iv catheter care: peripheral and central policy review description technical contact: content...
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IV Catheter Care: Peripheral and Central Policy Review
Description Technical contact:
Content contact:
If you have technical questions please contactthe Service Desk414-647-3520 in Milwaukee or 1-800-889-9677
Created: April 2012Reviewed:Updated:
Instructions on how to navigate this course.This course does have Sound. Your computer will require earbuds, headphones, or speakers to hear the narrative in the brief videos.This course does not have Notes.
Features:
For questions regarding this learning module, please contact your Clinical Education Committee Representative or refer to Intravenous (IV) Catheter Care: Peripheral & Central (Adult) policy #1007 in the Aurora Health Care Administrative Manual.
This module is an overview of the Aurora Health Care Intravenous (IV) Catheter Care: Peripheral & Central (Adult) policy. This module will take about 30 minutes to complete
Lana Peters, MSN, RNPatricia Stockhausen, MSN, RN
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Course Objectives
• After completion of this self paced course you will be able to:• Apply key Intravenous policy guidelines related to
peripheral IV insertion and care.• Discuss Intravenous policy guidelines related to Central
Venous Access Devices.• State several key infection prevention and patient safety
guidelines that pertain to vascular access devices, including tubings, dressings, caps, and flushes.
• Identify criteria necessary for quality blood draws from vascular devices.
The audience for this course includes all caregivers that care for patients with peripheral and central intravenous devices.
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Your Workplace
• Follow the correct link below for your workplace specific Intravenous guidelines
Aurora Inpatient Facilities
Includes All Medical Centers and Hospitals
Aurora Medical Group (AMG)Aurora UW Medical Group (AUWMG)Aurora Advanced Healthcare (AAH)
Clinic outpatient settings
• You will complete a workplace specific self-assessment after you have reviewed your workplace specific content
Aurora Inpatient Facilities
All Medical Centers and Hospitals
• The following information applies to Aurora inpatient facilities, Including all Medical Centers and Hospitals
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Introduction
• IV therapy is integral to providing safe and effective care to all patients – regardless of the type of intravenous device.
• This review of the policy consists of:• Chapter I – Peripheral IV• Chapter II – Central Venous Catheters (CVC)• Chapter III – Lines Used for CT scans• Chapter IV – Total Parenteral Nutrition (TPN)• Chapter V – Need To Know
• Many of the changes are based on the CDC and INS 2011 guidelines.
• Review the entire policy for details.
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Chapter I: Peripheral IVs• Insertion Guidelines• Dressings• End Caps• Tubing Guidelines• Assessment• Other
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Peripheral IV
Key Insertion Guidelines
• A physician’s order is necessary to perform venipuncture, including insertion, capping, and discontinuation of peripheral IV catheters except in circumstances where there are existing emergency protocols (e.g. Rapid Response Team, emergency triage).
• Scrub the skin with an antiseptic containing chlorhexidine gluconate for 30 seconds and allow to dry for 30 seconds.
• Once the site is prepared, the site cannot be touched unless a sterile glove is used.
• If using ultrasound to find a vein, sterile gel should be used when probing for vascular access.
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Insertion Guidelines• It is recommended that any one
competency tested nurse or caregiver attempt no more than two peripheral IV insertions.
• After two unsuccessful IV attempts, the nurse will contact a resource nurse to insert IV.
• After a total of four unsuccessful IV sticks, consider alternative IV access with appropriate agency resources (e.g., anesthesia, CRNA, PICC Service, etc.).
• If no vascular access is established, notify attending physician. A nurse should attempt no
more than two IV insertions. After a total of 4 unsuccessful attempts, consider alternate IV access.
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Dressings
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Dressings
• Transparent dressing is the IV site dressing of choice (INS, 2011).
• Tape is not placed under a transparent dressing.
• The transparent dressing must be made occlusive by pinching the dressing around the hub of the IV catheter or around the catheter itself in the case of a central line.
• When securing the IV tubing, do not overlap tape on top of the dressing.
Consider the application of a securement device for a peripheral catheter at risk for dislodgment.
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Dressings
• Routine site care and transparent dressing changes are completed when dressing is soiled or no longer intact.
• Gauze dressings are changed q 48 hours and PRN.
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End Caps
Positive displacement capMaxPlus Clear®
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End Caps
•In acute care facilities, a positive pressure IV access end cap will be used for all IV catheters: central lines, midline catheters, PICCs and peripheral catheters. •IV caps are replaced with a new sterile cap every time the cap is removed or disconnected or when visibly soiled.•Central Lines: Change needleless components including caps with administration tubing change every 96 hours.•Peripheral IVs: New sterile caps are applied when restarting the IV every 96 hours, or when the cap is removed, disconnected, or when visibly soiled.
When using a positive pressure IV access end cap for a peripheral catheter, an extension set should be used.
Positive displacement capMaxPlus Clear®
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End Caps – Priming and Access• Invert and tap IV end cap (needleless
connector) while priming with saline to purge air.
• Applying friction, vigorously scrub the top of connector with alcohol for a full 15 seconds and allow to dry before accessing.
• The Bard Scrub Site IPA (isopropyl alcohol) device can be used as an alternate to an alcohol wipe. (Follow your hospital site-specific policy). Review the manufacturer’s precautions and instructions.
• Verify connection is secure to connection tubing and valve, administer medication or flush. Scrub vigorously for 15
seconds and allow to dry
Invert to prime cap
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End Caps – Flushing Procedure
• Flush a peripheral IV catheter per manufacturer’s recommendations with preservative free normal saline (2 mL). • Every 12 hours or as ordered• Before giving medications• After giving medications • After intermittent IV therapy
• Always flush with saline immediately after blood infusion or sampling using a push-pause technique to clear the valve.
• Flush positive pressure valves until clear.• When flushing positive pressure valves,
disconnect syringe, then clamp.• Do not clamp before detaching syringe.• Clamp after detaching the syringe.
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End Caps - Changing
• Needleless components (e.g.. caps, J-loops) will be changed:
• If the connector is removed for any reason.
• If blood or debris is present within the connector.
• If contaminated.• When the IV is restarted.
• The catheter or extension set must be clamped when changing the end cap or when the cap is removed.
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Tubing
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Tubing Guidelines – GENERAL INFORMATION
• The infusion tubing or channel will be labeled with the date and time initiated.
• Tubing or channel will be marked with the medication being infused.
• Stopcocks are associated with an increased risk of infection and their use is not recommended. If a stopcock is in use, a closed system must be established and only sterile caps attached to the ports.
• All infusion tubing should be traced back to the insertion site to ensure the route is accurate.
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Tubing Guidelines – When to Change Tubing
• Infusion tubing will be labeled with the date and time initiated and the tubing or channel must be labeled with the medication.
• Change primary tubing every 96 hours or with any site change (CDC, 2011; INS, 2011).
• Change needleless components including caps with administration tubing change every 96 hours.
• Intermittent IV tubing is changed every 24 hours.
• Filtered tubing is changed every 48 hours (e.g., Phenytoin, 20-25% mannitol and amiodorone).
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Tubing Guidelines
• Vigorously scrub IV tubing ports with alcohol for 15 seconds and allow them to dry before accessing the port.
• Flush the Clearlink IV tubing port immediately after IV push injection with a minimum of 1ml to ensure complete infusion of medication and minimize risk of precipitation.
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Tubing Continued
• Sterile end caps must be applied if the primary or secondary tubing is disconnected.
• This will help prevent contamination to end of intermittent IV administration set.
• Do not leave any tubing with the end uncovered.
• To prevent contamination of the tubing NEVER loop the tubing to itself at another access port on the tubing.
• Intermittently used IV administration sets are changed every 24 hours.
Immediately apply a sterile end cap to an intermittent IV that is disconnected.
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Assessment/Reassessment - Prevention of Complications
• Peripheral IV Catheter insertion sites will be visually inspected and palpated approximately every 8 hours.
• Remove the IV catheter if patient develops signs of phlebitis, infection or catheter malfunctions.
• Restart the peripheral IV every 4 days (96 hours).• Vascular access devices placed in an emergency situation
should be replaced as soon as possible and no later than 48 hours.
• A physician order is needed for a peripheral IV site without IV related complications to be used more than 96 hours.
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Emergency Administration of Vesicant Drugs
• Central venous access is the preferred route to administer vesicant drugs (e.g., Dopamine, Dobutamine, chemotherapy), TPN, or sclerosing agents (INS, 2011).
• However, in an emergency or for short term peripheral infusion in consultation with a physician, a nurse may infuse vesicant drugs, TPN or sclerosing agents through a peripheral IV after performing an assessment of the patient’s veins.
• Ongoing assessment of the site is required, every 1 to 2 hours, to evaluate the peripheral site for pain, erythema or edema which may be signs of IV infiltration or extravasation. Assess for vein patency by using normal saline, not the infusing drip, to assess for blood return.
• Note: Standard for oncology is to limit vesicant infusions to 1 hour due to required site monitoring by nurse. If an infusion of a vesicant will take more than 1 hour, a central line is used.
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Midlines • A midline catheter is considered a
long-term peripheral catheter because the end of the catheter is not in the superior vena cava. It is not a central venous catheter.
• A midline is a 6 to 8-inch catheter for intermediate duration (i.e., several weeks) of IV therapy. • May remain in place indefinitely if no
complications.
• Use stabilization devices for midlines.
• Catheter dressing should be labeled as midline.
• RNs may discontinue midline catheters.
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Chapter II: Central Venous Catheters (CVC)
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Prevention of Central Line Infections
• Follow evidence-based processes to prevent central line infections during insertion of Subclavian CVC.
• Use maximal barrier precautions including:• A cap that covers all hair• Tight fitting mask• Sterile gown• Sterile gloves• Eye shield/eye protection
• Chlorhexidine skin antisepsis.• Collaborate with the physician daily to review
line necessity, promptly removing unnecessary lines.
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Prior to Using a CVC
• Placement of any type of central line catheter tip in the superior vena cava must be verified by X-ray or fluoroscopy prior to beginning an infusion.
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Current CVC Flushing GuidelinesCVC device Flush Frequency
Subclavian 3 ml NS Q 24 hr or after use
Tunneled Hickman – no valve
5 ml Heparin 10unit/ml 3 x week or after use
Tunneled Groshong – with valve
5 ml NS Weekly or after use
PICC – with valve 5 ml NS Weekly or after use
PICC – no valve 5ml of 10unit/ml heparin Q 24 or after use
PowerPICC – with valve 10 ml NS Weekly or after use
PowerPICC - no valve 1ml 10 units/ml heparin Q 12 hr or after use
Implanted Port – no valve 5ml of 10unit/ml heparin
Prior to de-accessing: 5ml of 100unit/ml heparin
Q 24 hr or after use
Implanted Port – with valve 5 ml NS Weekly or after use
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CVC – Flush Using Push-Pause Method
• Where indicated, use a Push-Pause pulsing method of flushing catheter lumens to create turbulence within the lumen.
• A push-pause-push technique causes turbulence in the catheter and flushes out blood and drug more effectively, thus preventing blood or fibrin adherence to the lumen wall and tip.
• Push-pauses are done in rapid succession, instilling 1 to 2 mL of flush solution each time force is exerted with a push on the syringe plunger ending with positive end pressure on the catheter lumen.
• Remove the syringe from the end cap and then close the clamp.
• If your patient has a groshong-type PICC or a tunneled Groshong CVC, use a rapid flush technique to open the valve.
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CVC Caps - Access and Flushing
• A positive pressure access system (e.g., Max Clear, Flolink or PosiFlow) will be used for all central lines (except CVP lines).
• Before accessing, remember to use friction and scrub the caps for a full 15 seconds with alcohol and allow to dry.
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Scrub the Hub for 15 seconds prior to each access
Bard Scrub Site
• The Bard Scrub Site IPA (isopropyl alcohol) device is an alternative to using an alcohol wipe to clean CVC caps (extraluminal and intraluminal). Follow the manufacturer’s instructions and precautions for use.
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Securement Devices for CVCs
• A securement device or catheter stabilization device is an external apparatus to secure a catheter (e.g. Stat Lock) and prevent catheter movement or displacement.
• A securement device is not applied to a subclavian line or a PICC that is sutured in place or with a tunneled central venous access device.
• Monitor securement devices daily and replace when clinically indicated, at least every 7 days and with every dressing change.
• Follow manufacturer’s recommendations for application and removal.
• If using a Stat Lock, the product must be loosened with alcohol.
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Aseptic Technique
• To prevent contamination by microorganisms, use appropriate hand hygiene, aseptic technique, sterile products, and gloves when performing infusion related procedures, such as dressing changes and implanted port access.
• Aseptic technique involves the use of added precautions, such as use of sterile gloves, mask, or sterile supplies.
• Use Aseptic technique for all CVC dressing changes or port access.
• Use Aseptic technique when collecting blood samples to culture.
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CVC Dressing Changes
•Wear sterile gloves when changing central line catheter dressings (CDC, 2011, p. 30) or when changing implanted port needle and dressing.
•CVC dressing changes will be completed using sterile supplies and aseptic technique including wearing a mask to reduce the transfer of microorganisms.
•Place a mask on the patient if they cannot turn their head away from the dressing site.
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Biopatch – Current Practice
• For long term Implanted ports a biopatch is placed under the disk of the huber needle.
• The dressing is effective for 7 days.• A sterile transparent dressing is applied
covering the biopatch and the entire area around the catheter.
• Change the biopatch whenever the transparent dressing is changed.
• Tunneled CVCs such as Hickman’s and Groshongs now require a biopatch to be applied to the exit site.
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Biopatch Dressing
• Blue side or grid side is visible (or up) when applied.
• The dressing must cover area around catheter; slit edges are under catheter and should be together.
• The Biopatch must be in contact with skin and covered with a transparent dressing.
• Dressing and Biopatch are changed every 7 days or when soiled, wet, blood soaked or loose.
• The biopatch can be pulled off while removing the transparent dressing.
• If the dressing sticks to the site, use alcohol to loosen.
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Blood Draws
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Blood Draw from Lines
• Stop the IV solutions if the line is in use.
• Use the proximal lumen if the device has more than one lumen (Perry & Potter, Clinical Nursing Skills and Techniques, 2010, p 777).
• The discard amount prior to blood draw from peripheral and central lines is 5 ml.
• Flush with 10 ml preservative free Normal Saline after a blood draw from all central lines except an implanted port.
• Use a 10 ml or larger syringe for all IV injections.
Flush with 20 mL preservative free Normal Saline after a blood draw from an implanted port.
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Establishing Patency – Huber needle
• Wear mask and gloves and maintain aseptic technique
• The sterile gauze and alcohol prep are used for cleansing the hub prior to attaching syringe
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Click on image to view a brief video
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Obtaining Lab Specimen – Huber Needle
• Mask and gloves are worn.
• A sterile gauze and alcohol wipe is held near the hub.
• Wipe the hub prior to attaching sterile syringe.
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Click on image to view a brief video
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Blood Draw from Central Lines Continued
• Vacutainer (to draw the sample directly into lab tubes) is NOT to be used with:• PICC• Midline• Implanted Ports
• If syringe is used, a blood transfer device must be used to transfer the blood into the lab tubes.
• Fill evacuated laboratory tubes in the “order of the draw” (e.g. blue top, red/yellow top, green top, lavender top) see policy Appendix A.
• Label the tubes in the PRESENCE of the patient.
Vacutainer Device is not to be used for PICC, Midline and Implanted Ports
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Key Points related to CVCs
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Key Points - Blood Cultures Drawn from a CVC
• Scrub top of the blood cultures bottles with an alcohol pad for 60 seconds, using 1 pad per bottle. Rest the alcohol pad on top of the bottle to avoid airborne contamination.
• Positive Pressure caps must be changed prior to drawing blood cultures off a line.
• Vigorously cleanse the Central line hub/cap with site approved cleansing product for 15 seconds (e.g. chlorhexidene swab). Allow hub to dry.
• Discard 5 mls. Using new syringes, draw the blood samples.• A sterile angel wing blood transfer device with female
adaptor is used to transfer the sample from the syringe to the blood culture bottles.
• Fill aerobic bottle first.
• Label bottles in the presence of the patient. • DO NOT COVER THE BARCODES ON THE BOTTLES
WITH THE LABEL.(The policy contains the complete step by step procedure)
Angel wing device with female adapter attached to a syringe.
Blood culture bottles tops prepped with alcohol
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Key Points – De-Clotting Central Lines
• Obtain MD order for Alteplase instillation.• Draw up 2 mL of 1 mg/mL reconstituted Alteplase (r-tPa) in a 10 ml
syringe. • Clamp the central line (if clamp is present), remove the end cap,
vigorously clean the hub and attach the Alteplase syringe to the occluded catheter. Unclamp and gently instill. Clamp, then disconnect the syringe.
• Apply a new end cap. • Wait 30 minutes and then try to aspirate.• If no blood return, allow the Altepase to dwell for an additional 90
minutes (total dwell time of 120 minutes), then reattempt another aspiration.
• If no blood is aspirated, withdraw the first dose of Alteplase, then instill a second dose of Alteplase. Repeat the steps. If unable to reestablish catheter patency after the second dose of Alteplase, notify physician.
(See the policy for the complete step-by-step procedure.)
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Key Points - Discontinuing Non-tunneled CVC - Precautions
• The risk of an air embolus increases when a CVC is removed while the patient is sitting upright due to increased intrathoracic pressure. • Patient should be supine - NOT IN A SITTING
POSITION. • Reposition the patient so the insertion site is at or
below the level of the heart to reduce the risk of air embolism.
• If the patient can tolerate being repositioned, the Trendelenburg position is preferred.
• Instruct the patient to take in a deep breath and then hold while withdrawing the catheter.
• Occlusive dressing over the site must remain in place for a minimum of 12 hours.
• If you suspect that the catheter has been broken, have patient lie still on left side and notify the physician STAT.
If the patient is on a ventilator, withdraw the catheter during the expiratory cycle
Trendelenburg is preferred if the patient can tolerate
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Key Points - Guidelines for Patient Transfer When the Patient has a CVC
• Upon transfer from another non-AHC facility, a central line dressing change should be done the day of transfer/admission to assess the site.
• If a central line was inserted without proper asepsis or if it was placed at another facility (non-AHC) without proper documentation, the physician is notified to determine if the central line requires replacement.
• If the catheter is replaced, all fluids and tubing are also replaced.
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Damaged Central Line – Key Points• If at any time catheter damage is suspected (tear, cut or puncture),
immediately apply a plastic toothless clamp close to body at the exit site and proximal to the damaged area. This will help prevent an air embolism.
• Reposition the patient with their head below the level of the heart, if tolerated.
• If the catheter is in an extremity put a tourniquet around the affected limb proximal to the catheter insertion site.
• If catheter embolism is suspected, observe patient for cyanosis, chest pain, hypotension, increased central venous pressure, tachycardia, fainting, or loss of consciousness.
• Repairing of a damaged tunneled Central Line is no longer recommended (this has been removed from the policy).
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Key Points - Hemodialysis Catheters Dressing Changes
• Mahurkar™ or Permcath™:• All nurses are responsible for completing the dressing changes
on hemodialysis catheters.• Use a Central Line Dressing kit and sterile gloves to change the
dressing.• Use Biopatch under transparent dressing.
• Note new product - Hemodialysis Bard Catheter• Use povidone iodine or dilute aqueoous sodium hypochloride
only.• No ointments containing polyethylene glycol or alcohol; may use
bacitracin zinc.
• Only dialysis or pheresis trained nurses may flush a hemodialysis catheter.
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Chapter III: Lines Used for CT Scans
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CVC Implanted Ports for CT Contrast Injections
• Only use a CT-Injectable implanted port for Power Injections.• Know how to differentiate these ports from standard
implanted ports.• Implanted ports that are not rated for CT contrast injections
may burst during the procedure due to the high pressures generated.
• Examples: PowerPort, Smart Port CT.
PowerPort
Smart Port CT
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Implanted Ports - Power Injectable
• PowerPort is indicated for power injection (when used with a PowerLoc™ safety infusion set).
• If the Powerport is being accessed for a CT scan with contrast, then the PowerLoc set MUST be used.
• The Powerloc™ Safety Infusion set also comes with a sticker indicating its Power Injection capability and CT parameters.
• Pressure extension tubing is also available if added length is needed for easier access during radiology procedures.
• When not being used for CT, the Powerport can still be accessed with a standard huber needle.
Above, Powerloc™ Safety Infusion set for CT power injection studies
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PICCs Designed for Power InjectionPower PICC – (purple) • Has clamps on lumens. • Can be used for CT IV contrast. • Labeled as Power Picc.
Power PICC Solo – (purple/blue) • NO Clamps. • Can be used for CT IV contrast.• Labeled as Power Picc Solo.• Incompatible meds should be
separated by 10 ml normal saline before and after medication.
Power PICC. Flush with normal saline before and after power injection studies, followed by heparin.
Power PICC Solo. Flush with normal saline before and after power injection studies.
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Chapter IV: TPN
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TPN (Total Parenteral Nutrition)
• All parenteral nutrition is filtered with a 0.22 micron filter.
• If a separate fat emulsion (Lipids) is ordered, the fat emulsion is filtered with a 1.2 micron filter. The fat emulsion may be piggybacked into the parenteral nutrition below the 0.22 micron filter or infused through a separate dedicated line.
• Change Parenteral Nutrition Tubing:• If TPN is only dextrose and amino acids, change
the tubing and filter every 96 hours.• If TPN with lipid emulsions, 3-in-1 admixture,
change tubing and filter every 24 hours.
Baxter Clearlink 1.2 micron filter for lipids
Baxter Clearlink 0.22 micron filter
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TPN continued
• No blood products, IV solutions, or meds should be administered through the TPN line unless peripheral access is impossible.
• Do not draw blood sample with TPN infusing unless no other access is available. Note if drawing from a line with TPN infusing, flush with 20 ml normal saline before the draw.
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Chapter V: Miscellaneous Need to Know
• TKO Rate• Secondary IVs & Flush Bags• PICC line migration• Intraosseous Catheter• Patient Education• Topical Skin Refrigerant
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Need to Know: TKO
• To Keep Open, Keep Open or Keep Vein Open (TKO, KO or KVO) will be run at 10 mL per hour unless otherwise specified in the order (Aurora Health Care collaboration).
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Need to Know: Secondary IVs
• Take into account secondary IV bag overfill and add the extra volume when programming the pump, do not administer by increasing the IV rate.
• A minibag should not hang by itself as the primary infusion.
• See the policy for using a flush bag when the circumstance exists for intermittent medications without a primary IV ordered.
• Use a 250 mL NS as the primary bag.• The volume to be infused is 30 mL.• The rate is the same as the secondary
medication.
• When both the primary and secondary are infused, cap the IV.
• Remember to change both the intermittently used bag and tubing every 24 hours.
Primary Flush bag must be hung fully extended from hanger.
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Need to Know: PICC Line Migration Outward - Precautions
• While accessing a PICC line and/or when performing a PICC line dressing change, the nurse should assess for any changes in the external length of the catheter to determine if the catheter has migrated.
• If the catheter has pulled out from the insertion site, do not attempt to push back in, or remove the catheter without notifying the physician.
• It is possible the PICC line can be exchanged without resticking the patient.
• No blood pressure measurement (can cause migration) or venipuncture in the extremity with the PICC line.
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Need to Know: Intraosseous Catheter
**There is an entirely new section on IO catheters in the policy**
• IO catheters are usually placed in the proximal tibia when there is an emergency need to establish access.
• Caregivers must have demonstrated competency to insert IO needles.
• IO catheter insertion sites are inspected for infiltration every 8 hours.
• Continued use of an Intraosseous catheter must be evaluated by the provider after 24 hours.
The insertion site used most frequently in adults and children is the proximal tibia (INS, 2011).
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Need to Know: Patient Education
• Patients may be sent home with different instructions for care of a tunneled catheter.
• Refer to FYWBs – e.g. Care After Placement of Your Tunneled Catheter x38157.
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Need to Know: Topical Skin Refrigerant
• Refer to Appendix B and C of the policy for methods of topical anesthesia application for pain control (saline, lidocaine, ice, etc.).
• Note that there is a new procedure for topical anesthetic skin refrigerant.
• Topical Refrigerant KEY POINTS• MD order NOT required.• Wash selected site with soap and water; dry.• Disinfect the area.• Hold the container 3 to 7 inches away and spray
an area as big as a quarter until it turns white (4 to 10 seconds).
• Perform needle stick procedure within one minute.• Advise patient thawing may cause discomfort.
Gebauer’s Pain Ease
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