Ava

Front 1

What should be considered for the renal patient, what stage of CKD do you need a nephro consideration?

Back 1

CKD 3 or higher
pg 4

Front 2

If pt has CKD 3 or higher what VAD is recommended?

Back 2

IJ

Front 3

Do you avoid placing a VAD on ipislateral side of a AVF?

Back 3

Yes

Front 4

When is the exception that a VAD can be placed on the same side of a AVF?

Back 4

Hospice patient but always discuss with the nephrologist.

Front 5

What should be considered for the renal patient, what stage of CKD do you need a nephro consideration?

Back 5

CKD 3 or higher
pg 4

Front 6

If pt has CKD 3 or higher what VAD is recommended?

Back 6

IJ

Front 7

Do you avoid placing a VAD on ipislateral side of a AVF?

Back 7

Yes

Front 8

When is the exception that a VAD can be placed on the same side of a AVF?

Back 8

Hospice patient but always discuss with the nephrologist.

Front 9

In the presence of a pacemaker or automatic intracardiac difibrillator (AICD), avoid PICC insertion on ipsilateral side for at least how long?

Back 9

6 months
p6

Front 10

When do you avoid placing a VAD in a pedi?

Back 10

Avoid CVAD and PVAD insertion in lower extremities of crawling or ambulating patient.

Front 11

Power injectable devices are made of polyurethane and engineered to withstand high pressures. What pressure can these devices withstand?

Back 11

>300 pounds per square inch PSI

Front 12

What is placed thru a power injectable device?

Back 12

IV contrast during a CT (computerized tomography) or MRI (magnetic resonance imaging)

Front 13

What is a PVAD?

Back 13

Perpherally Vascular Access Device (MLC and PIV)

Front 14

What is a CVAD?

Back 14

Central Venous Access Device (PICC, IVAD's, non-tunneled and tunneled central catheters)

Front 15

What is a IVAD?

Back 15

Implanted (subcutaneous) Venous Access Catheter

Front 16

When would PiCCs with antimicrobial properties be beneficial?

Back 16

MAY be beneficial with patients with probable septicemia and neutropenia.

Front 17

For Chemotherapy administration:
When is PICCs the device of choice

Back 17

When the duration is unknown
Short term <3 months

Front 18

For Chemotherapy administration:
When is a IVAD the device of choice?

Back 18

For complex chemo protocols
*infusion therapy > 3 months
*intermittent and continuous infusion chemo

Front 19

For Chemotherapy administration:
When is a Tunneled CVAD the device of choice?

Back 19

Patients with acute leukemia and other blood ca and pts undergoing blood and marrow transplants.

Front 20

What type of VAD in most frequently used in peds?

Back 20

Tunneled CVADs p6
IVADs are used less due to size, pt fear of needle access and potential dislodgemt of needle with activity.

Front 21

TPN:(p8)
What VADs can be used for yrs in home health settings or alternative care settings?

Back 21

IVADs and tunneled VAD

Front 22

TPN:p8
If TPN is given thru a multilumen VAD what should be considered?

Back 22

Consider ad dedicated lumen for TPN infusion.

Front 23

Chemotherapy: p7
Should chemo be interupted? why?

Back 23

No.
Increased risk of exposure to hazardous materials to pt and clinician.

Front 24

Frequent Blood transfusions: p8
What would be the device of choice?

Back 24

IVAD
ex sickle cell

Front 25

Give an ex. of when intravenous meds that require reliable venous access for daily or continuous infusion?

Back 25

Specific meds such as remodulin, prostacylin or flolan for pulmonary hypertension. These would be continuous infusions. p9

Front 26

For continuous or daily infusions, what is the VAD of choice?

Back 26

Single lumen tunneled CVAD is usually the choice.
PICC may be considered as a bridge. p9

Front 27

For plasmapheresis and stem cell collections what type of VAD is used? What are the required flow in ml/minute?

Back 27

Large bore catheter.
90 to 120 ml/minute

Front 28

What are the flow rates for a hemodialysis catheter?

Back 28

350-400 ml/minute p10

Front 29

How long after a lymph node is removed can lymphedema occur?

Back 29

can occur yrs or decades after original lymph node dissection surgery. p11

Front 30

If the pt has the inability to tolerate a pneumothorax, what VAD is contraindicated?

Back 30

Subclavian CVAD insertion p12

Front 31

Which patients would have the inability to tolerate a pneumothorax?

Back 31

Existing pneumo
COPD
pts who could decompensate
bullous lung disease
Bullous emphysema is one or more thin-walled, air-containing spaces, conflated by ruptured pulmonary alveoli. These air-containing spaces are termed as "bulla" (pl. bullae), which is a thin-walled air sacs in the lung tissue, more than 1cm, and filled with air with a tendency to burst. emphysema in which bullae form in areas of lung tissue so that these areas do not contribute to respiration

Front 32

What are some of considerations .when placing a VAD in a morbid obese patient?

Back 32

* Requires US guidance and experience
*Consider potential sites in terms of ability to maintain a dry and intact dressing and ability to stabilize the CVAD
*for a picc the cephalic vein may be most appropriate due to moist insertion site or dislodgement p13

Front 33

What are the risks of placing a CVD on the ipsilateral side of a AICD (Automatic Implantable Cardioverter Defibrillator)?

Back 33

*More recently placed the greater the risk of lead dislodgement
* risk of occlusion of the subclavin

Front 34

Which CVDs are contraindicated for sepsis/bacteremia?

Back 34

Tunneled CVDs
Acute CVDs without antimicrobial protection
Picc without antimicrobial protection

Front 35

What are the considerations for a patient with Reynauds Syndrome or peripheral vascular disease?

Back 35

Pt is at increased risk of catheter related thrombosis due to compromised circulation

Use the smallest gauge to accomplish the therapeutic goal.

Front 36

if on evaluation of site determination it is noted that there is prominent superficial vein in the area of planned CVAD, what may that indicate?

Back 36

Neighboring or central vein stenosis or thrombosis.

Front 37

Avoid non-compressible or partially compressible target veins, why?

Back 37

these veins may denote probable thrombosis.

Front 38

Measuring by anatomical landmarks:
How do you measure for a PICC placed in the arm?

Back 38

1.position the arm 90 degrees from the body
2. measure from the planned insertion site to the right clavicular head
3.then down to the 3rd intercostal space.
p17

Front 39

Studies using landmark-based methods have reported failure rates and complication rates as high as what %?

Back 39

Failure rates: 30%
Complication rates: 18.8%
p17

Front 40

Measuring by anatomical landmarks:
How do you measure for a PICC placed in the scalp?

Back 40

1. Identify planned insertion site
2. Measure from insertion site, along the jugular vein
3. to the right clavicular head and then to the 3rd intercostal space.
p17

Front 41

Measuring by anatomical landmarks:
How do you measure for a PICC placed in the lower extremity?

Back 41

1. Identify planned insertion site
2. Measure from the insertion site up the leg towards the umbilicus
3. to the xyphoid process
p17

Front 42

Measuring by anatomical landmarks:
How do you measure for a non-tunneled percutaneous catheters?

Back 42

1. Measure from the intended insertion site
2. Along the intended venous course
3. to the 3rd intercostal space
4. Along side the right side of the sternal border.
p17

Front 43

What is the function of the skin?

Back 43

1. barrier against microorganisms
2. provides sensory regulation
3 provides temperature regulation

Front 44

What are the layers of the skin?

Back 44

epidermis and dermis

Front 45

Skin ranges in thickness
What is the thickness of the eyelids?
heels/palms?
average of most of the body?

Back 45

eyelids: 0.5mm
palms/heels: 4mm
average of most of the body: 1-2mm

Front 46

What is the epidermis composed of?

Back 46

Forms the protective covering. It is composed of epithhelial tissue.

Front 47

What is the dermis composed of ?

Back 47

Composed of connective tissue
Highly sensitive and vascular...contains capillaries and nerve endings.

Front 48

What is composed of the superficial fascia or subcutaneous areolar/tissue connective tissue?

Back 48

Adipose tissue, the superficial veins used for peripheral venipunctures are located in this layer.

Front 49

Explain the systemic circulation on the venous side.

Back 49

*Transports deoxygentated blood from the tissues back to the right side of the heart.
*located superficial and deep
*thinner walls
*collapsible and distendable

Front 50

Explain the systemic circulation on the arterial side

Back 50

*Transport oxygenated blood from the left heart to the organs and tissues.
*Thicker walls
*Elastic tissue in walls: maintains pressure during diastole to maintain forward movemt of blood
*Generally located deep
*Rapid flow rates compared to venous.

Front 51

Explain the function of the pulmonary veins.

Back 51

Pulmonary vein transport the oxygenated blood to the left side of the heart. (atrium)

Front 52

Explain the function of the pulmonary arteries.

Back 52

Pulmonary arteries transports unoxygenated blood from right ventricle to the pulmonary capillary bed for oxygen and carbon dioxide exchange.

Front 53

What are the 3 layers of the vein?

Back 53

Tunica adventitia
Tunica media
Tunica intima (endothelium)

Front 54

What is the tunica adventitia?

Back 54

Vein: Outermost layer, Connective tissue, supportive layer

Artery: Outermost layer, thicker layer of connective tissue compared with veins

Front 55

What is the tunica media?

Back 55

Vein: Middle layer
Composed of smooth muscle and elastic tissues
Contains nerve fibers for vasoconstriction and vasodilation.
Collapsible/distensible

Artery: Middle layer
Composed of more layers of smooth muscle and elastic tissues & more rigid compared to veins.
Tend not to collapse
Regulates blood flow
Vasoconstricts with pain and anxiety.

Front 56

What is the tunica intima or endothelium?

Back 56

Vein: Inner most layer
* Single layer of smooth muscle, flat endothelial cells, lining all bl vessels, including veins, arteries, heart and valves & capillaries.
*Non-thrombogenic
*Damage to this layer exposes underlying collagen layer & initiates activation of plt to create a plt. plug and activates clotting cascade to deposit fibrin in the plt plug.
*Damage to this layer also allows fluid to leak across the vessel wall due to hydrostatic pressure as seen in infiltrates.

Artery: innermost layer
*Single layer of smooth flat endothelial cells, lining all bl vessels
*Non-thrombogenic
*Damage to this layer can cause thrombus formation; loosening of a large thrombus can cause significant embolic events...stroke, pulmonary embolus or other end organ or to the periphery

Front 57

Explan the basilic.

Back 57

Basilic vein continues up the medial side of the arm, across the antecubital fossa, traversing up the medial side of the upper arm terminating where it joins the brachial veins to become the axillary vein

Front 58

What is the vein of choice for PICCs or midlines?

Back 58

Basilic

Front 59

Explain the route of the brachial vein.

Back 59

Orginates in the antecubital fossa, traverse up the middle of the arm along with the brachial artery.

Front 60

Why use caution when using the brachial vein on pediatrics?

Back 60

PICC insertion in young or nonverbal pts do not have the ability to verbalize symptoms of nerve injury which includes pain or numbness.

Front 61

What does medial mean?

Back 61

Relating to, situated in, or extending toward the middle; median.

Front 62

What does dorsal mean?

Back 62

toward, on, in, or near the back or upper surface of an organ,

Front 63

Explain the route of the axillary vein

Back 63

Begins at the junction of the basilic and brachial veins, transverses through the shoulder and terminates at the lateral border of the first rib.

Front 64

Is the axillary vein easy to access?
When would this be accessed?

Back 64

Easy to access with ultrasound guidance.
Used for CVAD when trying to avoid the risk of pneumothorax or arterial puncture. p21

Front 65

When should the axillary vein not be used?

Back 65

Should not be used for CVAD in pts with CKD or ESRD unless cleared with a nephrologist.

Front 66

Explain the route of the subclavian vein.

Back 66

Subclavian vein is a continuation of the axillary vein and runs from the outer border of the first rib to the medial border of anterior scalene muscle.
Joins with the internal jugular vein to form the brachiocephalic vein (innominate vein)
p22

Front 67

CVAD insertion into the subclavian increases the risk for what?

Back 67

Risks include pneumothorax, hemothorax, subclavin arterial puncture and catheter pinch-off. p22

Front 68

When should a subclavian not be placed?

Back 68

Subclavian should NOT be placed in patients with CKD stage 3 or higher or ESRD unless cleared by a nephrologist.

Front 69

What does IHI recommend the subclavian or the IJ?

Back 69

Subclavian approach over the IJ site for lower CLABSI, intraclavicular sites have lower bioburden compared with the neck sites.
Bioburden: # of bacteria living on a surface before it is sterilized.

Front 70

Explain the route of the brachiocephalic on the left and right?

Back 70

Each is formed at the root of the neck by union of the ipsilateral internal jugular and subclavian veins.

Front 71

A catheter tip terminating in the brachiocephalic has a higher risk of what?

Back 71

High risk of causing venous thrombosis.

Front 72

Describe the route of the left brachiocephalic vein?

Back 72

Left brachiocephalic vein is longer compared with the right brachiocephalic and enters the SVC at a near 90 degree angle.

Front 73

What is the largest vein in the neck?

Back 73

internal jugular

Front 74

What site is recommended for the tunneled CVADS and ports?

Back 74

IJ p23

Front 75

What type of insertion runs the risk for pinch off ?

Back 75

subclavin, piccs

Front 76

Vein of choice for short term dialysis catheters?

Back 76

Vein of choice for insertion of dialysis short term CVAD as it avoids problems of stenosis that could impede creation of AVF on the ipsilateral side. p23

Front 77

Explain the route of the external jugular

Back 77

Superficial vein that originates near the angle of the mandible and courses over the sternocleidomastoid muscle. Ej dives into the subcutaneous tissue eventually emptying into the subclavian vein.
**Not used for venous access.

Front 78

When is an external jugular accessed (3)?

Back 78

*It is superficial accessed for emergent and very short IV access.
*When can't get another access, and large amts of fluid needs to be given.

Front 79

What size IV catheter can the EJ accommodate?

Back 79

18g or larger

Front 80

When an IV is placed in the EJ, what is at risk?

Back 80

thrombosis
extravasation

Front 81

What is the largest vein in the upper body?

Back 81

SVC

Front 82

What is the flow rates in the SVC?

Back 82

2 L per minute

Front 83

CVADs placed in the hepatic or thoracic veins or in the lower extremities should have their catheter tips located where?

Back 83

In the inferior vena cava above the level of the diaphragm.

Front 84

IVC may be accessed directly thru which approach?

Back 84

Via translumbar approach

Front 85

IVC may be accessed indirectly thru which approach?

Back 85

Via common fermoral veins or hepatic vein (transhepatic approach) p25

Front 86

When is the femoral site used for CVAD access?

Back 86

When used for short term access.

In pts with severe coagulopathy or profound resp failure, at risk for hemothorax or pneumo

When there are contradictions for placing a device in the neck or chest.

Front 87

How do you located the femoral for access?

Back 87

Lies within the femoral triangle in the inguinal-femoral area.

Surface anatomy is identified for venipuncture by palpating the point of maximal pulsation of the femoral artery immediately below the level of the inguinal ligament and marking a pt approximately 0.5cm medial to this pulsation.

Front 88

Disadvantage to the femoral site?

Back 88

It presents a field that is potentially contaminated because of the proximity of the perineal area.

Front 89

Where is the hepatic vein located?

Back 89

Near the liver and drains into the inferior vena cava

Front 90

What vein is typically accessed for a transhepatic access?

Back 90

Middle hepatic vein

Front 91

When is a transhepatic access done?

Back 91

Is an alternative approach into the IVC. it can be used in the setting of SVC occlusion and in pts with infrarenal vena cava occlusion.

Catheter tip terminated in the IVC.

Front 92

Describe the path of the posterior auricular vein.

Back 92

Superficial vein on side of head. Descends behind the ear to join the posterior section of the temporal maxillary vein into the external jugular

Front 93

What vein is located behind the ear and the pathway is tortuous?

Back 93

Posterior auricular

Front 94

Describe the pathway of the azygos vein.

Back 94

Azygos vein ascends from the abdomen and arches anteriorly to enter posterior wall of the SVC

Front 95

When would the azygos vein enlarge?

Back 95

Enlarges in the setting of SVC occlusion or stenosis.

Front 96

If a catheter tip is in the azygos, what needs to happen?

Back 96

Catheter must be repositioned or replaced.
**When left in a collateral vein for access, be cognizant of potential complications of occlusion of a dominant collateral, leading to venous outflow obstruction.

Front 97

Can the azygos be used to access for CVC placement?

Back 97

While not typically used for CVC tip placements, azygos offers an alternative before other sites (such as direct IVC placement) are entertained.

Front 98

Describe the pathway of the saphenous vein.

Back 98

Begins at the inner side at the arch on the dorsum of the foot, ascends along the inner side of the leg and behind the knee. This vein terminates into the femoral vein.

Front 99

What vein can be palpated or visualized above the ankle?

Back 99

Saphenous

Front 100

What are 2 considerations for lower-extremity CVC?

Back 100

*Do not insert a lower extremity CVC in a crawling or ambulatory patient
* Numerous valves in the legs may cause threading difficulties.

Front 101

Describe the route of the popliteal vein.

Back 101

Formed by the junction of the anterior and posterior tibial vessels, ascends thru the popliteal space where it becomes the femoral vein p 27

* Can be palpated or visualized by the knee.

Front 102

Can the umbilical vein be used to place a CVC?

Back 102

Yes.

Front 103

How long is the umbilical vein available to place a CVC?

Back 103

Patent vein in the umbilical cord available for up to 1 week post birth for vascular access.

Front 104

Where is the catheter tip located after inserting into the umbilical vein for CVC placement?

Back 104

catheter tip is placed above the level of the diaphragm for all types of infusates and CVC monitoring.

Front 105

Can you use a single or dual lumen catheter for umbilical access?

Back 105

Can use either

Front 106

How to find a choice of arterial access?

Back 106

Choice of artery is dependent on the ability to palpate a pulse or to locate it by Doppler flow or ultrasound guidance.

Front 107

Which artery is the most popular site for an art line?

Back 107

Radial

Front 108

Describe the path of the radial artery

Back 108

Begins at the bifurcation of the brachial artery, just below the bend of the elbow and pases along the radial side of the forearm to the wrist.

Front 109

What are the 3 arteries used for art lines?

Back 109

Radial
Femoral
Brachial

Front 110

Where do you access for a brachial art line?

Back 110

Several cms above the antecubital fossa, cannulation of the brachial artery may require ultrasound guidance as it courses deeper up the arm.

Front 111

For peds: the patient will usually have piccs inserted in a procedure room, why?

Back 111

To avoid violation of the "safe haven" of patients room p 29

Front 112

What should be considered when placing a CVAD in a peds pt? (5)

Back 112

1.Sedation: anxiolytics and mild, moderate and deep sedation
2. Anesthetics (topical, oral, IV)
3. Child life specialist involvement
4 Parental presence should be considered for planned PICC insertions.
5. Consider coordinating any CVAD insertion with other planned procedures

Front 113

What are considerations to look at prior to placing a CVAD in an infant?

Back 113

1. consider sucrose water to decrease pain
2. for infants and toddlers, use of heel warmers may help to dilate the veins
p30

Front 114

What position is appropriate for CVAD placement?

Back 114

Supine or trendelenberg

Front 115

For the infant what is an effective way to position in order to get the cvad in?

Back 115

For the young infant, bundling is an effective way to minimize movement and provide comfort. p30

Front 116

What does the maximal sterile barrier precautions include?

Back 116

cap
mask
sterile gown
sterile gloves
large sterile drape (total body drape)
Masks on all personnel in the room

Front 117

What is the difference between patient verification confirmation and time out?

Back 117

Time out:
verbally confirm name and DOB or/and MRN and site

Pt verification:
Have pt state name and DOB
or/and
verify armband for correct name and MRN with other documentation.
p31

Front 118

What is the proper skin antisepsis used for CVAD excluding the femoral? And how is it used?

Back 118

>0.5% Chlorhexidine with alcohol p40

Friction on the skin for 30 seconds and allowed to dry

Front 119

How long should the chlorhexidine be applied for a femoral site?

Back 119

Should be applied for at least 2 full minutes using friction and allowed to dry. p31

Front 120

The used of chlorhexidine as a skin antiseptic is not recommended for pts under what age?

Back 120

under 2 months of age

Front 121

Catheter is secured to the skin by what 3
methods?

Back 121

suture
staples
securement device
p32

Front 122

What are the 4 ways to verify catheter tip position?

Back 122

CXR
fluoroscopy (live xray)
intravascular ECG
intravascular doppler flow: method to determine blood flow velocity

Front 123

Peds:
Where is the optimal tip location for CVADs inserted in the upper chest or extremity?

Back 123

lower 1/3 of SVC or cavo-atrial junction
p33

Front 124

Peds:
Where is the optimal tip location for CVADs placed in the IVC?

Back 124

diaphragm and the right atrium

Front 125

Dialysis CVADs: where is the tip located in the short-term cuffed dialysis CVC vs the long term cuffed dialysis CVC?

Back 125

Short term: distal SVC/right atrial junction
Long term: right atrium

Front 126

Where is the tip of the femoral dialysis CVC located?

Back 126

IVC
p34

Front 127

Hemodialysis requires high flow rates, what is that rate?

Back 127

Usually >350ml/min

Front 128

What is the difference between a seldinger technique vs the modified seldinger technique?

Back 128

Seldinger involves accessing a vein or artery with a small needle introducing a flexible guidewire removing the needle and advancing the catheter over the wire.
Modified ST: accessing a vein with a small needle (21 or 22 g) into which a guidewire is advanced the needle removed and an introducer/dilator is advanced, the catheter is advanced thru the introducer.

Front 129

Catheter tip malposition accounts for what % if CVC complications?

Back 129

3%

Front 130

Repositioning is indicated for CVC tips outside of the ca junc or distal svc, excluding dialysis cvads. explain how thru flushing?

Back 130

tips may be repositioned by rapidly flushing with 20 ml of normal saline using a 10ml syringe or larger.

Front 131

How should the patient be positioned to promote optimal tip location when malpositioned in the internal jugular?

Back 131

HOB 45 to 90 degrees
Flush if real time ultrasound available visualize catheter in the vein to determine success of flush intervention using transverse and longitudinal views p38

Front 132

How should the patient be positioned to promote optimal tip location when malpositioned in the contralateral subclavian vein?

Back 132

Ipsilateral position, HOB elevated, Flush.

EX: catheter placement on the right, tip in the left subclavian, position patient on the right side.

Front 133

How should the patient be positioned to promote optimal tip location when malpositioned in the axillary vein?

Back 133

Contralateral position, HOB elevated, flush

EX: catheter placement on the right, tip in the right axilla, position pt on the left side

Front 134

How should the patient be positioned to promote optimal tip location when malpositioned in the azygous vein?

Back 134

Position of comfort with HOB 30 degrees...flush

Front 135

If the CVAD is in the RA, what action is taken to correct placement?

Back 135

retraction per doctors order.

Front 136

What are the adult and pediatric heparin dosages for heparin locking a catheter?

Back 136

10-1000u/ml for adults
1-10 u/ml for peds

Front 137

What dressing type is recommended to protect the insertion site of a CVAD?.

Back 137

Transparent, semi-permeable (TSM) polyurethane dressing
TSM dressings allow direct visualization of the insertion site and allows natural moisture produced by skin to wick away
p40

Front 138

How often do gauze dressings get changed?

Back 138

Every 2 days

Front 139

If allergic to chlorhexidine, what is an alternative?

Back 139

1% or 2 % iodine, iodophors and isopropyl alcohol

Front 140

If institutional rates of CLABSI are higher than institutional goals consider what?

Back 140

Chlorhexidine impregnated foam disc.

which is changed with each dressing change or if visibly soiled

Front 141

What is the only thrombolytic agent approved by the FDA?

Back 141

Alteplase produced by Genentech Inc.

Front 142

When is an antibiotic lock recommended?

Back 142

Indicated for pts with long-term catheters and diagnosis of CRBSI with no signs of exit site or tunneled infection and for whom catheter salvage is the goal.

Front 143

How is the antibiotic lock instilled and explain what is instilled?

Back 143

Instill supra-therapeutic dose of an antibiotic, to which the causative microbe is susceptible, in the catheter lumen and allow dwell of hr or days. Usually given in conjunction with systemic antibiotics. p 42

Front 144

Which microbe is most likely to respond to an antibiotic lock and which 2 microbes are not likely to respond?

Back 144

Coagulase negative staphylococci most likely to respond
and
S aureus and Candida are not

p42

Front 145

Which is harder to kill thru antibiotic lock, a sessile or planktonic bacteria?

Back 145

Sessile bacteria
Sessile:fixed in one place; immobile

Front 146

What concentration does the antibiotic for an antibiotic lock need to be in order to kill sessile bacteria?

Back 146

antibiotic conentrations need to be 100 to 1000 times greater to kill sessile bacteria

Front 147

Catheter removal recommended for CRBSI for what 2 types of bacteria?

Back 147

S aureus and Candida species

Front 148

What constitutes an antimicrobial catheter?

Back 148

Use of chlorahexadine/silver sulfadiazine
or
minocycline/rifampin
impregnanted CVCs

Front 149

When would an antimicrobial catheter be used?

Back 149

In a pt whose catheter is expected to remain in place for greater than 5 days if CLABSI rates are not decreasing after successful implementation of a comprehensive strategy to reduce infection rates.
p43
Comp strategy:
1 educating persons who insert and maintain the lines
2 use of maximal sterile barrier precautions
3 used of 0.5% chlorahexadine with alcohol

Front 150

What is the primary risk of catheter removal?

Back 150

air embolism

Front 151

What is the removal procedure of a central catheter?

Back 151

1 place pt in a flat or trendelenburg position.
2 pt should execute valsalva maneuver during which catheter is removed gently and swiftly.
* if pt is on a respirator catheter removal should occur at maximum inhalation and removed quickly.
3 quickly place 4x4 gauze pad over the site while applying continuous pressure
4. apply antiseptic ointment at the sited and cover with dressing for at least 24 hrs.
p44

Front 152

Is it necessary to place the pt in a supine or trendelenburg position to remove a PICC?

Back 152

No, since the PICC is in a peripheral vein.

Front 153

What is placed over the site on a PICC that has been removed?

Back 153

1 antiseptic ointment and sterile gauze over the site with continuous pressure
2 leave on for at least 24 hrs or until epithelialized.

Front 154

In an event of resistance on removal of a PICC what do you do?

Back 154

1 secure the line to the arm
2 warm pack to vasodilate the vein
3 reattempt removal after 15-30 min

Front 155

What do you do if meeting persistant resistance after 2 attempts?

Back 155

obtain an x-ray to rule out a knot in the line.

Front 156

For a PIV:
Is less than how many inch?
Intended for short term therapy for how many days?
pH? osmolality?

Back 156

less than 3 in
1-6 days
pH 5-9
osmolality <600

Front 157

Midline Catheters:
_to _ inches in length?
intended for how long?
pH? osmolality?

Back 157

3 to 8 inches
6day to 4 weeks
pH of 5-9
osmolality <600 mOsm/L

Front 158

Is the insertion of a midline a sterile procedure?

Back 158

Yes

Front 159

Which vein are used for the midline insertion?

Back 159

basilic and cephalic

Front 160

What size syringe is used to flush central lines?

Back 160

10 ml or larger

Front 161

Dressing Changes:
What type of dressing is rrecommended?

Back 161

(TSM) transparent semi-permable polyurethane dressing

Front 162

How often is a TSM dressing changed?

Back 162

every 7 days or as needed

Front 163

How often is a gauze dressing changed?

Back 163

every 2 days or as needed

Front 164

What is the preferred skin antiseptic?

Back 164

>0.5% chlorahexadine with alcohol

Front 165

If allergic to chlorahexadine, what are alternative skin antiseptics?

Back 165

1% or 2% tincture of iodine
70% alcohol
iodophors

Front 166

Replace a PIV no more frequently than ________ to ______ hrs.

Back 166

72 to 96 hours

Front 167

Midline
When removed what is placed over the site and for how long?

Back 167

Place sterile gauze with anitseptic ointment over the site while applying continuous pressure. Leave dressing on for at least 24 hrs or until site is epithelialized.

Front 168

How often do you replace a PIV in pediatrics?

Back 168

Replace PIV in children only when clinically indicated
p49

Front 169

What does the French scale measure?

Back 169

It is the measurement of the outside diameter of the catheter.

An increasing Fr size corresponds to a larger diameter catheter.
p51

Front 170

What do the catheter Fr sizes range from?

Back 170

1.9 Fr (neonatal PICCs) to 15 Fr (some dialysis CVADs)
p 51

Front 171

Gauge scale abbreviated g, what does the g sizes range from?

Back 171

Gauge sizes range from 30g (intradermal injections) up to 14 g.

the larger the g the narrower the bore of needle.

Front 172

Catheter materials in the US are radiopaque, why?

Back 172

To facilitate location of catheter emboli in the event of shearing or fracture.
p51

Front 173

What are the most commonly used catheter materials?

Back 173

Silicone
Polyurethane

Front 174

What is the difference between silicone and polyurethane?

Back 174

Silicone is not affected by chemicals such as alcohol

Polyurethane is affected by alcohol, some are designed to be "power injectable" withstand pressures of approximately 300 PSI

Front 175

PIV
what is the dwell time?

Back 175

72-96hrs

Front 176

PIV
What is the g ranges?

Back 176

24g to 14 g

Front 177

PIV
When using a butterfly or winged needle what is it intended for?

Back 177

single use administration

Not recommended for chemo administration

Front 178

Midline
Give a description of a midline

Back 178

Approx 20 cmin length and terminates in the upper arm at the level of the axilla.
p53

Front 179

Midline
what is the dwell time

Back 179

2-4 weeks

Front 180

Midline
What is the infusate parameters?

Back 180

pH of 5-9
osmolality <600mOsm/L

Front 181

Midline
What are the common veins accessed?

Back 181

basilic
brachial
cephalic

Front 182

Nontunneled CVAD
What is the dwell time?

Back 182

up to 7 days

Front 183

Non tunneled CVAD
What is a description of this?

Back 183

see p 54

Front 184

Non tunneled CVAD
What are the common veins accessed?

Back 184

Internal jugular
external jugular (not common)
axillary (not common)
subclavian
femoral (not recommended)

Front 185

PICC
common vein accessed?

Back 185

basilic
brachial
cephalic

IJ option for pts with poor access (not an RN access)
p55

Front 186

Tunneled CVAD
What is a description?

Back 186

Single, dual or triple lumen with tip in the distal SVC or CA Junc.

Antimicrobial cuff is present on the catheter below the skin surface and helps secure the CVC once the cuff has been embeded

Aval in power injectable

Front 187

Tunneled CVAD
What is the dwell time?

Back 187

Years

Front 188

Tunneled CVAD
Common veins used?

Back 188

Subclavian
internal jugular

Front 189

Implanted ports
What is the dwell time?

Back 189

Years

Front 190

Implanted ports
Common veins accessed?

Back 190

subclavian
IJ

Front 191

Implanted ports
How many ports can be available?

Back 191

single or double

Front 192

Implanted ports
When is the port the device of choice?

Back 192

Preferred device for frequent or long term intermittent IV therapy due to ease of use and low CRBSI rates
p 58

Front 193

Implanted ports
What type of needle is used to access a port?

Back 193

Non-coring needle

Front 194

Short term dialysis & apheresis
What is the dwell time?

Back 194

No more than 1 week

Front 195

Short term dialysis & apheresis
What is the 1st choice and 2nd choice of veins accessed?

Back 195

1st choice: Right IJ
2nd choice: Left IJ

Front 196

Short term dialysis & apheresis
What veins are avoided to preserve the vasculature for future fistula placement?

Back 196

Subclavin
axillary
cause of high rates of stenosis
p60

Front 197

Short term dialysis & apheresis
Large bore catheter are used what is the Fr size

Back 197

12-15 Fr

Front 198

Short term dialysis & apheresis
What is the flow rates for dialysis?

Back 198

at least 350 ml/minute

Front 199

Short term dialysis & apheresis
What is the flow rates for apheresis?

Back 199

90-120 ml/minute

Front 200

Short term dialysis & apheresis
What is the tip placement for short term catheters?

Back 200

distal/ca junction

Front 201

Long term dialysis
What is the tip placement?

Back 201

Proximal right atrium

Front 202

What is the difference on the placement of long vs short term dialysis catheters?

Back 202

Long term dialysis is inserted with a short tunnel on chest or thorax
p60

Front 203

Long term dialysis
What is the dwell time?

Back 203

weeks to months

Front 204

Long term dialysis
Common veins accessed?

Back 204

Right IJ 1st
Left IJ 2nd

Avoid the subclavin and axillary because of high stenosis rates
p60

Front 205

Which has higher infection rates Long term dialysis catheters or AVF?

Back 205

Long term dialysis catheters

Front 206

What is a pulmonary artery catheter?

Back 206

Swan-ganz catheter
Used primarily for diagnostic purposes

Front 207

Where does a pulmonary artery catheter/ swan-ganz catheter originate and where does it terminate?

Back 207

Common veins accessed:
R or L IJ
Subclavin
Femoral
advanced to the pulmonary artery

Front 208

What is a pulmonary artery catheter used for?

Back 208

Allows for pressures in the R atrium, R ventricle, pulmonary artery and wedge pressures (filling pressures of the left atrium)

detect heart failure
sepsis
evaluate the effects of drugs
monitor therapy

Front 209

What is a SvO2 catheter?

Back 209

Temporary CVAD with a special probe which is advanced and lodged into the ventricle wall providing instant readings of SvO2 or oxygen saturation of the ventricle tissues. p 62

Front 210

What is the SvO2 catheter designed to do?

Back 210

Designed to monitor mixed venous oxygen saturation and provides on going measurements of oxygen consumption and ability to assess dramatic changes in the critically ill patient. p62

Front 211

Common veins accessed for the SvO2 catheter?

Back 211

IJs
Subclavian
Axillary

Front 212

Dwell time for the SvO2 catheter?

Back 212

Days

Front 213

Common veins used for an aquapheresis catheter?

Back 213

IJs
Axillary
Subclavian

Front 214

What is the dwell time for an aquapheresis catheter?

Back 214

No more than a few days
p63

Front 215

What is an aquapheresis catheter used for?

Back 215

Remove excess salt and water from pts suffering with severe fluid overload that cannot be readily treated with traditional diuretics as seen in end stage heart failure. p 63

Front 216

What are arterial catheters used for?

Back 216

Used in CC settings for continuous blood pressure monitoring,
used for blood gas measurements and lab specimens

Front 217

What is the dwell time of arterial catheters?

Back 217

Days

Front 218

What can be infused thru the art line?

Back 218

No infusions other than NS flushes.

Front 219

Common veins used for the art line?

Back 219

Radial artery
Brachial artery
Femoral artery

Front 220

Art lines should not be used for injection or IV meds, why?

Back 220

Can cause arterial spasms, tissue damage and amputation.
p63

Front 221

When is an umbilical venous catheter used?

Back 221

Short term access in critically ill infants and neonates, up to 1 week of age.
p64

Front 222

Umbilical venous catheters come in how many lumens?

Back 222

single or double

Front 223

Umbilical venous catheters have a dwell time of?

Back 223

Up to 14 days.
p64

Front 224

Where is the tip location of a umbilical venous catheter?

Back 224

Tip of the catheter should be in the IVC above the level of the diaphragm.

This allows for CVP monitoring, infusion of meds/solutions or TPN.
p64

Front 225

US guidance:
What is it used for?

Back 225

US is used to
locate veins
determine vein depth, diameter and compressibility p 65

Front 226

US guidance:
Is there high success rates with US guidance and IJ placements?

Back 226

CVAD placement in IJ site is associated with high success rate, decreased mechanical complications and more rapid catheter placements.
p65

Front 227

US guidance:
What are the thoughts of rate of success for the subclavian insertions?

Back 227

Mixed results reported with use of US guidance during subclavian catherization due to difficulty visualizing subclavian vein p65

This technique requires training and is recommended especially for internal jugular vein or axillary vein catheterization.

Front 228

What is the transverse plane on the US?

Back 228

The cross sectional dimension of an object/ able to view the diameter of a vein.
p67

Front 229

Medical Imaging Technology: What are the three devices used?

Back 229

Fluoroscopy
Tranillumination
Infrared and near infrared vessel identification

Front 230

Medical Imaging Technology:
How does fluoroscopy add in insertion and placement of a CVAD?

Back 230

Fluoroscopy facilitates the initial puncture and also subsequent manipulations (stenosis, kinks, sharp angle and inadvertent entry into collateral pathways)

Front 231

Medical Imaging Technology:
What is transillumination?

Back 231

Veins are visualized because red blood cells absorb colors of the light.

Used for peripheral IV and lab draws
Useful for patients with poor access or obesity

Front 232

Infrared and near infrared vessel identification technology, how does it work?

Back 232

primary application uses the fact that the transmission and absorption of near infrared (NIR) light in human body tissues contains information about hemoglobin concentration changes.
p69

Front 233

How does transillumination work?

Back 233

veins are visualized because red blood cells absorb colors of the light. p69

Front 234

Infrared and near infrared vessel identification technology illuminates what color?

Back 234

green

Front 235

Infrared and near infrared vessel identification technology and transillumination, which can penetrate subcutaneous tissue to a certain depth?

Back 235

Infrared and near infrared vessel identification technology
p69

Front 236

What is an intravascular doppler?

Back 236

a stylet that has a doppler built into the tip to determine direction of bloodflow in the great vessels of the thorax: helps guide catheter towards distal SVC p70

Front 237

What is a breakaway needle? And who are they used on?

Back 237

1 Needles with prescored line down the back of the middle of the needle, used for shallow approaches
2 After catheter insertion breakaway neeldle is carefully w/drawn over the catheter 2 wings are grasped and broken

Used primarily on neonates for PICCs smaller then 2 fr.

Front 238

What gauge needle is used for PICCs

Back 238

21 g

Front 239

What gauge is used for larger CVADs?

Back 239

16-18 g

Front 240

Topical anesthetics are routinely used for who and when?

Back 240

For pediatrics
Routinely used for all types of venipunctures, including IV insertion and blood sampling. p72

Front 241

What type of lidocaine is routinely used for PIV, PICCs and CVC insertions?q

Back 241

1 or 2 %

Front 242

What size gauge needle is used to inject lidocaine?

Back 242

25-30 g

Front 243

What is added to lidocaine to buffer it or lessen the burning?

Back 243

Sodium bicarbonate
p 73

Front 244

What normal saline also has similar effects as lidocaine for decreasing venipuncture pain?

Back 244

Bacteriostatic normal saline

Front 245

What type of needle is used to access a port?

Back 245

A non coring needle

Front 246

Non-coring needles are used to access what (3)?

Back 246

implanted venous ports
hepatic arterial port/pumps
intra-peritoneal ports
p73 (see addit. sheets)

Front 247

When inserting a non-coring needle into a port what is ideal?

Back 247

The needle should reach the bottom of the port reservoir and
the external portion should lie relatively flat against the skin.
p73

Front 248

What are the risks associated with non-coring needles?

Back 248

Needle is very sharp, rebound injuries are common due to unusual force needed to overcome resistance of dense silicone septum.

needle designs can be active or passive
p74

Front 249

Needleless connectors were mandated by what?

Back 249

Bloodborne Pathogen standard from the OSHA (Occupational Safety and Health Administration).
p74

Front 250

Needleless connectors external surface must be cleansed with what and for how long?

Back 250

Alcohol wipe or chlorhexidine and alcohol using friction for at least 15 to 30 seconds.
p74

Front 251

How do you flush a split septum cap to prevent blood reflux into the catheter?

Back 251

Split septum is on the left.
Clinician must apply positive pressure to last milliliter of flush or lock solution in syringe, clamp (if present) then disconnect syringe from needleless connector.
p75

Front 252

What are the 3 types of Mechanical valve/luer activated valves for needless connectors?

Back 252

Negative displacement
Neutral displacement
Positive displacement
p75

Front 253

How is a needless connector with a mechanical valve and negative displacement flushed?

Back 253

apply positive pressure on flush syringe while clamping catheter then disconnect.
p75

Front 254

How do you flush a positive pressure needleless connecter with a mechanical valve? Neutral displacement?

Back 254

Clinician must disconnect flush syringe from needleless connector and clamp catheter after the syringe disconnection.
Clinician must disconnect syringe from needleless connector with no specific clamping sequence.
p75

Front 255

What does the maximal sterile barrier precautions include?

Back 255

cap
mask
sterile gown,
sterile gloves
large sterile drape (total body drape)
masks worn by all in room
p75

Front 256

Why use a 10ml syringe or larger when flushing?

Back 256

This allows the clinician to feel resistance or pressure when flushing against resistance.
p76

Front 257

What is typically used to flush a catheter?

Back 257

Normal saline 0.9%
p76

Front 258

If there is a known incompatibility of infusate with NS or other elecrolyte solutions, what is used as a flush?

Back 258

10ml of 5% dextrose solution followed by 10ml of NS flush.
p76

Front 259

Is there a clear minimum vol of flush solution that has been proven to be most efficacious in every situation and for every device?

Back 259

No, but it has become customary to flush with 10 ml of NS f (NaCL)or adult and older ped population.
p76

Front 260

Pediatrics flush volumes of NS vary in what amounts?

Back 260

0.5ml to 10ml
p77

Front 261

Are stopcocks used as a single patient use?

Back 261

Yes
p77

Front 262

When should stopcocks be changed?

Back 262

Should be changed with regularly scheduled IV tubing changes
p77

Front 263

When are topical hemostatic agents used?

Back 263

Used to stop bleeding within minutes with applied pressure immediately after CVC insertion procedures or post- insertion if bleeding is problematic.
p77

Front 264

What is the only FDA approved agent for thrombotic catheter occlusions?

Back 264

alteplase 2mg (Cathflo) or Cathflo Activase
generic: alteplase
trade: Cathflo
Formally known as t-pa or tissue plasminogen activator.
p78

Front 265

What is the mechanism of action of Cathflo?

Back 265

t-PA is a naturally occurring enzyme in the body that dissolves fibrin in clots when the body's natural fibrinolytic system is activated to dissolve clots when no longer needed.
p78

Front 266

When is t-PA indicated?

Back 266

For suspected thrombotic catheter occlusions or dysfunction when external mechanical occlusions have been ruled out; inability to infuse and/or lack of brisk bl return p78

Front 267

What is the dosage for Cathflo?

Back 267

2mg/2ml for adults and children >66lbs or 30kg and at least 2wks of age.
p78

Front 268

What is the efficacy of alteplase?

Back 268

83% restoration of patency with up to 2 doses, each dose instilled for up to 2 hrs.
p78

Front 269

What agent is used to dissolve a lipid precipitate/fat emulsions?

Back 269

70% ethanol (ethyl alcohol)

Front 270

What dosage of 70% ethanol is used to dissolve a lipid precipitate? And what is the dwell time?

Back 270

Catheter fill volume and 1 hour
p79

Front 271

What are the precautions when using 70% ethanol in a catheter?

Back 271

Do not use with polyurethane catheters as alcohol is known to degrade polyurethane over time with repeated and prolonged exposure.
p79

Front 272

What agent is used to dissolve mineral/acidic precipitate (pH1-5) in a catheter?

Back 272

hydrochloric acid (HCl)
p79

Front 273

What is the dosage of hydrochloric acid for a mineral/acidic precipitate (pH1-5)? And the dwell time?

Back 273

1ml of 0.1 Normal HCl
20 min, may repeat 1-2 times
p79

Front 274

What agent is used to dissolve alkaline precipitate/high pH 9-12 in a catheter?

Back 274

sodium bicarbonate (NaHCO3)
p79

Front 275

What is the dosage of sodium bicarbonate (NaHCO3) for an occluded catheter? And the dwell time?

Back 275

1ml of 8.4% of NaHCO3 and for 1 hr.
p79

Front 276

Antiseptic

Back 276

A chemical agent that destroys or inhibits microorganisms on skin or tissue and has an effect of limiting or optimally preventing infection.
p80

Front 277

Disinfectant?

Back 277

A chemical agent that destroys microorganisms on inanimate objects.
p80

Front 278

Bactericidal

Back 278

Kills microorganisms

Front 279

Bacteriostatic?

Back 279

Temporarily prevents microorganisms from multiplication, disrupts minor chemical reactions and slows metabolism resulting in increased time

Front 280

Properties of ideal skin antiseptic agents (6)?

Back 280

1. broad spectrum of activity
2. rapid bactericidal activity
3. persistence or residual properties on the skin
4. maintain its activity in the presence of organic material
5 be non-irritating or have low allergic and/or toxic responses
6. no or minimal systemic absorption
p.80

Front 281

Name the 3 types of solutions used on the skin?

Back 281

Chlorhexidine
Iodophors
Alcohol

Front 282

Chlorhexidine is a broad spectrum antiseptic what is it effective against?

Back 282

gram positive
gram negative
fair fungicidal agent
effective against most viruses
p81

Front 283

Chlorahexidine has a strong skin-binding property with up to how many hours of residual activity?

Back 283

6 hours
p81

Front 284

What % of Chlorahexidine with alcohol is preferred for insertion and maintenance site care of CVAD?

Back 284

>0.5% of Chlorahexidine
p81

Front 285

Pediatrics:
What age group can chlorahexidine be used?

Back 285

Not currently labeled for infants <2 months of age but there is supporting evidence to support its safety and effectiveness.
p81

Front 286

Iodophors, what is it?

Back 286

Solutions of iodine in complexes that contain a low amount of free iodine.
p81

Front 287

Povidone-iodine (Betadine) solutions contain up to ___% of an iodine complex and provide up to ___% free iodine for skin antisepsis.

Back 287

10% and 1%
p82

Front 288

Iodine tinctures and iodophors are safe antimicrobial agents effective against what?

Back 288

gram positive bacteria
gram negative bacteria
fungi
virsus
have minimal effect on bacterial spores
p82

Front 289

How long does iodine antiseptic need to be on the skin to be effective?
How long is the residual effect?

Back 289

2 minutes or more to release free iodine.
2 hours (residual effect)
p82

Front 290

What happens when iodine comes into contact with organic matter such as blood?

Back 290

It is neutralized and no longer effective.
p82

Front 291

Is iodophors recommended for skin antisepsis for the neonate population?

Back 291

Percutaneous absorption of iodine has been noted in neonates, with hypothyroidism induction in the newborn.
Iodophor solutions are usually not used in neonatal and infant populations.
p82

Front 292

What is the most common concentration (%) of isopropyl alcohol used for skin antisepsis?

Back 292

70%

Front 293

Alcohol demonstrates bactericidal effect on what organisms (4)?

Back 293

gram positive bacteria
gram negative bacteria
fungicidal
virucidal
p82

Front 294

What is the residual effect of alcohol?

Back 294

gone once it evaporates
p83

Front 295

Adhesive remover should not be used where?

Back 295

Do not use directly on insertion site.
p83

Front 296

What are the benefits of a skin protectant?

Back 296

Protects skin intergrity in pts with thin fragile skin
Enable dressing to adhere to skin, especially in diaphoretic pts
Do no use directly on the insertion site
p83

Front 297

How many liters of blood flow per minute with the body at rest?

Back 297

5 liters per minute
p88

Front 298

What is a direct measures of hemodynamic monitoring? (1)
Indirect measures of cardiac output (3)?

Back 298

direct: pulse rate and quality
indirect:
bl pressure
central venous pressure
continuous ECG
p89

Front 299

What is considered acidic/alkaline?

Back 299

pH<5 for acidic
pH>9 for alkaline
p91

Front 300

What 3 factors will increase the risk of catheter-related venous thrombosis?

Back 300

Inflammatory diseases
Solid tumor malignancies
Increased dwell time of catheter.
p92

Front 301

Which veins are of critical importance for the creation of hemodialysis fistula?

Back 301

Veins of the forearm, upper arm and subclavian.
p93

Front 302

Internal jugular vein is preferred vessel for central venous access, what french size and inserted how?

Back 302

<8 french and inserted via subcutaneous tunnel (reduces risk of CLABSI)
p93

Front 303

When are the 3 times a PICC would be appropriate for placement in a dialysis patient?

Back 303

Short life expectancy
Previous failure of arteriovenous access
Severe peripheral arterial disease with no possibility of future fistula construction in that limb.
p94

Front 304

What are the reasons for increase in number of leukocytes in the circulating blood?

Back 304

Infection
hemorrhage
coronary occlusion
malignant process or growth
pregnancy
toxemia

Front 305

When is it considered to place CVAD when the WBC is elevated?
What is the risk of placing CVAD when WBC is elevated?

Back 305

newly dxed leukemia pt often presents with elevated WBC. Immediate insertion of tunneled or PICC may be indicated for chemo.

May initiate bacterial "seeding" of catheter.
p94

Front 306

WBC normal range ?
Leukocytosis?

Back 306

4.5 - 10 thousand per microliter

Increase in # of leukocytes (above 10,000/mm) in circulating blood.
p94

Front 307

What is the normal range of plts?

Back 307

150-450 thousand per mcL
p94

Front 308

What is the usual lower limit for safe CVAD insertion into major thoracic vein?

Back 308

6 - 37 thousand per mcL
p94

Front 309

What is the device of choice for lower plt counts?

Back 309

PICC (<150 thousand per mcL)
p94

Front 310

What does creatinine measure?
How is it measured?

Back 310

Creatinine is a measure of kidney func

Chemical waste molecule generated from muscle metabolism and transported via blood to kidneys and filtered into the urine.
p95

Front 311

An elevated serum creatinine of what value or greater should have expert vascular access assessment before placement of any vascular access device?

Back 311

2ml/dl or greater
p95

Front 312

What does PT and INR measure?

Back 312

extrinsic pathway of coagulation. p95

Extrinsic Pathway - Is initiated with material outside of or "extrinsic" to the blood. This material, Tissue Thromboplastin (Factor III), is released by damaged tissue cells. Factor III permits the clotting process to take a chemical shortcut. As a result, the extrinsic pathway is a very rapid process, i.e., within 12 to 15 seconds. However, the production of Thrombin is low and the resulting clot is small. This pathway is most effective as a "quick patch" process.

Front 313

PT and INR are used to do what? (4)

Back 313

Monitor clotting tendency of blood

Measure warfarin anticoagulation

Measure liver function

Assess prior to invasive procedures such as CVAD insertion.
p95

Front 314

What are normal ranges for PT and INR?

Back 314

PT 11-16 seconds
INR 0.8-1.2 seconds
**INR indicative of therapeutic anticoagulation may be higher INR up to 2.5 when anticoagulants such as warfarin are used.
p96

Front 315

What does the PTT measure?

Back 315

Partial thromboplastin time measures intrinsic coagulation pathway. p96

Intrinsic Pathway - Is initiated by the blood coming in contact with exposed collagen in the blood vessel wall, i.e., material within the blood or blood vessel wall. This process is considerably slower (5 to 10 minutes) but results in the formation of larger amounts of thrombin. This allows the formation of larger clots.

Front 316

Air Embolus:
Arterial air embolism can result in what?

Back 316

Produces ischemia of any organ or extremity with poor collateral circulation.
p96

Front 317

Air embolism:
What are the causes? (7)

Back 317

1. Fracture of detachment of catheter connections.
2.Inadequate priming and/or failure to clamp lumens with open to air.
3. Presence of a persistent catheter tract following CVAD removal
4. Deep inspiration during insertion or removal (increases neg pressure within thorax)
5. Upright position reduces central venous pressure
6. Hypovolemia reduces central venous pressure.
7. Malfuction of self sealing valves in introducer sheaths.
p98

Front 318

What are the signs and symptoms of an air embolism?

Back 318

Dyspnea
Substernal chest pain
Sense of doom
Hemodynamic collapse
p98

Front 319

How does one prevent an air embolism?

Back 319

Position pt in supine or Trendelenburg during insertion/removal

Ask pt to Valsalva or hold his breath at CVAD insertion into chest veins and at removal

Occlude hub of the central venous catheter during insertion

Treat hypovolemia prior to catheter placement if possible

Use only luer lock connections
p98

Front 320

What is the intervention for an air embolism?

Back 320

*Place pt on the left side in Trendelenburg position
* Quickly identify the source of air entry and prevent further air embolization
* Administer oxygen if available
* Notify physician
* Monitor pt and vital signs closely
* Pt needs to be in an acute care setting.
*Supportive care (mech ventilation, vasopressors, vol resuscitation)
*Aspirate air from venous system only if central line is present.
*Closed chest cardiac massage
p98

Front 321

What is the second most common complication of non-imaging guided central venous access?

Back 321

Arterial puncture
p100

Front 322

Incidence of arterial puncture during attempted venous access performed without imaging guidance can be as high as ________%?

Back 322

7%
p100

Front 323

What are the 3 complications of an arterial puncture?

Back 323

Hemothorax
Major hematoma (especially the subclavin)
Compartment syndrome (serious condition that involves increased pressure in a muscle compartment. It can lead to muscle and nerve damage/problems with blood flow)
* especially damaging if artery in arm is punctured and unrecognized.
p100

Front 324

Why is it easy to have an arterial stick when placing a CVAD in a peds pt?

Back 324

In small infants, arteries can be compressed.
p100

Front 325

What are the s/s of an arterial puncture?

Back 325

*Bright red pulsatile bl return
*Pulsatile bl return may not be present in pts with very low bl pressure and catheter placement in the extrermity.
*Abrupt swelling at puncture site
*Pain, numbness, pallor or absence of pulse in affected extremity distal to punc site.
*Retrograde flow of blood in IV tubing
p100

Front 326

How to prevent an arterial puncture? (7)

Back 326

* Knowledge of general anatomic location of arteries in access area
* Real time ultrasound guidance in all CVC/PICC insertions
* Careful assessment of vessels prior to access
* Awareness of pts baseline coags
* Assessmt of bl return thru introducer needle prior to the dilator.
* Ability to visulize needle bevel as it enters the vein
* If not using USG, careful palpation of vessels to discern superficial artery vs vein.
p100

Front 327

What is the intervention with an arterial puncture?

Back 327

* If an artery vs vein placement is uncertain obtain bl gas sample for immediate interpretation.
* Prompt removal of needle/dilator/sheath/catheter when known arterial punc
*Apply pressure 5-10 min
*Apply pressure dressing
* May need to apply hemostatic dressing.
*Observe for additional bleeding
*Document adverse event/s/s/ interventions
p100

Front 328

Whatt is a Hemothorax?

Back 328

Blood in the pleural cavity?

Front 329

Accessing which veins will put you at risk for a hemothorax?

Back 329

axillary
subclavin
IJ
p101

Front 330

How is a hemothorax caused?

Back 330

Rare complication.....
likely dure to forceful insertion of introducer or catheter against vessel wall.
p101

Front 331

What are the s/s of a hemothorax?

Back 331

dyspnea
shallow breathing
chest pain
hypotension
tachycardia
restlessness
anxiety

Front 332

How do you prevent a hemothorax?

Back 332

ultrasound guidance

avoid forecful insertion of dilator/sheath/catheter
p101

Front 333

What interventions are taken in the event of a hemothorax?

Back 333

*Transfer pt to a higher level of care
*CXR or CT scan
*Chest tube placement to remove blood and/or air
*Repair injury to vessel
*Stabilize the pt
p101

Front 334

What is a pneumothorax?

Back 334

Air in the pleural space between the lung and the chest wall

Front 335

What is the most common insertion where a pneumothorax can take place?.

Back 335

Subclavin...most common with attempts at insertion into the subclavian vein as the apex of the lung lies above the subclavian
p102

Front 336

What are the causes of a pneumothorax?

Back 336

Not using US guidance and using just landmark insertion

multiple unsuccessful attempts in the upper chest (subclavian)
p102

Front 337

What are the s/s of pneumothorax?

Back 337

*There may not be any s/s
*S/S are determined by air leak size and speed by which it occurs
chest pain
SOB
p102

Front 338

How does one prevent pneumothorax on insertion?

Back 338

*Insert CVAD into an axillary vein located outside border of the first rib (beyond the apex of the lung field)
*US guidance
*Avoid back walling
p102

Front 339

What interventions are taken when a pneumothorax has happened on insertion?

Back 339

*CXR to determine size of the pneumo
*Small pneumo typically resolves without tx especially in pts without underlying lung disease.
*Observe pts for 48 hrs for s/s
*For larger or symptomatic ones a chest tube or needle may be inserted to remove air
*Repeated or unsuccessful attempts are an indication for follow up CXR to rule out pneumo or other detectable complications.
p102

Front 340

What are causes of difficult catheter advancement?

Back 340

*Congenital aberrant vascular anatomy
*Acquired vessel damage from trauma and/or accidents
*Repeated CVAD insertions
*Prolonged dwell times causing progressive thrombosis and stenosis of vessels along the route of intended catheter placemt
*Poor catheter tip location
*Large diameter catheter in small vein.
*Infusion of caustic and irritating causing vessel damage
*Mod to severe dehydration
*Environment too cold
*Venospasm
*Pt with pain
*Pt with anxiety

p103

Front 341

What are the s/s of difficult catheter advancement?

Back 341

Unable to advance catheter based on feel and/or based on indicators when using catheter navigation system.
p103

Front 342

What are ways to prevent difficult catheter advancement problems?

Back 342

Obtain a pt hx/assessment
hx of anxiety
hx of difficult hospitalization

Peds
*Assess need for sedation
*Apply warm packs to aid vasodilation
*Obtain detailed hx of previous CVADs
*Assure pt is adequately hydrated
*Assure rm temp is comfortable for pt or use warming blankets as needed.
p103

Front 343

Interventions for difficult catheter advancement?

Back 343

*If meeting resistance stop and assess how far catheter has advanced
*W/draw catheter a short distance and redirect
*Adjust arm position
*Ask pt to cough
*Ask pt to turn head to side
*Refer to IR
p103

Front 344

What is the risk of a malpositioned catheter?

Back 344

Risk of dysfunctional catheter, venous thrombosis and vessel erosion
p105

Front 345

What are the causes of a malpositioned catheter?

Back 345

*Misdirection of CVAD on insertion
*Aberrant vasculature
*Stenosis/thrombosis
*Pacemaker/AICD
*Venospasm
*Over insertion
*Inadequate catheter length
*Increased intra-thoracic pressures
ventilated pts
coughing
forceful flushing
High central venous pressure
CHF
Pulmon hypertension
p105

Front 346

What are interventions for a malpositioned catheter?

Back 346

*If in the ipsilateral jugular vein, rapid flushing with saline may help small bore cath to flip back.
*Reposition the arm or pt
*Pull back cath that is too deep
*Consider cath exchange or IR referral if grossly malpositioned.
p105

Front 347

What are the complications of a catheter or wire embolus?

Back 347

*thrombosis
*infections such as septic thrombophlebitis
*post-phlebitic syndrome
*pulmonary emboliism
p106
*arrhythmias
*cardiac and vascular damage

Front 348

What are the causes of catheter or wire embolus?

Back 348

*Operator error
*Over-insertion of guidewire
*Shearing of catheter or guidewire by pulling/withdrawing wire or catheter thru introducer against resistance
*Complete rupture of catheter internally due to excessively forceful flushing of cath with small syringe.
p106

Front 349

S/S of catheter or wire embolus?

Back 349

*often asymptomatic
*Sometimes recognized at the end of the procedure.
*Symptoms
SOB/Dyspnea
Anxiety
Tachycardia
Sudden pain at insertion site
Flank pain
p106

Front 350

What are ways to prevent catheter or wire embolus?

Back 350

*Use US guidance
*Avoid CVAD in subclavian beneath the clavicle .....devices placed via the SVC must enter laterally so device resides within the vein before passing thru the costoclavicular space to diminish risk of pinch off syndrome.
*Hold distal end of wire at all times
*Do not remove wire if there is resistance
*PICCs placed using MST, insert guidewire 15-20 cm into the vein
*Avoid forceful flushing
p106

Front 351

What are the interventions for a catheter or wire embolus?

Back 351

PICC with suspected or known catheter embolus
*Apply tourniquet high in the axilla in attempt to retain fragment or embolus
* Apply tourniquet tightly enough to restrict venous bl flow but not arterial bl flow
* Notify MD
* Pt on bedrest
* Order radiographic studies
* Assess pulses distal to the tourniquet every 5 min
* Refer to IR
* Individualize mgmt of high risk pts according to operative risk associated with leaving material in-situ
p106

Front 352

How does a cardiac arrhythmia occur during a CVAD insertion?

Back 352

Catheter tip touching sino-atrial node or ectopic foci in the right atrium.

May manifest as tachycardia/PVCs

Can occur during pre or post insertion.

**Exception is dialysis CVAD: tips should reside in the proximal right atrium for adequate flows
p108

Front 353

What causes cardiac arrhythmias in CVAD insertions?

Back 353

*Over-insertion of guidewire or catheter into right atrium
*Pts with ectopic foci may be sensitive to abnormal triggers
*Post-insertion migration
*Inadequate catheter securement at exit site
p109

Front 354

S/S of cardiac arrhythmias?

Back 354

*Pt senses palpitations, rapid heart pounding and/or irregular heart rhythm
*Irregular pulse
*Arrhythmia noted on cardiac monitor
p109

Front 355

How does one prevent cardiac arrhythmias?

Back 355

*Careful measurement and documentation of external anatomic landmarks
*If pt is on a cardiac monitor, observe for new arrhythmias during insertion/withdraw guidewire/catheter if indicated
*Place catheters in lower 1/3 of SVC or CA junc
p109

Front 356

What is the time frame that a CLABSI is a primary BSI in a patient that had a central line and is not bloodstream r/t an infection at another site?

Back 356

48 hours
p110

Front 357

What are the causes of a CRBSI or CLABSI?

Back 357

Microbes present on pts skin are primary source of infx r/t percutaneously inserted CVAD...contamination by:
*Improper preparation of skin at insertion site
*Poor hand hygiene
*Femoral CVAD
*Improper use or lack of MSBP
*Contamination during insertion
*Inserter inexperience
*Failure to adhere to insertion checklist/protocol

Patient Factors:
*Age (elderly or premature infants)
*Critically ill and co-morbidities
*Immune disorders and neutropenia

Maintenance care issues:

p111

Front 358

What are the s/s of a CRBSI AND CLABSI?

Back 358

*Sepsis (fever, chills, flu-like symptoms)
*Presence of CVAD inserted within the past 48 hrs with no other obvious source of infection.
*purulence, erythema at catheter exit site (not necessarily correlated with CRBSI)
p111

Front 359

How does on prevent a CLABSI/CRBSI?

Back 359

*Adherence to evidence-based guidelines from insertion to maintenced
*Clinical staff education
*Education to family/patients/caregivers

PREVENTION STRATEGIES:
*Hand hygiene
*Avoid femoral
*MSBP
*Chlorhexidine for 30 seconds and allow to dry
*Checklist
Consistant care
*Drsg change every 7 day or as needed
*Use biopatch if CLABSI rates do not decrease despite adherence to all other CLABSI prevention strategies.
*Selection of needleless connector with external and internal design to minimize microbial colonization and microbial entry.
*Scrub the hub
Maintain catheter patency as thrombotic catheter complications are associated with higher infection rates.
*Daily review and documentation of line necessiity
*Promptly remove unnecessary lines
p112

Front 360

What are the interventions to a CRBSI/CLABSI?

Back 360

*Assess for s/s of catheter related infx
*Carefully examine pt to rule out other possible sources of infx.
*Consider Time-to-Positivity Blood Cultures to determine if the cath is the source.
*If blood culture drawn from catheter grows out faster by at least 2 hrs compared with peripheral blood culture drawn at the same time and both cultures grow out the same microorganism, the cath is the source of infx.
*Antimicrobial therapy is based on identified/presumed microorganism
*Draw blood cultures prior to initiation of antimicrobial therapy.
p111

Front 361

Can nerves be seen on ultrasound?

Back 361

Nerves cannot be visualized with percutaneous insertion of catheters and cannot be seen on ultrasound except as nerve bundles in certain situations.
p113

Front 362

What are the causes of nerve injury/irritation?

Back 362

*Nerve contact with needle
*Insertion of needle/guidewire/dilator/sheath/ catheter thru a nerve bundle
*Catheter resides in place with s/s of nerve damage
*Temporary nerve irritation can occur with prolonged positioning of arm during cath insertion.
p113

Front 363

S/S of nerve injury/irritation?

Back 363

*reports sudden electric shock like pain if in arm, pain may shoot down arm.
*In comatose/confused pts, arm may move reflexively and rapidly when nerve is touched.
*Paralysis of extremity
* Tingling/weakness
p113

Front 364

How does on prevent nerve irritation/injury?

Back 364

*Inserter possesses knowledge of anatomic location of nerve
*If brachial vein is to be accessed visualize and identify median nerve with ultrasound.
p113

Front 365

What are the interventions to nerve injury/irritation?

Back 365

*Recognition of nerve irritation or injury
*Prompt removal of needle or other material
*Document s/s of injury/irritation and explain situation
*Provide emotional support
*Notify physician
p113

Front 366

Forceful flushing of a severely occluded CVAD can lead to

Back 366

catheter breakage
catheter embolus
venous thrombosis
CRBSI
p114

Front 367

S/S of cath dysfunction/occlusion?

Back 367

*There may not be any s/s
*Difficulty/inability to infuse
*Inability to draw blood back, sluggish
*Pain discomfort
*flushing noise in ear
*Leaking around the exit site
*Leaking along cath track with infusion or flushing.
p114

Front 368

What are the interventions to prevent cath dysfunction or occlusion?

Back 368

*Appropriate intervention depends on type of occlusion
*CXR may determine malposition or improper tip location
*If completed occlusion or blood return is sluggish ...alteplase
**For complete fibrin sheath, refer to IR for cath contrast study
**Catheter stripping of fibrin can also be done on larger more permanent CVADs by IR
p115

Front 369

What causes extravasation?

Back 369

*Infusion of hyosmolar solution or infusate that causes trauma to endothelial lining of tunica intima
*Inadequate securement of a VAD
*Traumatic insertion
*Multiple venipunctures
*Nonverbal or sedated pt
*Small or frail veins
*PIV site in area of flexion
*Use of an infusion pump or power injection
*For CVADs: presence of a fibrin sheath, dislodged noncoring access needle in port.
p116

Front 370

How to prevent extravasation?

Back 370

*Routine assessment of PIV and CVAD insertion sites
*Be familiar with agent know to produce tissue damage
*Instruct pt to inform staff of pain and burning at insertion site.
*Avoid using the dorsal surface of hand and areas of flexion where tendon and nerve damage is more likely
*Give vesicants last when multiple drugs are ordered
p116

Front 371

What are the interventions for extravasation?

Back 371

Nonpharm measures:
*Elevate extremity
*Contact physician
*Cooling applications are used for most except VINCA ALKALOIDS, VINCRISTINE and EPIPODOPHYLOTOXINS
*Detailed documentation to include photo per policy
*PHARM MEASURES: antidotes not generally recommended based on limited data except for sodium thiosulfate for mechlorethamine hydrochloride and concentrated cisplatin extravasations
p116

Front 372

What are the vinca alkaloids?

Back 372

Cancer drugs
Vinblastine
Vincristine
vindesine
Vinorelbine
p116

Front 373

What is Epipodophylotoxins?

Back 373

Medication to treat cancer
Etoposide
Teniposide
p116

Front 374

What medication is used to treat extravasation of mechlorethamine hydrochloride (Mustargen)?

Back 374

sodium thiosulfate
p116

Front 375

NMC
If there is an extravasation of
Dobutamine
Dopamine
Epinephrine
Norepinephrine
Phenylephrine
Vasopressen
What medication is given?

Back 375

Phentolamine
near p116

Front 376

NMC
If there is an extravasation of
(only listed some)
Calcium Salts
Dextrose (greater than 10%)
Potassium
TPN
Vanco
What medication is given?

Back 376

Hyaluronidase
near p 116

Front 377

When a CVAD is inserted where, does one find a greater risk for pinch off syndrome?

Back 377

Occurs when a long term CVAD is inserted into the subclavin vein close to the head of the clavicle, positioning the catheter in the small gap b/w the first rib and clavicle.
p117

Front 378

What is the cause of pinch off syndrome?

Back 378

Infraclavicular approach (between the first rib and clavicle)
p117

Front 379

What are the s/s of pinch off syndrome?

Back 379

*intermittent catheter occlusion that can be relieved by a change in position (raising the arm, rolling the shoulder)
*Catheters that are positional or appear to be occluded.
p117

Front 380

How to prevent pinch off syndrome or complications of pinch off syndrome?

Back 380

*Use internal jugular vein
*Position pt's hand at his side for post CXR and not with the shoulder in a raised or forward position.
*Radiographic followup of long term infraclavicular indwelling CVADs should be performed routinely to detect pinch off syn, fracture or embolization.
p117

Front 381

What is the intervention for pinch off syndrome?

Back 381

*Pinch off syndrome can occur immediately or there have been reports of detection after 5 yrs of dwell.
*If the subclavian vein is used and upright CXR should be obtained after the procedure and periodically thereafter
*In case of pinch off syndrome GRADE 2 it is recommended that the CVC be removed.
p117

Front 382

Pinch off Syndrome is graded from 1-3, describe each of them?

Back 382

Grade 1: abrupt change in the course of the catheter w/o luminal narrowing.

Grade 2: Luminal narrowing.

Grade 3: Complete catheter fracture.
near p 117

Front 383

What are the causes of a broken/leaking catheter?

Back 383

*Excessive pressure when inserting or flushing catheter
*Manipulating catheter when there is resistance
*Sharp instruments near external portion of catheter
*Use of toothed clamp on external portion of the catheter.
p118

Front 384

What are the s/s of broken/leaking catheter?

Back 384

*S/S may be absent
*Obvious breakage of the external portion of the catheter.
*Leakage at exit site
*Wet drsg
*Moisture/leakage noted when flushing or infusing
p118

Front 385

How does one prevent broken/leaking catheter?

Back 385

*Never w/draw against resistance or flush against resistance
*Do not flush with smaller than 10ml syringe.
*Secure external portion of catheter to prevent tension
p118

Front 386

What are the interventions to a broken/leaking catheter?

Back 386

*Have repair kit that is designed specifically for device
*Determine risks/benefits of repairing and/or removing catheter.
p118

Front 387

What is the risk of a dysfunctional catheter secondary to cath malposition/migration?

Back 387

venous thrombosis
vessel erosion
p119

Front 388

What are the causes of a catheter malpostition/migration?

Back 388

only listed some
*High central venous pressures as seen in : CHF, pulmonary hypertension
*Vigorous exercise
*Erosion by catheter tip into an extravascular area
*if picc, arm movement up/down
p119

Front 389

S/S of catheter malpostition/migration?

Back 389

*There may be no signs
*Lack of blood return or sluggish
*Difficulty flushing or infusing
*CXR reveals malposition
*Swelling/pain
*Hearing odd sound in the ear
*Arrhythmias
*Dyspnea
*Hypotension
p119

Front 390

Prevention of catheter malpostition/migration?

Back 390

*Optimal cath placemt
*device stabilization and drsg secured
*Daily assessmt of line and pt (pain hearing sounds, etc)
*Consider institutional policy for periodic CXRs to confirm cath tip location for long term CVADs
p119

Front 391

What is a venous thrombosis?

Back 391

Formation of fibrin along the vessel wall. Fibrin production is stimulated by vessel injury or presence of a catheter. Fibrin can coat the cath surface and cause partial or total occlusion of vessels.
p120

Front 392

What are the causes of Venous thrombosis?

Back 392

*Ca dx
*Size and # of lumens
*Microtrauma to the subclavian vein from repetitive overhead arm mvmt or vigorous exercise
*Renal disease
*Infammatory/infectious process
*Pregnancy
*Oral contraceptives
*Vessel trauma on insertion
*Cath tip malposition
*Rigid cath
*Prior CVC
*Dwell time greater than 2 wks
*Surgery/trauma
*vessels in radiation field
*Pt immobility
*Effort related thrombosis (Paget-Schroetter syndrome)
p120

Front 393

What are the s/s of Venous thrombosis?

Back 393

not all listed
* most are asymptomatic
*Inability to aspirate/infuse
*Leakage at insertion site
*Erythema, pallor, edema of extremity
*pain/numbness
*pulmonary embolus
*appearance of collateral veins
*abnormalities of the costoclavicular junc.
p120

Front 394

How does one prevent Venous thrombosis?

Back 394

*Pre insertion hx
*Vessel assessment prior to insertion
*Vessel selection choose smallest cath that meets infusion needs
*Use USG and MST
*Routine flushing of CVAD
*Avoid restrictive wrap of extremity
*Instruct the pt to avoid heavy lifting/ repetitive motion with affected arm.
p120

Front 395

What anticoagulant is recommended for Venous thrombosis?

Back 395

low molecular-weight heparin (LMWH)

unfractionated heparin

vitamin K antagonist for at least 3 m per MD order

p120

Front 396

What are the interventions of Venous thrombosis?

Back 396

*Cath removal is not routinely recommended
*Do not remove a cath when s/s of DVT are mild
*Anticoagulant : LMWH or unfractionated heparin
*Cath removal
*Vitamin K antagonists (warfarin) for at least 3 months per md order
p120

Front 397

When is cath removal warranted in Venous thrombosis?

Back 397

*Cath related infection
*malfunc not resolved with conservative interventions
*anticoagulant therapy is contraindicated
*massive or worsening s/s of DVT
*Cath is no longer indicated
p120

Front 398

What is phlebitis?

Back 398

Inflammation of the vein
p121

Front 399

What are the 3 types of phlebitis?

Back 399

CHEMICAL:
Administration of infusates or solutions that are acidic, alkaline or hyperosmolar
MECHANICAL:
*Insertion of large g cannula into small vessel
*Vessel trauma during insertion
*Excessive mvmt for manipulation of cannula
*Inadequate securement
*Extended dwell time of PIV
BACTERIAL:
Inadequate skin antisepsis and/or break in aseptic technique
p122

Front 400

What are the s/s of phlebitis?

Back 400

*erythema (reddness of the skin)
*swelling
*pain/tenderness
*cording
*red streak formation
p122

Front 401

How often does one assess a PIV in a peds for continuous infusions?

Back 401

assess PIV site every hr
p122

Front 402

How to prevent phlebitis?

Back 402

*administer infusates with a pH b/w 5-9 and osmolarity <600
*use proper venipuncture techniques
*Use proper securemt devices
*Insert appropriate size PIV cath based on pts vessel size and prescribed therapy
*Change PIV every 96 hrs
p122

Front 403

What are the interventions for phlebitis?

Back 403

*Stop infusion at once
*Apply a warm pack (increases blood flow)
*Consider starting a new PIV
*Consider alternative VAD
p122

Front 404

Who requires that Manufacturer instructions for use (IFU) to include all info any user needs to reliably and safely use the product?

Back 404

FDA
p123

Front 405

FDA requires IFUs to include the following information?

Back 405

*Proprietary and established product name
*Intended use for the product or equipment
*Explanation of why the product is useful
*Info on appropriate use at the time of insertion, implantation and/or use during dwell time
*Instructions for use
*Quality control requirements
*Instructions for management of inherent residual risk/avoidance of misuse
*Cleaning/sterilization instructions
*List of accessories/consumables validated by the manufacturer
*Requirements for safety inspections
*Requirement for planned maintenance
*Technical/clinical performance characteristics (accuracy, reliability)
*Explanation of potential adverse outcomes
*manufacturer name, place of business and contact info
*date & most recent revision of pkg insert to verify most current info.
p124

Front 406

What are the different CXR views (4)?

Back 406

Posterior-Anterior (PA)
Anterior-Posterior (AP)
Oblique
Lateral view
p125

Front 407

What is an anterior-posterior (AP) view on x-ray?

Back 407

Back against the film as applies with a portable CXR.
*greater potential for distortion
*Heart is further away from film: parallax effect with greater change in position.
p125

Front 408

What is a PA (posterior-anterior) CXR?

Back 408

Board placed on the chest- image reflected on the board
*Heart sits anterior in chest
*less distortion
*greater radiation energy
p125

Front 409

What is an oblique CXR?

Back 409

Pt's torso is angled to enhance visualization of catheter tip, away from anatomic structures such as spinal processes or artificial devices in chest such as wires, rods or catheters
p125

Front 410

What are the radiographic anatomic landmarks to identify catheter tip placemnt?

Back 410

1. 3-5 cm below the carina
2. Right tracheobronchial border
3. 1-2 cm below atrial appendage
p125

Front 411

What are the factors that interfere with interpretation of catheter tip?

Back 411

*Wet lungs caused by fluid overload, pneumonia
*Morbid obesity, especially >300lbs and CXR is AP
*Pacemaker/AICD wires
*Other CVADs
*Spinal rods
*Pt position (from supine position to standing position, cath tip can move as much as 2-3 cm)
*Arm position
Catheter placed in the basilic vein will move more than those in the cephalic
*Picc tips with move at least 2 cm closer to the right atrium, piccs placed in the right arm will move more than those place in the left.
p126

Front 412

Definitions:
Novice
Advanced Beginner

Back 412

Novice: no experience in the skill needed to perform

Advanced beginner: able to demonstrate marginally acceptable performance
p126

Front 413

Definitions:
Competent
Proficient
Expert

Back 413

C: able to adequately perform the skill after conscious, abstract and analytic contemplation of the problem or situation.

P:Holistic understanding of the problem or situation and confidently performs the skill.

E: intuitively grasp problems and situations and appears to effortlessly perform the skill
p126

Front 414

Professional licensure examines is a measure of what?

Back 414

Measures minimal competency in a professional field.
p127

Front 415

Competency assessment?

Back 415

an eval measuring a set of skills and knowledge. Eval includes technical skills, critical thinking skills and ability to apply skills and knowledge in the right way at the right time.
p127

Front 416

Certification?

Back 416

Formal recognition of specialized knowledge, skills and experience demonstrated by achievement of standards identified by a professional organz or entity.
p127

Front 417

Professional development?

Back 417

The process of assessing and developing professional competencies
p127

Front 418

Standards of practice?

Back 418

authoritative statements by which a profession describes responsibilities for which its practitioners are accountable.
p127

Front 419

Clinical practice guidelines?

Back 419

systematically developed statements of appropriate care; issued by reputable authoritative organizations and based on current and relevant research.
p127

Front 420

Nursing and medical education r/t vascular access and infusion therapy generally focuses on _____?

Back 420

theory
p127

Front 421

Is Hands on skill in vascular access usually acquired in the nursing workplace and physician residency programs? (T or F)

Back 421

Usually, True
p127

Front 422

What are the vascular access teaching techniques and aids?

Back 422

* Simulator training using models and devices
* Virtual simulator training (model or device links to computer screen)
* Virtual reality products (models respond with bleeding, vein collapse)
*Anatomical models (Chester chest, Peter PICC line)
*Tissue models and cadavers (human and animal)
p128

Front 423

What is the purpose of medical documentation?

Back 423

*Provides enduring record of pt care
*Promotes communication among healthcare providers
*Supports billing and reimbursement
*Supplies data for internal/external analyses (disease incidence, outcome indicators, adverse events)
p128

Front 424

What are the documentation issues that increases risk of legal liability? (7)

Back 424

1. Lack of doc of informed consent, treatment, pt teaching or discharge
2. Unexplained delays in treatment
3. Substandard or inappropriate tx
4. Charting inconsistencies or conflicting documentation
5. Late entries
6. Improper alterations of the medical record
7. Missing and/or destroyed records.
p128

Front 425

What are the 2 regulatory agencies for incident reporting on medical devices?

Back 425

FDA MedWatch reporting

Manufacturer and User Facility Device Experience (MAUDE)
p130

Front 426

What are the 2 federal statutes (laws enacted by Congress) and regulations associated with product use?

Back 426

Needlestick Safety and Prevention Act (2001)

Safe Medical Device Act (1990)

p131

Front 427

What is the Needlestick Safety and Prevention Act?

Back 427

Mandated revision of the 1991 OSHA Bloodborne Pathogens Standard to include more engineering controls: requires exposure control plans, solicitation of employee input and detailed recordkeeping.
p131

Front 428

What is the Safe Medical Device Act?

Back 428

Requires device users to notify the FDA and device manufacturer (if known) of incidents in which a medical device may have contributed to serious injury, serious illness or death of a patient.
p131

Front 429

What are the elements of negligence (4)?

Back 429

* Duty of care
* Breach of duty
* Causation
* Legally compensable injury
p131-2

Front 430

Breach of duty?

Back 430

Clinicians failure to provide care that is consistent with the standard of care.

Example: acts of commission ( med error)
acts of omission (failure to properly monitor the pt
p132

Front 431

Causation?

Back 431

Patients injuries must be the result of clinicians negligent conduct.
p132

Front 432

Legally compensable injury?

Back 432

Final element that must be proven when negligence/malpractice is allegedto have occurred. Pt must prove that injury has occurred and that it is the type of injury in which the law allows compensation.
Ex.:pain&suffering is allowable under some state laws but not in others.
p132

Front 433

What is the code of ethics for nurses?

Back 433

*Practices with respect and compassion
*Has a primary commitment is to the pt
*protects the pt and is an advocate for the pt.
*Takes action when questionable or impaired practice occurs
*is accountable & responsible for actions/practice
*Owes the same duties to self as to others (self-respect, professional growth)
*participates in advancement of the profession
*collaborates with other health prof
*articulates nursing values and maintains the integrity of the profession
p133
*

Front 434

What are the ethical principles?
(Be just autonomous Veracity Truth)

Back 434

beneficence: the obligation to do no harm
Justice: fair and unbiased actions
Autonomy: the right of a person to make independent decisions
Veracity: obligation to tell the truth
p133

Front 435

Federal and state healthcare regulations mandate that pts have certain rights, what are the 5 rights?

Back 435

1. Refusal of treatment
2. Discharge planning
3. Freedom for restraints and abuse
4. Confidentiality
5. Informed Consent
p141

Front 436

Patients have the right to confidentiality, what Act protects patients and what does it protect?

Back 436

HIPAA, 1996 - Health Insurance Portability and Accountability Act:
provides federal protections for personal health info held by covered entities (hospitals, clinics, etc) and gives pts rights r/t that info.
p141

Front 437

What are the 2 organizations involved in patient safety goals r/t vascular access?

Back 437

The Joint Commission National Patient Safety Goals (NPSG)

Institute for Healthcare Improvement (IHI)
p145

Front 438

What organization issued the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery and to perform the "time out" before starting a procedure?

Back 438

Joint Commission National Patient Safety Goals (NPSG).

p145

Front 439

IHI (Institute for Healthcare Improvement) patient safety provides resources for tracking 3 types of safety measures, what are they?

Back 439

Outcomes
Process
Balancing

Outcomes:determine if changes are actually leading to improvemt. ex. central line infx incidence

Process: determine if improvemts to core processes are occuring or being adhered to. Ex Central line bundle compliance

Balancing: if changes in one part of the system is causing problems in other parts of the system.
p146

Front 440

What are some of the IHI initiatives r/t vascular access?

Back 440

1. Prevention of central line infections
2. Prevention of surgical site infxs
3. Prevention of adverse drug events
p146

Front 441

What are the interventions that improve cultural competence in healthcare (5)?

Back 441

1. Recruitment and retention of staff who reflect cultural diversity of the community served.
2. Use of interpreter services or bilingual providers for clients with limited English language and literacy proficiencies.
3. Ongoing cultural competency training for providers
4. Use of linguistically and culturally appropriate health educ materials
5. Culture specific healthcare programs
p148

Front 442

What is peer review?

Back 442

Evaluation of work or performance by individuals in the same field in order to maintain or enhance the quality of the work or performance.

The word peer is often defined as a person of equal standing....generally used in a broader sense to refer to people in the same profession of the same or higher rank.
p148

Front 443

Statistics terms:
Incidence?

Back 443

Occurrence of new cases of disease for injury in a population over a specified pd of time.
p152

Front 444

Statistics terms:
Prevalence?

Back 444

The number of cases, both old and new, present at a point in time in a defined population.
Ex: 10% of pts in the intensive care unit have positive bl cultures during the stay.
p152

Front 445

Statistics terms:
Morbidity?

Back 445

rate of which an illness or abnormality occurs, calculated by dividing the number of affected people in a group by the entire number of people in the group.

Ex. Morbidity of diabetes is 30% among hospitalized patients.
p152

Front 446

Statistics terms:
Mortality?

Back 446

Death rates
p152

Front 447

Research:
Qualitative?

Back 447

Detailed descriptions of specific situations using interviews, observations and document review.

You describe things as they are.
p153 (read)

Front 448

Research:
Quantitative?

Back 448

Numerical descriptions (frequency, average, mean, median, mode)

You measure things as they are.
p153 (read)

Front 449

Research:
Randomization?

Back 449

A study in which there are two or more interventions and study participants are allocated at random (by change alone) to receive on of these interventions.
p153

Front 450

Research:
Effect size?

Back 450

The difference b/w the groups studied and is a measure of strength of the relationship b/w two variables.
Effect size is one factor to determine necessary sample size. Large effect size increases the probability of statistical significance and power.
p154

Front 451

Research:
Meta-analysis?

Back 451

Method of summarizing and synthesizing results of findings accumulated from a variety of sources and studies. Combines results of several studies on one topic into one large study with many participants.
a. general aim is to more powerfully estimate the true "effect size" as opposed to a smaller "effect size" derived in a single study under a given single set of assumptions and conditions.
b. Considered more informative than any one of the included studies in the analysis considered alone.
p154

Front 452

What is considered when evaluating research reports? (8)

Back 452

* Read and critique the entire study
* Examine the significance of the prob
* Determine if the literature review is current and complete
* review the study design and study population and determine appropriateness to research question being posed.
* Identify strengths (randomized study) and limitations of the study (conducted at one institution)
* Review findings and their interpretation. Have inappropriate generalizations been made?
* Determine the feasibility of replicating the study
* Review usefulness of the findings to practice (Do study findings justify or support a change in clinical practice)
p154

Front 453

What is empirically-supported treatment?

Back 453

evidence-based practice
p154

Front 454

What is evidence-based practice?

Back 454

a problem solving approach to the delivery of healthcare that intergrates the best evidence from well-designed studies and patient care data and combines it with patient preferences and values and (clinicians) expertise.
p154

Front 455

What is considered the "gold standard of care"?

Back 455

Evidence based practice.
p155

Front 456

What are barriers to evidence-based practice?

Back 456

*Lack of organizational culture and readiness
*lack of ebp mentors and champions
*inadequate ebp knowledge and skills
*lack of ebp valuing
*large amt of aval info and literature
*contradictory research findings
*pt expectations and demands
*conflicting priorities (workload may impair time for research activities)
*level of clinician authority to initiate practice
p155

Front 457

What are the seven steps of evidence-based practice?

Back 457

1. cultivate a spirit of inquiry
2. ask clinical questions in specific format (PICOT)
*P: pt pop of interest
*I: Intervention or area of interest
*C:Comparison intervention group
*O:Outcome
*T:Time
3.Search for best practice
4.Critically appraise evidence
5.Integrate evidence with clinical expertise and pt preferences and values
6.Evaluate outcomes of practice decisions or changes based on evidence
7.Disseminate EBP results
p156

Front 458

Evidence based practice resources (3)?

Back 458

1. Agency for Healthcare Research and Quality
2. Cochrane Database of Systemic Reviews
3.Clinical Evidence
p156

Front 459

What is "mistake proofing" for vascular access products?

Back 459

use of design features to prevent errors or negative outcomes. Ex: coloring added to skin prep solution to enhance identification of areas missed during application
p156

Front 460

Vascular access products:
What is failure mode effects analysis?

Back 460

The process of analyzing a product design to learn how it can fail.
Ex: identifying "work arounds" or short cuts used by clinicians when programming infusion pumps and using this info to improve pump design and function.
p157

Front 461

All equipment used to deliver infusion therapy is regulated by who (2)?

Back 461

FDA
Center for Devices and Radiologic Health
p 156

Front 462

The device class determines the Center for Device and Radiologic Health review process.
What is a Class I, II and III device?

Back 462

Class I:devices with the lowest risk of pt harm (cath stabilization device, Iv poles)

Class II:devices with a moderate risk (catheters, introducers, wires)

Class III: devices with the greatest risk (cardiac pacemakers, mechanical heart valves)
p157

Front 463

VA products:
Pre-market notification process?

Back 463

process of documenting that a new device is substantially equivalent to a similiar product sold in the US. Usually does not require clinical studies and is commonly used process for approving class II devices
p157

Front 464

VA products:
Pre-market approval?

Back 464

process in which laboratory, animal and clinical studies are usually required to demonstrate that the device is safe and effective when used as directed. This process is used for most class III devices.
p157

Front 465

VA products:
Post-market surveillance?

Back 465

Also known as a medical device reporting system (MDR). Involves device manufacturers, healthcare facilities and clinicians with the goal of identifying adverse events associated with the device. It is the process of reporting device malfunctions and serious injuries or deaths associated with a device to the FDA.
p158

Front 466

Evaluation of new products:
What is life-cycle thinking?

Back 466

the process of considering the products life and the environment, including use and disposal
p158

Front 467

Performance Improvement, a term introduced by who?

Back 467

The joint commission for assessment and improvement of performance.
p159