Central Venous Access Devices: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of central venous access devices in order to:
- Educate the client on the reason for and care of a venous access device
- Access venous access devices, including tunneled, implanted and central lines
- Provide care for client with a central venous access device (e.g., port-a-cath, Hickman)
There are several types of venous access. Venous access can be done with a peripheral intravenous device and a central venous access device. Peripheral intravenous devices are used for short term intravenous therapy including fluids, electrolytes, medications and chemotherapy when the client has accessible and usable veins. Generally speaking peripheral intravenous catheters should be the shortest possible in terms of their length which is usually about 3 inches for the adult client and, as with other invasive therapies, peripheral intravenous devices should be left in place for the shortest possible period of time in order to prevent catheter related infections. Short peripheral catheters can typically stay in place for 72 hours; and a longer peripherally inserted midline catheters can remain in place for a longer period of time up to about 4 weeks in duration. These peripherally inserted midline catheters are longer than 3 inches and they range up to 8 inches in length and they are advanced into the brachial, basilic or cephalic veins.
The intravenous catheter size depends on the patient's condition and their anticipated needs. For example, an 18 gauge catheter is used when the administration of a blood transfusion is anticipated; a larger gauge catheter, typically a 16 gauge catheter is used for a major trauma client with often unpredictable needs; and a smaller 22 or 24 gauge intravenous catheter is used when a client only needs intravenous fluids and medication with their peripheral venous catheter. A butterfly can be used for short term peripheral intravenous access of less than 24 hours and an Angiocatheter is used for peripheral intravenous therapy of more than 24 hours.
Vein selection for a peripheral intravenous device should be based on a number of considerations. The best veins to select are the distal veins on the nondominant hand so that the client is able to fully use their dominant hand. The side of a client's mastectomy, paralysis and a dialysis access device are not used. Additionally, areas distal to a previous phlebitis or infiltration site should also not be used. The veins in the hand are not the veins of choice. Whenever possible, the upper extremities, rather than the legs, are used to prevent lower extremity phlebitis and emboli.
The procedure for inserting a peripheral intravenous catheter is:
- Explain the procedure to the client and use sterile supplies and sterile technique to start an intravenous line.
- Choose a suitable vein.
- Place the tourniquet on the client's arm about 3 to 4 inches above the selected site.
- Palpate the vein.
- Clean the site with an alcohol prep pad with a circular pattern from the site of the venipuncture to the area surrounding the site of the venipuncture Permit the area to dry.
- Ask the patient to make a fist. Warm compresses and moving the limb to a dependent position can also be used to dilate the vein. The client should not pump the limb.
- Pull the skin taunt so the vein is accessible.
- Insert the catheter needle into the vein at a 15 to 30 degree angle with the bevel up.
- Look for the flashback of blood into the catheter.
- Lower the angle of the catheter needle.
- Gently advance the catheter so it is at the same level as the surrounding skin.
- Remove the tourniquet and connect the intravenous tubing to the hub of the catheter.
- Secure and stabilize the catheter with a manufactured catheter stabilization device to prevent vein irritation and an inadvertent dislodgment.
- Adjust the infusion rate according to the doctor's order.
After the intravenous catheter is successful inserted, the intravenous line and the insertion site is monitored and maintained by the nurse. The intravenous line is monitored to insure that the line is patent and that the rate of flow is as ordered. The intravenous site is inspected for any signs of infiltration and infection. The dressing is changed and dated according to the particular healthcare facility's policy and procedure which is typically every 24 hours.
Central venous catheters are inserted into the right atrium of the heart through the central venous superior vena cava. Central venous catheters can be advanced into the superior vena cava through a peripheral vein, as is the case with a peripherally inserted central venous catheter, or PICC, and also into the central venous system through the subclavian or jugular vein. Some of these catheters have multiple lumens, up to 3, and they vary in terms of how long they can remain in place. For example, a percutaneous, non tunneled subclavian catheter is used when immediate and short term treatments are anticipated, and other central venous catheters are tunneled and cuffed. For example, an implanted tunneled and cuffed central venous catheter can have a port that is subcutaneously placed and accessed with a non coring needle into the port's reservoir.
Central venous catheters are a preferred method of venous access when the client is getting intravenous fluids or therapies in the home and also when the client:
- Does not have suitable peripheral veins for necessary therapies.
- Is receiving continuous or intermittent multiple therapies such as chemotherapy, blood, medications and total parenteral nutrition.
- Has a long term chronic disease or condition, such as cancer for example.
Strict sterile technique is used for maintain and caring for a central venous catheter. Central venous catheter dressings are changed at least every forty eight hours unless it is an occlusive transparent dressing. These occlusive transparent dressings can be changed every 7 days unless they are wet, soiled or loosened.
Some central venous catheters have a couple or several lumens. Each lumen must be flushed with a heparin solution on a daily basis in order to maintain patency. The injection cap on each lumen should be changed every 7 days or any time that the cap is leaking.
Some of the complications associated with central venous catheters include infection, pneumothorax, hemothorax, thrombosis, emboli and an accidental cardiac perforation during the insertion procedure.
Patient and family education about venous access devices begins with the informed consent procedure and it continues throughout the client's use of these devices. Some of the components of this education should include:
- The purpose of the venous access device
- The risks associated with these devices
- Alternatives to the venous access device
- How the venous access device will be maintained and care for
- Things that the client should report to their doctor or nurse such as burning or redness at the site
All venous access devices are accessed and maintained using sterile technique, therefore, nurses and not unlicensed assistive personnel insert, maintain and manage venous access devices. Additionally, some health care facilities limit the insertion, maintenance and care of all IVs to only registered nurses.
Peripheral venous access devices are accessed by disinfecting all hubs prior to administering a piggy back or an Intravenous push bolus medication.
For example, the procedure for an intravenous secondary piggy back line is as follows.
- The nurse identifies the patient and informs the patient about the medication that will be administered
- Insure that the intravenous solution is compatible with the piggyback medication
- The piggyback is hung
- The primary intravenous site is cleansed with alcohol
- The piggyback is inserted into the primary intravenous line
- The primary intravenous and the piggyback are then allowed to run together until the piggyback administration is completed
Although both peripheral and central venous access devices are managed and maintained with sterile technique, additional measures such as wearing sterile gloves and masks are needed with central venous lines because their risk for infection is much greater than that of a peripheral intravenous line. Both the nurse and the client wear a mask when a central venous access device is being accessed and cared for.
A chlorhexidine solution is used to cleanse the insertion site and a chlorhexidine solution impregnated dressing is used to cover the site. The caps are changed and the flushing of the line is done before and after each access, such as when a medication or chemotherapeutic agent is administered.
Central venous catheter dressings are changed at least every 48 hours unless it is an occlusive transparent dressing. These occlusive transparent dressings can be changed every 7 days unless they are wet, soiled or loosened. Some central venous catheters have a couple or several lumens. Each lumen must be flushed with a heparin solution on a daily basis in order to maintain patency.
The injection cap on each lumen should be changed every 7 days and any time that the cap is leaking.
Blood pressure readings and invasive procedures such as laboratory specimens are not done on the side of the central venous access device.
- Adverse Effects/Contraindications/Side Effects/Interactions
- Blood and Blood Products
- Central Venous Access Devices (Currently here)
- Dosage Calculations
- Expected Actions/Outcomes
- Medication Administration
- Parenteral/Intravenous Therapies
- Pharmacological Pain Management
- Total Parenteral Nutrition