GIPPSLAND HEALTH SERVICES CONSORTIUM

Gippsland region SDLP: CVAD of 65 Revised March 2021

GIPPSLAND HEALTH SERVICES CONSORTIUM

NAME________________________________________

HEALTH SERVICE / DEPARTMENT________________________

GRCE Points 6 for package + 2 point for competency assessment TOTAL 8 POINTS


CONTENTS

Contents

Page No.

Acknowledgements/Copyright/Disclaimer/Navigation Tools

3

Introduction & Learning Outcomes

4

Resource Documents

5

eviQ Education

6

Glossary

7

Module One: Characteristics of Central Venous Access Devices (CVAD)

10

Module Two: Key Principles of Care

13

Module Three: Peripherally Inserted Central Catheter (PICC)

23

Module Four: Implantable Venous Ports (IVP)

32

Module Five: Tunnelled Catheter

43

Module Six: Potential Complications of CVADS & Management

48

Reference List

54

Written Assessment

56

Clinical Competency Tool: PICC

63

Clinical Competency Tool: IVP

64


ACKNOWLEDGEMENTS This package was reviewed by the Gippsland Chemotherapy Nurse Unit Managers Group in May 2013, Gippsland Regional Education Group with special input from GRICS. Reviewing team 2014 Linda Fiddelaers, Prue Berry, Helen Reid & Robyn Godbold. Reviewed 2021 by Cassandra Moore: Nurse Practitioner & Clinical Nurse Educator Chemotherapy Day Unit LRH

COPYRIGHT Wherever possible permission has been obtained for reproduction of materials and images and the compilers acknowledge the rights of the copyright holder in all reproduced materials which are referenced on the page or in the reference notes. Product photographs are provided with the permission of the relevant company. Similar products may be available from other companies and the use of product photographs or images within this learning package does not indicate an endorsement of one particular product over another. DISCLAIMER The information in this learning package is intended to be a guide only and Health Care Professionals should be aware of the policies and procedures of their employing organisation to guide their practice. This learning package consists of current best practice at the time of publication, however it should be noted that changes in the medical and nursing field can occur quite rapidly therefore it is up to the individual to ensure they are accessing current information. NAVIGATION TOOLS

Critical areas of practice & key points

* Refers to definitions included in glossary

# Refers to eviQ Cancer Treatments Online


New Terminology: Types of CVADs

New CVAD terminology is emerging in order to standardize CVAD names and terminology globally. eviQ in their latest updates are utilizing the new terminology and have provided this table. The new terminology will be incorporated into this SDLP when the package is next reviewed. In the interim this table has been provided so that learners can familiarize themselves with the new terminology.

NSW Government 2021


INTRODUCTION:

This is a learning package only and clinicians should refer to their own organizational policy and procedures to direct their practice. The package has been divided into six modules. MODULE 1: Characteristics of Central Venous Access Devices (CVAD) MODULE 2: Key Principles of Care MODULE 3: Peripherally Inserted Central Catheters (PICC) MODULE 4: Implanted Venous Port (IVP) MODULE 5: Tunnelled Central Venous Device MODULE 6: Complications of CVAD’s and Management

• Learning outcomes have been identified and apply to all modules contained within the package.

• There is a set of questions at the end of the package. Please complete the questions and return these to your Clinical Nurse Educator.

• Task trainers (Peter PICC & Chester Chest) are available in most Gippsland Hospitals. Speak with your Educators about accessing these to practice the skills learnt in this package (or find out about the CVAD programs at your hospital)

• On completion of the SDLP you will be required to undertake a competency based assessment with a Clinical Educator at your workplace. You will be expected to demonstrate competence only in the clinical skills that apply to your nursing role. For example, a ward nurse may only need to attain competence in accessing and dressing a PICC line however a chemotherapy nurse may need to demonstrate competency in accessing implantable ports and tunnelled central venous devices.

AIM: On completion of this learning package and successful sign-off of competency, you should possess the necessary prerequisite knowledge and skills to manage CVADs safely according to any organisational policies, procedures or clinical guidelines. LEARNING OUTCOMES: Post completion of this learning package you will be able to:

• Differentiate between the different types of CVADs and their clinical indications.

• Describe the principles of care for all CVADs.

• Have a good understanding of the infection prevention and control principles in relation to caring for a patient with a CVAD.

• Identify the potential complications related to the use of CVADs and provide strategies for prevention and management, including escalation of care.

• Be able to source guidelines on eviQ website to support your practice in relation to CVADS

• Be conversant with and confidently source local hospital policy & procedures on the management of a patient with a CVAD


RESOURCE DOCUMENTS:

This package is to be used in conjunction with:

• ‘eviQ Cancer Treatments Online’ @ http://www.eviq.org.au. This website will provide you with clinical information on Cancer Treatments and Protocols on Central Venous Access Devices (CVAD).

• To access information on CVAD click on ‘Clinical Resources’ followed by ‘Central Venous Access Devices (CVAD)’ link. You do not need to register with this website to access these resources.

http://www.eviq.org.au/


• ‘eviQ Education’ can also be accessed @ https://education.eviq.org.au/. You can access a wide variety of Cancer related courses, including courses on CVAD care and management. You must register with ‘eviQ Education’ by following the prompts.

To access the CVAD courses click on ‘Course Library’, then ‘Clinical and Community Setting’, followed by the ‘CVAD course’.

These sites are to be used as a learning resource only. Refer to your local policy and procedure guidelines to direct your clinical practice

https://education.eviq.org.au/


GLOSSARY: Aseptic non-touch technique (ANTT): A technique used to prevent contamination of key parts and key sites by microorganisms that could cause infection. Asepsis is ensured by identifying and protecting key parts/sites by hand hygiene, non-touch technique, sterile equipment or cleaning existing key parts to an aseptic standard. Aseptic technique – Standard: Requires a main general aseptic field and non-sterile gloves employing micro aseptic fields and non-touch technique to protect key parts and key sites. Aseptic technique – Surgical: Requires a main critical aseptic field and sterile gloves and often full barrier precautions. Where practical critical micro aseptic fields and non-touch technique should be utilised. Closed system: When the central venous line is being accessed via the needleless connection cap (bung) or an access port of the IV giving set and the dressing is intact. Critical aseptic field: Used when key parts (usually due to their size and number) cannot easily be protected at all times with covers and caps or handled at all times with non- touch technique. It provides a large aseptic field to which only sterile materials can be placed. Critical micro aseptic field: Involves covering or protecting key parts with sheaths, covers or packaging to protect key parts. (So that they remain sterile) Escalation Protocol: The protocol that sets out the organisational response required for different levels of abnormal physiological measurements or other observed deterioration. Extravasation: Accidental administration of vesicant solutions or medications into tissues surrounding the catheter. Flashback: The appearance of a small amount of blood in the neck of a syringe or the IV administration set. Heparin lock: Heparin solution used to lock the CVAD when not in use to prevent occlusions by preventing blood flow back into the catheter, and reduces blood clotting risk if blood backflow occurs. Hub of the catheter refers to the threaded plastic connection on the external, proximal end of the catheter to which syringes needleless injection cap (bung) and fluid administration lines can be attached. Infiltration: In advertent administration of non-vesicant solutions or medications into tissues surrounding the catheter. Locking: Specific technique to instill fluid into a CVAD that prevents catheter occlusions by preventing backflow into the catheter when the CVAD device is not in use.


Needleless injection cap (bung): A Removable device that is attached to the catheter hub to maintain a closed system. The needleless connector can be a negative, neutral or a positive displacement valve. Negative needleless injection cap (bung): A Device that may be attached to the catheter hub, maintaining a closed system. Connectors with negative displacement allow blood to be pulled back, or to reflux, into the catheter lumen during connection, disconnection or when the administration set is attached. Neutral needleless injection cap (bung): A device that may be attached to the catheter hub, maintaining a closed system. Neutral fluid displacement prevents blood from moving into the catheter lumen upon connection or disconnection (Hadaway, 2012, pp33) Non coring needle: Needle designed in such a way that it does not take a core of the material as it is inserted. One-way block: Able to infuse normal saline but unable to aspirate blood. Two-way block: Unable to infuse normal saline or aspirate blood. Causes may include a kinked catheter, catheter migration, fibrin sheath or a drug precipitate as a result of incompatible drug infusion. Open System: Where the integrity of the system is exposed and there is risk of contamination e.g.: changing of dressing / needleless connection cap (bung). Pinch off syndrome: Compression of the catheter by the clavicle and the first rib. PICC line catheter migration: The movement of the PICC line catheter which leads to a loss or gain of catheter length. Migration can lead to further complications. Positive needleless injection cap (bung): A device that may be attached to the catheter hub, maintaining a closed system. On disconnecting the syringe on completion of the flush, a small amount of flush fluid contained within the device, is forced forward, through the catheter to the tip (positive displacement). This assists in preventing clot formation within the catheter. Positive pressure lock technique: Maintaining pressure on the syringe plunger whilst clamping the CVAD line and before removing the syringe from the needleless injection cap– prevents blood flow back into the catheter and subsequent thrombus formation and catheter occlusion. Pulsatile Flush: When flushing a CVAD a turbulent flow is caused by using a “push-pause” technique, pressing the syringe plunger with a push/pause or stop/start motion. Rapid Response System: The protocol set out by organisation in order to obtain emergency assistance in response to severe deterioration it is included as part of escalation protocol. (MET call or Code Blue) Securement Device: Is an anchoring device for a PICC. The securement device anchors the distal end of the PICC to the skin adjacent to the insertion site to prevent migration of the catheter.


Stat lock: A Securement device used to secure a PICC line to the skin Tip: Of the catheter refers to the distal end of the catheter which resides in the SVC. Trendelenburg position: A supine position which the pelvis is higher than the head with the knees flexed. Valsalva manoeuvre: A manoeuvre elicited by bearing down for the purpose of decreasing venous blood return to the right side of the heart. Vesicant: A drug or solution which if extravasated is capable of causing tissue necrosis.


MODULE ONE: CHARACTERISTICS OF CENTRAL VENOUS ACCESS DEVICES OVERVIEW A Central Venous Access Device (CVAD) “is a small flexible plastic tube inserted into the large vein entering the heart (Superior Vena Cava) through which access to the bloodstream can be made. The insertion site maybe peripheral but the proximal end is always central”. (Cancer Nurses Society of Australia, 2007)

This diagram illustrates a PICC line. Note the tip inserted into the Superior Vena Cava (SVC) superior to the heart. (paediatricsurgerymd.org)

Placing the catheter tip in the SVC has distinct advantages over the use of a peripheral vein. These advantages include:

• The SVC being a large vessel with a wide diameter, allowing good blood flow around the catheter with rapid dilution of the infused agent.

• Unlike peripheral veins, the SVC does not contain valves; therefore, there is a reduction in turbulent blood flow with a lower incidence of the infused agent adhering to the vessel wall.

• Reduction in the risk of chemical phlebitis which allows for a greater range of fluids and medications to be safely administered.

An associated risk with a CVAD is that the tip of the catheter can migrate into the right atrium or it can withdraw from the SVC. Due to the associated risk with this occurring, CVADs that have moved in either direction should be considered as not safe for use until further direction from a Medical Officer. The use of an x-ray with contrast may be required. Most long-term devices are made from silicone or polyurethane.

• Silicone is a soft, biocompatible material. Catheters made from silicone provide benefits for the patient as the material reduces the adherence of fibrin to the catheter and offers increased biocompatibility. Due to the flexibility, special insertion technique is required, however once positioned these catheters are often more comfortable than other devices. (Cancer Nurses society of Australia, 2007)


• Polyurethane is a stronger, firmer material, which allows the walls of the CVAD to be thinner while still providing the same lumen diameter. This material does soften following insertion in response to body temperature and offers increased biocompatibility and less adherence of fibrin, when compared to other materials. (Cancer Nurses Society of Australia, 2007).

TYPES OF CENTRAL VENOUS ACCESS DEVICES CVAD’s can be classified as either:

• Internal devices (Implanted Venous Port (IVP)).

• External devices (tunnelled and non-tunnelled). Internal Devices Implantable Venous Port

• Access is gained via intact skin directly into the center-point of the device: the self-sealing septum. The IVP is connected to a catheter which feeds directly into the central venous system.

• IVP’s can remain insitu long term.

• IVP’s are surgically implanted. (Cancer Institute NSW 2019). External Devices Tunnelled

• Section of catheter positioned in subcutaneous tunnel between skin entry site and vein e.g. Hickman’s.

• Surgically implanted device. (Cancer Institute NSW 2019) Non Tunnelled

• Skin entry site is directly above the vein.

• May be peripherally inserted i.e. PICC.

• Centrally inserted i.e. via jugular, subclavian or femoral CVC (not discussed in this package).

(Cancer Institute NSW 2019). There are two main types of CVAD catheters: Valved & Non valved This refers to the proximal end of the catheter (tip sitting in SVC):

• Non valved (open ended).

• Valved (closed ended) when not in use the valve remains in a closed position preventing reflux of blood into catheter.

(Cancer Institute NSW, 2019). The device may also be power injectable or non-power injectable. Power injectable CVADS are designed to tolerate pressures required for injection of contrast media during radiological procedures such as CT. They should be easily identifiable as power injectable.

https://radiopaedia.org/cases/chest-port-on-chest-x-ray


CHOICE OF VENOUS ACCESS DEVICE The choice of a central venous access device (CVAD) should be made based on the following:

• A patient's diagnosis.

• Length and type of therapy.

• Patient preference.

• Clinical status.

• Availability and quality of patient veins.

• Operator experience.

• Previous CVAD history. (Cancer Institute NSW, 2019). DURATION OF INSERTION

• Central Venous Catheter (“CVC”) – in situ short term only.

• Peripherally Inserted Central Venous Catheter (“PICC”) – in situ up to 1 year or more. Utilized for intermediate and long term therapies.

• Implanted venous port (e.g. “Porta Cath”) – up to 5 years’ dependent on the number of accesses to the silicone reservoir. For long term therapy.

• Tunnelled central venous catheter (e.g. “Hickman”) - in situ 2 years plus. For long term therapy.

(CSNA, 2007) A CVAD may be indicated for any of the following reasons:

• If venous access is unavailable, poor or difficult to obtain. • Where multiple or continuous infusions are required i.e. IVT or multiple IV antibiotics. • Continuous infusions of chemotherapy from an ambulatory device. • To avoid the risk of localized permanent tissue damage caused by extravasation from

the administration of vesicant chemotherapy agents. • Treatment requiring peripheral stem cell rescue / transplant. • Continuous fluid volume monitoring +/- high volume flow infusion requirements. • Central Venous Pressure monitoring. • Total Parenteral Nutrition (TPN).

(CSNA, 2007).


MODULE TWO:

KEY PRINCIPLES OF CARECancer Society of Australia

The underpinning management of a CVAD is reliant upon the clinician taking a holistic assessment of firstly the patient and secondly the CVAD that is indwelling.

• Patient comfort, safety and assessment.

• Patient and carers knowledge of device.

• Adherence to the key principles of care.

• Early recognition of complications & appropriate escalation and management if they occur.

(CNSA, 2007). CONFIRMATION OF PLACEMENT

• The anatomical position of the catheter tip must be verified immediately after insertion by chest x-ray (and again if catheter *tip migration is suspected) (Cancer Institute NSW, 2019).

• Verification of the insertion and correct placement of the CVAD must be documented in the patient notes, and not be based on verbal confirmation alone.

• Once documented confirmation of correct CVAD placement has been achieved and catheter patency checked, administration of required infusions/medications via the device can be commenced. (Cancer Institute NSW, 2019).

CATHETER PATENCY

Prior to infusion of any solution, the integrity of the lumen should be determined by obtaining a blood return *flashback. This confirms that the CVAD is in the venous system. (Cancer Institute NSW, 2019). You should also be able to freely infuse a flush of N/Saline 0.9%.


# Refer to eviQ Clinical Procedures http://www.eviq.org.au or more specifically:

https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads

SYRINGE SIZE

The minimum size of a syringe used to access or flush a CVAD is 10 mls. Smaller sized syringes can generate pressure in the line higher than 40PSI, resulting in damage or rupture the catheter. Rupture of the catheter can lead to many complications.

(Cancer Institute NSW, 2019). FLUSHING

Flushing of CVADs with 10-30mls of 0.9% sterile sodium chloride solution using

a *pulsatile flush technique is recommended: This technique creates turbulence in the

CVAD removing residue from the interior lining of CVAD, reducing the risk of occlusion. A pulsatile flush must be administered:

• Before and after administration of medication, blood and blood products and intermittent IV therapy.

• After obtaining blood specimen/s. • When converting from intermittent therapy. • For device maintenance when not in use.

(Cancer Institute NSW, 2019).



Never use excessive force when attempting to flush a CVAD (Cancer Institute NSW, 2019). Use the following resource document as a guide:

# Refer to eviQ Resource Document http://www.eviq.org.au or more specifically

https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads Clinical Procedure Central Venous Device Accessing & Central Venous Access Device

CLAMPING REQIREMENTS Will be influenced by:

• Type of *needleless connection caps/valve (bung) i.e. positive or neutral in place.

• Whether the CVAD catheter *tip is close ended (valved) or open ended (non-valved).

Follow the product recommendations and your local hospital clinical guideline.

CVADs with clamps should NEVER have the clamp removed!!!!




HAND HYGIENE Hand hygiene: the washing and/or use of alcohol-based rubs by healthcare workers to clean their hands. It should be performed according to the World Health Organisation’s (WHO) ‘Five Moments for Hand Hygiene' (WHO 2018).

The 5 moments of hand hygiene should be applied to all CVAD manipulations and procedures to avoid bloodstream infections (BSI’s). (Hand Hygiene Australia, 2020).

(Hand Hygiene Australia, 2014)


ASEPTIC TECHNIQUE Aseptic technique aims to prevent the introduction of pathogenic organisms causing infection to susceptible sites by hands, surfaces and equipment. Aseptic technique is ensured by identifying and then protecting key parts and key sites from contamination, by using sterile equipment, aseptic non-touch technique, the use of aseptic fields and either a standard or surgical aseptic technique (NHMRC, 2019). Aseptic non-touch technique (ANTT) Infection control principles that apply to aseptic technique involve:

• Key parts and key sites identification and protection.

• Aseptic key parts must only come into contact with other key parts and or key sites.

• Hand hygiene.

• Glove use.

• Aseptic fields.

• Sterile equipment

Aseptic fields Aseptic fields are important in providing a controlled aseptic working space to help maintain integrity of the asepsis during clinical procedures.

• *Critical aseptic fields are used when key parts (usually due to their size and number) cannot easily be protected at all times with covers and caps or handled at all times with non- touch technique (i.e. performing PICC dressing, accessing a IVP)

• *Critical micro aseptic fields involve covering or protecting key parts with sheaths, covers or packaging to protect key parts.

(NHMRC, 2019). Aseptic technique is divided into: Standard Aseptic Technique

• Typically, short duration.

• Technically simple.

• Involves few small key parts.

• Use of critical micro aseptic fields and non-touch technique is used where practical to do so.

(NHRMC, 2019) A *standard aseptic technique is used when accessing a *closed system’ for:

• Administration of medications and fluids.

• Blood sampling.

• Changing of an IV line.


Surgical Aseptic Technique

• Technically complex procedures.

• Involve extended periods of time.

• Large open key sites or large number of key parts exposed at once.

• Requires main critical aseptic field and sterile gloves and full barrier precautions (the latter again dependant on the amount of exposed key parts).

(NHMRC, 2019). A *surgical aseptic technique is used when accessing an *‘open system’ e.g.

• PICC dressing.

• Changing of *needleless injection caps (bung).

• Accessing an IVP.

• Insertion of any CVAD (the latter requiring full barrier precautions; i.e. hat, mask, gown, gloves).

ACCESSING & DEACCESSING A CVAD

• Use the appropriate *aseptic non-touch technique depending on whether it is a *closed system or *open system when accessing a CVAD (NHMRC, 2019).

• Create the appropriate aseptic field for the task you are undertaking (NHMRC, 2019).

Refer to your local Hospital guidelines to guide your practice & ensure you have the appropriate knowledge & skills required to undertake these procedures. You can practice this skill on a task trainer, or see your local Clinical Educator to find out about CVAD competency within your organisation. More information on this will be provided in Module 3, 4 & 5 of this SDLP.

# Refer to eviQ Clinical Procedures http://www.eviq.org.au or more specifically

https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads for information on accessing & de-accessing PICC, IVP & Tunnelled Catheter

CHANGING AN ADMINISTRATION SET

• A *standard aseptic technique is required when the system is *closed (NHMRC, 2019).

• Change continuous IV infusion lines and intermittent lines as per local hospital guidelines.

• Administration sets used for infusion of blood, blood products or lipid emulsions should be changed on completion of infusion or at least every 24 hours (NHMRC, 2019). Check your local hospital guidelines

• Once an IV line has been disconnected, it should not be reconnected (NHMRC, 2019).




BLOOD SAMPLING This is done utilizing *standard aseptic technique utilising a *critical micro aseptic field (Cancer Institute NSW, 2019).


https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads for information on:

• Implanted Venous Port Blood Sampling

• Central Venous Catheter Blood Sampling.

FLUSHING & LOCKING CVADS WHEN NOT IN USE This is done to maintain patency of the CVAD. Flushing Sodium Chloride 0.9% is used for flushing CVADS. This is performed at regular intervals when the CVAD is not in use.

• Please refer to your local guideline for flushing intervals (frequency) for lines not in use

After flushing the CVAD is locked as described below: Locking The CVAD is locked when not in use to prevent back flow into the catheter (Cancer Institute NSW, 2019). N/Saline 0.9% & Heparinised Saline are the 2 types of locking solutions. Some CVADS may require heparin locking when not in use. Refer to local Policy and Procedure & manufacturers instruction for guidance on this. Prior to locking you need to know the following

• Type of CVAD being used: whether the* tip is open ended (non-valved) or closed ended (valved)

• Type of needleless cap (bung) being used: e.g. positive pressure cap/bung

• Locking solution & concentration

• Locking technique: e.g. positive pressure locking technique Heparin should be used only when recommended by the product manufacturer and in the lowest concentration and volume possible i.e. 50 units Heparin in 5mls normal saline (Cancer Institute NSW, 2014).


https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads Clinical Procedure Central Venous Catheter Deaccessing & Central Venous Access Device






NEEDLELESS INJECTION CAPS (BUNGS) Below are examples only (check what is used at your hospital)

Photo Courtesy of GSHS chemotherapy

*Needleless injection caps (bungs) are devices that:

• Allow a CVAD to remain *closed system.

• Allow for needleless access to the CVAD therefore reducing the risk of needle stick injuries among health care workers (Hadaway, 2013).

• Luer lock design.

*Needleless injection caps (bungs) can be further classified by how the fluid is displaced within the catheter when they are applied to the proximal end of the CVAD:

• *Negative

• *Neutral

• *Positive It is important for you to know what type of *needleless injection caps (bungs) are available and how they are used with regard to flushing & locking. General Care

Prior to accessing a CVAD through a *needleless injection caps (bungs) the bung must be cleaned with a 70% alcohol swab or 2% chlorhexidine gluconate & 70% isopropyl (check local hospital policy) using vigorous friction using Aseptic Non Touch Technique (ANTT). Allow to dry. (Cancer Institute NSW, 2019). If allergy to above utilise an alternative such as an alcohol based betadine solution.

• The integrity of the*needleless injection cap (bung) should be confirmed before and after each use.

• Access using *standard aseptic non-touch technique (ANTT).

• Must only be accessed with sterile key parts.

• *Needleless injection caps (bung) should be changed at least every week or earlier if compromised by presence of blood or lack of integrity.


• Any time a *needleless connection cap (bung) is removed from the catheter, it should be discarded, and a new one attached, utilising *surgical aseptic technique.

• All CVADS should have a neutral or positive *needleless injection cap (bung) attached.

PATIENT ASSESSMENT Patient assessment must be carried out

• Prior to insertion of a CVAD

• During their care whilst they are in a health care facility

• Prior to discharge and during home care. Ongoing patient assessment must be carried out within the context of their presenting complaint, co-morbidities and general wellbeing, the indwelling CVAD is part of the overall picture. Patient assessment should include

• Clinical

• Physical

• Psychosocial assessments Thorough and regular patient assessment allows for the early detection of potential complications associated with the CVAD.

• General assessment of patient’s condition including routine observations, level of comfort and pain and general wellbeing of the patient.

• Daily assessment of CVAD & insertion site and prior to administration of medications & fluids:

o Site appearance – erythema, ooze, tenderness, swelling. o Dressing & line integrity.

• Escalate care according to local escalation protocol in response to abnormal findings.

PATIENT EDUCATION

Patient and carer education should be tailored to the individual and delivered using appropriate terminology and in an environment which will enhance the learning. It should be culturally and linguistically appropriate utilising a range of modalities.

Patient, carer and or family education should cover the following:

• CVAD insertion and potential complications.

• How to care for their catheter.

• How to check each day for signs of infection. o observing for signs of infection e.g. pain, redness, swelling, discharge or

leakage of fluid. o to palpate the exit site on top of the dressing for any tenderness (this may

also indicate extravasation; do not proceed to use in either case).

• What to do in the event that the catheter ruptures or begins to leak

• Details of appropriate and readily accessible 24-hour medical and nursing contact to which patients can direct queries.

• Details of follow up care and appointments


Patients should be supplied with any printed information currently available regarding the care of their CVAD and must be given the opportunity to ask questions. Patient information sheets are available on eviQ specific to the type of CVAD the patient has and in multiple languages. This should be printed off and given to the patient for future reference. Also check your local hospital documents for patient handout information.

# Refer to eviQ Patient Information http://www.eviq.org.au or more specifically

Patient information sheets | eviQ for patient education resources.

DOCUMENTATION Documentation is essential after each treatment or shift, as per the individual organization’s policy and should include:

• Patient assessment details both initial and ongoing.

• Consent process

• Initial documentation of insertion including X-ray confirmation of placement.

• Type of CVAD & relevant details (i.e. number of lumens) & product serial number

• Confirmation of blood return on accessing.

• All treatment administered including any medications, flushes, IV fluids and locking solutions.

• Type of *needleless connection cap (bung) being used.

• Relevant information associated with a dressing change e.g.: state of insertion site and surrounding skin, external length of catheter.

• Signs and symptoms of infection or thrombosis.

• Any trouble shooting treatment required.

• Due date of dressing and IV tubing changes if relevant.

• Ongoing treatment, referrals provided and appointments

• Education provided and emergency contact details provided to patient


https://www.eviq.org.au/patients-and-carers/patient-information-sheets


MODULE 3:

PERIPHERALLY INSERTED CENTRAL CATHETERS (PICC) A Peripherally Inserted Central Catheter (PICC) is a CVAD that is inserted into the basilic or cephalic vein (peripherally) with the tip located in the SVC. PICCs may be single or multi lumen and can be indwelling for up to 12 months or longer. (Cancer Institute of NSW 2019). INDICATIONS

• Intermediate or long term therapies– i.e. drugs, infusions or chemotherapy.

• Continuous infusions.

• Poor venous access.

• Administration of drugs or fluids that may be irritable or damaging to peripheral veins.

• Administration of total parenteral nutrition (TPN). (CSNA, 2007).

There are three main types of PICCs Valved, Non Valved & Power Valved or non-valved refers to the proximal end of the catheter (tip sitting in SVC).

• Non valved (open ended).

• Valved (closed ended) when not in use the valve remains in a closed position preventing reflux of blood into catheter.

Power PICC: Power injectable tolerate pressures required for injection of contrast media during radiological procedures such as CT (Cancer Institute NSW, 2019).


https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads for Central Venous Access Device

ADVANTAGES

• A PICC is usually radiologically inserted but also may be inserted at the bedside by a medical officer or by a registered nurse trained in the procedure.

• Suitable for continuous or intermittent therapies. • Suitable for home therapy. • Avoids repeated peripheral cannulation. • Blood sampling can occur from a PICC 4 French gauge or larger. • Suitable for delivery of medications that can cause venous irritation or peripheral

damage.




DISADVANTAGES

• Abnormal venous anatomy may prevent insertion of a PICC.

• High level requirements of care required- e.g. regular dressings and flushing.

• Not suitable for rapid IV infusions of large volumes.

• Altered body image.

• Lifestyle considerations e.g. level of activity, water activities

• Use of semi-permeable dressings do not allow for water submersion of PICC.

ADDITIONAL KEY PRINCIPLES OF CARE FOR A PICC


https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads Central Venous Access Device & Clinical Procedures Central Venous Catheter: Accessing, Blood Sampling and Deaccessing

Post Insertion Management

• Post insertion there is a higher likelihood to bleed from the insertion site due to trauma to the vein.

• Restrict arm movement for the first two hours.

• Apply a pressure bandage directly over the occlusive dressing and avoid redressing the insertion site frequently in the first 24 hours.

• A dressing change is usually required 24 hours post insertion.

• A PICC dressing *needleless connection cap (bung) change is required every seven days thereafter, unless obvious signs of bleeding or poor dressing adherence is observed.

• Avoid taking blood pressures on the arm with a PICC insitu. (Cancer Institute NSW, 2019). Confirmation of Placement

• Checking of documentation for medical confirmation of correct PICC placement confirmed by x-ray report.

• Ensuring documentation of correct placement in patient’s notes.

Catheter Patency

• Aspiration of blood from PICC line *flashback. • Free flow of flushing or infusing solutions. • Measurement of PICC length from insertion site to catheter hub shows consistency

with the length at the time of insertion, as per documentation (see diagram next page) (Cancer Institute NSW, 2019).




Initial Documentation after Insertion

• Ensure PICC Worksheet is completed on insertion & document in patient progress notes.

• Brand of PICC, product number, lot number should be documented by inserter.

• Size of PICC, number of lumens.

• Anatomical location of PICC & x-ray confirmation

• Internal and external catheter length on insertion.

• If the catheter has been shortened prior to insertion e.g. tip cut off.

• Upper arm circumference.

• Type of *needleless connection cap (bung) used.

• Name of person who verified x-ray placement if possible.

• Name and signature of person inserting PICC.

• Medications and flushes administered.

• Any troubleshooting required.

• 24 hour post insertion dressing plan.

External Measurement

• Measure from insertion site of PICC to catheter *hub as displayed in diagram.

• Measure and record the exposed catheter length at each dressing change to ensure migration has not occurred.

If movement of the PICC in either direction is greater than 2 cm the correct placement may be compromised, escalate care prior to use. An x-ray may be required. (Cancer Institute NSW, 2019). Clamping requirements

Is dependent on the type of PICC used. PICC’s with a positive pressure bung are not usually clamped.


https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads f

CLAMPS must be left on the catheter! These have been placed on the device by the manufacturer to ensure safety in the event of accidental disconnection of the positive or neutral displacement valve. These are also required to be on for use during valve/bung replacement.




Dressing post insertion

Dressing types include;

• Transparent semi-permeable polyurethane dressing.

• Gauze dressings. A dressing change is usually required 24 hours post insertion as there may be some initial ooze but may be dependent on the type of PICC line inserted alongside other factors. Dressing requirements (see page 29 for example of PICC dressing). Transparent semi-permeable membrane (TSM) dressings are generally used. These dressings should be changed using a *surgical aseptic technique every seven days or earlier if integrity of dressing is compromised. (Cancer Institute NSW, 2019) *The needleless connection cap (bung) should be changed each time the dressing is attended. If a clamp is present on the PICC line, clamp the PICC line prior to changing the bung. Semi-permeable dressings allow moisture evaporation whilst acting as barrier to extrinsic liquid and micro-organisms (Camp-Sorrell, 2004). Not all transparent dressings are suitable, since they may not be semi-permeable. Sterile gauze dressings are sometimes used immediately following catheter insertion when the site might be bloody or oozing or in the cases of patients who are allergic to particular dressing adhesives or are diaphoretic. Gauze dressings do not provide an occlusive barrier but do have absorbing action (Camp-Sorrell, 2004). Gauze dressings should be changed every 48 hours using a *surgical aseptic technique (Cancer Institute NSW, 2014). A disadvantage of this type of dressing is that the insertion site is unable to be clearly assessed for infection. Securement Device *Stat lock: Is used as a securement device to secure PICC line to the skin (see picture page 29). This should also be changed as per dressing requirements above.

# Refer to eviQ Clinical Procedure http://www.eviq.org.au or more specifically

https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads for information on Clinical Procedure Central Venous Device Dressing and Needleless Injection Cap Change.




Accessing & de-accessing a PICC

Prior to every access of a CVAD through a *needleless injection caps (bung)

• Bung must be cleaned with a 70 % alcohol swab or 2% chlorhexidine gluconate & 70% isopropyl using vigorous friction. (Povidone-iodine solution 10% can be used if the patient has allergies to chlorhexidine).

• Allow to dry. (Cancer Institute NSW, 2019).

• Aspirate to ensure *flashback

• Flush10-30mls of 0.9% sterile sodium chloride solution using a *pulsatile flush

technique (Cancer Institute NSW, 2019).


https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads for information on Accessing Peripherally Inserted Central Catheter (PICC) & Peripherally Inserted Central Catheter (PICC) De-accessing

• Use the appropriate *aseptic non-touch technique for accessing a *closed system (NHMRC, 2019).

• Utilise a *Critical micro aseptic field when accessing the *Needleless connection cap (bung) (NHMRC, 2019).

Refer to your local Hospital guidelines to guide your practice & ensure you have the appropriate knowledge & skills required to undertake these procedures. Seek supervision as required. Taking Blood from a PICC

• Do not attempt to take blood from a PICC line 4fr or smaller.

• Ensure Hand Hygiene and Aseptic technique

• Clean catheter hub or bung with reccomended solution and allow to dry

• Aspirate to determine blood return & discard aspirate (normally 3-10mls depending on size of patient)

• Collect blood samples according to order of draw

• Flush the line according to protocol

• If blood cultures required do not disgard initial aspirate and use this for the blood cultures



https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads for information on Peripherally Inserted Venous Catheter (PICC) Blood Sampling.

Photo courtesy LRH Chemotherapy Unit






Patient Assessment

• General assessment of patient’s condition including routine observations, level of comfort and pain, general wellbeing and psychosocial of the patient.

• Daily assessment of; o Site appearance – erythema, ooze, tenderness, pain, warmth or swelling. o Dressing & line integrity. o Length of catheter & measurement.

• Escalation of care according to local guideline in response to abnormal findings.

Ongoing Documentation

Clear consistent documentation is essential after each PICC access or if not in use, at least once per shift, if inpatient. If in community care with each visit or intervention. This should include:

• External length of PICC from insertion site to catheter hub in relation to initial insertion measurements.

• Ability to confirm placement via blood return.

• *Needleless injection cap (bung) change and type used.


• When dressing was attended and is next due.

• Signs and symptoms of infection or thrombosis (if present on assessment).


• Any patient education provided Patient Education See Module One for general principles. Print copy of document for patient/carer and discuss key points. Check your local hospital guidelines for your own version of patient information handouts.


https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads for information on Peripherally Inserted Central Venous Catheter (PICC line).




PICC LINE, DRESSING STATLOCK, NEEDLELES CONNECTION CAP/BUNG & MEASUREMENT

Photo courtesy of LRH chemotherapy unit xx .

Stat lock To be changed weekly. PICC securing device, to be situated approx. 1.5cm from insertion site.

Insertion Site Must be covered at all times with a transparent dressing. Observations of the insertion site must be documented each shift and escalation of care in response to any abnormalities.

Needleless injection cap/bung. To be changed weekly If PICC in regular use, end of bung may be left exposed for easy access but dressing applied in order to keep valve secured and waterproof.

Measurement Measure and document at each dressing change from this point (the hub) to the insertion site.

Dressing To be changed weekly A large transparent dressing must be used to cover a large area around the insertion site, in order for it to be observed for infection. Dressing type according to hospital guideline.


Removal of PICC

• Verify order for PICC removal and ensure consent

• Ensure that the patient’s coagulation profile is within normal limits. Escalate care if required

• Ensure Hand Hygiene and Aseptic Technique *Standard ANTT technique required.

• Should be removed only by a practitioner deemed competent in the management of PICCs.

• It is recommended that the patient should be positioned supine with head slightly down if tolerated and the *Valsalva manoeuvre be used to prevent an air embolus.

• Do not apply undue force as this may fracture the catheter. If catheter breaks or unable to remove refer to local guideline and esclate care

• Remove the PICC slowly to minimise venospasm.

• Apply pressure to the exit site until haemostasis has been achieved.

• Apply occlusive dressing to the site.

• Measure and examine the PICC to ensure it is intact.

• Collect catheter tip for culture if ordered.

• Escalate care if required (Cancer Institute NSW, 2019).

# Refer to eviQ

https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads Clinical Procedures: Peripherally Inserted Venous Catheter (PICC) Removal

COMPLICATIONS SPECIFIC TO A PICC LINE

Migration of PICC

If PICC migrates more than 2 cm in or out, it may no longer in the correct position as the *tip may have moved out of the central circulation.

• Consult with Medical Officer. • Do not use PICC until correct placement is confirmed by X-Ray.

(Cancer Institute NSW, 2014). Mechanical Phlebitis Is a common problem that develops within about 1 week of insertion of the PICC, where movement of a foreign body within the vein causes inflammation. The symptoms include:

• redness

• swelling

• pain

• heat and venous cording When symptoms of mechanical phlebitis are present, it is important to rule out other causes such as thrombosis or infection.

• Treat mechanical phlebitis with the use of intermittent, warm compresses to the red tender area of the upper arm and elevate the limb.



If the phlebitis does not settle within two days or if the patient develops fever or a purulent drainage or the site appears worse after two days of treatment, consider infection and escalate care (Cancer Institute NSW, 2019).


MODULE 4: IMPLANTABLE VENOUS PORTS (IVP) An IVP allows for long term intermittent central venous access. IVP’s have a fully implantable reservoir with a self-sealing silicone septum. IVP’s can be either surgically inserted, or inserted by a trained radiologist. IVP’s sit under the skin within the subcutaneous tissue of the chest wall. Their catheter extends from the reservoir, residing its tip in the SVC (Cancer Institute NSW, 2019).

http://www.portadvantage.com/patient/about_implanted_ports.html

http://newcastleradiology.com/wp-content/uploads/2013/03/port-access.jpg

http://www.portadvantage.com/patient/about_implanted_ports.html

http://newcastleradiology.com/wp-content/uploads/2013/03/port-access.jpg


INDICATIONS

• Poor venous access. • Infusion of vesicant medications. • Intermediate and long term therapies.

(Cancer Institute NSW, 2019). ADVANTAGES • Minimal interference with body image. • Low incidence of infection. • Low maintenance when not in use - flush with heparin every 4 weeks (Cancer Institute NSW, 2019). DISADVANTAGES

• Pain when accessing (may use local anaesthetic patches or creams). • Cost – more expensive than other types of CVADs. • Insertion and removal of IVP is an invasive surgical procedure. • May require a general anaesthetic or sedation. IVP ACCESS NEEDLES

Only use a *non-coring needle to access an IVP such as a Huber needle or a Gripper needle to prevent coring of the silicone septum which can be caused by using a standard hypodermic needle

• The choice of needle length is determined by surgical placement of an IVP and patient dimensions. An IVP that is deep in the subcutaneous tissue will require a longer access needle than one that is easily palpated. The needle length may change according to patient weight loss / gain, or the position of the IVP.

• A *non-coring needle attached to a syringe /or line must be primed with normal saline prior to accessing the IVP

(Cancer Institute NSW, 2014). The self-sealing septum of the IVP:

• Allows access needle to enter which then stabilizes the needle whilst infusion is in progress.

• Reseals once access needle is removed.

• Is designed for 1000-2000 punctures with a non-coring needle over time. (Cancer Nurses Society of Australia, 2007).


Huber Needles

Gripper Needles

Photo courtesy GSHS Chemotherapy Unit

http://www.isips.org/products/graphics/GRIPPER_PLUS_1.jpg Cited 17/04/2013


http://www.isips.org/products/graphics/GRIPPER_PLUS_1.jpg

http://www.isips.org/products/graphics/GRIPPER_PLUS_1.jpg


ADDITIONAL KEY PRINCIPLES OF CARE FOR IMPLANTED VENOUS PORT


https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads for Implanted Venous Port (IVP) information.


Care of the surgical wound until incision has healed.

• Surgical wound will require a dressing initially.

• Observation of surgical wound for signs of infection, bleeding & healing.

• Protect surgical wound as per Hospital protocols & post-operative surgical orders.

• It is recommended that you avoid accessing the port for one week after insertion to endure some healing time, however please follow your local policy.

Confirmation of placement

Initial written x-ray report is required to confirm correct placement of the IVP available in patient record. Catheter Patency Every time the IVP is accessed confirm:

• Feeling the non-coring needle hit the base of the metal-like IVP on access. • Aspiration of blood *flashback. • Ability to easily infuse solutions. • Normal appearance of IVP site.


• Brand of IVP, product number, lot number should be documented by the inserter.

• Size of IVP, number of lumens.

• Anatomical location of IVP.

• Type of *Needleless injection cap (bung) used when the IVP is accessed.

• Name of person who verified x-ray placement Name and signature of person inserting IVP.


• Any troubleshooting required. Needleless injection cap (bung) A *needleless injection cap (bung) should be attached when an IVP needle is:

• Left insitu for intermittent access i.e. 6 hourly antibiotics. • Disconnection from an IV line for a diagnostic procedure. • For continuous therapy for inpatients. • For short term intermittent therapy.

Refer to your local hospital guidelines regarding the type of *needleless injection cap (bung) & management of flushing & locking.





https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads for Implanted Venous Port (IVP) & Implanted Venous Port (IVP) Accessing & Locking, Deaccessing and Locking information.

Accessing an IVP (refer to eviQ & local guidelines for more details) IVP’s are accessed with a *non-coring needle using *surgical aseptic technique utilizing *critical aseptic field

• Ensure Hand Hygiene & Asepsis

• Prep skin using friction covering the whole area that will be under dressing using recommended prep solution, allow to dry

• Access the port using a non-coring needle with primed line and *needleless injection cap (bung) attached

Following access, the *non-coring needle must be fastened and secured with a dressing. Once *non-coring needle, dressing, access tubing & *needleless injection cap (bung) are in place this can now be accessed using a *standard aseptic technique as the system is now *closed. Escalate any issue encountered with access. Set up for accessing port: always use a surgical aseptic technique when accessing an IVP & a critical aseptic field.

Accessing a port using a gripper needle





Access using non-coring needle-IVP Access

Taking Blood from a IVP (refer to eviQ & local guidelines for more details)

• Access port if not already done

• Ensure Hand Hygiene and Asepsis

• Clean *needleless injection cap (bung) using vigorous friction and allow to dry

• Attach vacutainer or syringe & withdraw specimen, discard first draw

• Discard the first five 3-10mls of blood withdrawn before collecting sample

• Obtain further specimens according to order of draw • When taking blood cultures, do not discard the first draw sample. Retain

initial sample for blood culture. • Flush IVP with 10-30 mL of Normal Saline after blood sampling, continue with

treatment or lock as indicated • If unable to withdraw blood escalate care (Cancer Institute NSW, 2019).


https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads for information on Implanted Venous Port (IVP) Blood Sampling.

Photos courtesy LRH Chemotherapy Unit




De-accessing an IVP The IVP is flushed & *locked prior to removal of the non-coring needle and access tubing.

Routine flushing, *locking and/or *heparin locking is recommended for dormant ports with a flushing interval every four to six weeks (Cancer Institute NSW, 2019). Again this will be determined by whether the catheter tip is valved (close ended) or non-valved (open ended). For open ended catheters instil 5 to 10 mL of sodium chloride 0.9% or 5 mL of heparinised saline (as per institutional policy):

• If using a neutral *Needleless injection cap (bung) instil and clamp while instilling the last 0.5 mL

• If using a positive *Needleless injection cap (bung) do not clamp prior to removing the syringe


https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads For information on Implanted Venous Port (IVP) De-accessing and Locking

Patient Assessment


• Daily assessment of; o Site appearance – erythema, ooze, tenderness, warm & swelling. o Palpate IVP site for tenderness.

• If insitu access catheter & dressing should be observed for integrity.

• Ensure IV tubing is secured for ambulant patients to prevent accidental dislodgement of needle.

• Escalate care according to hospital escalation protocol


Clear consistent documentation is essential after each IVP access or if not in use, at least once per shift if an inpatient and on regular visits if in home care. This should include:

• Ability to confirm placement via blood return. This is essesntial.

• *Needleless injection cap (bung) change and type used if access line insitu.

• Medications and flushes/locking solutions administered.

• Signs and symptoms of infection or thrombosis (if present on assessment)

• Any troubleshooting required




Patient Education See Module One for general principles


https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads for information on Implanted Venous Port (IVP).

Print copy of document for patient/carer and discuss key points. Removal of IVP

Removal of an IVP is a surgical procedure.

COMPLICATIONS SPECIFIC TO AN IVP Skin erosion over the IVP site Causes

• IVP placed too close to epidermis.

• Trauma at port site.

• Poor nutritional intake.

• Extravasation at the site.

• Inadequate site care.

• Wrong size/type of needle used.

• IVP pocket infection (Welker, 2004).

Signs and symptoms

• Redness

• Tenderness

• Swelling

• Pain

• Open wound

Treatment

• Immediately notify Medical Officer of symptoms.

• Use alternate site for IV therapy.

• Apply sterile dressing to portal site to prevent infection.

• Catheter may require removal (CGHS, 2013).

Prevention

• Daily site assessment of the IVP site.

• Adherence to key principles of care as outlined.




Extravasation and Infiltration *Extravasation: Accidental administration of vesicant solutions or medications into tissues surrounding the catheter. *Infiltration is the inadvertent administration of non-vesicant solution or medication into surrounding tissues. Causes

• Needle dislodgment out or partially out of the septum.

• Inappropriate length of the non-coring needle on accessing of an IVP.

• Inappropriate placement of the non-coring needle when accessing an IVP.

• Internal catheter damage.

• Inappropriate management of the CVAD device.

• Development of a fibrin sheath at tip and along external segment of the catheter (Cancer Nurses Society of Australia, 2007).

Signs and symptoms

• Pain/burning on infusion at the insertion site, along the catheter tunnel which may develop erythema or oedema (may be pitting from interstitial fluid).

• If not obvious oedema, lay patient flat to assess as a dependant site may swell (CNSA, 2007).

• Absence of free flow when administered by infusion (in Oncology only i.e. vesicants).

• Aspiration difficulties.

• Resistance on bolus medications.

• Leakage at IVP needle.

• Necrosis may occur up to 2 weeks post extravasation (CNSA, 2007). Treatment for infiltration of a non-vesicant medication (swelling around IVP or any pain/burning during infusion).

• Stop infusion.

• Do not aspirate or flush.

• Leave non-coring needle insitu.

• Contact Medical Officer for further investigation (X-Ray or Porto gram).

• Further management will be based upon cause of infiltration, type of medication or fluid that has infiltrated and amount.

(CGHS, 2013) Treatment for extravasation of vesicant or irritant medications. Extravasation is an emergency. Escalate care/rapid response system according to Hospital Escalation Protocol.

# Refer to eviQ Extravasation http://www.eviq.org.au or more specifically

https://www.eviq.org.au/search?searchtext=extrav for useful information & assessment tools.


https://www.eviq.org.au/search?searchtext=extrav


SLAP is the acronym utilised by eviQ to manage extravasation

• Stop infusion

• Leave gripper in place

• Attempt to aspirate

• Plan further action

• Escalate care

• Consider a surgical review

• Contact Oncology immediately if available at your organisation.

• Refer to local hospital guideline regarding assessment, prevention & management of extravasation of cytotoxic agents which may include the use of a warm or cold compress (depending on the drug), or an antidote (DMSO 99% solution application or hyaluronidase). A spill kit should be always available within your unit. Refer to eviQ extravasation management for detailed guideline


Prevention

• Confirmation of placement (blood return and ability to flush) of CVAD prior to any infusion.

• If only able to flush and not aspirate, report to the medical team or In-charge nurse and do not use the IVP until cause determined.

• Only educated and trained staff should administer irritant and vesicant medications.

• Educate patient to immediately report any signs and symptoms of burning or pain during infusion.

• Observe for swelling, flushing or skin changes near the port during administration of any chemotherapeutic agent.

Needle Dislodgement Causes

• Accidental dislodgment by patient.

• Incorrect placement on insertion.

Signs and symptoms

• Inability to infuse or aspirate.

• Protruding gripper needle at IVP entry site. Treatment

• Stop infusion.

• Assess for any signs and symptoms of infiltration or extravasation (see extravasation and infiltration signs and symptoms above. If either present, follow instructions for treatment).

• If no signs and symptoms of infiltration or extravasation, de-access IVP


• Re-access IVP with new non-coring needle, confirm placement with blood return and ability to flush (see withdrawal occlusion if unable to aspirate blood and DO NOT proceed to administer treatment).

Prevention

• Ensure IV tubing is secured to patient to prevent direct pulling of the gripper needle.

• Frequent observation of the IVP gripper needle whilst accessed.

• Patient education regarding management when IVP is accessed and prompt reporting if suspected dislodgement occurs.


MODULE 5:

TUNNELLED CENTRAL VENOUS CATHETER The tunnelled CVAD catheter is tunnelled subcutaneously and exits the skin usually through the chest or abdominal wall. Within the tunnel there is a cuff to allow for the adherence of fibrous tissue which helps to prevent dislodgement and acts as a mechanical barrier to ascending bacteria into the circulatory system. Single, double and triple lumens of varying bore size are available. A Hickman Catheter is an example of a tunneled Central Venous Catheter. (Cancer Institute NSW, 2019) Tunnelled Catheter

INDICATIONS

• Intermediate and long term therapies most commonly.

• For patients with haematological conditions.

• Reliable for large volume infusions

• Frequently used in paediatrics. (Cancer Institute NSW, 2019).


ADVANTAGES

• Reduced incidence of infection. • The larger bore lumens allow for rapid infusions. • Single, double or triple lumens allow for multiple infusions. • Less restrictive to activities of daily living. • Nil pain on access

(Cancer Institute NSW, 2019). DISADVANTAGES

• Altered body image. • Surgical requirements for insertion and removal.

ADDITIONAL KEY PRINCIPLES OF CARE FOR A TUNNELLED CVAD CATHETER (HICKMANS)

# Refer to eviQ Resource Document http://www.eviq.org.au

Tunnelled Central Venous Catheters (Hickman)


• Observe insertion site.

• Follow post-operative orders if sutures are present. A dressing change is usually required 24 hours post insertion (Cancer Institute NSW, 2019). Please refer to your local guidelines. Confirmation of Placement Initial written x-ray report is required to confirm correct placement of the tunnelled catheter available in patient record. (Cancer Institute NSW, 2019). Catheter Patency Catheter patency is determined by:

• Aspiration of blood from catheter *flashback • Ability to easily infuse solutions. • Normal appearance of tunnelled catheter site.

Initial documentation after insertion

• Brand of Tunnelled Catheter, product number, lot number should be documented by inserter.

• Size of catheter, number of lumens.

• Anatomical location of tunnelled catheter.

• Type of*Needleless injection cap (bung) used.

• Name of person who verified x-ray placement name and signature of person inserting tunnelled catheter or x-ray report confirming these findings.





Dressing requirements

• Sterile dressings are appropriate immediately following catheter insertion when the site might be bloody or oozing. This dressing will require changing 24 hours post catheter insertion

• 24 hours post catheter insertion the dressing should be changed to a semi- permeable polyurethane dressing which allows for observation of the insertion site

• Until there is complete wound healing at the insertion site, dressing should be changed every 7 days or earlier if required

• Dressings are not usually required after the insertion wound has healed. This usually occurs within 21 days of insertion. Securement of catheter at exit point should continue.

(Cancer Institute NSW, 2014)


https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads for information on Tunnelled Central Venous Catheter (Hickman) Dressing and Needleless Injection Cap Changes.

Accessing & Deaccessing a Tunnelled Central Venous Catheter

Prior to accessing a CVAD through a *Needleless injection cap (bung) the area must be cleaned with an alcohol swab (2% chlorhexidine gluconate & 70% isopropyl) using vigorous friction (Cancer Institute NSW, 2019) or a 70% alcohol swab (check your local hospital policy). Povidone-iodine solution 10% can be used if required when the patient has allergies.

# Refer to eviQ Clinical Procedure http://www.eviq.org.au or

https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads for information on Accessing a Tunnelled Central Venous Catheter or Tunnelled Central Venous Catheter Deaccessing

• Use the appropriate *standard aseptic technique when accessing a *closed system (NHMRC, 2010) via a *Needleless connection cap (bung)

• Utilise a *Critical micro aseptic field when accessing the *Needleless connection cap (bung) (NHMRC, 2010).

Refer to your local Hospital guidelines to guide your practice & ensure you have the appropriate knowledge & skills required to undertake these procedures. View these clinical procedures as a guide to your practice.






Taking Blood from a Tunnelled Catheter Aseptic technique as above for accessing a closed system:

• Ensure Hand Hygiene and Aseptic technique

• Clean catheter hub or bung with reccomended solution (vigorous friction) and allow to dry

• Aspirate to determine blood return & discard aspirate (normally 3-10mls depending on size of patient)

• Collect blood samples according to order of draw

• Flush the line according to protocol

• If blood cultures required do not disgard initial aspirate and use this for the blood cultures


# Refer to eviQ Clinical Procedure http://www.eviq.org.au or

https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads for information on Tunnelled Central Venous Catheter (Hickman) – Blood Sampling.

Patient Assessment


• Daily assessment of; o Site appearance – erythema, ooze, tenderness, swelling o Dressing & line integrity o Cuff exposure o Length of catheter

• Escalate care in response to abnormal findings (Cancer Institute NSW, 2019). Flushing and locking

Refer to local Hospital Guidelines and or information from inserting hospital to guide this practice

# Refer to eviQ Resource Document http://www.eviq.org.au or

https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads for information on Flushing Techniques and Locking Solutions.






Patient Education See Module One for general principles.

# Refer to eviQ Patient Information http://www.eviq.org.au or

https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads for information on Tunnelled Central Venous Catheter (Hickman’s).

Print copy of document for patient/carer and discuss key points. Removal of a Tunnelled Catheter

This requires a surgical procedure please refer to organisational policy or guideline. This will be done by a trained professional.

Hickman Catheter (double lumen)




MODULE 6: POTENTIAL COMPLICATIONS OF CVAD’S & MANAGEMENT Nurses caring for a patient with a CVAD require knowledge, skill and judgment to prevent, competently and promptly recognize complications and intervene appropriately for positive patient outcomes. Most importantly if you are unsure, ask an experienced staff member for assistance before progressing and escalate care as required. INFECTION Any infection associated with an indwelling CVAD has the potential for increasing morbidity or mortality for a patient (Gabriel, 2012). Infections may be localized at the insertion site or could be occurring systemically. Nurses caring for patients with an indwelling CVAD must be vigilant in their assessment to detect any signs of infection both local & systemic and escalate care according to your local hospitals *escalation protocol. Risk Factors

• Age.

• Immune status (Patient may be undergoing chemotherapy & thus be immunocompromised).

• Severity of underlying illness.

• Co-morbidities

• Other sites of infection.

• Poor CVAD care.

• Patients with poor personal care. (CNSA, 2007) Signs & Symptoms

• Redness, swelling, tenderness & pain at insertion site.

• Fever.

• Cellulitis or exudate.

• Signs of systemic infection- rigors, chills, hypotension, shortness of breath, tachypnea.

The nurse caring for a patient must be aware that signs & symptoms in an immunocompromised patient may be subtle.

The most common life-threatening complication of CVAD's is catheter related blood stream infections (CRBSI)



Intravascular devices provide an entry route for microorganisms or biofilm directly into the systemic circulation and surrounding tissue via either the intraluminal or extra luminal aspect of the catheter.

• Intraluminal contamination occurs through connectors and when accessing an open system.

• Extra luminal may occur through catheter migration as the catheter moves in and out at the external exit site, takes normal skin flora with it (this emphasizes the importance of securement devices). Fibrin sheath development outside of the catheter can also contribute to this. (Macklin, 2010: Reder, 2013).

Incidence of infection can also increase as a result of thrombus formation and build-up of biofilm (Mehell et al, 2002; Donlan, 2001 as cited in CSNA, 2007, pp. 76). Extra luminal contamination may also be localised at the CVAD exit site, along the cutaneous tunnelled tract or at the skin pocket containing an implanted IVP (Rosenthal, 2004 as cited in CSNA, 2007, pp. 75). Evidence is mounting that the density of skin flora at the insertion site is major risk factor for CRBSI’s with the majority of CRBSI’s originating from the patient’s own skin flora (especially in non-tunnelled CVC’s) (Rosenthal, 2013).

TPN or parenteral nutrition has been identified as an independent risk factor for the development of CRBSI due to the solution itself (lipid), an increase in blood sugar levels during administration and the fact that it must be administered via a CVAD with (Reyen, 2013) declaring that an individual receiving TPN has a 6% greater chance of developing a CRBSI than an individual who has a CVAD insitu who is not.

Septic shower A septic shower may occur immediately after flushing due to infection in the line. There may be an absence of obvious infection at entry site, however the patient will experience rigors and generally feel unwell. If this occurs escalate care & follow your hospitals *escalation protocol. Nursing interventions to prevent infection

Rigorous hand hygiene and adherence to key principles of aseptic non-touch technique are the two most critical factors in the prevention of hospital acquired infections. (CDC Guidelines, 2011).

Nursing interventions include:

• Strict adherence to 5 moments of Hand Hygiene

• The use of appropriate aseptic non-touch technique (surgical or standard) for the task or procedure being carried out

• Minimising the number of times, the CVAD is accessed (Cancer Institute NSW, 2014).


• Changing dressing and caps at least every seven days, or more often as required (Cancer Institute NSW, 2019).

• Never reconnect administration sets that have been disconnected.

• Effective disinfection of key parts – e.g. vigorously cleansing the access port for and allowing it to dry prior to manipulation (Cancer Institute NSW, 2019).

• The use of at least a 2% chlorhexidine with 70% alcohol based solution for cleansing insertion and securement sites (the area under the dressing). (O’Grady et al, 2011).

• There is new evidence to suggest that Chlorhexidine patches applied to the entry site may also reduce the risk of normal flora accumulation and therefore the risk of contamination along the catheter (Warren, 2013).

• Removal of the CVAD device in a timely manner when no longer required.

• Patient education in care of their CVAD and signs of infection

If signs of infection occur escalate care according to patient condition and hospital *escalation protocol.

CVAD OCCLUSION

Types of CVAD occlusion include

• Non thrombotic (CSNA, 2007)

• Thrombotic

Non thrombotic causes

• Kinked or clamped tubing

• CVAD tip malposition

• Catheter abutment against a valve or vessel wall (Camp-Sorrel, 2004)

• Compression of the catheter by the clavicle and first rib, known as *pinched off syndrome

• Damage or malposition of the catheter or needle

• Chemical occlusions may be caused by precipitates or lipid deposits from infusions of incompatible solutions

Thrombotic causes include

• The development of a fibrin sheath or tail on the catheter tip acting as a one-way valve permitting infusion but not withdrawing of blood (the sheath being ‘sucked’ up against the tip of the catheter on vacuum withdrawal).

• A mural thrombus when the fibrin from the catheter surface binds with fibrin from a vessel wall injury forming a thrombus. When a vessel wall injury occurs, platelets are recruited to the area to seal the breach. Blood coagulation initiated from tissue factor also occurs concomitantly to develop thrombin and fibrin resulting in the formation of a thrombus (Furie & Furie, 2008, pp. 938).

• Fibrin deposits and /or sludge accumulation within a portal reservoir.

• An intraluminal blood clot


Nursing Management Flushing using a *Pulsatile Flush technique

• With the correct solution volume and technique

• At the correct frequency for the device in use

• Flushing between drugs to prevent drug precipitation.

• Following blood withdrawal and transfusion of blood products

Use of heparinised lock where applicable.

Use of positive or neutral *Needleless injection cap (bung) which prevent the backflow of blood into the catheter lumen.

Nursing Interventions if blockage is evident: If a blockage is evident steps that need to be taken within a systematic manner include:

• Initial checking the line for kinks or clamps closed.

• Checking for old blood in the *needleless injection cap (bung) (if present replace).

• Checking that the needle (for IVP) is positioned correctly and there is no swelling around the IVP reservoir.

• Asking the patient if they are experiencing any pain around any area where the CVAD is insitu.

• Checking that the length of the exposed PICC or tunnelled catheter has not altered.

• Checking for swelling in the arm where a PICC or IVP is insitu or venous distension if an IVP reservoir is sitting in the chest. If present DO NOT USE and report to Medical Officer.

• Catheter function and history of function: ability to withdraw and infuse. Has the ability to flush and withdraw happened over time or suddenly post medication administration? If over time, more suggestive of fibrin build up.

• Changes in catheter’s function related to patients posture and position suggests pinched off syndrome (catheter fracture discussed under catheter fracture).

• Physical assessment: signs of oedema, redness, venous distension. If present, DO NOT USE and escalate care.

• Pinch-off syndrome, thrombosis and fibrin sheaths involves medical review and the use of medical imaging (chest XRAY, vascular ultrasound and dye studies).

If unable to withdraw blood, using a 10ml syringe filled with N/Saline, gentle flushing and aspiration may clear the line, and blood flashback may be returned. If this method is unsuccessful and a complete thrombotic occlusion is suspected and only after the above assessment has been performed, then the instillation of a thrombolytic agent has been found to be safe and effective at restoring patency.


The administration of a thrombolytic agent should only be performed by a competent practitioner in consultation with treating medical team. Patients’ coagulation status needs to be ascertained prior to installation. Patient consent is also required prior to this procedure as risk of bleeding is a potential side effect. Check your local hospital policy regarding use of thrombolytic agents and competency required before being permitted to instil.

# Refer to eviQ Clinical Procedure http://www.eviq.org.au or https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads/771-central-venous-access-device-cvad-restoring for information on Restoring patency to a Central Venous Access Device (Partial and Complete Occlusion).

AIR EMBOLISM

Air embolism occurs when intrathoracic pressure is less than atmospheric pressure, allowing air to enter the patient’s venous circulation through the open end of the catheter. (Cancer Nurses Society of Australia, 2007). The air travels to the right ventricle impeding outflow of blood from the pulmonary artery causing a decrease in cardiac output, venous return, and coronary artery flow. The degree of harm caused is directly related to the gauge of the CVAD insitu, the volume of air infused, the rate of air entry and the patient’s position at the time of the event. Vascular collapse, arrhythmias, hypoxaemia, hypercapnia, neurological deficits and death may ensue. (Cancer Nurses Society of Australia, 2007). Interventions to reduce the risk of air embolism include

• Timely assessment of catheter and required intervention

• Inserting the smallest gauge CVAD possible.

• Placing the patient supine or in Trendelenburg position when inserting/removing.

• Using luer-lock intravenous tubing and syringes.

• Using intravenous pumps with in-line air detection.

• Clamping lumens prior to disconnecting and / or reconnecting access caps.

• Ensuring all clamps are present on CVAD lumens.

• Clamping the catheter proximal to any detected breaks or leaks in the catheter.

• Instructing the patient to perform a *valsalva manoeuvre during CVAD removal.

• Applying gentle pressure at catheter exit site until haemostasis is achieved.

• Dress exit site with occlusive dressing


https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads/771-central-venous-access-device-cvad-restoring

https://www.eviq.org.au/clinical-resources/central-venous-access-devices-cvads/771-central-venous-access-device-cvad-restoring


ARRYTHMIAS If the tip of the catheter is advanced too far or migrates into the right atrium this can cause irritation to the myocardium resulting in arrhythmias.

If a patient develops a new cardiac arrhythmia the location of the catheter tip needs to be determined by a chest X-ray, as determined by a Medical Officer. If the tip has migrated into the right atrium the catheter may need to be withdrawn, as per medical direction. CATHETER FRACTURE:

Immediate management of a fractured or damaged PICC

Damage to the integrity of PICC lines can be sustained over time or from ‘pinched off syndrome’ (Cancer Institute NSW, 2014) or with improper handling. Tears and splits in the catheter can occur at any point along the length of the PICC line and may present as:

• Leakage from the PICC line when flushing. • Unexplained fluid or precipitate under the dressing or along the external part of

the catheter. • Separation of the connector from the catheter.

(Cancer Institute NSW, 2019) If the catheter breaks externally

• Immediately clamp the remaining portion of the catheter. • Stabilise the catheter to prevent migration into the vein. • Repair or remove the catheter. • Escalate care

(Cancer Institute NSW, 2019) If the catheter fracture occurs within the vein

• Manage the presenting symptoms & escalate care according to hospital *escalation protocol.

• Place the patient in the *trendelenburg position. • Urgent x-ray to confirm catheter fragmentation and location. • If the catheter breaks while being removed immediately tourniquet the arm to

prevent bleeding/blood loss and monitor vital signs and pulses. (Cancer Institute NSW, 2019)

This is the end of the CVAD self-directed learning package please complete the following questions & return them to your Clinical Educator for marking.


Reference List Australian Commission on Safety & Quality in Health Care. (ACSQHC) 2017. National Consensus Statement Essential elements for recognising and responding to acute physiological deterioration. 2nd Edition

https://www.safetyandquality.gov.au/

Australian Institution of Health & Welfare. (AIHW) (2020). Bloodstream infections associated with hospital care 2018–19

https://www.aihw.gov.au/reports/health-care-quality-performance/bloodstream-infections-associated-with-hospital-care/contents/what-is-australia-doing-to-reduce-sab-infections

Camp-Sorrell, D. (Ed), (2011). Access device guidelines: recommendations for

nursing practice and education (3rd ed.). Oncology Nursing Society: Pittsburgh.

Cancer Institute NSW. (2019). eviQ Clinical Resources Central Venous Access

Device (CVAD) Information Area. https://www.eviq.org.au/Category/tabid/65/categoryid/432/Default.aspx

Cancer Nurses Society of Australia. (2007). Central venous access devices:

principles for nursing practice and education. Dougherty, L. (2000). Central venous access devices. Nursing Standard. 14(43), 45-

55. http://rcnpublishing.com/doi/abs/10.7748/ns2000.07.14.43.45.c2876?journalCode=ns

Furie, B. & Furie, B.C. (2008). Mechanisms of thrombus formation. The New England

Journal of Medicine 359, 938-949. http://www.nejm.org/doi/full/10.1056/NEJMra0801082

Gabriel J. (2013). Preventing and managing complications of CVADS. Nursing Times.

109(40), 20-23. Hadaway, L. (2006). Technology of flushing vascular access devices. Journal of

Infusion Nursing. 29(3), 137-145. Hadaway, L. (2012). Needless connectors for IV catheters. American Journal of

Nursing.112(11), 32-42. Macklin, D. (2010). Catheter management. Seminars in Oncology Nursing. 26(2), 113-

120. National Hand Hygiene Initiative (NHHI). (2020). National Hand Hygiene Initiative

Manual. https://www.safetyandquality.gov.au/sites/default/files/2020-09/nhhi_user_manual_-_sep_2020_1.pdf

https://www.safetyandquality.gov.au/




https://www.eviq.org.au/Category/tabid/65/categoryid/432/Default.aspx

http://rcnpublishing.com/doi/abs/10.7748/ns2000.07.14.43.45.c2876?journalCode=ns

http://rcnpublishing.com/doi/abs/10.7748/ns2000.07.14.43.45.c2876?journalCode=ns

http://www.nejm.org/doi/full/10.1056/NEJMra0801082


National Health and Medical Research Council 2019 Australian guidelines for the prevention and control of infection in healthcare.

https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-prevention-and-control-infection-healthcare-2019

O'Grady, N. O., Alexander, M., Burns, L. A., Dellinger, p., Garland, J., O'Heard, S.,

Lipsett, P., Masur, H., Mermel, L., Pearson, M., Raad, I., Randolph, A., Rupp, M., Saint, S., & the Healthcare Infection Control Practices Advisory Committee (HICPAC). (2011). CDC guidelines for the prevention of intravascular catheter-related infections. Atlanta: Department of Health & Human Services USA. http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html.

O’Grady, N., Alexander, M., Patchen-Dellinger, E., Gerberding, J., O’Heard, S., Maki,

D., Masur, H., McCormick, R., Mermel, L., Pearson, M., Raad, I., Randolph, A. & Weinstein, R. (2002). Guidelines for the prevention of intravascular catheter-related infections. Infection Control and Hospital Epidemiology. 23(12), 759-769.

Schiifer, C.A, Mangu, P.B, Wade, C, Camp-sorrell, D, Cope, D.G, El-Rayes, B.F,

Gorman, M, Ligibel, J, Mansfeild, P & Levine, M (2013). Central Venous Catheter Care for Patients with Cancer: American Society of Clinical Oncology Clinical Practice Guideline. Doi: 10.1200/JOP.2012.000780.



http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html


CVAD SDLP WRITTEN ASSESSMENT

NAME_____________________________ DATE______________________ PART A MULTICHOICE QUESTIONS

1. Which of the following is NOT a type of CVAD? a). Hickman’s catheter b). Peripheral Intravenous Cannula c). Peripherally inserted central catheter (PICC) d). Implantable Venous Port 2. The tip of a CVAD is located in the? a). Superior vena cava b). Right atrium c). Femoral artery d). Subclavian vein 3. In which of the following situations is a CVAD NOT required? a). Poor, difficult or unavailable venous access b). Infusions of vesicant drugs, that may cause damage and/or pain if infused peripherally c). Administration of four doses of post-operative antibiotics d). Continuous or multiple infusions 4. A standard aseptic technique is used with a CVAD when? a). Attending a dressing b). Accessing an open system c). Changing a cap/bung d). Accessing a closed system 5. A surgical aseptic technique is used with Central Vascular Access Devices? a). When accessing a closed system b). Every time a CVAD is accessed c). When accessing an open system d). When disconnecting a syringe


6. Pulsatile flush technique refers to? a). The stop/start method of flushing a CVAD b). Checking a patient’s pulse before using a CVAD c). Flushing a CVAD before and after accessing d). Flushing a CVAD to determine patency 7. The rationale for using a pulsatile flush technique is used to? a). Block a CVAD b). Create turbulence in the syringe c). Create turbulence in the CVAD to reduce the incidence of occlusion d). Determine patency of a CVAD 8. The external length of a PICC is measured from? a). The insertion point to the hub of the PICC b). The insertion point to the bung c). The anchoring device to the bung d). The insertion point to the anchoring device 9. The minimum size of a syringe used when accessing a CVAD is? a). 3ml b). 10ml c). 5ml d). 20ml 10. The only type of needle that should be used to access an IVP? a). Non-coring needle b). Intravenous needle c). Hypodermic needle d). Butterfly needle 11. Which of the following is NOT an advantage of having an IVP? a). Minimal interference to body image b). Low incidence of infection c). Low maintenance when not in use d). Requires a surgical procedure for insertion

12. IVP’s need to be locked prior to removal of the non-coring needle & access line? True of False


13. Which of the following is NOT a major complication of CVAD use? a). Localised bleeding at the insertion site within the first 24 hours b). Infection c). Thrombosis d). Blockage 14. PICC dressings should be changed? a). If soiled with blood underneath the dressing or integrity is compromised b). 24 hours post insertion, then every seven days if dressing remains dry and intact c). Every 48 hours if gauze is present beneath the occlusive dressing d) All of the above

15. A needleless injection cap (bung) should be present on a PICC when? a) Only for the first 24 hours following insertion of the PICC b) At all times c) Only if infusing fluids d) Only when taking blood 16. When a CVAD is used for blood sampling, the first 3-10mls is? a). Never discarded b). Discarded when taking blood for blood cultures c). Discarded when taking routine blood tests d). Always discarded

17. Prior to infusion of any solution how is catheter patency determined? There are 2 correct answers a). Don’t need to if correct placement was determined by x-ray b). Aspiration of blood (flashback) in a syringe c). It was handed over as being patent last time it was accessed d). Ability to easily flush N/Saline

18. After blood sampling a CVAD should be flushed in a pulsatile manner with? a). 10ml-30mls sterile water b). 20ml weak heparin saline c). 10-30ml normal saline d). 5ml normal saline


19. At what interval should the status of a CVAD be clearly and consistently documented? a). At the end of the week b). Only when there is a complication c). Only after insertion d). At the end of each shift (inpatient) and/or treatment and/or access

20. If blood cannot be aspirated via the CVAD and swelling and pain is evident, the appropriate course of action involves? (more than one answer is correct) a). Escalate care b). Possible radiological investigation c). Not using the CVAD until placement is confirmed d). Attempt aspiration with a 2ml syringe

21. What type of dressing should be over the PICC line insertion site? a) A transparent semi permeable dressing b) A simple gauze dressing and bandage c) Any dressing d) No dressing is required 22. A septic shower? a) Will only occur if there are obvious signs of infection at the entry site b) Is harmless and will not affect the patient in any way c) Is a possible complication of all CVAD’s d) Can only occur with IVP’s 23. On completion of treatment via a Hickman’s catheter you must? a) Administer a 500-unit heparin lock b) Administer a 50-unit heparin lock c) Administer a normal saline lock d) Consult inserting hospital for guidelines re locking solutions


PART B SHORT ANSWER QUESTIONS 1. What is the rationale for using a syringe 10mls or larger for flushing and all

other CVAD manipulations? _____________________________________________________________________

_____________________________________________________________________

__________________________________________________________________

2. Immediately following insertion of a CVAD what diagnostic test must occur before the administration of medications or fluids? _____________________________________________________________________

_____________________________________________________________________

_________________________________________________________________

3. What is the post insertion management of a PICC? (first 24 hours) _____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

____________________________________________________________________

4. You attempt to administer an IV antibiotic via a PICC line and you find that you can neither flush nor obtain a blood return from the PICC. Identify three possible causes for this and the trouble shooting methods for each cause. _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Mr. Wilson has had a PICC line insitu for two months. You are ready to

administer his antibiotics but notice that there is redness and swelling with purulent discharge at the insertion site.

a. What is the most likely reason for these signs?

____________________________________________________________________

____________________________________________________________________


b. State the trouble shooting actions you would now undertake?

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

c. Another nurse arrives and proceeds to administer the antibiotics, what is a possible consequence of this action and how would you recognise it occurring? ____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

_____________________________________________________________________

6. You have just completed Mr. Davies PICC line dressing and upon

measuring the PICC line you notice that the external measurement is 3cm longer than previously documented

a. What does this indicate and what is the significance? ______________________________________________________________________________________________________________________________________ b. What would be your actions ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

7. You are accessing Mrs. Wrights PICC Line: for a routine blood sample

a. Describe the procedure for taking a blood sample from a PICC line. _____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

8. Following completion of blood sampling how would you flush a tunnelled

catheter? _______________________________________________________________

_______________________________________________________________


_______________________________________________________________

_______________________________________________________________

_____________________

9. Mr. Jones has had an implantable IVP inserted 8 weeks ago for long term antibiotic therapy. Half way through the administration of Vancomycin Mr. Jones complains of pain around his IVP site, upon inspection you identify swelling around the IVP site?

a. What does this indicate and what is the consequence?

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

_______________________________________________________________

b. What would your actions be?

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

______________________________________________________________


CLINICAL SKILLS COMPETENCY: PICC LINE NAME:_________________________________________ DATE:______________

DEMONSTRATES: The ability to effectively and safely undertake the management of a PICC line.

CRITERIA C = Competent S = Requires supervision

D = Requires development

C S D

1. Demonstrates correct technique including compliance with principles of asepsis when accessing PICC

2. Demonstrates correct technique including compliance with principles of asepsis when flushing a PICC

3. Demonstrates the correct technique, which includes compliance with the principles of asepsis, for collecting blood

4. Demonstrates the correct technique, which includes compliance with the principles of asepsis, for changing a PICC dressing

5. Demonstrates the correct technique, which includes compliance with the principles of asepsis, for changing a stat lock

6. Demonstrates the correct technique, which includes compliance with the principles of asepsis, for changing a positive pressure bung

7. Demonstrates a pulsatile flush

8. States the reason for flushing a PICC

9. Discusses possible complications and there management

10. States the circumstances under which the PICC is flushed with normal saline

11. States the documentation required for the management of a PICC

COMMENTS________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

COMPETENT YES NOT YET – REQUIRES FURTHER SUPERVISION NOT YET – REQUIRES FURTHER DEVELOPMENT Registered Nurse___________________________ Educator__________________________________


CLINICAL SKILLS COMPETENCY: IVP’s NAME:__________________________ DATE:______________

DEMONSTRATES: The ability to effectively and safely undertake the management of a IVP

CRITERIA C = Competent S = Requires supervision

D = Requires development

C S D

1. Demonstrates correct technique including compliance with principles of asepsis and use of a non-coring needle when accessing IVP

2. Demonstrates correct technique including compliance with principles of asepsis when flushing a IVP

3. Demonstrates the correct technique, which includes compliance with the principles of asepsis, for collecting blood

4. Demonstrates the correct technique, which includes compliance with the principles of asepsis, for changing a IVP access needle and dressing

5. Demonstrates the correct technique, which includes compliance with the principles of asepsis, for changing a bung

6. Demonstrates a pulsatile flush

7. States the circumstances under which a IVP is flushed with normal saline

8. States the circumstances under which the IVP requires a heparin lock

9. States the documentation required for the management of a IVP.

COMMENTS____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

COMPETENT YES NOT YET – REQUIRES FURTHER SUPERVISION NOT YET – REQUIRES FURTHER DEVELOPMENT Registered Nurse___________________________ Educator__________________________________

GIPPSLAND HEALTH SERVICES CONSORTIUM

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