CARE OF patient with CVc.

Introduction
• A central venous catheter (CVC), also known as a central
line, central venous line, or central venous access catheter, is
a catheter placed into a large vein. It is a form of venous access.
Catheters can be placed in veins in the neck (internal jugular
vein), chest (subclavian vein or axillary vein), groin (femoral vein), or
through veins in the arms (also known as a PICC line, or peripherally
inserted central catheters). It is used to administer medication or fluids
that are unable to be taken by mouth or would harm a
smaller peripheral vein, obtain blood tests (specifically the "central
venous oxygen saturation"), and measure central venous pressure.
ARTICLES REQUIRED FOR CENTRAL VENOUS CATHETER CARE

1. A sterile dressing tray containing

 Artery forceps -2
 Thumb forceps
 Cotton Swabs
 Gauze Pieces
2. Betadine solution /swabs
3. Betadine ointment
4. Sterile Gloves
5. Adhesive tape and scissors for fixing the dressing
6. Label with date and time of dressing change
7. Facemask
Best Practice Guidelines for Site preparation.
• CLSI - Clinical and Laboratory Standards Institute, USA
• Cleansing the site first with 70% isopropyl alcohol, Allow it to air dry
• Followed by application of the main disinfectant - Povidone Iodine or CHG
• INS (1998, S53) - Infusion Nursing Society, USA
• Antimicrobial solution containers should be in a single-unit of use and that
• they should be discarded after individual use
• Excess hair over venipuncture site should be clipped instead of shaved
• CDC - Centre for Disease Control and Prevention, USA
• 2% Chlorhexidine based antimicrobial preparation is preferred*
• Palpation of catheter insertion site should not be performed after
• application of antiseptic*
• Allow the antiseptic to remain on the insertion site and to air dry before
• catheter insertion*
CENTRAL VENOUS SITE CARE

 Assemble all articles on right side of the patient - Saves time and reduce workload.

 Wash hands with aseptic solution – Reduces transmission of micro-organisms.

 Explain procedure to the patient - wins co-operation of the patient and reduces anxiety.

 Wear face mask and examination gloves – Prevents transmission of micro-organisms.

 Remove dressing & discard in appropriate waste segregation containers.

 Exposes the catheter site for inspection & cleansing.

 Gauze dressing should be changed everyday.

 Transparent dressing should changed at least every 7 days .

 Dressing should always be changed if it becomes damp, loosened or soiled.

 Inspect the site for erythema, tenderness swelling exudates, leaking of catheters-
Detects signs of leakage , catheter dislodgement, leakage or loose sutures.

 Remove & discard gloves – Maintain aseptic technique.

 Gently tug catheter to evaluate the integrity of suture- Avoids dislodgement of

catheter.

 Cleanse insertion around the insertion site at least 3 inches with 2% chlorhexidine
solution & allow it to dry. The catheter has to be cleaned with alcohol swab from exit
to distal end- Removes soap dirt and moisture.

 Apply semipermeable transparent dressing at the site- Protects skin injury upon
removal .
 If there is any discharge from site apply 4*4 gauze pad at site and secure it in site with
adhesive plaster- provides occlusive seal at site and absorbs moisture.

 Tape the tubing's to arms chest and neck dressing- Discourages inadvertent
disconnection.

 Make sure that the cap is always closed when catheter is not in use- Reduces chances of
air embolism.

 Remove & discard gloves – Reduces infection spread.

 Wash hands and replace articles- reduces transmission of microbes.

 Document in nurses notes and CVC checklist –Documentation is an evidence of nurses

action.
To measure CVP

• Assemble all needed articles on right side of bed – Reduces work load and
saves time .
• Wash hands – Reduces transmission of microbes
• Explain procedure to the patient – Win co-operation and reduces anxiety.
• Place the patient in flat supine position- This baseline position is used for
subsequent readings.
• Locate the phlebostatic axis, Mark the level of right atrium(At the mid-axillary
about 1/3rd , of the distance from anterior to posterior chest wall) in the 4th
intercostal space with an X mark using marker pen – The term phlebostatic
axis may be used to identify the level of the right atrium.
 Fix the level of the manometer on an IV pole such that it is zeroed at the x
mark- Helps minimize variance in measurement.
 Connect the IV fluid (usually normal saline)to a three-way a stopcock & flush
the two others ports- Forces air-out of the stopcock.
 Apply sterile gloves & mask – aseptic technique minimizes chance of
infection.
 Connect the CVP manometer to the upper port of the stopcock.
 Connect the CVP tubing from the patient to the second side port of the stop-
establishes IV line from normal saline to CVP Catheter.
 Turn off stopcock at the patient side & fill manometer with normal
saline to the 20cm mark above the anticipated reading- The normal
CVP reading varies from 8 to 12 cm of water.

 Hold the manometer at the phlebostatic axis and turn off the stopcock
to the normal saline- System is open from the manometer to the patient.

 Watch as the fluid falls in the manometer take the central venous
pressure reading when the fluid stabilizes.
 The fluid will stabilize at a level equal to the pressure in the right atrium or
central veins .if the fluid level fluctuates with the patients respiration’s, take
the reading at the end of the patients expiration.
 Turn the stopcock off to the manometer – Re-establishes fluid flow from the
IV to the patient.
 Reposition the patient.
 Keep the manometer in the upright position (Usually hanging from the IV
pole) to prevent air bubbles from entering the fluid column or the patient & to
prevent contamination of the manometer- The top of the manometer remains
open to the air, if manometer is not properly stored, contamination or air can
enter the manometer and be flushed into the patient.
 Wash and dry hands – Prevents spread of micro-organisms.
 Document the reading obtained in the patients medical record – Provides
continuity of care.
Central Venous Access

 Catheters inserted into large veins in central circulation

 Tip of catheter threaded to reside in lower third of the vena
cava
 Chest X-ray to confirm correct placement
 Central Venous Access

Indications:
 Patients requiring multiple sites for IV access
 Patients lacking usable peripheral IV sites
 Patients requiring central venous pressure monitoring
 Patients requiring total parenteral nutrition
 Patients receiving incompatible medications
 Patients requiring multiple infusions of fluids, medications, or chemotherapy
 Patients requiring long term antibiotic therapy
 Patients subject to frequent blood sampling or receiving blood transfusions
 Patients requiring a temporary access site for hemodialysis
 Patients receiving infusions that are hypertonic, hyperosmolar or infusions
that have divergent pH value.
 ADMINISTERING MEDICATION THROUGH CVC LINE

• Steps to give medications

 Prepare a work area
 Clean the work area
 Gather supplies – Alcohol wipes, clean gloves, IV set, pre-filled flush
syringe & medication .
 Before preparing medication check for date of manufacture, date of expiry
,any signs of contamination ,discoloration, crystal formation.
 Wash hands – If using an alcohol based hand cleaner rub all over and only
touch supplies.
 Mix the medication as per its dilution , insert the IV tubing- it will have a
spike ,a drip chamber and several clamps and keep it primed.
DRAWING BLOOD SAMPLES FROM CENTRAL VENOUS CATHETER

• Explain procedure to patient prior to commencement-Win cooperation of the

patient and reduce the anxiety.
• Follow aseptic preparation prior commencing procedure- Reduce transmission
of microbes.
• Place patient in supine position. Turn the patients head towards the opposite
side from central venous catheter site during procedure-prevents contamination
with airborne pathogens and make site appear clear.
• Turn off infusion at least one minute prior to sampling – Gives wrong values
as blood is diluted.
• After removing 5ml of blood from CVC pigtail attached syringe and remove
required amount of blood for blood test using aseptic technique.
• Put on the clean gloves & scrub the access port with the alcohol swab for
about 15 seconds and allow it dry and flush the line with 10mL normal
saline.
• Insert the primed IV tubing to the cvc port .Incase of 8th or 6th hourly single
shot drug administration we have to scrub the cvc port with the alcohol swab
,flush the line and administer the injection.
• After administering the drug scrub the cvc port with an alcohol swab and
flush the line with 10ml normal saline and seal the port with the stopper.
• Note :- Any drug administration or fluid infusion it has to be followed with
flushing of the line with 10ml normal saline prior and 10 ml normal saline
after.
 Central venous Catheter Dressings
Centers for Disease Control and Prevention (CDC)
Recommendations:
Use either sterile gauze or sterile transparent semipermeable dressing
Ifpt is diaphoretic or site is bleeding or oozing, use gauze until
resolved
Replace dressing if damp, loosened, or visibly soiled
Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis
catheters, because of their potential to promote fungal infections and antimicrobial
resistance.
Dressing Changes
Short-term CVC sites 2 days for gauze and at least 7 days for transparent
2% Chlorhexidine to cleanse skin during dressing changes
Dressing Removal:
 Stabilize catheter and Luerlock hub to prevent dislodgement
 Separate dressing away from Luerlock hub and toward insertion site
 Chlorhexidine should be used to swab in a back and forth pattern for
30 seconds to ensure the skin is clean and disinfected.
 If patient is diaphoretic with a great deal of fluid present on skin, area
should be scrubbed for 2 minutes to ensure bactericidal activity
 During dressing change- assess external catheter length to determine if
migration had displaced catheter tip
 Sterile occlusive dressing should cover entire insertion site, suture
wing and at least 2.5 cm of the extension tubing is recommended.
 Dressing Change Procedure
 Gather supplies
 Hand hygiene
 Don clean gloves and mask (patient)
 Remove old dressing (toward insertion site) and discard
 Remove gloves, perform hand hygiene, and don sterile gloves
 Inspect catheter, site, surrounding skin, and pt’s arm/chest/neck
 Cleanse site (chlorhexidine) back and forth motion
 Allow to air dry and Secure catheter in place
 Apply sterile dressing to site
 Document date, time, and initials on new dressing
 Document the procedure, any complications, and external catheter length
to patient’s chart
 Open Ports

• CDC - Centre for Disease Control and Prevention

• Stopcocks represent a potential portal of entry for microorganisms into vascular
access
• Stopcock contamination is common, occurring in 45-50% cases
• INS - Infusion Nursing Society, USA
• Studies have shown stopcocks have often been cause of microorganisms entering the
IV system through
• hands of personnel,
• syringes used to flush or draw blood
• residual blood that remains in the port after use, serving as breeding ground for
bacteria
• Failure to keep a sterile cap on when not in use
Closed port
Open Vs Closed ports

• Incidence of CRBSI was 0.7/1000 days of catheter use with closed ports

• Versus 5 /1000 days of catheter use with open ports

• To add a disinfect able , needle free connector reduces the incidence of

CRBSI in critically ill patients with CVC’
 Caps: Needleless Access Devices
 CDC recommends changing caps at least as frequently as
administration sets
 No benefit to changing these more frequently than every 72 hours
 TPN/Lipids (enhance microbial growth)
 Accessing: “Scrub the Hub” for 15 seconds
 Flushing Lines
 A single use syringe should never be used more than once
 10 mL syringes should not be divided into several doses
and used for multiple lumens
 Never use a syringe smaller than 10 mL
 Thepressure created by smaller syringes could damage the
catheter
 Volume: Minimum of twice the volume of the catheter
should be used to flush
 In general for adults 10 ml is sufficient
 0.9% NaCl solution should be used
 Frequency: If being used a minimum of 8 hours, flush with 10 mL NS
before and after every use and for lines in maintenance mode flush with
10 mL NS every 24 hours.
 Flush using a “stop-start” technique
 Creates turbulence within the catheter to adequately flush medications
from the line.
 Preventing: Blood Reflux

 Major problem
 Catheters are deep in the body, reflux cannot be seen
when it occurs
 Caused by inadequate flushing, also b/t flushes
caused by increased intravascular pressure (ex:
coughing, vomiting) leading to biofilm formation
and buildup, occlusion, and even infection.
 Assessment

 Visually examine insertion site daily for erythema, drainage, tenderness,

suture integrity, and catheter position
 Routine IV site assessments
 Routinely assess dressings (change if necessary)
 Daily assessment of need for Central Line and promptly discontinue lines
which are no longer indicated
 Nursing staff should be encouraged to notify physicians of Central Lines
which are unnecessary.
 Documentation

The following should be included in the patient’s chart:

 Product Name
 Date of insertion, inserter
 Anatomical location
 Catheter depth according to catheter reference
markings
 X-ray confirmation of catheter tip location
 Port designation for infusions/measurements, e.g. TPN, CVP, Medications
Ensures uniform use of lumens
 Amount, type, and frequency of flush solution
 Dressing and tubing changes
Document exposed catheter length with dressing changes
 Site assessments should be done for every shift
 If any complications arise, remove catheter and apply air-impermeable
dressing
 Central venous catheter care bundle includes.
• Hand hygiene :Hands are decontaminated immediately before and after each episode of
patient contact using the correct hand hygiene technique.

• Site inspection :Site is inspected daily for signs of infection, and finding is recorded in
the patient’s record.

• Dressing :An intact, dry, adherent transparent dressing is present. Insertion site should be
cleaned with 2% chlorhexidine gluconate in 70% isopropyl alcohol prior to if dressing
changed.

• Catheter injection ports :Injection ports are covered by caps or valved connectors.

• Catheter access :Aseptic techniques are used for all access to the line.
• Ports or hubs are cleaned with 2% chlorhexidine gluconate in 70%
isopropyl alcohol prior to catheter access.

• Administration set replacement :Set is replaced immediately after

administration of blood/blood products. Set is replaced after 24 hours
following total parenteral nutrition (if it contains lipids). Set is replaced
within 72 hours of all other fluid sets.

• Catheter replacement :Catheter is removed if no longer required or

decision not to remove is recorded. Details of removal are documented in
the records (including date, location, and signature and name of operator
 References
 Angiodynamics (2014). Bioflo picc with endexo technology: Directions for use. Marlborough, MA: Navilyst Medical, Inc.
 Arrow (1996). Central venous catheter: Nursing care guidelines. Reading, PA: Arrow International, Inc.
 Centers for Disease Control and Prevention (2011). Basic infection control and prevention plan for outpatient oncology
settings. Retrieved from
http://www.cdc.gov/HAI/settings/outpatient/basic- infection-control-prevention-plan-2011/central-venous-catheters.html
 Centers for Disease Control and Prevention (2011). Guidelines for the prevention of intravascular catheter-related infections.
Retrieved from http://www.cdc.gov/hicpac/bsi/bsi-guidelines- 2011.html
 Ignatavicius, D.D., & Workman, M.L. (2013). Medical-surgical nursing: Patient-centered
collaborative care (7th ed.). St. Louis, MO: Elsevier Saunders.
 Kallen, A. (2009). Central line-associated bloodstream infections (clabsi) in non-intensive care unit (non-icu) settings toolkit. Atlanta,
GA: Centers for Disease Control and Prevention.
 Stacey, K.M. (2014). Peripherally inserted central catheter (picc): Maintenance and dressing change quicksheet. Mosby’s
Skills. St. Louis, MO: Elsevier, Inc.
 Schallom, L., & Shomo, J.E. (2011). Keeping the lines open with evidence-based practice and technologies: A continuing
educational activity for pharmacists and nurses. Irving, TX: VHA, Inc.
 The Nebraska Medical Center (2012). Standardizing central venous catheter care: Hospital to home
(2nd ed.). Omaha, NE: The Nebraska Medical Center.
Questions?