NCP Central Venous Access Devices

Central Venous Access Devices

Broviac; Hickman; Groshong; Implantable Ports; Peripherally Inserted Central Catheter; Tunneled

Central venous access devices are indwelling catheters placed in large vessels using a variety of approaches. These catheters or devices are indicated for multiple blood draws; total parenteral nutrition; blood administration; intermittent or continuous medication administration, especially with vesicant agents or chemotherapy; parenteral fluids; and long-term venous access. Central venous access devices are beneficial for patients who receive intravenous (IV) therapies that require the hemodilution of large central veins. Patients with limited peripheral venous access also benefit from placement of a central venous access device for IV therapy and blood draws. Catheters can be implanted for as long as 1 to 2 years. Common vascular access devices include Silastic right atrial catheters such as Hickman, Broviac, and Groshong catheters, peripherally inserted central catheters (PICCs) positioned in the superior vena cava, and implantable infusion ports. Each catheter has specific requirements for flushing, heparinization, and dressing changes. Common complications include phlebitis, infection, and catheter occlusion. These types of access devices are encountered not only in the hospital but also in the ambulatory care and home setting.

Nursing Diagnosis

Risk for Injury: Impaired Catheter Function

Common Risk Factors
Mechanical impairment (e.g., clotting of catheter) Catheter break, migration, and/or pinch-off syndrome
Common Expected Outcome Patient’s catheter function is maintained, as evidenced by patency with acceptable two-way function (inflow and outflow).	NOC Outcomes Risk Detection; Risk Control NIC Interventions Venous Access Device Maintenance; Peripherally Inserted Central Catheters

Ongoing Assessment

Actions/Interventions

Rationale

Inspect for catheter integrity: check for patency; observe for kinks; note leakage or resistance when flushing line; observe gravitational flow (e.g., in transfusion of blood products); check clamp; and check patency of Huber needle with implantable port.

Early assessment facilitates prompt intervention and reduces complications.

Therapeutic Interventions

Actions/Interventions	Rationale
Flush the catheter according to established institutional policy and procedure and manufacturer's guidelines, and at the end of every blood-drawing procedure, at the completion of each IV solution and blood product, and before capping the catheter.	Flushing prevents catheter clotting. Each catheter has specific requirements for routine flushing and heparinization. This may include flushing with heparin or routine flush with tissue plasminogen activator (t-PA).
Avoid administering incompatible solutions and medications.	Infusion of incompatible solutions may cause precipitation within the catheter and eventual obstruction.
Use mechanical IV pumps.	Infusion pumps prevent “dry” IVs and backing up of blood into the catheter.
Avoid blood pressure measurements in the arm with the PICC.	Even short-term compression might compromise blood flow.
Avoid use of scissors around the device (especially when changing the dressing); use noncrushing clamps and hemostats when needed.	Precautions are needed to prevent catheter damage.
Troubleshoot the catheter and port for common problems (e.g., sluggish inflow and inability to draw blood).
·     Alternate irrigation and aspiration of catheter using 15 mL of normal saline solution in a 30-mL syringe with the patient in a lying, arm-raised, sitting, or side-lying position. Do not force if resistance is felt.	Gentle irrigation of the catheter may dislodge small obstructions.
·     Obtain prescription for use of t-PA or urokinase for clearance of occluded catheter or port if other measures to restore catheter function are unsuccessful.	t-PA and urokinase are effective in lysing clots.
Repair external catheter damage according to manufacturer's recommendations or established procedures.	Specially trained nurses familiar with a variety of catheter types should be available to assist as needed (e.g., chemotherapy specialists, nutritional support staff).
Notify the physician of suspected internal catheter damage.	Replacement may be indicated.

Nursing Diagnosis

Risk for Infection

Common Risk Factors
Indwelling catheter Manipulation of catheter connecting tubing Prolonged use of catheter Neutropenic patient
Common Expected Outcome Patient is free of infection, as evidenced by normal temperature and no signs of redness, warmth, or drainage.	NOC Outcomes Immune Status; Risk Detection; Risk Control NIC Interventions Intravenous (IV) Therapy; Venous Access Device Management; Peripherally Inserted Central Catheter Care

Ongoing Assessment

Actions/Interventions	Rationale
Check the catheter/port site for signs of infection.	Redness, warmth, tenderness, and “streaking” over the subcutaneous tunnel and exudate from the exit or portal pocket or needle insertion site are signs of infection.
Assess vital signs as needed.	Elevated temperature above 38.3 ° C (101° F) may be related to bacteremia from the central venous catheter.

Therapeutic Interventions

Actions/Interventions	Rationale
Follow institutional policy and procedure for catheter-related care.	Strict adherence to catheter care procedures reduces the possibility of contamination when performing the following: changing IV solution, tubing, adapters, or caps; changing site care and dressings; drawing blood; accessing and deaccessing port; flushing and heparinizing the catheter. The antiseptic used for care at the insertion site should be compatible with the catheter material. Each catheter manufacturer provides information about the appropriate antiseptic for the catheter. Commonly recommended antiseptics include povidone-iodine, chlorhexidine, and electrolyte chloroxidizers. Transparent dressings are used to cover the catheter insertion site. Povidone-iodine ointment may be used at the insertion site if it is compatible with the catheter material.
If infection is suspected, notify the physician for culturing, treatment, and possible catheter removal.	Aggressive treatment is indicated to prevent spread of infection. If the catheter is removed, the tip may be sent to the laboratory for testing.

Nursing Diagnosis

Acute Pain

Common Related Factors	Defining Characteristics
Difficult or traumatic insertion Needle displacement from port with extravasation Tunnel phlebitis Deep vein thrombosis	Report of discomfort Edema of neck and extremity Limited movement of extremity
Common Expected Outcomes Patient verbalizes relief of pain. Patient appears comfortable.	NOC Outcome Pain Control NIC Interventions Venous Access Device Management; Pain Management; Peripherally Inserted Central Catheter Care

Ongoing Assessment

Actions/Interventions	Rationale
Check insertion site every 4 hours or as needed for signs of inflammation or discomfort.	Pain at the insertion site related to initial placement of the device should be temporary and easily relieved with mild analgesics. Persistent pain at the insertion site may indicate infection or malfunction of the device or infiltration of IV therapy solutions into surrounding tissues.
Check the site for swelling. Check hand, arm, and neck on affected side for edema; compare to unaffected side. If swelling is present, assess for catheter displacement, needle displacement from port, infection, or deep vein thrombosis.	Accurate assessment of the cause of swelling guides appropriate treatment.
Monitor effectiveness of pain relief measures.	There may be a discrepancy between the patient’s behavior and the actual perception of pain. Accurate assessment is necessary.

Therapeutic Interventions

Actions/Interventions	Rationale
Maintain optimal position of the extremity. Elevate the distal portion of the extremity.	Elevation may reduce swelling.
Avoid tight bandaging of the affected extremity. Use occlusive but nonconstricting dressing.	The dressing should be applied to allow adequate circulation.
Perform active and passive range of motion, noting limitation of the catheter.	This promotes circulation of the affected extremity.
Administer analgesic as indicated.	Pain medications are absorbed and metabolized differently by patients, so their effects must be evaluated.

Nursing Diagnosis

Deficient Knowledge

Common Related Factor	Defining Characteristics
New procedure	Many questions Lack of questions Verbalized misconceptions
Common Expected Outcomes Patient verbalizes reasons venous access device has been inserted and common complications associated with it. In home care setting, caregiver demonstrates correct technique in caring for venous access device.	NOC Outcome Knowledge: Treatment Procedures NIC Interventions Teaching: Procedure/Treatment; Teaching: Psychomotor Skill

Ongoing Assessment

Actions/Interventions	Rationale
Assess the patient and caregiver’s understanding of indications for venous access device, dressing changes, and catheter care.	Education of the patient and caregivers for home management of a central venous access device is based on their understanding of the device and related therapy.
Assess the patient and caregiver’s skill in managing the central venous access device.	This can be assessed first in the hospital setting, then again in the home environment by the home health nurse.
Assess financial and environmental resources for maintaining equipment and supplies in the home.	Supports and resources may be available to reduce stressors.

Therapeutic Interventions

Actions/Interventions	Rationale
Instruct the patient and caregiver regarding the importance of and process for maintaining and reordering necessary equipment and supplies (e.g., needles, syringes, tubing, solution bags, pumps) for catheter care and infusion treatment.	The patient and caregivers will be responsible for maintaining correct function of the device and preventing complications associated with long-term IV therapy.
Instruct the patient and caregiver regarding the following:
·     Importance of hand washing and aseptic technique	Hand washing is the most effective method to reduce touch contamination during catheter care.
·     Dressing changes; IV tubing changes	Frequency and technique will vary depending on catheter type and whether it is used intermittently or continuously.
·     Injection cap changes	These are usually performed by the home health nurse.
·     Keeping ports capped and clamped	This prevents air embolus.
·     Site care	This prevents infection.
·     Flushes	These maintain patency.
Instruct the patient and caregiver how to start and discontinue IV therapy as prescribed.	A successful treatment plan requires the support and cooperation of the patient and caregiver.
Instruct regarding signs of phlebitis and site infection, and to whom to report these signs.	Early assessment facilitates prompt intervention and reduces complications.
Inform the patient and caregiver how to notify the home health nurse in case any problems occur.	Many problems can be handled by telephone triage.
Instruct the patient and caregiver to maintain a catheter repair kit at home for use by the home health nurses, as indicated.	Patient safety is a priority.