Basic procedures in healthcare 1 (SOL / VCA81) TOPICS: 9a) Peripheral venous cannulation 9b) Central venous cannulation 9c) Implantable venous port

Basic procedures in healthcare 1 (SOL / VCA81)

TOPICS:

9a) Peripheral venous cannulation9b) Central venous cannulation9c) Implantable venous port

indication

PVC insertion site

PVC care

Possible complications in inserting

PVC removing

thrombophlebitis, phlebothrombosis

Maddon classification (for thrombophlebitis grades)

9a) Peripheral venous cannulation (PVC)

stab and accessibility of peripheral veins in order to intravenous administration,

PVC (used abbreviation).

indication:- infusion,- transfusion,- parenteral nutrition,- drug application i. v.,- administration of contrast solution before an examination,- blood sampling for diagnostic purposes.

peripheral venous catheter- individual parts


back of the hand or forearm (if possible, the on non-dominant patient´s hands because of his / her comfort),

vena jugulars,

area over the inner ankle,

instep,

in kids – veins on the head.

PVC insertion site

peripheral venous cannulation


Tools


tools for PVC

check the patient's medical records, disinfect the hands, wash connecting tube with 0,9% NaCl (5 - 10 ml in syringe), leave the syringe on the one end of this tube and do not take

off the cap from the other one! check patient´s identity + explain the procedure, chose the appropriate site for insertion i. v. cannula (without

haematomas, edema… ), put a swab under the patient´s limb, put on the disposable gloves, prepare needed tools near to you, but never on patient´s bed,

Procedure


attach and tighten the tourniquet 5-10 cm above the puncture site,

disinfect the skin,

grip cannula firmly („three-point grip“),

pull the skin off downward direction from the injection site,

inject the skin with i. v. cannula at an angle of 15-30°,(angle depends on the depth location of a vein)

check it – when properly puncture the vein blood appears in signalling chamber in the cannula,

hold insertion cannula needle in the place and introduce only the plastic part of cannula into the vein,

introduce the whole plastic cannula (up to its transition in a part of hard plastic),

loosen the tourniquet,

Procedure


put cellulose swabs under the i. v. cannula to catch any flowing blood,

squeeze the vein above the puncture site and pull the insertion needle,

never return the insertion needle back to cannula!!!

screw the pre-wash connecting tube in the end of i. v. cannula,

remove cellulose swabs,

perform aspiration and subsequent flushing of i. v. cannula,

fix the i. v. cannula with sterile covering,

mark sterile dressing of cannula with the date and timeof introduction,

„break“ the connecting tube and close its end with plastic cap,

Procedure


wrap the connecting tube loosely and fasten it to the patient´s hand with adhesive plaster,

eventually bandagewith gauze bandage(e. g. in restless kidsand confused patients),

clean the tools.

Procedure


… description of peripheral venous cannulas

https://www.youtube.com/watch?v=O3F4FeOCQEA

time: 1:03

… PVC insertion procedure

https://www.youtube.com/watch?v=MHKAIoa1Ooo

time: 5:00

Videos with…


1. monitoring- PVC,- around the injection site (redness, edema… ),- patent´s body temperature,

- PVC can be inserted in a vein max. 72 hrs.- exceptionally 5-7 days, but only if there are NO complication and if it allows the producer's recommendations,- a physician record the extended period of PVC in the patient´s medical record.

2. asking the patient- soreness at the injection site,- burning or stinging during the administration of infusion therapy and i. v. injections through PVC.

Specifics of care of the patient with PVC


*

3. covering exchange

- individual - it depends on the kind of coverage and the producer's recommendations.

Specifics of care of the patient with PVC

covering of PVC


allergic reactions to disinfect, adhesive plaster,

paravenous insertion followed by haematoma onset and edema,

infection,

phlebitis (thrombophlebitis, phlebothrombosis),

embolism (air, blood clot),

damage to the innervation,

hitting the artery.

Possible complications in PVC inserting


*

inflammation of the superficial veins (possible PVC complication),

symptoms: palpation and spontaneous tenderness over the affected vein, redness, mild edema, induration due to the current vein thrombosis.

Maddon classification – thrombophlebitis grade specification *

0 – no pain or reaction around1. grade – only pain, no reaction around2. grade – pain and redness3. grade – pain, redness, edema, painful streak over a vein4. grade – pus, edema, redness, painful streak over a vein

* Source: VŠPJ – Hodnotící a měřící škály pro nelékařské profese [online]. 2015 [cit. 2015-04-29]. Available from: http://www.vspj.cz/ISBN/Skripta%20-%20V%C5%A0PJ/Hodnot%C3%ADc%C3%AD%20a%20m%C4%9B%C5%99%C3%ADc%C3%AD%20%C5%A1k%C3%A1ly%20pro%20nel%C3%A9ka%C5%99sk%C3%A9%20profese%20-%20Lada%20Cetlov%C3%A1%20a%20kol..pdf

Thrombophlebitis


thrombophlebitis in inserted PVC

Phlebothrombosis

deep vein inflammation associated with the formation of blood clots (possible PVC complication, when PVC is administeredin lower limbs),

symptoms: edema of the limbs with painful tension, livid colour and general symptoms (↑ body temperature, ↑ pulse).

phlebothrombosis


haematoma:solution compression, pressure bandage, Heparoid (ung.)

extravasation (seepage or leak of agents into tissues) necrosis- symptoms: slowed infusion, resistance to bolus application of i. v. injection…- risk in: ATB, vasoconstrictor drugs- solution interrupt of infusion therapy, removal of the cannula, pressure bandage in the area of swelling, cold tiles application

Other complications


Tools:

disposable gloves,

vomit bowl,

disinfection (Septoderm),

cellulose swabs,

adhesive plaster.

PVC removing


prepare the tools,

disinfect the hands,

put disposable gloves on,

inform the patient about the procedure,

prepare adhesive plaster,

prepare cellulose swabs,

hold the cannula on the place with one hand,

peel the skin from the covering with the other hand,

if the covering is loosen take prepared cellulose swab and put them on the insertion site,

PVC removing - procedure


pull out the cannula while firmly hold the cellulose swabs,

fix the cellulose swabs with adhesive plaster,

clean the tools.

PVC removing procedure


removing PVC

indication

CVC insertion site

catheter insertion

CVC care

possible complications after insertion

9b) Central venous cannulation (CVC)

access to the central venous system,

in local anaesthesia, it is introduced to some of the larger veins, while one it‘s end is located in the upper / inferior vena cava, the other end opens the skin's surface,

CVC (used abbreviation),

indication:- administration of parenteral nutrition,- administration of drugs (antineoplastic agents, ATB, immunosuppressive… ),- chemotherapy,- transfusion,- very bad state of veins on the periphery,- repeated blood sampling,- measurement of central venous pressure (CVP),- the possibility of applying drugs that would otherwise irritated the thin peripheral veins and could cause them nonbacterial inflammationand thrombosis.


vena subclavia,

vena jugularis externa et interna,

vena basilica et mediana,

vena femoralis.

Insertion site


by a doctor, nurse assists,

catheters are divided into one-way, two-way, three-way and antimicrobial (for high risk patients with antimicrobial correction).

CVC insertion


catheter must be treated according to a predetermined written protocol (the standard of nursing care), which must respond toa specific type of catheter,

bandages and manipulationmust be carried outstrictly aseptically.

CVC care

after CVC insertion


face mask,

disposable gloves,

sterile gloves,

sterile swabs,

alcohol disinfection,

disinfectant solution,(according to the standard of nursing care)

sterile covering,

adhesive plaster,

vomit bowl.

CVC dressing tools


transparent covering

disinfect the hands,

perform the dressing in collaboration with other health professionals to ensure antisepsis (when working alone, prepare sterile area or tools so we keep sterile environment during the whole procedure),

inform the patient about the procedure,

position the patient to the appropriate position (semi sitting),

put disposable gloves on,

put the face mask on,

gently remove the old bandage (we start at the top and continue downward – we must be very gentle to not injure the patient´s skin or pull out the catheter),

CVC dressing procedure


take off disposable gloves after removing the bandage,

disinfect the hands again,

put on sterile gloves,

check carefully insertion site of the catheter,

take a swab with alcohol disinfection,

put the swab on the catheter insertion site and start wash it spirally and one stroke (spirals clockwise while away from the catheter outlet),

change the swabs according to need and continue to proceed the same way until circuit of at least 8 cm is not clean,



never return to the catheter insertion site with the swab which has already touched any part of the skin,

clean the same area in the same way twice,

check each used swab with your sight – if there are not any pathological traces of impurities,

once we have cleaned the skin with alcohol disinfectant, we repeat everything once again, but with disinfectant solution according to the relevant nursing standard,

disinfecting solution should be let to dry properly, (therefore adhere to the specified expiration)

after drying, we put sterile adhesive plaster on the catheter insertion site,

at each dressing change, we must also examine the position, the sufficiency of fixation and the length of the external portion of the catheter,



all these details are recorded in the medical documentation, including information on the status of catheter patency,

first 24 - 48 hours (after catheter insertion) it is the preferred a fixation bandage in form of non-transparent porous breathable cover,

after 2 days, it is chosen another procedure according to the appearance of the output location of the catheter, which includes a choice of disinfectant, typesof coverage and frequency of dressing changes,

disinfectant solution must not be in conflict with the catheter producer's recommendations (could lead to deterioration of the surface of the catheter),

the frequency of dressing changes depends on the standard of nursing care,recommendations from the producer of the catheter or the individual needs of each patient,

we change also Posiflow modules, infusion sets, etc. during CVC dressing procedure.



exchange of CVC covering

… CVC dressing

https://www.youtube.com/watch?v=HrkFXfOkj2M

time: 4:40

Video with…


skin infection around CVC – redness, skin formation- solution: Framykoin, Inadine, Betadine ung. or sol.

disorder of skin integrity around CVC (resulting from ↑ skin sensitivity - mostly after radiotherapy)- solution: Greasy tulle, nothing to be paste on the given place

CVC pulling out (due to loosening of securing stitchor inconsiderate treatment of CVC)- solution: RTG checking, proper fixation

CVC obstruction- solution: report a physician, the physician determines next steps

CVC extraction- solution: IMMEDIATE applying of sterile swabs, which we push on the insertion site and we call the physician IMMEDIATELLY

Possible complications of CVC


*

artery puncture

pneumothorax

Other possible complications of CVC


*

9c) Implantable venous port

indication

care of implantable venous port

closed system, which consists of a catheter (introduced intoa central vein) and port (small chamber), to which the catheter is firmly connected,

port:- small chamber placed under the skin, usually on the front side of chest, it is well palpable),- silicone membrane can withstand about 2 000 punctures,

indication:- chemotherapy,- long-term parenteral nutrition,- long-term ATB therapy, analgesics,- another portion of i. v. therapy.


implantable venous port

disinfect the hand before the manipulation,

prepare a sterile table with tools (face sterile mask, sterile swab, Huber needle, sterile gloves, disinfectant solution, adhesive plaster, syringe with saline),

work with a face mask and sterile gloves,

give the mask face to the patient as well,

disinfect the area above the port properly,

pulp the port and fix it between the 2 fingers,

hold the Huber needle in one hand and perpendicular to the port membrane,

push the needle onto the membrane (do not twist it!!!),

aspire blood into the syringe,

rinse the port with saline,

Port care – Huber needle puncture


apply the medication or infusion slowly,

underlay needle sterilely, cover it and fix with adhesive plaster,

application to the port must be continuous,

in case of interruption, flush it with of heparin cap,

the port is usually flushed 1x per month,

every drug application (or blood sampling) finish with flushingof 20 ml of saline and after that 5 ml of heparin cap(5 000 j / 100 ml),

syringe smaller than 10 ml cannot be used when taking care of the port,

an inspection X-ray with spraying the port must be made beforethe first series of chemotherapy.

Port care


description of implantable venous port with Huber needle

… implantable venous port dressing

https://www.youtube.com/watch?v=r9USin6Ly4Q

Video with…


disinfect the hand before the manipulation,

prepare a sterile table with tools (face sterile mask, sterile swab, sterile gloves, disinfectant solution, adhesive plaster, syringe with heparin cap),

work with a face mask and sterile gloves,

disinfect the port around,

when pulling out push the port to the chest wall,

the needle is drawn upwards and in the direction perpendicular to the port,

AT THE SAME TIME we have to apply the heparin cap (if we do not, blood can be sucked back into the port),

after pulling out the needle, disinfect the insertion site and cover it sterilely.

Port care – Huber needle removal


Revision

List the most common indications for the PVC inserting.

Which sites are suitable for the PVC inserting in adults?

In what time frame do we change PVC covering at the patient?

What is Madon classification for?

What is phlebothrombosis?

Describe the procedure for the removal of PVC.

What does PVC or CVC mean?

List the tools you need for CVC dressing.

What complications may occur after the CVC insertion?

What is an implantable venous port for?

What is the Huber needle for?

Reference:

BRAUN, B. Ošetřovatelská péče o centrální žilní katetr v podmínkách JIP a ARO [online]. 2015 [cit. 2015-04-07]. Dostupné z: http://braunoviny.bbraun.cz/osetrovatelska-pece-o-centralni-zilni-katetr-v-podminkach-jip-aro

CETLOVÁ, L., DRAHOŠOVÁ, L., TOČÍKOVÁ I. Hodnotící a měřící škály pro nelékařské profese [online]. 2015 [cit. 2015-04-28]. Dostupné z: http://www.vspj.cz/ISBN/Skripta%20-%20V%C5%A0PJ/Hodnot%C3%ADc%C3%AD%20a%20m%C4%9B%C5%99%C3%ADc%C3%AD%20%C5%A1k%C3%A1ly%20pro%20nel%C3%A9ka%C5%99sk%C3%A9%20profese%20-%20Lada%20Cetlov%C3%A1%20a%20kol..pdf

DONOR, Z. S. Péče o CŽK [online]. 2015 [cit. 2015-03-27]. Dostupné z: http://www.donor.cz/file/download/71

KOMÍNEK, V. Péče o periferní žilní vstupy na vybraných pracovištích FN Brno [online]. 2015 [cit. 2015-04-28]. Dostupné z: https://is.muni.cz/th/101036/lf_b/Charakteristika_problemu.txt

LF3 – CUNI. Studijní materiály – Implantabilní venózní port [online]. 2015 [cit. 2015-03-27]. Dostupné z: http://www2.lf3.cuni.cz/opencms/export/sites/www.lf3.cuni.cz/cs/pracoviste/osetrovatelstvi/vyuka/studijni-materialy/CNSKZO2/studijni-materialy/Implantabilnx_venxznx_port.pdf

LF3 – CUNI. Studijní materiály – Centrální žilní katetr [online]. 2015 [cit. 2015-03-27]. Dostupné z: http://www.lf3.cuni.cz/opencms/export/sites/www.lf3.cuni.cz/cs/pracoviste/osetrovatelstvi/vyuka/studijni-materialy/CNSKZO2/studijni-materialy/Centrxlnx_xilnx_katxtr.pdf

VELKÝ LÉKAŘSKÝ SLOVNÍK [online]. 2015 [cit. 2015-03-27]. Dostupné z: www.lekarske.slovniky.cz

WIKISKRIPTA. Zajištění žilního přístupu [online]. 2015 [cit. 2015-04-27]. Dostupné z: http://www.wikiskripta.eu/index.php/Zaji%C5%A1t%C4%9Bn%C3%AD_%C5%BEiln%C3%ADho_p%C5%99%C3%Adstupu

PICTURES * (if it is not stated differently): pinterest.com, google.com

Documents

Basic procedures in healthcare 1 (SOL / VCA81) TOPICS: 9a) Peripheral venous cannulation 9b) Central venous cannulation 9c) Implantable venous port