CHILDREN SUPPORTED BY MEDICAL TECHNOLOGY IN SCHOOLS: CARE AND MAINTENANCE OF CENTRAL VENOUS LINES

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1 CHILDREN SUPPORTED BY MEDICAL TECHNOLOGY IN SCHOOLS: CARE AND MAINTENANCE OF CENTRAL VENOUS LINES Lauren E.B. Stone, MSN, RN, VA-BC Nurse Manager IV Team and Blood Donor Center Boston Children's Hospital FINANCIAL DISCLOSURES Disclosure of Relevant Financial Relationships I have no financial relationships to disclose. Disclosure of Off-Label and/or investigative uses I will not discuss off label use and/or investigational use in my presentation. 1

2 OBJECTIVES The learner will be able to describe principles of basic care of Peripherally inserted central catheter (PICC) and central venous catheter (CVL) Site assessment Dressing change practices The learner will be able to state appropriate interventions and maintenance of central venous catheters Appropriate interventions for complications Emergent catheter issues OUTLINE Vascular Anatomy IHCP and Developmental stages Line Types Reasons for selecting Line care Flushing and dressing changes Complications Infiltration, phlebitis, infection, occlusion, skin allergy Emergent issues: bleeding, catheter fracture, air embolism 2

3 INDIVIDUALIZED HEALTH CARE PLAN Specific to student s age, developmental stage and clinical care needs Medical conditions and allergies Type of vascular access device Conditions to report to family/provider Steps to be taken if complications occur Emergent and non-emergent Supplies/prescribed medications (flushes) Activity restrictions (based on type of device) 3

4 Developmental Stages Developmental Stage Characteristics CVC Care Interventions Neonate Self-centered. Develops trust as needs are met. Unpredictable response to repeated procedures. No routine dressing changes on preemies. At BCH, IV RN performs dressing change for age < 1yr unless in NICU. Always have assistant to hold/stabilize. Keep infant warm and wrapped. Tactile contact for comforting, pacifier, sucrose solution. Involve parent/caregiver in comforting or holding during procedures. Infant Begins to separate self from others. Mistrust develops as needs not consistently met. Recognizes primary care takers & responds with fear of change. At BCH, IV RN performs dressing change for age < 1yr. Always have assistant to hold/stabilize. Avoid procedures in patient's bed/crib. Involve parent/caregiver in comforting during procedures but should not help restrain child. Distraction with brightly colored objects/toys. Pacifier, sucking for comfort Toddler Differentiates self from objects. Ritualistic. Oppositional "No" stage. Early aggression and manipulative behavior. Has many fantasies. May demonstrate regressive behaviors. Prepare immediately before procedure. Use calm, positive, firm approach: concrete words. Always have assistants to hold/stabilize (restraint requires more than one person - use restraints minimally). Avoid procedures in patient's bed/crib. Child Life for distraction Involve parent/caregiver in comforting during procedures but should not help restrain child. Offer immediate rewards. Pre-school Exhibits general interest. Fears bodily injury, loss of control, the unknown. Short attention span. Egocentric. Demonstrates "Magical Thinking. Give control where possible. Explain procedures in simple terms. Prepare just before procedure. Encourage assistance from child as appropriate. May need assistant to hold/stabilize. May avoid procedures in patient's bed. Child Life for distraction. Involve parent/caregiver whenever possible: Child may be more cooperative if parent is not present. Praise cooperation. School-Age Enjoys learning. Wants to participate. Needs to know how things work. Concrete operational thinking. Increased self control. Fear of body muliltation, loss of control. Develops "magical" sense of denial. Prepare child in advance and discuss procedure step by step: diagrams & models are helpful. Distraction as needed. Enlist child's cooperation - allow to participate/assist with procedure when possible. Offer reassurance. Give child the choice of parent/caregiver involvement. Adolescent Vacillates between dependence and independence. Questions authority figures. Strong need for privacy. Able to understand abstract ideas. Able to consider alternatives. Fear of loss of control, altered body image. Discuss procedure and rationale: prepare well in advance of procedures. Allow time for questions/further discussion. Provide privacy. Engage patient in procedures. Offer choices and negotiate: set behavioral limits, but allow leeway where possible. May involve parents/caregiver: direct explanations to patient while parent is present. Reference: Hankins, Judy et al. (Eds.). (2001). Infusion Therapy in Clinical Practice, 2 nd Edition. (pp ). Philadelphia, PA: Saunders. CENTRAL VENOUS ACCESS CATHETERS Peripherally Inserted Central Catheters (PICCs) Implanted Ports Tunnelled Catheters Power injectable Catheters Specialty use Devices Hemodialysis Apheresis 4

5 CENTRAL VENOUS ACCESS Peripherally Inserted Central Catheters (PICCs) Devices placed for access into Superior Vena Cava Allows for infusion of highly concentrated medications and vein irritants Several weeks to months of therapy No limitation in dwell time per INS Inserted via antecubital fossa or in upper forearm Length customized to patient s anatomy 5

6 DOUBLE LUMEN CATHETER TIP 6

7 SURGICALLY IMPLANTED DEVICE Implanted Port/Disc (aka: Port-A-Cath, Venous Access Disc ) Tunneled Catheters (aka: Hickman or Broviac Catheters) Specialty Catheters Hemodialysis Apheresis IMPLANTED PORTS Single Lumen Titanium Body Double Lumen Plastic Body 7

8 IMPLANTED PORTS 8

9 SURGICALLY IMPLANTED DEVICES Tunneled Catheter (aka: Hickman or Broviac ) Considered permanent device for long term central access therapy Surgically placed by MD Generally located near subclavian area of chest but can also be placed lower (even near abdomen) Catheter has cuff near exit site that allows for epithelial growth that eventually holds catheter in place Single or double lumen devices 9

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11 Power PICC POWER!! Power Tunneled Catheter Power Port SPECIALTY DEVICES Apheresis and Dialysis Catheters Surgically placed permanent devices with large internal lumens Generally located in neck or upper chest Used ONLY for Apheresis or Dialysis access by nurses in these specialty areas Kept patent with 1000u/cc or 5000u/cc heparin solution CAUTION: Attempting to infuse via these devices can compromise patient s access for Apheresis and Dialysis and can cause anticoagulation with a heparin bolus 11

12 APHERESIS AND DIALYSIS CATHETERS Apheresis Catheter Hemodialysis Catheter CENTRAL LINE COMPLICATIONS Infection Migration Occlusion Phlebitis Infiltration Skin Allergy Emergent Issues 12

13 INFECTION Prevention: hand washing, aseptic technique Gloves, Masks Assessment Skin integrity Moisture and temperature- bacterial growth PREVENTION I - Implement Insertion, Care, and Maintenance Bundles S - Scrupulous Hand Hygiene A - Always Disinfect Every Needleless Connector V - Vein Preservation E - Ensure Patency Cleanse access site thoroughly before EACH access Use devices for accessing tubing/catheter hub ONCE Cap all tubing sets between uses and keep clean Follow policies for changing tubing at appropriate intervals 13

14 INFECTION Causes Compromise in site dressing or non-antiseptic hub and IV tubing manipulation allowing bacterial infiltration Symptoms Pain Exudate Redness around insertion site Elevated temperature, WBC with no other source Interventions Notify Provider/family Often requires removal of catheter MIGRATION Causes Inadvertent dislodgement Catheter movement with dressing changes Symptoms External catheter present Increase in amount of external catheter present Interventions Notify Provider/family 14

15 DRESSING CHANGES Aseptic technique Sterile field Mask, Gloves, 4x4 gauze, CVL dressing kit Stabilize to prevent line migration CATHETER SECUREMENT PICC secured with subcutaneous device, CHG disc and bordered transparent dressing PICC secured with adhesive device and transparent dressing 15

16 IMPAIRED CATHETER FLOW Nursing Indications ALWAYS check for vigorous blood return before flushing/infusing via catheters SVC blood flow is approx. 2 liters/minute Should have free-flowing blood return, WITHOUT resistance Check for sluggishness with flushing Partial vs. Complete Occlusion 16

17 IMPAIRED CATHETER FLOW Nursing Indications Check first for mechanical causes Clamps External Kink Reposition patient Consider recent line care When last flushed Flushing immediately at end of infusion OCCLUSION Inability to flush or aspirate blood from catheter Causes precipitates, blood back up, thrombus, fibrin sheath, catheter kinking, catheter malposition Interventions dressing, cap change Further evaluation by provider Prevention: Flushing SASH Positive pressure 17

18 PHLEBITIS Causes Mechanical or Chemical irritation of vein wall Catheter size Infusate Symptoms Pain, tenderness, redness, edema at or above insertion site, palpable cord Interventions Heat warm pack Further evaluation by provider LISTEN to your patient! Pain means problem! 18

19 Insertion Site INFILTRATION Causes Cannula displacement from vein or leakage of infusate around cannula hub into surrounding tissue Symptoms Swelling Cool to palpation (IV fluid is room temperature-cooler than body temperature) May still obtain blood return on aspiration 19

20 INFILTRATION INFILTRATION Prevention Assess site prior to infusion Visual inspection Tactile inspection Flush catheter and check blood return Monitor infusion Interventions Stop infusion Further evaluation by provider 20

21 SKIN ALLERGY Causes Allergic response to skin prep or dressing materials Symptoms Rash, redness around site, Interventions Allow all skin prep solutions to thoroughly dry before applying dsg. Further evaluation by provider Patient with allergic reaction to dressing materials EMERGENT ISSUES Development of a fever, redness at the CVC site, drainage, increased fatigue, irritability, or headache (potential S&S infection) Catheter cap is missing Catheter pulled or falls out Catheter fracture Child complains of chest pain or shortness of breath 21

22 INFECTION Development of a fever, redness at the CVC site, drainage, increased fatigue, irritability, or headache Notify provider/family MISSING CAP Clamp catheter Keep protected and as clean as possible Scrub the hub Cleanse with alcohol prep Replace cap Notify provider/family 22

23 CATHETER IS PULLED Stay calm Reassure the student Cover the CVC exit site with sterile gauze if immediately available or a clean dressing; applying gentle pressure to the site. Inspect the exterior of the dressing. If the dressing is intact and the tape still holds the looped catheter, it is probable that no significant trauma to the child or the line has occurred. If the tape or dressing has been disrupted, it should be taken off and the exit site inspected. A new dressing should be applied if there is no evidence of bleeding or trauma at the exit site. CATHETER FALLS OUT Stay calm Reassure the student If the catheter has fallen completely out, apply firm pressure to the exit site with sterile gauze if immediately available or a clean dressing Save catheter for inspection Measure length to identify that entire catheter has been removed Notify the physician and family immediately 23

24 IMPLANTED PORT NEEDLE FALLS OUT Stay calm Reassure the student Inspect the insertion site for bleeding/trauma Apply gauze if bleeding or oozing noted at site Handle/dispose of needle carefully, according to school sharps safety policy Notify the family and/or physician CATHETER FRACTURE Stay calm Reassure the student Clamp the catheter as close to the child s body as possible above the break. Wrap the broken end with sterile gauze. Notify the family and physician immediately. 24

25 CHEST PAIN/SHORTNESS OF BREATH Stay calm Reassure the student Position the student lying down on his/her left side This helps prevent an air bubble from entering the heart Transport the child to the school nurse s office via wheelchair Do not let the student walk The student should be transported as soon as possible to the appropriate emergency room Notify family and physician immediately NURSING CARE PLAN Catheter assessment Quality of flow when flushing/infusing Use pulsating or positive pressure technique when flushing and clamp all devices (if required) when not in use to prevent backflow of blood and clotting Integrity of device 25

26 NURSING CARE PLAN Site assessment With every access/flush of the device Dressing integrity Look for redness, swelling, exudate, discomfort i.e.: pain or burning Palpate for temperature changes at or above site Complications should be treated appropriately as soon as possible Time delay in treatment can affect outcomes RESOURCES Individual Health Care Plans Organizational Guidelines Orders/treatment plans from Providers and referring agencies Supporting Students with Special Health Care Needs Guidelines and Procedures for Schools, Third Edition Editors: Stephanie M. Porter M.S.N., RN, Patricia A. Branowicki MS, RN, NEA-BC, FAAN, and Judith S. Palfrey M.D. 26

27 Thank you! 27