dressing change).

Peripherally Inserted Central Catheter Care - Procedure

1. Administration of Infusion or Sampling of Blood from PICC

a. Perform hand hygiene.

b. Apply gloves. Apply gown and goggles (check institution policy) if drawing blood sample.

Rationale: Prevents transfer of body fluids.

c. Use antimicrobial preparation swabs to cleanse injection cap or catheter hub according to institution
policy.

Rationale: Prevents introduction of microorganisms into catheter.

d. Prepare two syringes with 10 ml normal saline each.

Rationale: Used to flush catheter.

e. If injection cap will be removed, clamp catheter.

Rationale: Catheter must be clamped if injection cap is removed to prevent entrance of air.

f. If injection cap is in place, insert needleless access syringe containing 10 ml normal saline, and flush.
If injection cap is removed, connect syringe tip to catheter hub, release clamp, flush with positive
pressure, and reclamp.
 Rationale: Flushing ensures patency of catheter. Catheter must always be clamped during change of
syringe or tubing to prevent exposure to air.

If catheter is occluded and resistance is felt, do not force flushing. Vigorous flushing may cause
catheter rupture or catheter emboli.

g. Connect syringe for blood sampling, and release clamp. Aspirate 5 ml fluid, reclamp, and discard
aspirate. (Do not discard if drawn for blood culture.)

Rationale: Discarding initial 5 ml of aspirate avoids diluting sample.

h. Attach or insert syringe of size equal to volume of blood sample to withdraw into catheter. Release
clamp. Withdraw necessary blood for samples, and reclamp.

Rationale: Samples should be collected at one time to minimize time with open catheter system.

i. Attach or insert syringe filled with 10 ml normal saline to catheter. If clamp is present, release, flush
vigorously, and reclamp.

Rationale: Catheter should be cleared of all blood or medications that may clog catheter lumen or
precipitate with additives in IV fluids.

j. If no continuous infusion is indicated, flush catheter with heparin or normal saline as appropriate.
Connect syringe containing 5 ml heparin (100 units/ml) or normal saline flush solution. If clamp is
present, release, flush with positive pressure, and reclamp.

Rationale: A catheter not in use must be flushed to prevent clot formation. This is commonly done
with heparin; however, Groshong catheters are flushed with normal saline only.

k. Attach new cap to end of catheter, and remove clamp.

Rationale: Maintains sterile seal to catheter.

l. If IV fluids will be administered, connect IV tubing to end of catheter, being sure both ends are
sterile.

Rationale: IV system should be closed to maintain sterility.

m. Regulate IV infusion as ordered.

Rationale: Maintains ordered fluid intake and keeps catheter patent.

n. Secure all tubing connections.

Rationale: Prevents accidental tubing disconnection and catheter displacement. Luer-Lok connections
should be used.

o. Dispose of soiled equipment and used supplies. Remove gloves and perform hand hygiene.

2. Dressing Change

a. Perform hand hygiene and apply clean gloves.

b. Mask self and patient, if indicated (check institution policy).

Rationale: Prevents exposure of catheter exit or placement site to airborne microorganisms.

c. Carefully remove old dressing in the direction in which the catheter was inserted, noting drainage and
appearance of catheter.

Rationale: Remove tape carefully because patients commonly have alterations in skin integrity.
Prevents dislodgment of catheter.

d. Inspect site for signs of redness, swelling, inflammation, tenderness, and exudate.

Rationale: This is a potential site of infection.

e. Inspect catheter and hub for intactness, and remove clean gloves.

Rationale: Catheter may become torn, cut, displaced, cracked, or split.

f. Perform hand hygiene, and open dressing kit in a sterile manner. Most institutions have dressing kits
that contain all needed dressing-change supplies.

g. Apply sterile gloves.

Rationale: Prevents direct transmission of microorganisms to skin exit site.

h. Clean site with antimicrobial swab, moving first in a horizontal pattern. With a new swab move in a
vertical plane, and then use a final swab in a circular pattern, moving outward in concentric circles
from insertion site out. Allow to dry.

Rationale: It is impossible to sterilize skin. Organisms that accumulate must be eliminated by

mechanical and chemical means. Mechanical friction in this pattern allows penetration of the
antiseptic solution into the cracks and fissures of the epidermal layer of the skin. Antiseptic solutions
should be allowed to air-dry completely so as to effectively reduce microbial counts. If antiseptic
agents are used in combination, allow each to air-dry separately.

i. Place Steri-Strip or securement device over catheter See Figure 1.

Rationale: Provides security to prevent catheter dislodgment. PICC lines may be sutured in place,
preventing placement of gauze underneath.

j. Redress site using sterile gauze and tape or transparent dressing as indicated.

Rationale: Prevents entrance of bacteria into exit or placement site.

k. Secure connections. Luer-Lok connections are preferred.

Rationale: Prevents accidental pulling and displacement.

l. Label date, time of dressing change, and size of cannula in place.

 Rationale: Documents dressing change. Provides guideline for time of next change.

m. Dispose of soiled supplies; remove gloves, and perform hand hygiene.

Peripherally Inserted Central Catheter Care - Post Procedure and Variations

1. When continuous infusions are administered, observe and calculate drip rate hourly. Note
Post Procedure ease with which fluid rate can be increased.

Rationale: To maintain proper fluid infusion, desired drip rate should be regulated
continually. A gradual slowing in rate or the inability to increase rate may indicate
catheter occlusion.

2. Routinely assess vital signs of patient, noting changes symptomatic of infection.

Rationale: Catheter-related sepsis can cause fever, chills, flushed skin, tachycardia.

3. Observe site when dressing is removed [See Table 1].

Rationale: Continual monitoring for signs of inflammation or infection is essential.

4. Observe all catheter connection points periodically.

Rationale: An intact system prevents accidental blood loss and entrance of air.

5. Inspect condition of catheter and connecting tubing daily for leaks, holes, tears, splits, and
cracked hubs.

Rationale: A break in the integrity of the system predisposes patient to hemorrhage or air
embolus.

6. Measure amount of catheter that remains external with each dressing change.

Rationale: Detects catheter migration.

7. Consult x-ray examination reports for catheter placement.

Rationale: A routine chest x-ray examination can locate position of catheter tip.

8. Evaluate ability of patient and family to provide care and maintain catheter or infusion
port through discussion and return demonstrations of dressing changes and skin care.
Determine need for restrictions of daily activities.

Rationale: Measures patient's ability to care for self and any additional learning needs.

 Record gauge and length of PICC, insertion site, location of catheter tip, radiographic
Documentation confirmation of location of catheter tip (if x-ray examination has been completed),
presence or absence of signs and symptoms of complications.
  Report status of PICC, therapy being administered, and development of complications and
their treatment.

 Because PICC insertion and care may be unfamiliar to the patient, implement careful and
Patient repeated verbal explanations with written follow-up.
Education  Instruct patient and caregiver about signs and symptoms of the most common
complications: phlebitis, clotting, leaking at catheter insertion site, and breaking of the
catheter. Instruct patient in how to respond to each of these complications.
 Because the dressing is the anchor for the PICC, instruct patient and caregiver to notify
nurse if dressing becomes loose. Nurse will perform a dressing change.
 If PICC becomes clotted, instruct patient to promptly seek care so that declotting measures
can be instituted.
 The PICC dressing should not become wet, so instruct patient to adapt bathing to keep
cannulated arm dry.
 Advise patient to avoid vigorous activities (e.g., weight lifting) because catheter may be
damaged.
 Inform patient that he or she can move arm freely because there is less chance of
infiltration and dislodgment than with a peripheral venipuncture using a short catheter.

Age-Specific Pediatrics
Considerations
 An advantage of the use of PICCs is the longer duration and stability of use compared
with traditional peripheral catheters. PICCs have a reduced risk for causing infections
compared with umbilical venous catheters in neonates.
 In neonates the antecubital veins, long saphenous vein, and superficial temporal vein in
the scalp are most commonly used. The external jugular vein, popliteal vein, veins in the
ankle, and axillary veins may be used.

Table 1: Complications of Vascular Access Devices

Complication Assessment Prevention Intervention

Catheter damage, Observe for pinholes, Follow proper Use a catheter stylet for
breakage leaks, tears during clamping procedure. temporary repair.
every shift.
Avoid sharp objects Use permanent repair
Assess for drainage near the catheter. kit.
after flushing.
Use needleless Remove catheter.
system device.
Occlusion: thrombus, Assess for blood Follow routine Reposition patient.
precipitation, return. flushing with positive
Have patient cough and
malposition pressure and/or use
Assess for inability deep breathe.
positive pressure
 to infuse fluid. valve injection cap. Raise patient’s arm.
Assess equipment. Avoid tugging on Obtain venogram if
CVC. ordered.
If port, reaccess and
verify Huber needle Administer low-dose Administer
placement. oral anticoagulant thrombolytics if
therapy. ordered.
Assess with syringe
directly on catheter. Avoid using Remove catheter (CVC
excessive force. requires order).
Assess for
discomfort or pain in Flush between drugs. Obtain x-ray
shoulder, neck, or examination as ordered.
Flush vigorously
arm at insertion site.
after viscous If precipitate, try
Assess for neck or solutions. hydrochloric acid or
shoulder edema. ethanol solution per
Avoid mixing
orders.
Assess sutures to incompatible drugs.
ensure no restriction Do not use a 1-ml
Avoid kinking
or pinching of syringe to instill saline
catheter.
catheter. because pressure
exceeds 200 psi.
Infection: exit site, Assess exit site for Use aseptic Administer antibiotic
tunnel, thrombus, port redness, drainage, technique. therapy as ordered.
pocket edema, or tenderness. (Draw blood cultures
Adhere to dressing
first when ordered.)
Assess vital signs. change technique.
Remove catheter (CVC
Monitor laboratory Apply dressing over
requires order).
findings. exit site.
Administer
thrombolytic agent if
ordered.
Replace catheter.
Obtain blood cultures
peripheral and from
CVC if ordered.
Dislodgment Assess length of Loop and tape the Insert new catheter.
catheter daily. catheter securely.
Secure catheter with
Inform patient of Use occlusive securement device.
possible catheter dressing.
Teach patient not to
dislodgment.
Avoid pulling on manipulate catheter.
Identify edema at CVC.
exit site or drainage.
Handle with care.
Palpate exit site and
Avoid manipulating
tunnel for coiling
catheter by hand.
(catheter can be felt
and traced Protect site with soft
underneath the skin). outer cover.
Assess for distended
neck veins.
Catheter migration, Assess for patient Avoid trauma. Reposition under
pinch-off syndrome, complaints of fluoroscopy as ordered.
port separation gurgling sounds. Avoid placement Remove catheter as
Assess for change in near site of local ordered.
patency of catheter infection, scarring, or
Stop all fluid
by evaluating change skin disorder.
administration.
in flow rate, local
irritation, swelling,
occlusion,
tenderness, pain,
inability to aspirate
fluid and/or blood.
Obtain x-ray
examination.
Assess edema of arm
and hand on side of
insertion.
Assess for distended
neck veins.
Assess for inability
to infuse fluids.
Assess length of
catheter daily.
Skin erosion, Assess for loss of Maintain nutritional Remove CVC as
hematomas, cuff viable tissue over status. ordered.
extrusion, scar tissue septum site.
Avoid pressure or Improve nutrition.
formation over port
Assess for separation trauma.
Provide appropriate
of exit site edges.
Rotate site with each skin care.
Assess for drainage port access.
at exit site.
Assess for redness.
Assess for edema,
contusions.
Note if tunneled
catheter is exposed.
Infiltration, Assess for erythema. Stop vesicant Apply cold/warm
extravasation administration compresses according
Assess for edema.
immediately. to specific vesicant
Assess for spongy protocol.
Administer antidote
feeling.
or therapeutic Provide emotional
Assess for swelling medications to support.
around the IV site maintain tissue
Obtain x-ray
and at the integrity according to
examination if ordered.
termination of the protocol.
catheter tip. Use antidotes per
protocol.
Assess for labored
breathing. Discontinue IV fluids.
 Assess for aspiration
of fluid and/or blood.
Assess for
complaints of pain.
Assess for no free-
flow IV drip.
Pneumothorax, Assess for Use injection cap on Administer oxygen as
hemothorax, air subcutaneous distal end when not ordered.
emboli, hydrothorax emphysema by in use.
Elevate feet. Aspirate
inspecting and
Do not leave catheter air, fluid.
palpating skin around
open to air.
insertion site and If air emboli suspected,
along arm. place patient on left
side with head elevated
Inspection may
slightly. Remove
reveal edema where
catheter as ordered.
the air is located, and
the air may travel if Assist with insertion of
the skin is loose. chest tubes as ordered.
Palpation reveals a
crackling sensation
such as popping
plastic bubble wrap.
Assess for chest pain.
Assess for dyspnea,
apnea, hypoxia,
tachycardia,
hypotension, nausea,
confusion.
Incorrect placement Cardiac Obtain x-ray Stop all fluid
dysrhythmias. examination after administration until
placement. placement is confirmed.
Assess for
Discontinue catheter
hypotension. Reposition catheter
(CVC requires order).
as warranted.
Assess for neck
Obtain x-ray
distention.
examination and
Assess for narrow electrocardiogram (for
pulse pressure. PICC and CVC).
Assess for Administer support
medications as or
inadequate blood
withdrawal.
Assess for retrograde
flow of blood (the
flow of blood back
into the tubing,
usually caused by
decreased pressure
gradient between the
venous system and
the access device
unit [e.g., IV
 infusion, heparin
lock]).

LESSON 16
Peripherally Inserted Central Catheters (Advanced Practice) - Overview

PICCs are used to deliver central venous therapy for 2 weeks to 12 months and to provide
Overview: venous access for patient's who require multiple venipunctures. PICCs are used to
administer long-term antibiotic therapy, chemotherapy, total parenteral nutrition,
analgesia, blood products, intermittent inotropic therapy, and fluids.
Ideally, the patient receiving a PICC should have a peripheral vein that can accommodate
a 14-gauge or 16-gauge introducer needle. If necessary, a 22-gauge microintroducer can
be used to dilate a vein to accommodate an introducer sheath. The basilic and cephalic
antecubital fossa veins are the preferred veins for cannulation with a PICC See Figure 1.
The basilic vein is the larger of the two veins and is the vein of choice for insertion of a
PICC. Once inserted, the PICC is advanced to the superior vena cava.
Indications for the insertion of a PICC vary. PICCs are being used more frequently for
patient's receiving intravenous (IV) therapy in the home setting for chronic heart failure,
cancer treatment, chronic pain management, nutritional support, and fluid replacement.
PICCs may be preferred over percutaneously inserted central venous catheters for
patient's with trauma (e.g., burns) of the chest or those who have certain pulmonary
disorders (e.g., chronic obstructive pulmonary disease or cystic fibrosis).
IV therapy via the PICC poses fewer risks and is associated with less severe
complications (including infections) than IV therapy with percutaneously inserted central
venous catheters. Several types of PICCs are available for use. PICCs are flexible
catheters that are made of silicone or polyurethane. PICCs are available as single- or
double-lumen catheters and can be inserted with or without the use of a guidewire.
Several types of safety-engineered introducers are available and should be used to reduce
the risk of blood exposure and needlestick injury.
Individuals who perform this procedure should have the following prerequisite
knowledge:

 Specialized education in PICC insertion

 Clinical and technical competence in suturing PICC lines in place
 Understanding of sterile technique
 Anatomy and physiology of the vasculature and adjacent structures in the upper
extremity, neck, and chest

LESSON 16
Peripherally Inserted Central Catheters (Advanced Practice) - Outcomes

 The PICC tip is positioned in the superior vena cava.

Expected Outcomes  The PICC remains patent.
 The insertion site and upper extremity remain free of phlebitis and
thrombophlebitis.
  The insertion site, catheter, and systemic circulation remain free of infection.

 Pain or severe discomfort during the procedure

Unexpected Outcomes
 Complications on insertion, such as cardiac dysrhythmias, pericardial tamponade,
air embolism, catheter embolism, arterial puncture, and nerve (brachial plexus)
injury
 Complications after insertion, such as phlebitis, thrombophlebitis, catheter
occlusion, infection (e.g., insertion site, catheter, systemic), and infiltration

Peripherally Inserted Central Catheters (Advanced Practice) - Assessment and Preparation

1. Ensure that the patient and family understand preprocedural teaching. Answer
Preparation questions as they arise, and reinforce information as needed.
2. Ensure that informed consent has been obtained.
3. Assist the patient to a semi-Fowlers or dorsal recumbent position, depending on the
patient's clinical condition and level of comfort.
4. Position the selected arm at 45 degrees of extension from the body for anthropometric
measurement. For catheter placement in the superior vena cava, use nonsterile
measuring tape to measure the distance from the selected insertion site to the
shoulder See Figure 2a and from the shoulder to the sternal notch See Figure 2b. Add
3 inches (7.5 cm) (or the measured distance from the sternal notch to the third
intercostal space) to this number for catheter placement in the superior vena cava.
5. Measure the mid-upper arm circumference of the selected extremity.
6. Stabilize the position of the arm with a towel or pillow.
7. Instruct the patient on proper head positioning. The head is positioned to the
contralateral side (away from the insertion site) throughout the procedure, except
when advancing the catheter from the axillary vein to the superior vena cava. At this
point, the patient is instructed to position his or her head toward the ipsilateral side
(toward the insertion site) with the chin dropped to the shoulder.

 Catheter insertion kit

Supplies  PICC of choice
 Single-use tourniquet or blood pressure cuff
 Sterile and nonsterile measuring tape
 Waterproof underpad/linen saver
 Sterile gown and cap
 Mask
 Goggles
 Two pairs of nonpowdered, sterile gloves
 Sterile drapes and towels, including one fenestrated drape
 Antiseptic solution (e.g., 2% chlorhexidine-based preparation)
 10-ml vial of heparin (concentration and use per institutional policy)
 30-ml vial of NS
 Luer-Lok injection port (cap) with short extension tubing
 One 10-ml, 20-gauge, 1-inch needle syringe (blunt needle recommended)
 One 3-ml, 20-gauge, 1-inch needle syringe or one 5-ml, 20-gauge, 1-inch needle
syringe if a double-lumen catheter is being inserted (blunt needle recommended)
  Three to four sterile 4 x 4 gauze pads or sponges
 1% lidocaine without epinephrine, or 1 to 2 ml of eutectic mixture of local anesthetics
(EMLA) cream (optional)
 Two sterile 2 x 2 gauze pads or sponges
 Sterile, transparent, semipermeable dressing

Additional equipment as needed includes the following:

 One 1-ml, 25-gauge, 5/8-inch needle syringe (if using intradermal lidocaine)
 One 3-0 or 4-0 nylon suture on a small, curved cutting needle (if suturing)
 Alternative catheter securement device (e.g., sterile wound closure strips) if not
suturing

1. Assess the patient's medical history for mastectomy, fistula, shunt, or radial artery
Assessment surgery.
2. Obtain the patient's baseline vital signs and cardiac rhythm.
3. Assess the vasculature of the antecubital spaces of both arms, focusing on the basilic
and cephalic veins See Figure 1. A tourniquet or blood pressure cuff should be applied
on the mid-upper arm for vein assessment and then removed.
4. Determine the patient's allergy history (e.g., lidocaine, heparin, EMLA cream,
antiseptic solutions, tape, latex).

Peripherally Inserted Central Catheters (Advanced Practice) - Procedure

1. Wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

2. Place a waterproof pad under the selected arm.

Rationale: Avoids soiling bed linens.

3. Position the tourniquet high on the upper extremity, near the axilla, but do not constrict venous blood flow at
this time.

Rationale: Placement high on the extremity avoids contamination of the sterile field.

A blood pressure cuff may be used in place of a tourniquet.

4. Open the PICC insertion tray, and drop the remaining sterile items onto the sterile field.

Rationale: Maintains aseptic technique; prepares the work area, including procurement of all necessary
equipment; avoids interruption of the procedure and contamination of the work area.

5. Don cap, mask, goggles, sterile gown, and sterile gloves.

Rationale: Standard precautions; PICC insertion is a sterile procedure.

Blood splashing may occur with the use of guidewires, stylets, and breakaway or peel-away
introducers.
6. Using the sterile measuring tape, cut the catheter to the predetermined length.

Rationale: Catheters are provided in various lengths.

a. Add 1 inch (2.5 cm) to the premeasured length to be left outside the insertion site.
b. Remove the guidewire, and cut the tip of the catheter straight across with the sterile scissors See
Figure 3.

Rationale: Prevents the catheter tip from lying flush against the vessel wall, which can increase the
incidence of clot formation.

A catheter with a guidewire or stylet is recommended to reduce the risk of the catheter coiling
or knotting in the vein and for ease of insertion.

7. Reinsert the guidewire so that the tip of the wire is covered by approximately 0.5 to 1 cm of the catheter.

Rationale: Facilitates the removal of the guidewire; provides softness and flexibility at the catheter tip, thus
preventing perforation of the vein during insertion.

8. Fill the 10-ml syringe with normal saline (NS). Add the injection port (cap) to the short-extension tubing and
prime it with NS. Leave the syringe attached.

Rationale: Avoids inadvertent introduction of air into the system.

If a double-lumen catheter is being inserted, prime the additional lumen of the catheter with NS.

9. Prepare the site using a 2% chlorhexidine-based antiseptic solution. Cleanse the site using a back-and-forth
motion while applying friction for 30 seconds. Allow the antiseptic to remain on the insertion site and to air-
dry completely before catheter insertion.

Rationale: Limits the introduction of potentially infectious skin flora into the vessel during the puncture.

10. Remove gloves, wash hands, and apply the tourniquet (or blood pressure cuff) snugly, approximately 6
inches (15 cm) above the antecubital fossa.

Rationale: Provides vasodilatation of the vein for venipuncture.

Constriction should effectively cause venous distention without arterial occlusion. A blood pressure
cuff may be used and may be more effective, especially with obese patient's. After the cuff is inflated,
palpate the radial artery to assess for arterial blood flow.

11. Don a new pair of sterile gloves. Instruct the patient to lift his or her arm, and place a sterile drape underneath
the arm and the fenestrated drape over the prepared area, leaving the venipuncture site exposed. Place a
sterile 4 x 4 gauze pad over the tourniquet. Instruct the patient to turn his or her head away from the insertion
site.

Rationale: Maintains the sterile field and facilitates aseptic technique. Prevents contamination of the field by
organisms from the patient's respiratory tract.

12. Inject a skin wheal of approximately 0.5 ml of 1% lidocaine without epinephrine at or adjacent to the
venipuncture site.

Rationale: Provides local anesthesia for venipuncture with large-gauge needles and introducers. Research
suggests that local anesthesia should be considered when a PICC is inserted.

Most patient's report less pain when a local anesthetic agent is used before venipuncture. Lidocaine
may produce stinging, burning, obliteration of the vein, or venospasm. The use of EMLA (a topical
 anesthetic cream) before venipuncture has been researched. If it is used, the manufacturer's
recommendations should be followed.

13. Perform the venipuncture according to catheter design and manufacturer's instructions.

Rationale: Catheters vary according to design and introducing techniques.

14. Use the modified Seldinger technique See Figure 4 (1).

Rationale: Verifies venous access.

Place a finger over the orifice of the catheter to limit blood loss and risk for air embolism See Figure 4
(2). If there is no blood return, the procedure should be terminated, and an alternate access site should
be selected.

a. Insert a peripheral IV, and observe for blood return in the flashback chamber See Figure 4 (1) and 4
(2)
b. Remove the stylet, and advance the guidewire 2 to 4 inches (5 to 10 cm) through the IV catheter See
Figure 4 (3)
c. Remove the IV catheter, and insert the dilator/introducer over the guidewire See Figure 4 (4)

Rationale: Use of a guidewire enhances the advancement of the dilator/introducer.

A small skin nick may be made at the venipuncture site to facilitate the advancement of the
dilator/introducer See Figure 4 (3). If a scalpel is not provided in the PICC insertion kit, a No.
11 blade should be used. Place a finger over the orifice of the introducer to limit blood loss and
the risk for air embolism See Figure 4 (6).

d. Gently advance the dilator/introducer until the tip is well within the vein See Figure 4 (5)
e. Remove the dilator and guidewire, leaving the introducer in place See Figure 4 (6)
f. Insert the catheter approximately 6 to 8 inches (15 to 20 cm) See Figure 4 (7)

Rationale: Establishes venous access.

Sterile forceps may be used to insert the catheter into the introducer and advance the catheter
into the vein.

15. Release the tourniquet using the sterile 4 x 4 gauze pad.

Rationale: Continued vasodilatation may not be required for catheter advancement.

If a blood pressure cuff is used, it may remain inflated throughout the advancement of the catheter.
Leaving the tourniquet in place (or the blood pressure cuff inflated) may facilitate catheter
advancement if vascular insufficiency is evident.

16. Instruct the patient to turn his or her head toward the cannulated arm and to drop his or her chin to the chest.

Rationale: Changes the angle of the jugular vein and decreases the potential for malpositioning of the catheter
in the jugular vein.

17. Advance the remainder of the catheter until approximately 4 inches (10 cm) remain. Observe (or palpate) the
patient's heart rate and rhythm.

Rationale: Cardiac dysrhythmias may occur if the catheter is advanced into the heart.

Never advance the catheter if resistance is felt. Excessive pushing could lead to perforation of the vein
 or myocardium.

18. Instruct the patient to return his or her head to the contralateral side (away from the insertion site).

Rationale: Prevents contamination of the field by organisms from the patient's respiratory tract.

19. Pull the introducer out of the vein and away from the insertion site, and remove it See Figure 4 (8) and 4 (9)

Rationale: The introducer sheath is not needed once the catheter is in place.

Methods of removing the introducer vary according to the manufacturer.

20. Measure the length of the catheter remaining outside the skin, and reposition, if necessary, to the
predetermined length. Approximately 1 inch (2.5 cm) of the catheter should remain externally.

Rationale: Ensures proper catheter tip position.

21. Attach the primed extension tubing (with injection port) to the catheter; aspirate for evidence of blood, and
flush with NS using a push/pause technique.

Rationale: Use of extension tubing provides easier access to the catheter and reduces local trauma at the
insertion site. Aspiration affirms patency of the catheter. The push/pause technique while flushing optimizes
long-term patency of the catheter.

22. Inject the recommended amount and concentration of heparin into the catheter, clamp the extension tubing,
and remove the syringe. Repeat the procedure if a double-lumen catheter is being used.

Rationale: Maintains catheter patency and prevents backflow of blood into the catheter.

Recommendations vary regarding the use, amount, and concentration of heparin to maintain catheter
patency. Heparin is contraindicated in patient's with known allergies to heparin. Institutional policies
should be followed.

23. Secure the catheter at the insertion site by suturing or applying an alternate catheter securement device See
Figure 5.

Rationale: Prevents inward or outward migration of the catheter.

A nylon suture is recommended. Institutional guidelines should be followed.

24. Cover the insertion site with a sterile, 2 x 2 gauze pad or pads. Cover the site with a sterile, transparent,
semipermeable dressing See Figure 6

Rationale: Decreases catheter-related infections.

A 2 x 2 gauze pad can be folded and placed immediately below the insertion site to act as a "wick" for
any drainage in the first 24 hours. It is not needed after the first dressing change.

25. Discard used supplies, and wash hands.

Rationale: Reduces the transmission of microorganisms and body secretions; standard precautions.

26. Prepare the patient for a chest x-ray examination.

Rationale: Confirms placement of the catheter tip and detects any complications.

Some PICCs require contrast media for good visualization. Infusions should not be initiated until
 catheter tip placement has been confirmed.

Peripherally Inserted Central Catheters (Advanced Practice) - Post Procedure and Variations

1. Observe the patient for signs or symptoms of cardiac dysrhythmias and

Post Procedure pericardial tamponade during the procedure. If cardiac dysrhythmias occur,
pull the catheter back, and reassess the patient.

Rationale: Cardiac dysrhythmias may occur if the catheter is advanced into the
heart. Pericardial tamponade may occur if the catheter penetrates the atrium.

Cardiac dysrhythmias or hemodynamic instability (changes in vital signs,

level of consciousness, peripheral pulses, narrow pulse pressure, jugular
venous distention) should be reported if they persist despite nursing
interventions.

2. Assess the patient and obtain the chest x-ray report confirming proper catheter
tip placement before initiating administration of any IV solutions.

Rationale: Ensures accurate catheter tip placement and aids in identifying

potentially life-threatening complications.

Abnormal chest x-ray report, change in lung sounds, chest pain, or

respiratory distress should be reported if they persist despite nursing
interventions.

3. Observe the dressing and insertion site every 30 minutes for the first 4 hours
after insertion.

Rationale: Postinsertion bleeding may occur in patients who have

coagulopathies or arterial punctures, when multiple attempts at venipuncture
are made, or when the through-the needle introducer design is used for
insertion.

Excessive bleeding, hematoma, or changes in vital signs should be

reported if they persist despite nursing interventions.

4. Assess the insertion site and upper extremity every shift for signs and
symptoms of phlebitis, thrombophlebitis, or infiltration.

Rationale: Mechanical phlebitis is the most common complication within the

first 72 hours after insertion. Thrombophlebitis may occur within 0 to 10 days
of catheter insertion.

Pain along the vein; edema at the puncture site; erythema; ipsilateral
swelling of the arm, neck, face; venous occlusion (changes in arm
circumference greater than 2 cm from baseline); or infiltration (infusion
continues in spite of restriction to venous blood flow by tourniquet) should
be reported if they persist despite nursing interventions.

5. Assess the catheter for venous blood return and patency before initiating
infusions. Connect a 10-ml syringe filled with 10 ml of NS to the extension
tubing. Release the clamp, and aspirate slowly to verify blood return. Flush
with 10 ml of NS (using a push/pause technique), and then administer the
 infusion.

Rationale: Verifies position of the catheter in the vascular space and patency
before infusions are initiated.

Catheter occlusion (failure to obtain blood return on aspiration or

resistance to irrigation) should be reported if it persists despite nursing
interventions.

6. Assess the catheter for dislodgment or migration by measuring the length of

the external catheter.

Rationale: The catheter may no longer be properly positioned if the length of

the external catheter is longer or shorter than the length measured at the time of
insertion.

Change in external catheter length, catheter occlusion, cardiac

dysrhythmias, pain or burning during infusions, palpation of the catheter
in the internal jugular vein, palpation of a coiled catheter, or infiltration
should be reported if they persist despite nursing interventions.

7. The initial dressing should be left in place for 24 hours. After this, assess the
insertion site and upper forearm while performing a sterile dressing change.
Transparent, semipermeable dressings should be changed at least weekly.
Sterile gauze dressings should be changed every 48 hours. Dressings should be
changed if they become damp, loosened, or visibly soiled.

Rationale: Policies may vary regarding the type of dressing and frequency of
dressing changes after the initial dressing change.

Redness, warmth, hardness, tenderness or pain, or swelling at the

insertion site; presence of purulent drainage from the insertion site; or
local rash or pustules should be reported if they persist despite nursing
interventions.

8. Monitor the insertion site and patient for signs and symptoms of local or
systemic infection.

Rationale: The incidence of infection related to the catheter may result from
failure to maintain asepsis during insertion, failure to comply with dressing
change protocols, immunosuppression, frequent access to the catheter, and
long-term use of a single IV access site.

Redness, warmth, hardness, tenderness or pain, or swelling at the

insertion site; presence of purulent drainage from the insertion site; local
rash or pustules; fever, chills, or elevated white blood cell count; or nausea
and vomiting should be reported if they persist despite nursing
interventions.

9. Avoid measuring blood pressure, performing venipunctures, or administering

injections in the extremity with a PICC.

Rationale: Minimizes the risk for catheter-related complications and catheter

damage.
  Patient and family education
Documentation  Signature on the informed consent form
 Known allergies
 Mid-upper arm circumference
 Date and time of the procedure
 Catheter type, size, and length, including the length of catheter remaining
outside the insertion site
 Type and amount of local anesthetic (if used)
 Location of the PICC insertion site and the vein accessed
 Method of securing catheter (suture, Steri-Strips)
 Confirmation of catheter tip placement
 Problems encountered during or after the procedure or nursing interventions
 Patient's tolerance of the procedure
 Vital signs and cardiac rhythm
 Assessment of the insertion site

 Explain the reason for the PICC, as well as the benefits and risks associated
Patient Education with the catheter and the alternatives to PICC placement.
 Describe the major steps of the procedure, including the patient's role in the
procedure.
 Instruct the patient and family to refuse injections, venipunctures, and blood
pressure measurements on the arm with the PICC.
 Provide appropriate patient and family discharge education regarding the care
and maintenance of the PICC.

LESSOn 17
Peripheral Parenteral Nutrition with Lipid (Fat) Emulsion - Overview

The administration of parenteral nutrition via peripheral veins requires the use of lower
Overview: concentrations of dextrose and amino acids to lower tonicity and lessen the risk for vein
damage [See Table 1]. For example, 2 L of peripheral parenteral nutrition (PPN)
consisting of 10% dextrose and 10% amino acids supplemented by 500 ml of 1% IV fat
emulsion provide 2000 kcal/day. PPN is usually administered in conjunction with fat
emulsion. Unfortunately, PPN is often difficult to maintain because of frequent episodes
of phlebitis in superficial arm veins and infiltrations of solutions into subcutaneous tissue.
Therefore, the final dextrose concentration must be no greater than 10%, because the
peripheral vein will sclerose at higher concentrations. However, solutions of lower
concentration make it difficult to supply adequate calories and amino acids through a
peripheral vein. This problem, in addition to the scarcity of adequate access sites, is the
reason many experts recommend PPN for only short periods of time. Nutrients given
through central veins may be very concentrated (e.g., 1800 mOsm). However,
concentrations this great are not tolerated in peripheral veins because of their relatively
low blood flow. Indications for PPN include the following:

1. Short-term need for parenteral nutrition: NPO for more than 5 days but anticipation that
the patient will tolerate enteral or oral nutrition within 7 to 10 days.
2. History of problems with central vein access or inability to establish central vein access.
Patients with a history of multiple central venous catheter infections or occlusions have
 increased risks associated with catheter placement. Multiple catheter placements may
deplete access sites.
3. Adequate peripheral access. Despite its lower osmolality, PPN tends to cause phlebitis
and may require frequent changes in the access location.
4. Ability to tolerate larger volumes of fluid. Because of the lower concentration of dextrose
in PPN, a larger volume of fluid is required to attain adequate calories. Patients with
impaired renal or cardiac function may not tolerate PPN.
5. Ability to tolerate lipid emulsions. Lipid is the most calorically dense nutrient, and PPN
without lipid would not provide adequate calories unless very large volumes of fluid were
provided. One liter of 10% dextrose provides only 340 kcal. Five hundred ml of 10%
lipid provides 550 kcal.

Table 1: Comparison of Central Parenteral Nutrition (CPN) and Peripheral

Parenteral Nutrition (PPN)

CPN PPN

Osmolality 1800 to 2000 mOsm 600 to 700 mOsm

Route of administration
Usual daily caloric intake (cal)
Fat emulsion
Objectives
Duration of therapy
Central venous catheter
2000 to 4000
Minor caloric source, provides
essential fatty acid
Weight maintenance, weight
gain
6 days or longer
Small peripheral vein
700 to 2000
Major caloric source, provides
essential fatty acid
Weight maintenance
3 to 7 days

Peripheral Parenteral Nutrition with Lipid (Fat) Emulsion - Outcomes

 Triglyceride level is stable.

Expected Outcomes  Venipuncture site is free of phlebitis, pain, swelling, redness, and inflammation.
 Patient does not show signs of systemic infection (e.g., elevated temperature).

 There is intolerance to fat emulsion, as evidenced by increased triglyceride

Unexpected Outcomes levels, increased temperature (3° to 4°F), chills, headache, nausea and vomiting,
muscle ache, backache, chest pain.
 There is redness, swelling, and tenderness around the venous access site,
indicating possible exit site infection.
 Patient develops fever, malaise, and chills, indicating systemic infection.
 Infusion stops flowing or flows at a rate slower than ordered.
 Patient experiences weight gain greater than 1 lb/day. Taut skin turgor may also
be present. Crackles auscultated over lung fields.
  Serum glucose is greater than 200 mg/100 ml. Indicates patient's intolerance to
glucose load in the CPN solution.
 Serum electrolytes are out of normal range.

Peripheral Parenteral Nutrition with Lipid (Fat) Emulsion - Assessment and Preparation

1. Explain purposes of PPN.

Preparation 2. Place patient in a comfortable position for IV insertion or initiation of infusion.
3. Check that ordered PN solution is correct with correct additives and properly labeled.
Check solution expiration date. Also check patient's name. Inspect bottle for opacity
and consistency in texture and color.
4. Warm solution to room temperature if refrigerated.

 PPN solution
Supplies  Lipid emulsion
 Two sets of IV tubing (filter optional—0.22 µm for amino acid/dextrose solution)
 Needle (19 gauge), Y connector, or stopcock
 Alcohol swab
 Infusion pump
 Disposable gloves

1. Assess patient for potential lipid intolerance. Assess serum triglyceride level. Serum
Assessment triglyceride should be drawn before initiation of fat therapy (baseline) and 6 hours
after fat has infused.
2. Select or initiate appropriate functional IV site (18-G catheter) to administer PPN and
lipid emulsion. Assess its patency and function.
3. Check physician's order for volume of fat emulsion and PPN solution.
4. Check administration time for fat emulsion.
5. Use care in locating fat emulsion from supply area. Read label of solution.

Peripheral Parenteral Nutrition with Lipid (Fat) Emulsion - Procedure

1. Perform hand hygiene, and apply gloves.

2. Check patient's identification band, and ask patient to state name.

Rationale: Ensures correct patient receives correct intravenous solution.

3. Connect IV tubing to PPN solution, run fat emulsion into IV tubing, and remove excess air.
Turn roller clamp to off position.

Rationale: To prevent air from entering vascular system, all tubing must be
purged.

4. Clean peripheral line tubing injection port of primary IV with alcohol swab. (Option: Use Y
connector.)

Rationale: Removes surface organisms at injection site and prevents organisms

from entering blood system.

5. Insert end of fat emulsion infusion tubing into injection port of main IV, proximal to the
venipuncture site, below the infusion filter on the main parenteral nutrition line.

Rationale: Fat emulsions cannot infuse through a 0.22-m IV filter-the emulsion

would separate.

6. Open roller clamp completely on fat emulsion infusion, and then set flow rate on infusion
pump.

Rationale: Up to 2.5 g fat per kilogram per day may be infused, but fat emulsion
should not exceed 60% of total calories. Recommended daily fat percentage is
30% or less of total calories.

7. Begin PPN at ordered rate-10% fat emulsions are infused over at least 4 hours, and 20%
fats are infused over at least 6 hours. All lipids can hang for 12 hours; admixing lipids with
parenteral nutrition can hang for 24 hours.

Rationale: The rate of PPN administration does not need to be gradually

increased. The lower concentration of dextrose allows most patients to tolerate the
full administration rate without difficulty.

8. Discard supplies, and perform hand hygiene.

Peripheral Parenteral Nutrition with Lipid (Fat) Emulsion - Post Procedure and Variations

1. Measure vital signs and patient's general comfort level every 10 minutes for
Post Procedure first 30 minutes.

Rationale: Monitors patient for fat emulsion intolerance.

2. Measure patient's laboratory values (e.g., triglycerides) daily.

Rationale: Provides objective data to measure the response to therapy.

3. Monitor temperature every 4 hours, and regularly inspect venipuncture site for
signs of phlebitis or infiltration.

Rationale: Determines onset of fever, a complication of intolerance to fat

emulsion or sepsis. Determines integrity of IV system.

4. Assess patient's weight, intake and output (I&O), condition of peripheral

extremities (for edema), and breath sounds.

Rationale: Weight gain, I&O imbalance, peripheral edema, and crackles in

lungs can indicate fluid retention.

 Record intake and output every 8 hours on flow sheet.

Documentation  Record temperature every 4 hours.
 Record condition of IV site, type of PPN, and rate and status of infusion.
 Report development of fever or symptoms of fat intolerance to physician.

 Teach patient and primary caregiver to monitor patient's weight, calorie count,
Patient Education intake and output, and IV site.

Age-Specific Pediatrics
Considerations
 Indications for parenteral nutrition for infants include gastroschisis, congenital
anomalies of the gastrointestinal system, short-bowel syndrome, extensive
burns, children receiving chemotherapy and/or radiation who are not tolerating
oral feedings, and children who are NPO for extended periods.
 CPN can cause hepatobiliary dysfunction in infants.
 With children requiring long-term parenteral nutrition, it may be possible to
change them to a cycle when they have stabilized. This will allow them to
receive the parenteral nutrition at a time when they may be less active, thus
 allowing more normalcy in the family during the time the child is not receiving
the solution.

Geriatrics

 Older adults may have lipid intolerance.

LESSON 18
Implanted Venous Port Devices Accessing - Overview

An implanted port consists of a tunneled catheter attached to an injection port with a self-
Overview: sealing septum See Figure 1. The device is implanted under the skin and must be
accessed through the skin. Although most frequently used for venous access, implanted
ports may also be placed intra-arterially, epidurally, or intraperitoneally. Venous ports are
usually located in the chest; however, some ports are located in the upper extremity, with
the catheter insertion site in the basilic or cephalic vein and the tip threaded into a central
vein, similar to a peripherally inserted central catheter (PICC). Catheter tip placement
must be confirmed by aspiration of blood before the port is used. There are many brands
of implanted ports, including one with the Groshong catheter attached. Many ports are
available in single- or double-port or lumen configuration. Most septa are located on the
top of the port. Patients may carry written information about their ports.

Implanted Venous Port Devices Accessing - Outcomes

 Patent catheter from which blood samples can be drawn and through which
Expected Outcomes medications can be administered
 No signs of infiltration or infection

Unexpected Outcomes
 Infection
 Medication or fluid extravasation
 Catheter pinch-off syndrome and transection
 Catheter occlusion
 Air embolism
 Central venous thrombosis
 Catheter rupture
 Hematoma
 Pneumothorax

Implanted Venous Port Devices Accessing - Assessment and Preparation

1. Place patient in a supine position.

Preparation
 To avoid an air embolism, the patient should be supine and should
perform the Valsalva maneuver, or the extension set should be clamped
any time the IV line is disconnected.

a. The head of the bed may be elevated 30 degrees or to patients comfort.

2. Assemble all equipment.

 Two pairs of sterile gloves

Supplies  Three antiseptic swab sticks (povidone-iodine preferred)
 Sterile fenestrated drape
 Noncoring or Huber needle
 Luer-Lok T extension set or short extension set, if not already attached to the needle
 Bulldog or padded clamp, if not provided on the extension set
 Sterile normal saline solution for injection
 Two 10-ml syringes with needles
 Dressing materials (if the port is to remain accessed), skin tapes, 4- to 5-cm
transparent dressing, 2 × 2 sterile gauze dressings, tape
 IV solution as prescribed or a male adapter plug
 Blood-specimen tubes, if needed
 5 ml of heparin (100 units/ml) if heparin lock is needed

1. Assess patient's need for procedure.

Assessment a. Patient's condition requires infusion of intravenous (IV) fluids, and standard
peripheral IV access is unavailable or unobtainable.
2. Assess insertion site of catheter for signs of infection:

a. Redness
b. Exudate
c. Warm to the touch

Implanted Venous Port Devices Accessing - Procedure

Port Access

1. Prepare all supplies on a sterile field.

2. Expose the chest, and identify the septum by palpating the outer perimeter of the port. The septum is located
in the middle of the port.

Although the port is sutured in place, it is possible for it to flip over. Palpate the septum of the
 port to ensure that it is right side up before attempting needle insertion.

3. Wearing sterile gloves, clean the skin over the port with an antiseptic swab stick, working outward in a spiral
motion to cover an area 4 inches in diameter. Clean with the second and third swab sticks in the same
manner. Allow to air dry.

4. Apply the sterile fenestrated drape, leaving only the area over the port exposed.

Rationale: Creates a sterile field.

5. Change gloves.

6. Fill the 5-ml syringes with normal saline solution. Attach the extension set to the noncoring needle, if
necessary, and prime the needle or extension setup with normal saline solution to purge all air. Leave the
syringe attached to the needle or extension set.

Rationale: Avoids introduction of air into the catheter once the Huber needle is inserted.

7. Stabilize the port with the forefinger and thumb (one on each side of the port). Insert the noncoring needle
through the skin and into the middle of the septum. Hold the needle perpendicular to the port, and apply only
downward pressure. Do not twist, rock, or manipulate the needle sideways during or after needle insertion,
because this may core the septum and cause leaking from the port. Continue to apply downward pressure on
the needle until it hits the back of the septum and can go no farther See Figure 2.

Rationale: Ensures the integrity of the septum during and after the procedure.
Use only noncoring or Huber-point needles to access an implanted port because other needles
may damage the port septum, leading to extravasation of fluids or medications See Figure 3.
Noncoring needles are available in 19-, 20-, and 22-gauge sizes in either a straight
configuration for one-time access or at a 90-degree angle with or without an attached
extension set for continuous infusion. If blood samples are desired, use a 19-gauge noncoring
needle.
To administer whole blood or packed red blood cells, use a 19-gauge noncoring needle to
access the port. It is usually necessary to use an infusion pump or add 50 ml of normal saline
solution to the blood bag or run a normal saline solution concomitantly with the blood to
maintain adequate flow rates.

8. Aspirate 5 ml of blood to confirm port patency. To facilitate blood return, have the patient raise his or her
arms, cough, perform the Valsalva maneuver, or change position.

Rationale: Each of these maneuvers increases blood return to the heart, thereby facilitating the blood
draw.

9. If no blood return is obtained, the needle may be located at the side of the septum over the outer periphery of
the port. If you are unable to achieve a blood return, remove the needle, and try again with a new needle. If
there is visual confirmation that the new needle is in the port, attempt to irrigate the port with 10 ml of normal
saline solution. If there is no resistance during irrigation, proceed with the infusion (the IV fluid should drip
freely by gravity if the needle is in the port) while monitoring the patient for signs of extravasation. To assess
for extravasation, place the patient on his or her back, and compare the breasts and both sides of the chest and
 neck. Observe for asymmetry, swelling, redness, or the patient's complaint of tenderness. A chest radiograph
helps confirm catheter placement and rule out a catheter pinch-off or transection. The only definitive
diagnostic study is a cathetergram with contrast injected into the port. If there is resistance to irrigation, a
cathetergram is strongly recommended to determine catheter placement. Fibrinolytic therapy may be required
to restore patency to a clotted catheter.

If the patient feels pain or an abnormal sensation at the port site during infusion, it may
indicate that the medication has extravasated. The infusion should be stopped immediately
until port patency has been determined. A chest radiograph helps verify catheter placement if
blood return is not obtained when the port is accessed. When port patency is uncertain, the
only conclusive way to determine patency is to perform a cathetergram by injecting contrast
dye into the port.

10. After port patency is confirmed and blood specimens are obtained, if necessary, flush the port with 10 ml of
normal saline solution.

Rationale: Prevents clot formation within the catheter and maintains patency.
When not accessed, the port should be flushed once per month with 5 ml of heparin, 100
units/ml. Ports placed in the hepatic artery are flushed weekly.

11. If the port is to remain accessed, apply a dressing as follows:

a. Tape all connections that will be under the dressing with sterile tape.

b. Place a 2 x 2 sterile gauze pad under the angled needle to provide support, as needed.

c. Place skin tapes over the needle to secure it in place. To facilitate patient assessment, do not obscure
the needle insertion site.

d. Cover the entire setup with a transparent dressing, leaving only the end of the extension set with the
clamp exposed.

e. Label the dressing with the date of insertion and needle size.

The needle should be changed every 7 days or sooner if the flow rates decrease or blood
return is absent.
Blood Sampling
NOTE: The use of a heparinized catheter for blood sampling for coagulation studies is not recommended if
results are to be used to monitor anticoagulant therapy or to evaluate coagulopathy, because this technique
yields falsely elevated levels.If coagulation studies are necessary for such an evaluation, use a separate
peripheral site for the venipuncture. Blood samples from a heparinized catheter may be used to determine
whether the results of coagulation studies are normal.If the catheter must be used for coagulation studies,
note this on the laboratory request form.
For a routine heparin flush of the port, use 5 ml of heparin (100 units/ml). Other concentrations of
heparinized saline solution (10 to 1000 units/ml) may be used, depending on the patient's medical
condition, laboratory test results, and home care or physician protocols.

1. If a continuous IV is running, stop the infusion for 1 minute.

2. Aspirate and discard 10 ml of blood from the port.

3. Attach the sampling syringe, withdraw the amount of blood needed, and place it in appropriate specimen
tubes.

Implanted Venous Port Devices Accessing - Post Procedure and Variations

1. Remove the needle from the port.

Post Procedure a. Flush the port with 10 ml of normal saline solution for injection.
b. Flush the port with 5 ml of heparin (100 units/ml).
c. Stabilize the port with the thumb and forefinger of one hand while
removing the needle with the other hand.

2. Clean the injection site, and apply a bandage or small dressing.

 In the patient's chart, document a thorough assessment of the site before the
Documentation procedure.
 Record in patient's chart:
o Size of needle, if used to access port
 Patency of system every 4 hours or according to your organization's policy.
 Thorough assessment of the insertion site immediately after the procedure.
 If catheter is used for blood draw, document:
o Ease of blood return with draw
o Type and amount of flush used after the procedure
 If catheter is used for IV fluid infusion, document:
 o Time infusion was begun

 Ports are preexisting central catheters, so most patients should be familiar with
Patient Education self-care measures. Patients should be reminded to have the catheter flushed at
monthly intervals when it is not in use.
 If it is determined that the patient requires further training for home
management of the catheter, a referral to the home health service or the
primary provider should be considered.

Age-Specific Pediatrics
Considerations
 A smaller port and a shorter catheter are used for infants and children;
therefore there are lower blood discard volumes for laboratory draws and
flushing volumes.
 Volumes should equal approximately two to three times the catheter or port
volume, which can be found on the package insert. If the catheter volume is
unknown, it is generally adequate to withdraw 5 ml of blood before the blood
draw.

LESSON 19
Implantable Venous Accessing Device Access, Deaccess, and Care (Advanced Practice) - Overview

Implantable venous access devices or ports are used to deliver medications, parenteral
Overview: solutions, blood products, and cytotoxic agents and for blood sampling for patients
requiring long-term venous access.
Implanted venous access devices are surgically placed, totally implanted in a cutaneous
pocket (usually in the chest wall), and designed to provide venous access for intermittent
or continuous infusions while maintaining a patients intact body image when not
accessed. Implanted devices consist of a slim tube or catheter connected to a reservoir,
which is covered by a disc 2 to 3 cm in width See Figure 1. The disc is made of silicone
and is referred to as the septum. The septum is capable of resealing when deaccessed. The
internal catheter is connected to the patient's venous system.
The implanted venous access device is percutaneously accessed with a noncoring needle.
The use of a noncoring needle allows for repeated accessing of the venous device without
damage to the silicone core. The noncoring needle chosen should be of optimal length,
with the most common length for adults being 1½ or 1¾ cm. Patients with increased
subcutaneous tissue may require a longer needle for accessing. A needle that is too short
may cause the flanges to press against the skin surrounding the portal chamber, leading to
patient discomfort and possibly resulting in damage to the skin overlying the venous
access device. A needle that is too long may result in a rocking motion that can cause
discomfort, possible migration out of the portal septum, or damage to the integrity of the
septum, impairing it for future use.
Individuals who perform this procedure should have the following prerequisite
 knowledge:

 Understanding of the implantable venous access device, including the septum and outer
borders
 Anatomy of the venous system
 Principles of medication delivery-intermittent and continuous
 Principles of aseptic and sterile technique
 Properties of chemotherapeutic or cytotoxic agents and preferred delivery techniques
 Consequences of infiltration of vesicant substances

Implantable Venous Accessing Device Access, Deaccess, and Care (Advanced Practice) - Outcomes

 Site without redness, pain, or tenderness

Expected Outcomes  Venous access device stable
 Venous access device is accessed without difficulty
 Venous access device flushes easily without evidence of resistance or infiltration
 No evidence of leakage at septal site
 Blood specimens are obtained as prescribed
 Venous access device is deaccessed without difficulty

 Port reddened, tender, or painful on palpation

Unexpected Outcomes  Implanted device unstable in chest wall with palpation
 Patient describes burning sensation in subcutaneous tissue with flushing or
infusion
 Sluggish or no blood return with aspiration
 Evidence of leakage of flushing solution at septal site
 Patient describes pain at site, chest, ear, or shoulder with flushing
 Signs or symptoms of local or systemic infection
 Swollen neck and/or arm

Implantable Venous Accessing Device Access, Deaccess, and Care (Advanced Practice) - Assessment
and Preparation

1. Ensure that the patient and family understand preprocedural teaching. Answer
Preparation questions as they arise and reinforce information as needed.
2. Assist the patient to a supine position with the head of the bed elevated up to a 30-
degree angle.

 Nonsterile gloves
Supplies  Sterile gloves
 90-degree-angled winged noncoring needle with extension tubing (available in ¾-, 1-,
 1¼-, and 1½-inch lengths)
 Dressing supplies
 Skin antiseptic solution (e.g., 2% chlorhexidine-based solution)
 Two 10-ml syringes
 Luer-Lok vial access device
 Prepierced needleless injection cap
 Single-use 30-ml vial NS
 2-inch Steri-Strips
 Heparin flush, 100 unit/ml concentration
 Central venous catheter dressing change kit

Additional equipment as needed includes the following:

 10% Betadine solution and 70% alcohol solution site prep swabs
 Supplies for obtaining blood for laboratory analysis

1. Review the patient's medical history specifically related to problems with device
Assessment implantation, complications with previous accesses, and allergies to antiseptic
solutions.
2. Obtain the patient's vital signs.
3. Review the patient's current laboratory status, including coagulation results.

Implantable Venous Accessing Device Access, Deaccess, and Care (Advanced Practice) - Procedure

Accessing an Implantable Venous Access Device

1. Wash hands, and don nonsterile gloves.

Rationale: Reduces the transmission of microorganisms; standard precautions.

Both conventional antiseptic containing soap and water or waterless alcohol-based gels or
foams are considered acceptable by the Centers for Disease Control and Prevention.

2. Remove patient's gown away from the venous access device. Palpate the subcutaneous tissue to determine the
borders of access device.

Rationale: Optimizes the viewing area.

3. Palpate the venous access device borders and locate the septum and the center of the septum.

Rationale: Allows for palpation of the venous access device borders and identification of the septal
center.

4. Assess the site for signs and symptoms of infection (e.g., erythema, induration, pain, or tenderness at the
site).

Rationale: Minimizes the risk for accessing an infected area.

Erythema, swelling, or tenderness may indicate system leakage. An x-ray film is recommended
 if leakage is suspected.

5. Discard gloves, and wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

6. Open the central venous catheter dressing kit using the sterile inner surface of the wrap to create a sterile
field.

Rationale: Maintains asepsis and prepares supplies. Creates a sterile field.

Disinfect the table as needed. Venous access devices have the lowest risk for catheter-related
blood system infections, provided that aseptic and sterile techniques are used throughout care
delivery.

7. Prepare supplies:

a. Using sterile technique, remove the wrapper from two 10-ml syringes and place them on the sterile
field.

Rationale: Places equipment within reach during procedure. Maintains sterility of procedure.

b. Remove the packaging and place the winged or safety noncoring needle with extension tubing,
needleless injection cap, Luer-Lok vial adapter, and Steri-Strips on the sterile field.

Rationale: Protects the clinician from potential needle injury. Maintains sterile technique.

8. Aseptically connect the vial adapter device to the vial.

Rationale: Prepares supplies.

9. Remove the cap from the normal saline (NS) vial. Wipe off top of the NS vial with an alcohol wipe and allow
to dry.

Rationale: Reduces microorganisms.

10. Prepare supplies:

Rationale: Prepares supplies for procedure.

a. Put a sterile glove on your nondominant hand.

b. With the sterile hand, pick up a 10-ml syringe.

c. Using the nonsterile, dominant hand, pick up the NS vial with the Luer-Lok adapter while using the
 sterile, gloved hand to access the NS vial and withdraw 10 ml of NS.

12. Repeat step 10 with the second 10-ml syringe; then discard the NS vial.

13. Don the remaining sterile glove.

Rationale: Maintains asepsis.

13. Using sterile technique:

Rationale: Prepares the equipment. Removes air from the extension tubing, preventing possible air
embolism.

a. Attach the needleless injection cap to the extension tubing on the noncoring needle.

b. Attach the 10-ml NS syringe to the needleless valve.

c. Prime the tubing with NS away from the sterile field.

15. Retain the priming syringe on the needleless cap and return the primed equipment to the sterile field.

16. Cleanse the implanted venous access device or port with antiseptic solution (e.g., 2% chlorhexidine-based
preparation).

Rationale: Reduces infection.

16. Use the nondominant hand to stabilize the borders of the venous access device and use the dominant hand to
pick up the noncoring needle with the NS syringe attached.

17. Triangulate the venous access device between the thumb and first two fingers of the nondominant hand and
aim the needle for the center point of these three fingers. With the dominant hand, firmly grasp the protective
 cap or wings of the noncoring needle and insert it firmly into the center of the port septum using a 90-degree
angle perpendicular to the skin surface See Figure 2.

Rationale: Stabilizes the venous access device within the chest wall and prevents slippage. Protects
the clinician from a potential needle injury.

18. Advance the needle through the skin and septum until reaching the base of the portal reservoir See Figure 3.

If using a noncoring safety needle, grasp the vertical fin between the thumb and middle finger
and press downward with the index finger.

19. Note that resistance will be felt as the needle reaches the base of the reservoir.

Once the septum is punctured, avoid tilting or rocking the needle, which may cause fluid
leakage or damage to the system.

20. Flush the venous access device with 5 ml of NS.

Rationale: Determines the patency of the venous access device.

Avoid using syringes with less than a 10-ml volume for flushing or administering infusate.
Smaller syringes exert pressure exceeding 40 psi per square inch and may cause catheter
rupture or fragmentation with possible embolization.

21. Observe the skin surrounding the noncoring needle for leakage of fluid or infiltration at the access site.

Rationale: Assesses for potential access problems.

22. Gently aspirate blood; then flush with the remaining 5 ml of NS.

Rationale: Verifies placement.

If blood return is not evident, gently flush using push-pull method and reposition patient. If
continued lack of aspirate, continue the accessing procedure and apply a dressing to minimize
the risk of infection. Confer with care provider and consider administration of lytic agent and
radiographic or dye shadow studies to confirm placement.

23. Remove the protective cap from the winged needle. Position the wings flush with the patient's skin.

Rationale: Anchoring minimizes muscular discomfort for the patient.

24. Stabilize the needle by attaching Steri-Strips in a cross or star pattern over the wings of the noncoring needle.

Rationale: Stabilizes the needle inserted in the septal core and minimizes rocking of the needle,
which can cause damage to the septum and patient discomfort. Minimizes needle movement in the
septum, thereby ensuring integrity of the septal core for future use.

25. Apply a dressing according to institution protocol.

Rationale: May aid in stabilizing the device and maintaining asepsis.

A gauze dressing is preferred if oozing or blood seepage occurs at the insertion site.

26. Label the dressing with the date, time of cannulation, needle gauge/length, and your initials.

Rationale: Provides important clinical information.

 If the accessed device is not to be used immediately, flush with heparin as prescribed.

27. Initiate continuous or intermittent infusion.

Rationale: Begins therapy.

28. Discard used supplies, and wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

Deaccessing an Implantable Venous Access Device

1. Wash hands, and don nonsterile gloves.

Rationale: Reduces the transmission of microorganisms; standard precautions.

2. Flush the venous access device with 10 ml of NS, followed by heparin as prescribed (e.g., 5 ml of 100 units
per ml heparin).

Rationale: Prepares and optimizes catheter patency while not in use.

3. Loosen the transparent or gauze dressing and Steri-Strips from the site.

Rationale: Facilitates removal.

4. Use the thumb and forefinger of the dominant hand to grasp the dressing and Steri-Strips along with the
winged flanges of the needle See Figure 4.

Rationale: Prepares for needle removal.

5. With the nondominant hand, apply gentle stabilizing pressure to the venous access device while removing the
needle by pulling straight up and out in a firm, continuous motion.

Rationale: Minimizes patient discomfort and ensures controlled withdrawal of a sharp object.
If using a noncoring safety needle, grasp the horizontal flanges securely, pull up, and squeeze
the flanges together. The flanges will fold together, forcing the needle inside the locked wings
and covering the needle. The clinician will see and feel the wings lock in place See Figure 5.

6. Assess the site for redness or drainage.

Rationale: Identifies possible complications.

7. Discard the noncoring needle in a designated container.

Rationale: Standard precautions.

8. Apply a dressing to the site if oozing occurs.

Rationale: Provides absorption.

9. Discard supplies, and wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

Obtaining a Blood Specimen from an Implantable Venous Access Device

1. Wash hands, and don nonsterile gloves.

Rationale: Reduces the transmission of microorganisms; standard precautions.

2. If present, shut off the intravenous (IV) infusion and disconnect the IV tubing from the extension tubing on
the noncoring needle.

Rationale: Maintains asepsis.

3. Place a sterile cap on the end of the IV tubing.

Rationale: Maintains asepsis.

4. Thoroughly cleanse the injection cap with an alcohol wipe and allow it to dry. Do not remove cap.

Rationale: Minimizes infection and clinician exposure to blood/body fluids.

5. Attach a 10-ml syringe with NS and flush the venous access device.

Rationale: Clears the catheter of medication or IV fluid.

6. Attach a new, sterile 10-ml syringe or a VACUTAINER® with a needleless Luer-Lok adapter needle.

Rationale: Prepares supplies.

7. Gently aspirate the discard volume into the syringe or engage a blood specimen tube into the
VACUTAINER® to obtain the discard volume and allow the tube to passively fill.

Rationale: Discard method recommended for obtaining laboratory samples.

VACUTAINER® system is the current national standard. Minimizes needle stick injury,
exposure to blood, and decreases infection risk to the patient by reducing incidence of opening
the catheter system.

8. Remove the discard syringe or tube and discard in the appropriate receptacle.

Rationale: Removes discard safely.

Research shows 95% reliability of laboratory samples using a minimum discard volume of 3
times the dead space volume of the indwelling catheter system. Portal reservoirs average 0.5
ml volume; catheters average 0.6 ml for single-lumen systems.

9. Insert a new syringe into the injection cap or place a new blood specimen tube into the
VACUTAINER® system.

Rationale: Prepares for removal of the blood sample.

10. Slowly and gently aspirate blood or engage the blood specimen tube into the VACUTAINER ® system.

Rationale: Obtains the blood specimen.

11. After the blood specimen is obtained, flush with 10 ml of NS.

Rationale: Clears blood from the system.

Flush with an additional 10 to 20 ml of NS if the blood does not clear completely from the
 extension tubing.

12. Clamp the extension tubing.

13. Apply a new injection cap using strict aseptic technique.

Rationale: Reduces infection.

14. Reconnect the IV line and continue infusion.

Rationale: Resumes therapy.

If the IV infusion is completed, administer heparin as prescribed.

15. Discard used supplies, and wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

16. Send laboratory specimens for analysis.

Rationale: Expedites determination of laboratory results.

Implantable Venous Accessing Device Access, Deaccess, and Care (Advanced Practice) - Post
Procedure and Variations

1. During IV infusions, assess the venous access device for patency and signs of
Post Procedure infiltration every 4 hours and as needed.

Rationale: Determines adequate functioning of the venous access

device.
Signs or symptoms of infiltration at the venous access site should be
reported if they persist despite nursing interventions.

2. Follow institution standard for frequency and type of dressing change.

Rationale: The dressing should be changed if it becomes damp,

loosened, or soiled or when inspection of the site is necessary.
Signs or symptoms of infection should be reported if they persist
despite nursing interventions.

3. Replace gauze dressing every 2 days, and transparent dressing every 7 days.
Change either dressing if soiled, dampened, or loosened.

Rationale: Prevents infection.

4. Change access device every 7 days.

Rationale: Maintains patency.

 5. Follow-up care for deaccessed device includes flushing monthly with 5 ml of
heparin flush solution (100 units/ml).
6. Assess for signs and symptoms of infection.

Rationale: Determines the presence of infection.

Redness, pain, or drainage at the site; fever; or elevated white blood cell
count should be reported if they persist despite nursing interventions.

 Location and cannulation of the device

Documentation  Needle length and gauge
 Appearance of blood return
 Access of the site
 Deaccess of the site
 Specimens obtained and sent for analysis
 Laboratory results
 Unexpected outcomes
 Additional interventions

 Assess patient and family readiness to learn, and identify factors that will
Patient Education affect learning.
 Provide information about the implantable venous access device and the
methods used for accessing it.
 Explain the patient's role during the procedure and expected outcomes.
 Explain the anticipated sensations during the accessing procedure.
 Explain site care and signs and symptoms of infection and infiltration.

LESSON 20
Obtaining an Arterial Blood Gas Specimen - Overview of the Skill

Overview: Arterial blood gases are measured to assess a client's oxygenation, ventilation, and
acid-base balance. The blood sample is easily, although often painfully, obtained from
an artery and is analyzed for arterial blood pH, partial pressure of oxygen (PaO2),
partial pressure of carbon dioxide (PaCO2), and arterial oxygen saturation (SaO2). The
analysis can quickly provide information on the client's respiratory or metabolic status
and response to a disease process. Clients who require mechanical ventilation or have
sudden respiratory distress or change in level of consciousness may benefit from this
test for diagnosis and treatment.

Assessment: 1. Assess the type of symptom and lung sounds that require an arterial blood gas (ABG)
sample. Signs and symptoms may include, dyspnea, sudden change in respiratory rate
or pattern, unequal breath sounds, unequal chest expansion, cyanosis, change in level
of consciousness, self-extubation, and increased work of breathing. Determines when
an ABG is needed.
2. Assess if the client has just awakened, just been suctioned, or had a change in oxygen
or ventilator settings within the last half hour. Identifies factors that may affect
an ABG measurement.
3. Assess collateral blood flow by performing Allen's test to choose a site
for ABG sample.
4. Assess tissue surrounding artery to avoid sites of previous punctures and proximity
 to veins.
5. Assess baseline or most recent ABG for client to compare with current status.
6. Assess client's knowledge about the procedure of obtaining an ABG sample to ensure
cooperation and reduce anxiety.

Diagnosis:  Impaired Gas Exchange

Planning

Planning Needs: Equipment Needed (see Figure 8-24-1):

 Heparinized syringe with cap, 3 ml (check institution policy for heparin solution use)
 A 23 or 25-gauge needle
 Povidone-iodine and alcohol swabs
 Gauze pad, 2 × 2
 Heparin 1:1000 solution
 Cup with crushed ice
 Label with date, time, and client's name
 Laboratory requisition
 Disposable gloves
 Protective eye wear

Expected Outcomes: 1. The client will have normal ABG results.

2. The pulse, color, and temperature of the client's extremity distal to the puncture will
be unchanged.
3. The client will be calm and free of pain.
4. The client will have minimal bleeding from the site following the puncture.

Client Education 1. The client should be taught the rationale for the ABG sample.
Needed: 2. Prepare clients by telling them that the needle stick will be painful so they do not
reflexively pull their arm away.
3. Client should be instructed to breathe slowly and deeply.
4. The client should be taught to report these symptoms immediately: numbness,
burning, tingling, or bleeding in the hand that was punctured.

LESSON 20
Obtaining an Arterial Blood Gas Specimen - Implementation—Action/Rationale

Implementation
Action/Rationale
ACTION RATIONALE
1. Identify client and explain procedure to 1. Ensures proper client identification and
client in calm tone of voice. reduces anxiety and promotes
cooperation.
2. Prepare syringe with heparin: 2. Needed if a heparinized syringe is not
available.
 Aspirate 0.5 ml sodium heparin
(1000 U/ml) into syringe from vial.  Prevents blood from clotting
 Withdraw plunger entire length of before analysis is performed.
syringe and eject all heparin out of
 syringe.
3. Select safest and most accessible site for
ABG sample:
 Perform Allen's test. Have client
make tight fist and apply direct
pressure to both radial and ulnar
arteries. When client opens hand,
release pressure over ulnar artery
and observe color of fingers,
thumbs, and hand. Fingers should
flush within 15 seconds-a positive
Allen's test.
 If Allen's test is positive, use the
radial artery.
 Brachial artery should be used if
radial artery is inaccessible or
Allen's test is negative.
 Femoral artery should be used only
by specially trained nurses or health
care providers.
4. Wash hands and put on gloves.
5. Palpate selected radial site with fingertips
and stabilize artery by slightly
hyperextending wrist.
6. Use alcohol swab to clean in a circular 6.
motion the area above the pulse (see Figure
8-24-2).
7. Hold alcohol swab in fingers of one hand
while keeping a fingertip from the other
hand on the artery.
8. Insert needle with bevel up into artery at a
45° angle (see Figure 8-24-3).
9. Hold the needle and syringe still when
blood appears in the syringe.
10. Allow arterial pulsing to slowly pump 2 to 3 10. Prevents air bubbles from entering
ml of blood into heparinized syringe.
11. When sample is collected, hold alcohol
swab over the puncture site and withdraw
needle.
12. Apply pressure with the alcohol swab over
the puncture site for 5 minutes, or 10
minutes if the client is on anticoagulant
therapy or has a bleeding disorder.
 Coats the barrel of syringe with
heparin. More than 0.25 ml of
sodium heparin in 3 ml of blood
may affect the pH level.
3. Arterial puncture may result in spasm,
clotting, or hematoma, which could
reduce blood flow, so collateral flow is
essential.
 Determines adequate blood flow
to the hand by removing blood
from hand, obstructing blood
flow, then allowing blood to flow
into hand through the ulnar artery.
Indicates collateral flow is
positive.
 The radial artery is the safest and
most accessible site.
 Has collateral blood flow but is
less superficial and more difficult
to palpate and stabilize and has
risk of damage to adjacent
structures such as brachial nerve
or vein.
 Has no collateral blood flow if
obstructed below the inguinal
ligament, is difficult to stabilize,
and is adjacent to femoral vein.
However, this is the best artery to
use in emergency such as cardiac
arrest or shock.
4. Reduces number of microorganisms.
5. Determines area of maximal impulse for
puncture site and facilitates successful
insertion of needle.
Reduces number of bacteria on surface of
skin.
7. Keeps swab accessible during procedure.
8. Allows for better arterial flow into needle.
Oblique hole in artery seals more easily.
9. Prevents traversing needle through artery.
sample, which can alter results.
11. Swab minimizes pulling of skin as needle
is withdrawn.
12. Ensures adequate coagulation at puncture
site.
 13. Inspect site for signs of complications: 13. Determines need for further treatment.

 Bleeding  Indicates need to exert pressure.

 Change or disappearance of pulse  Shows change in blood flow to
 Color of hand hand.
 Paleness may indicate obstruction
of blood flow.

14. Remove gloves and wash hands. 14. Reduces transmission of organisms.
15. Prepare sample for laboratory and send it: 15.  Prevents false ABG results.
 Ensures results are correct for
 Expel air bubbles from syringe. client.
 Label syringe with client  Reduces blood cell metabolism.
identification.  Ensures proper identification of
 Place syringe in cup of crushed ice. sample.
 Fill out requisition form, including
amount of oxygen the client is
receiving (e.g., 2 liters O2 by nasal
cannula, room air, 70% on
ventilator)

Note: Some laboratories also require a

recent body temperature.
16. Review results of ABG sample and compare 16. Identifies abnormality:
with normal values:
 pH and decreased PaCO2-
 pH 7.35 to 7.45, PaCO2 35 to 45 respiratory alkalosis; pH and
 PaO2 80 to 100 increased PaCO2-respiratory
 SaO2 94% to 98% acidosis
 PaO2 -inadequate oxygenation
 SaO2 -contamination of sample

17. Report ABG results to health care provider 17. Ensures proper treatment of client:
and perform nursing measures accordingly:
 Encourage coughing and deep
 Respiratory acidosis breathing; perform tracheal
 Respiratory alkalosis suctioning, elevate head of bed,
administer or increase oxygen
therapy, hold pain medication if
possible.
 Encourage slow, deep breaths;
have client breathe into a paper
bag, administer pain medication,
help client alleviate anxiety.

Obtaining an Arterial Blood Gas Specimen - Post-Skill

Evaluation:  The client has normal ABG results.

 The pulse, color, and temperature of the client's extremity distal to the puncture
is unchanged.
 The client was calm and free of pain.
 The client had minimal bleeding from the site following the puncture.

Documentation: Nurses' Notes

  The date and time of the ABG sampling should be recorded in the narrative
notes.
 Also record the reason for the test, the results of Allen's test, the client's
response to the blood sampling, and any unusual observations.
 Note the route and amount of oxygen the client is receiving and any respiratory
assessment observations.
 Record the condition of the puncture site prior to the blood draw and after the
blood draw.
 Be sure to note the follow-up check on the condition of the site.
 For the laboratory requisition slip, record the date and time of the sample, the
client's name and room number, the site the sample was drawn from, and the
amount and route of oxygen delivery.

Variations

Geriatric Variations:  Blood vessels can be fragile in elderly clients.

 Capillary refill can be slow in older clients.
 If Allen's test is failed in hands, it may be necessary to use the brachial or
femoral artery.

Pediatric Variations:  A heel stick for obtaining a capillary blood gas may be used in neonatal or
pediatric clients.
 Values for neonatal clients may be different from adult values.

Home Care Variations:

 Arterial blood gas samples are less stable than venous blood samples and should
be tested as soon as possible. When drawing this sample in the home care
situation, take the blood to the laboratory as soon as possible.
 Between the time the arterial blood is drawn and the time it is tested, it should
be stored in ice. Be sure to have ice in a cup or plastic bag available prior to
drawing the sample. If the weather is hot or the drive to the laboratory is long,
the nurse might want to have a small, portable ice chest available for
transporting the sample.

Long-Term Care  Clients with chronic obstructive pulmonary disease may have peripheral
Variations: vascular insufficiency and may require a brachial or femoral sample.
 Clients with chronic obstructive pulmonary disease often have abnormally high
PaCO2 levels. The nurse should be aware of this when assessing blood gas
results.
 The high PaCO2 levels should not be treated with increased oxygen as this could
cause the client to stop breathing.

Obtaining an Arterial Blood Gas Specimen - Common Errors

Possible Errors: Air bubbles enter the syringe while obtaining the ABG.

Prevention: Do not pull back on the plunger of the syringe while obtaining arterial blood. Be sure the
 needle is attached securely to the syringe before inserting the needle into the artery. If a
sufficient amount of blood has been obtained, remove the needle and expel the air bubbles from
the syringe. If not, remove the needle, apply pressure to the site, wait 5 minutes, and obtain the
sample at another site with a new needle and syringe.

Nursing Tips:

 Prepare the heparinized syringe before going into the client's room.
 Remember that superficial arteries are at the distal ends of extremities.
 Be sure to calmly warn the client before you insert the needle so he or she does not pull
back the hand.
 A rolled towel placed under the client's wrist helps to relax the hand and allows easier
access to the artery.
 Never pull back on the plunger of the syringe while sampling arterial blood.
 Bring a cup of ice into the room to have available to transport the sample.

Critical Thinking Skill

Introduction: The rate and depth of respirations can affect the results of an ABG sample. It is necessary to
assess the client's respirations before obtaining the sample.

Possible Scenario: A 19-year-old presents to the emergency room complaining of difficulty breathing. Her lungs
are clear and her physical assessment does not seem to indicate poor oxygenation. The
emergency room doctor orders ABGs to be sure the teenager's blood oxygen level is normal. As
the nurse explains the test to the client and prepares the needle and syringe, the client becomes
increasingly anxious. Her respiratory rate increases to 36 breaths per minute.

Possible Outcome: The test results show respiratory acidosis. While examining the results, the nurse remembers
that the client had been very anxious about the procedure and that her respiratory rate had
increased dramatically. As the nurse gives the doctor the blood gas results, she reports this
observation. The doctor recognizes that the blood gas results are probably not indicative of the
client's actual blood gas levels. As the client's other symptoms do not indicate respiratory
acidosis, the physician pursues other possible causes for the client's shortness of breath. The
eventual cause is found to be a sinus infection that has caused swelling of the nasopharyngeal
mucosa.

Prevention: Assess the client for deficient knowledge of the procedure as well as fear and anxiety. Take
time to explain the procedure to allay the client's fears. Instruct the client to breathe normally.
Note and record the client's respiratory rate and depth at the time of the ABG test. If the test is
not consistent with the client's observable condition, treat the client, not the test results.
LESSON 21
Epidural Catheters - Overview

An epidural catheter is used to deliver medication directly into the epidural space
Overview: surrounding the spinal cord, thereby providing site-specific analgesia. Epidural pain
management is used for short-term (e.g., acute, obstetric, postoperative, trauma) or long-
term (e.g., chronic pain, advanced cancer pain) management. State boards of nursing may
have detailed guidelines involving epidural analgesia. Each institution providing this
therapy also has policies and guidelines pertaining to epidural therapy. The nurse should
be aware of state guidelines and institution policies and understand the principles of
aseptic technique. The epidural catheter placement and the continuing pain management
of the patient should be under the supervision of an anesthesiologist, a nurse anesthetist,
or an acute pain service to ensure positive patient outcomes.
 The spinal cord and brain are covered by three membranes, called meninges: (1) the outer
layer is the dura mater; (2) the middle layer is the arachnoid, which lies just below the
dura and, with the dura, forms the dural sac; (3) the inner layer is the pia mater, which
adheres to the surface of the spinal cord and the brain. The cerebrospinal fluid (CSF)
circulates in the subarachnoid space, also called the intrathecal space. The epidural space
lies between the dura mater and the bone and ligaments of the spinal canal See Figure 1.
The epidural space (potential space) contains fat, large blood vessels, connective tissue,
and spinal nerve roots.
Analgesia via an epidural catheter may be given by continuous, intermittent, or a patient-
controlled epidural analgesia (PCEA) pump system. A variety of medication options are
available, including local anesthetics, opiates, mixtures of local anesthetics and opiates,
alpha-adrenergic agonists, and other agents (e.g., midazolam, ketamine, and
neostigmine). All medications should be preservative-free for epidural administration.
The pharmacology of agents given for epidural analgesia, including side effects and
duration of action, should be understood. Knowledge of the signs and symptoms of
profound motor and sensory blockade or overmedication is essential. Intravenous (IV)
access and immediate availability of an opioid antagonist and vasopressors are necessary.
According to the American Pain Society, the most common reason for unrelieved pain in
hospitals is the failure of staff to routinely and adequately assess pain and pain relief.
Many patients silently tolerate unrelieved pain if not specifically asked about it. The
Agency for Health Care Policy and Research urges health care professionals to accept the
patient's self-report as the single most reliable indicator of the existence and intensity of
pain. Behavioral observations are unreliable indicators of pain levels. Pain is an
unpleasant sensory and emotional experience that arises from actual or potential tissue
damage or is described in terms of such damage. No matter how successful or how deftly
conducted, surgical operations produce tissue trauma and release potent mediators of
inflammation and pain.
Pain is just one response to the trauma of surgery. In addition to the major stress of surgical
trauma and pain, the substances released from injured tissue evoke stress hormone responses in
the patient. Such responses promote breakdown of body tissue; increase metabolic rate, blood
clotting, and water retention; impair immune function; and trigger a fight-or-flight alarm reaction
with autonomic features (e.g., rapid pulse) and negative emotions. Pain itself may lead to shallow
breathing and cough suppression in an attempt to splint the injured site, followed by retained
pulmonary secretions and pneumonia. Unrelieved pain also may delay the return of normal gastric
and bowel function in the postoperative patient. Epidural analgesia provides a number of well-
documented advantages in the postoperative period, with attenuation of the surgical/trauma stress
response, including excellent analgesia, earlier extubation, less sedation, decreased incidence of
pulmonary complications, reduction in blood loss, earlier return of bowel function, decreased
deep venous thrombosis, earlier ambulation, earlier discharge from high-acuity units, and shorter
hospital stays.

Epidural Catheters - Outcomes

 The epidural catheter is inserted into the epidural space

Expected Outcomes  Pain is minimized or relieved
 The patient experiences little or no sedation
 The patient experiences little or no numbness and no motor loss in the limbs

Unexpected Outcomes
 Inability to insert the epidural catheter
 Suboptimal pain relief
 Oversedation or drowsiness
 Respiratory depression or hypoxia
 Hypotension
 Motor blockade of limbs
 Sensory loss in the limbs
 Patchy block (e.g., uneven pain relief)
 Unilateral block (e.g., pain relief on one side of the body only)
 Nausea and vomiting
 Pruritus
 Urinary retention
 Accidental dural puncture into the subarachnoid space
 Dural puncture headache
 Epidural catheter tip migration into a vessel or adjacent structure
 Redness or signs of skin breakdown at pressure area sites (e.g., sacrum, heels)
 High epidural block
 Total spinal blockade
 Occlusion of epidural catheter
 Accidental epidural catheter dislodgment
 Leakage from the epidural catheter insertion site
 Cracked epidural filter
 Local anesthetic toxicity
 Anaphylaxis
 Epidural hematoma
 Epidural abscess
 Nerve or spinal cord injury
 Accidental connection of the epidural solution to the intravenous fluids
 Cardiopulmonary arrest

Epidural Catheters - Assessment and Preparation

 Ensure the patient and family understand preprocedural teaching. Answer questions as
Preparation they arise and reinforce information as needed.
 Ensure the informed consent has been obtained.
 Wash the patient's back with soap and water and open the gown in the back.
 Consider nothing by mouth (NPO), especially if sedation or general anesthesia is to be
employed.
 Establish intravenous (IV) access or ensure the patency of IV lines.
 Position the patient on his or her side in the knee-chest position or have the patient sit
on the edge of the bed and lean over a bedside table with a pillow for comfort See
Figure 2.
 Reassure the patient.

 One epidural catheter kit or the following supplies:

Supplies

o One 25-G x 5/8-inch (0.5 x 16 mm) injection needle

o One 23-G x 1¼-inch (0.6 x 30 mm) injection needle
 o One 18-G x 1½-inch (1.2 x 40 mm) injection needle
o One 5-ml Luer-Lok syringe
o One 20-ml Luer-Lok syringe
o One Luer-Lok loss-of-resistance syringe
o One 18-G x 3¼-in (1.3 x 80 mm) epidural needle (pink)
o One 0.45 x 0.85 mm epidural catheter
o One introducer stabilizing catheter guide
o One screw-cap Luer-Lok catheter
o One screw-cap Luer-Lok catheter connector
o One 0.2 µm epidural flat filter
o Topical skin antiseptic, as prescribed (e.g., 2% chlorhexidine nonalcohol-
based preparation)
o Sterile towels
o Sterile forceps
o Sterile gauze 4 x 4 pads
o Sterile gloves, face masks with eye shields, sterile gowns
o 20 ml normal saline
o 5 to 10 ml local anesthetic as prescribed (e.g., 1% lidocaine) (local
infiltration)
o 5 ml local anesthetic as prescribed (e.g., to establish the block)
o Test dose (e.g., 3 ml 2% lidocaine with epinephrine 1:200,000)
o Occlusive or transparent dressing to cover the epidural catheter entry site
o Tape to secure the epidural catheter to the patient's back and over the patient's
shoulder
o Labels stating epidural only and not for intravenous injection
o Pump for administering analgesia (e.g., volumetric pump/dedicated for
epidural use with rate and volume limited, which has the ability to be locked
to prevent tampering and preferably is color-coded [e.g., yellow] or a patient-
controlled epidural analgesia pump)
o Dedicated epidural portless administration set
o Specific observation chart for patient monitoring of the epidural infusion
o Prescribed medication analgesics and local anesthetic medications
o Equipment for monitoring blood pressure, heart rate, and pulse oximetry

Additional equipment, as needed, includes the following:

 Ice or alcohol swabs for demonstrating block, if desired

 Emergency medications
 Respiratory equipment: oxygen mask and tubing, intubation equipment, hand-held
resuscitation bag and tubing, and flow-meter

 Assess the patient for local infection and generalized sepsis.

Assessment  Assess the patient's concurrent anticoagulation therapy.
 Obtain the patient's vital signs.
 Assess the patient's pain.

Epidural Catheters - Procedure

Assisting with Insertion and Initiating Continuous Infusion

1. Wash hands and don nonsterile gloves, gowns, and masks with eye shields.

Rationale: Reduces the transmission of microorganisms and body secretions; standard precautions.

2. Obtain the prepared epidural fluid with medication from the pharmacy as prescribed.

Rationale: The medication should be prepared by aseptic technique by the pharmacy under laminar
flow or prepared commercially to decrease the risk for an epidural infection.
All epidural solutions are preservative-free to avoid untoward reactions.

3. Connect the epidural tubing to the prepared epidural fluid with medication, and prime the tubing.

Rationale: Removes air from the infusion system.

4. Ensure the patient is in position for catheter placement See Figure 2.

Rationale: Facilitates ease of insertion of the epidural catheter.

5. Assist as needed with the antiseptic preparation of the intended insertion site.

Rationale: Reduces the transmission of microorganisms into the epidural space.

6. Assist with holding the patient in position or consider sedation, if necessary.

Rationale: Movement of the back may inhibit placement of the catheter.

7. Assist the physician or advanced practice nurse as needed with the epidural catheter placement.

Rationale: Facilitates catheter insertion.

8. After the epidural catheter is inserted, assist as needed with application of an occlusive dressing.

Rationale: Reduces the incidence of infection.

Use of a transparent stabilizing dressing allows for ongoing assessment of the insertion site for
infection, leakage, or dislodgment.

9. Secure the epidural filter to the patient's shoulder with gauze padding.

Rationale: Avoids disconnection between the epidural catheter and filter. Gauze padding prevents
discomfort and skin pressure from the filter.

10. The physician or advanced practice nurse administers a bolus dose of medication.

Rationale: Facilitates a therapeutic level of analgesia and confirms correct catheter position.
If a local anesthetic is used for the bolus, monitor the blood pressure frequently for 20
minutes, assessing for possible hypotension. Some analgesics (e.g., morphine) may take up to 1
hour to be effective.

11. Connect the prescribed medication infusion system.

Rationale: Prepares the infusion system.

 12. Initiate therapy:

a. Place the system in the epidural pump or the PCEA pump and set the rate and volume to be infused.

Rationale: No other solution or medication (e.g., antibiotic or total parenteral nutrition)

should be given through the epidural catheter.
Responses to epidural analgesia vary individually, and epidural analgesia is tailored
according to individual responses.

b. Attach an epidural only label to the epidural tubing and tape over the ports or, preferably, use a
portless system.

Rationale: Inadvertent intravenous administration of some epidural solutions can cause

serious adverse reactions, including hypotension and cardiovascular collapse.

c. Do not use a burette.

d. Lock the key pad on the epidural or PCEA pump.

14. Assess the effectiveness of the analgesia.

Rationale: Excellent pain scores should be reported at rest, and very little pain should be
experienced with deep breathing, coughing, and movement.

a. Determine the pain score (0-10 scale).

b. Test the level of the epidural block with ice or an alcohol swab.

Rationale: The ideal epidural block should be just above and just below the surgical incision
or the trauma site.

14. Discard used supplies and wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

Bolus Dose Administration Without a Continuous Infusion

1. Wash hands and don nonsterile gloves, gowns, and mask with face shield.

Rationale: Reduces the transmission of microorganisms and body secretions; standard precautions.

2. Boldly label the epidural catheter used for intermittent bolus dosing (suggest color coding).

Rationale: Reduces the risk for administration of medication into intravenous lines.

3. Identify the correct patient and medication by utilizing the five rights of medication administration.

Rationale: Reduces erroneous administration of medication.

4. Inform the patient of the procedure.

 Rationale: Prepares the patient for the quick relief of pain.

5. Prepare the bolus dose as prescribed.

Rationale: Use only preservative-free dilutant.

Do not use multidose vials because this increases the risk for contamination and the risk for an
epidural infection.

6. Prepare and cleanse the epidural filter with an antiseptic agent.

Rationale: Do not use an alcohol-based preparation. Use aqueous chlorhexidine.

Preparations with alcohol are neurotoxic to the epidural space.

7. Utilize a sterile technique to administer the epidural bolus:

Rationale: Administers medication.

Follow state and institution guidelines as to who is able to provide bolus doses.

a. Connect the syringe with the bolus medication to the catheter port.

Rationale: Prepares for injection.

b. Aspirate the epidural catheter. Note: If more than 0.5 ml of blood is aspirated, do not inject. Notify
the physician or advanced practice nurse.

Rationale: The epidural catheter may have migrated into an epidural vessel.

c. Administer the medication slowly. Note: If excessive pressure occurs, assess for kinks in the catheter
and/or reposition the patient.

Rationale: Some resistance will be felt because the diameter of the epidural space is small
and the epidural filter will be in place.
Excessive pressure may be more pronounced if the epidural catheter is placed at the
lumbar dermatome as opposed to the thoracic dermatome. If resistance continues to
impair administration of a bolus dose, contact the physician.

8. Assess the effectiveness of the medication.

Rationale: Pain should be relieved or decreased.

Report unrelieved or excessive pain.

9. Monitor vital signs.

Rationale: An epidural bolus may cause hypotension or increased sedation.

Report untoward decrease in blood pressure and sedation.

10. Discard used supplies and wash hands.

Rationale: Reduces the transmission of microorganisms; standard precautions.

Epidural Catheters - Post Procedure and Variations

 1. Assess the patients level of sedation using a sedation scale See Figure 4 every
Post Procedure 1 to 2 hours or more frequently, if needed, during the first 12 to 24 hours of
therapy in an opioid-naïve patient.

S = Sleeping, easily aroused; requires no action.

1 = Awake and alert; requires no action.
2 = Occasionally drowsy, easy to arouse; requires no action.
3 = Frequently drowsy, arousable, drifts off to sleep during
conversation; decrease the opioid dose.
4 = Somnolent, minimal or no response to stimuli; discontinue opioid
and consider use of naloxone (Narcan).
Rationale: Sedation precedes opioid-related depression. A sudden
change in sedation scale may indicate that the epidural catheter may
have migrated into an epidural blood vessel or the intrathecal space.
Increasing sedation and drowsiness or sudden change in sedation
scale should be reported if they persist despite nursing
interventions.

2. Assess the patient's level of pain using a pain scale every 1 to 2 hours, or more
frequently if needed, during the first 12 to 24 hours of therapy in an opioid-
naïve patient.

Record the patient's subjective level of pain, using the numerical rating
scale (NRS), of 0 to 10:
0 = No pain
5 = Moderate pain
10 = Worst possible pain
Rationale: Describes patient response to pain therapy. A low pain score
is expected both at rest and during movement. Analgesic goal is safe,
steady pain control at a low level that is acceptable to the patient (e.g.,
less than 2 on the pain scale when at rest and less than 4 during
movement).
Moderate-to-severe pain scores should be reported if they persist
despite nursing interventions.

3. Assess respiratory rate every 1 to 2 hours and prn.

Rationale: Provides data for diagnosis of respiratory depression.

Increasing respiratory depression or sudden change in respiratory
rate combined with increasing somnolence should be reported if
they persist despite nursing interventions.

4. Assess heart rate every 1 to 2 hours and prn.

Rationale: Tachycardia may indicate a condition such as shock.

Bradycardia may indicate opioid overmedication and sympathetic
 blockade by the local anesthetic.
Change in heart rate, abnormal heart rate, or abnormal cardiac
rhythm should be reported if they persist despite nursing
interventions.

5. Assess blood pressure every 1 to 2 hours and prn.

Rationale: Epidural solutions containing a local anesthetic may cause

peripheral and venous dilation, providing a sympathectomy. The
hypotensive effect of a local anesthetic is most common when a patient's
fluid status is decreased. Epidural analgesia may not be the sole cause of
hypotension but may reveal hypovolemia.
Hypotension should be reported if it persists despite nursing
interventions.
If hypotension occurs:

a. Turn off the epidural infusion and call the physician, the advanced
practice nurse, or the acute pain service.
b. Place the patient in a supine, flat position.
c. Administer IV fluids as prescribed or according to protocol.
d. Administer vasopressor medications as prescribed.

6. Monitor the infusion rate hourly. Ensure the control panel is locked if using the
volumetric infusor or ensure the PCA program is locked in via key or code
access.

Rationale: Ensures the medication is administered safely.

7. Monitor oxygen saturation regularly or continuously per institutional policy.

Rationale: Assesses oxygenation.

Oxygen saturation less than 93% or a decreasing trend in
oxygenation should be reported if it persists despite nursing
interventions.

8. Obtain the patient's temperature every 4 hours; assess more frequently if

febrile.

Rationale: Increasing hyperpyrexia could signify an epidural space

infection or systemic infection that is a potential risk when an epidural
catheter is in place.
Temperature greater than 101°F (38.5°C) should be reported if it
persists despite nursing interventions.

9. Assess the epidural catheter site every 4 to 8 hours and as needed.

Rationale: Identifies site complications and infection. An epidural

abscess is a very rare but serious complication. Patient recovery without
neurologic injury depends largely on early recognition.
Redness, tenderness, or increasing diffuse back pain; pain or
paresthesia during epidural injection induration; and swelling or
presence of exudates should be reported if they persist despite
 nursing interventions.

10. Monitor urine output.

Rationale: Provides data regarding urinary retention and possible early

signs of epidural abscess or epidural hematoma.
Urinary incontinence, change in bladder function, and lack of
urination for more than 6 to 8 hours should be reported if they
persist despite nursing interventions.

11. Monitor sensory See Figure 3 or motor loss (e.g., leg numbness or inability to
bend knees).

Rationale: Motor or sensory loss in the extremities may be an early

warning sign of an epidural abscess or hematoma or may indicate an
excessive dose of a local anesthetic. An epidural hematoma is a very
rare but serious complication; if undetected, it may result in permanent
paralysis.
Change in sensory or motor function in extremities, sudden onset of
back pain with decreasing motor weakness, and loss of bladder and
bowel function (incontinence) should be reported if they persist
despite nursing interventions.

12. Assess for tingling around lips.

Rationale: If a local anesthetic is used in the epidural solution, tingling

around the lips may indicate impending local anesthetic toxicity.
Tingling around the lips should be reported if it persists despite
nursing interventions.

13. Assess for tinnitus.

Rationale: If a local anesthetic is used in the epidural solution, ringing in

the ears can be a sign of toxicity.
Tinnitus and deccreasing or sudden change in patient's hearing
should be reported if it persists despite nursing interventions.

14. Monitor and check skin integrity of sacrum and heels every 2 hours and as
needed. Change patient's position as needed.

Rationale: If a local anesthetic is used in the epidural solution, check for

pressure points and decubitus ulceration (patient may have sensory loss
in lower limbs).
Increasing redness or blistering of the skin on the sacrum or heels
should be reported if it persists despite nursing interventions.

15. Change the epidural catheter insertion site dressing as prescribed or if soiled,
wet or loose.

Rationale: Provides an opportunity to cleanse the area around the

catheter and to assess for signs and symptoms of infection that may
indicate early signs of an epidural abscess.
 Swelling, site pain, redness, leakage of epidural solution, and
drainage should be reported if it persists despite nursing
interventions.

16. Assess for the presence of nausea or vomiting.

Rationale: Antiemetics may have to be administered; the medication

may need adjustment (e.g., opiates may have to be decreased or
removed if nausea and vomiting are not well controlled).
Unrelieved nausea and vomiting should be reported if they persist
despite nursing interventions.

17. Assess for the presence of pruritus.

Rationale: Epidural opiates may cause itching. Medications such as

antihistamines (may cause sedation) or other low-dose opioid
antagonists may be necessary to relieve pruritus. IV ondansetron
(Zofran) at the time therapy is initiated has been shown to prevent
pruritus.
Itching, redness, and rashes should be reported if they persist
despite nursing interventions.

18. Label the epidural pump and consider placing the epidural pump on one side of
the patient's bed and all other pumps on the other side of the bed.

Rationale: May aid in minimizing the risk for mistaking the epidural
infusion for an IV infusion system. Cardiopulmonary arrest and seizures
may occur if the epidural solution is infused intravenously.
Infusion of IV fluid into the epidural space and infusion of epidural
solution into the IV should be reported if they persist despite
nursing interventions.

 Patient and family education

Documentation  Any difficulties in insertion
 Type of dressing used
 Confirmation of epidural catheter placement (e.g., decrease in blood pressure,
demonstrable block to ice)
 Site assessment
 Assessment of pain, including levels of motor and sensory blockade See Figure
3 (documented on an appropriate flow chart at regular intervals)
 Sedation score assessment
 Vital signs and oxygen saturation
 Epidural analgesic medication and medication concentration being infused and
infusion rate per hour
 Bolus dose administration and patient response following bolus dose, including
effectiveness of pain relief
 Occurrence of unexpected outcomes and/or side effects
 Nursing interventions taken
 Pump settings when programmed for PCEA
 Medication concentrations, continuous infusion rate, bolus dose, lockout
interval, and 1- or 4-hour limit
  Explain the reason and purpose for the epidural catheter
Patient Education  If available, supply easy-to-read written information
 Explain to the patient and family that the insertion procedure can be
uncomfortable but that a local anesthetic will be used to facilitate comfort
 During therapy, instruct the patient to report side effects or changes in pain
management (e.g., suboptimal analgesia, numbness of extremities, loss of
motor function of extremities, acute onset of back pain, loss of bladder and
bowel function, itching, and nausea and vomiting)