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IV THERAPY PART 4 Alternative Access & Complications Catherine Luksic, BSN RN Alternative access routes 1. Central Venous Lines - percutaneous -<60 days, subclavian or internal jugular veins - Single, double, triple, quad-lumen - Sutured in place, Sterile dressing change q.7 days *check policy….may be q 48-72 hr. - May require daily heparin flush **check policy 2. Tunneled catheters – Hickman, Broviac, Groshong - Percutaneous, tunnelled under skin - Single, double, or triple lumen - Long term use 1-2 years 3. PICC lines - Peripherally Inserted Central Catheter - placed peripherally, longer term use Alternative Access Routes 4. Implantable Ports Single or double lumen Single or double port Metal chamber connected to silicone catheter POC (port-a-cath) Requires huber needle to access Change needle q. 5-7 days *check policy first 5. Tesio Catheter For hemodialysis use ONLY Do NOT access, flush, aspirate or administer meds via Tesio For dialysis staff only ! Require heparin Central Venous Line Most common use = hospital Usually have multiple lumens Advantages: Can be inserted at bedside. Easy to use Multi-lumen Disadvantages: Requires sterile dressing changes (check policy) Risk of infection May require daily heparin flush (if not used continuously) Requires activity restrictions Triple Lumen Catheter (TLC) Central Venous Line (CVL) Central Venous Lines Tunneled Catheters Placed surgically in OR Tunnel is made from surgical site near the subclavian to an exit wound further down on chest. (2 surgical wounds) Cuff forms a barrier under the skin - stabilizes catheter and prevents bacterial migration into bloodstream examples : Broviac, Hickman, Groshong Groshong Catheter Implanted Ports Relatively common Placed and removed in OR Common use = chemo Port is placed in a surgically made “pocket” and sutured in place. Catheter extends into vein from this port/reservoir. Must be “accessed” for use w/ huber needle *LPN may NOT access POC Port a Cath (POC) PICC Lines Can be 20x longer than peripheral cath Can be used up to 1 year (usually less) Common use = long term antibiotic therapy; TPN Must be confirmed by xray before use Advantages: Can be inserted by specially trained nurse at bedside Low infection rate Disadvantages: Requires daily flush Limits activity (external catheter) Cannot use for high pressure infusions PICC PICC Lines FLUSHING – used to maintain patency of the line. Dictated by agency policy. Most commonly normal saline, followed by heparin. (Volume determined by manufacturer, usually 5-10cc). Check for allergies, incompatability, bleeding, etc. Check policy re: heparin use MUST USE 10cc SYRINGE PICC LINE CARE CXR MUST BE DONE TO CONFIRM PLACEMENT ROUTINE IV SITE MONITORING PLUS: ARM CIRCUMFERENCE (DO NOT USE FOR BP) TEMP ↑, RESP STATUS, CARDIAC IRREG EXTERNAL CATH LENGTH – measure, check markings PATIENT EDUCATION Central Lines SCRUB THE HUB 15 seconds APPLY ANTIBACTERIAL CAP BETWEEN USES Central line dressing change Change as needed and according to institution policy q 48-72 hr for CVC or…. Q 7 days for CVC **check policy ! Q 7 days for PICC Must be performed as sterile procedure Inspect site at each change Central Line Dressing Change Cleanse from insertion site outward for 4-6 in area Cleanse site well with alcohol first, then chlorhexadine or povidine-iodine (betadine) Clean in a circular motion, allow to dry ASSESS SITE Apply transparent dressing, reinforce with tape, and LABEL. Document Documentation Legal, ethical , and professional responsibility Includes: Insertion procedure Proper infusion and maintenance Monitoring of site and infusion Direct care given (i.e. dressings, tubing changes, patient education, etc.) Complications Systemic - problem involving the entire body, related to IV therapy Local - adverse reaction or trauma to the surrounding venipuncture site. Hypersensitivity - can be systemic or local Systemic Complications Circulatory overload - usually infused too fast, or with hepatic, cardiac, renal disease Dyspnea, cough, edema, wt. gain, rales or crackles Decrease IV rate, elevate HOB, obtain vitals & assess the patient, notify physician Infection (septicemia) - microorganisms in circulatory system Fever, chills, tachycardia, tachypnea, headache ? IV contaminated, break in aseptic technique Notify physician, treat symptoms, blood cultures, remove IV Establish another IV site Systemic Complications Venous Air Embolism - rare, but lethal Air trapped in Rt. Ventricle lodges against pulmonary valve Blocks flow of blood to pulmonary artery Right heart overfills Small bubbles may enter pulmonary circulation Tachycardia, SOB, shoulder pain, JVD, hypotension, weak pulse, lightheadedness Immediately – pt. on left side, trendelenburg, notify physician Causes air to rise in right atrium, prevents air from entering pulmonary artery Obtain vitals and pulse oximetry, administer oxygen Systemic Complications Speed Shock - foreign substance (usually medication) is rapidly introduced into circulation Usually results in hypertension Slow infusion rate, notify physician Vancomycin = “red man syndrome” Incompatibility Drug interactions Allergic reaction Local Complications *Common area for nursing malpractice Phlebitis - Inflammation of the vein, common Redness, pain, swelling, induration *symptoms worse w/ thrombophlebitis = clot Remove IV and relocate Tx: Warm compresses Prevention = rotate sites every 72 hours ASSESS site hourly ! Local Complications Infiltration - seeping of fluid into surrounding tissue Site is cool with dependent edema, and often painful. Tx: Discontinue IV solution, remove catheter, apply warm compresses, elevate extremity Prevention = hourly IV site checks ! Local Complications Infection - related to microbial contamination of the catheter or the infusate Extravasation - infiltration of a vesicant medication, can cause blisters and subsequent sloughing of tissues Chemo IV potassium at higher concentration (over 40meq) Dopamine Dilantin Flagyl Local Complications Hematoma – infiltration of blood into extravascular tissues SQ hematoma is a localized collection of blood and is the most common local complication. May see discoloration of skin Usually related to nursing skills Higher risk in pts. on anticoagulants Higher risk in elderly Preventing Complications Use aseptic technique HANDWASHING Inspect all fluids & equipment before use Be alert to signs of circulatory overload JVD, elevated BP, elevated RR, moist crackles, edema weight gain Anchor IV cannula well to prevent motion Do not use veins over area of joint flexion PN Scope of Practice Must complete state approved infusion course Must attend annual review (CEU’s) to maintain skills May not administer meds which require titration (insulin, heparin, cardizem, etc.) May not administer blood products May administer saline flushes & heparin flushes May administer TPN & lipids PN Scope of Practice Peripheral Line: may insert & D/C, flush, change tubing, site care PICC Line: may not insert or D/C; ok to flush, change tubing, site care, draw blood ?? Check hospital policy ! Central Line: may not D/C; ok to flush, draw blood, change tubing and perform site care ?? Check hospital policy ! POC: may NOT flush or access, may not draw blood, may change tubing and administer IVPB ?? Check hospital policy ! PN Scope of Practice Guidelines are provided by State Board of Nursing MUST always follow institution policy – this may vary from state guidelines INS Standard The nurse shall educate the patient, caregiver, or legally authorized representative: Prescribed infusion therapy Plan of care Potential complications associated with therapy Peripheral or Central Risks Benefits