Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
CATEGORY:
General – RN, RPN – Section A-H
Advanced Practice LPN – Sections B-G Only
SNP – RN – ICU/CCU/PACU Only (Section I)
PURPOSE
To provide safe, standardized, evidence based process for CVC care and maintenance.
NURSING ALERT:
CODE C.2
EQUIPMENT
1. PPE for assistants – clean gloves, protective gown, mask, safety glasses, head covering
2. PPE for physicians – sterile gloves, safety glasses, plus PPE items in Central Line Insertion Kit
3. Short term CVC – type and size determined by physician
4. Introducer (if requested by physician)
5. Central Line Insertion Kit: (#319123)
Head covering
Sterile physician’s gown
Face mask
Sterile full body drape (Large #22)
Sterile absorbent towel
Chlorhexidine 2% with 70% alcohol (ChloraPrep®) (10.5 mL)
Sterile bowl with 8 oz sponge
Sterile needle holder
Sutures – 2.0 silk
10 gauze 4x4’s
Sterile transparent semi-permeable dressing
Pre-filled normal saline (N/S) syringes 10 mL (x3) – sterile packaging
6. Needleless access adapters (x4) (#313420)
7. Ultrasound machine
8. Sterile ultrasound transducer cover (Special Order #CV610-637)
9. Local anesthetic
10. Intravenous (IV) solution and primed luer-lock tubing
11. Primed pressure monitoring system (transducer set-up), as required
CODE C.2
PROCEDURE
NOTE: Every individual in room must wear a mask, safety glasses, gown and head
covering.
NOTE: Physician will open insertion kit and set up sterile field.
NOTE: Inform patient that full body drape will be used to reduce risk for infection.
11. Add needleless access adapters and sterile N/S syringes to sterile field for physician to
flush lumens.
13. Assist physician with applying sterile ultrasound transducer cover to ultrasound probe.
NOTE: Physician will insert CVC and assess for adequate blood return.
15. Ensure needleless access adapters are flushed and attached to each lumen.
16. Ensure transparent semi permeable dressing has been applied over insertion site.
17. Request chest x-ray to confirm position of catheter unless femoral insertion site used.
CODE C.2
NURSING ALERT:
CVCs with jugular or subclavian insertion sites must have placement confirmed by chest
x-ray prior to use. If patient’s condition warrants need for immediate infusion, a
physician’s order is required.
19. Document insertion site, patient’s response, type, size and confirmed position.
B. ASSESSMENT
NURSING ALERT:
Proper care and handling of CVC is essential to prevent central line associated blood stream
infections (CLA-BSI).
Accessing any part of CVC for any reason requires:
o Hand hygiene.
o Cleansing of connection site vigorously with alcohol swab using a 15 second scrub (let dry).
Assess need for existing CVC daily.
Notify Most Responsible Practitioner (MRP) if signs of malposition are present:
o Inability to withdraw blood.
o A “gurgling” sound heard when flushing CVC (if subclavian or jugular insertion).
o Edema in neck or shoulder.
o Chest, shoulder or back pain.
As much as possible, when administering Parenteral Nutrition (PN), use a dedicated lumen
and document specified lumen on patient’s plan of care.
PROCEDURE
1. Perform hand hygiene prior to touching any component of CVC, administration set, or fluid
solutions.
2. Assess site minimum once per shift, with each patient assessment and prior to accessing
CVC.
2.1. Palpate area around insertion site (through dressing)
2.2. Assess for tenderness or discomfort
2.3. Assess surrounding areas for redness, warmth, edema and drainage
2.4. Assess chest wall for engorged superficial veins (if subclavian or jugular insertion)
3. Document assessment and any unusual findings. Notify MRP of any unusual findings.
CODE C.2
NOTE: Change needleless access adapter at least every 7 days or at any sign of
adapter damage (i.e. cracking, leaking or contamination) and prior to blood
culture collection.
NOTE: Ensure alcohol is dry before applying needleless access adapter to catheter
lumen hub.
EQUIPMENT
PROCEDURE
3. Don PPE.
7. Cleanse adapter connection site vigorously with alcohol swab using 15 second scrub (let dry).
NURSING ALERT:
Ensure asepsis is maintained during needleless access adapter change.
NOTE: Avoid using forceps on catheter lumen hub. This may damage hub.
NOTE: Clean CVC catheter lumen hub threads with alcohol only if visibly soiled;
ensure alcohol is dry before attaching adapter. If visible encrustations will
not come off with alcohol, soak threads with normal saline soaked gauze
prior to cleaning CVC lumen threads with alcohol.
Approved: June 7, 2017 Page 5 of 21
HEALTH SERVICES
CODE C.2
9. Attach pre-flushed needleless access adapter with N/S filled syringe in place.
NURSING ALERT:
If unable to aspirate blood try the following techniques in this order:
Have patient change position, as appropriate to location of CVC, cough or take deep breath
and hold.
Instill 1 – 2 ml of N/S using push-pause technique and attempt to aspirate.
May repeat above steps. (For pediatrics may repeat x 2).
If still unable to aspirate for blood, label lumen plugged, document and notify physician.
Attempt access of another lumen.
Use of fibrinolytic agents has not been studied in short term central lines, therefore
fibrinolytic use on short term central lines is not recommended at this time.
NOTE: For pediatrics, refer to Appendix A. Follow steps 12 and 13 with heparin as
required.
15. Document.
D. FLUSHING
NURSING ALERT:
Avoid previously accessed multi-use vials and bag spikes when flushing CVC.
Flush with 10 mL N/S (5-10 mL for pediatrics) between incompatible solutions and 20 mL
(10-20 mL for pediatrics) after administration of blood products, PN or blood sampling.
Flushing should be done every 24hrs to each unused lumen including introducer and after
each access.
Heparinization is not required for adults. (Heparin may be required from pediatrics – see
Appendix A).
EQUIPMENT
1. PPE
2. 10 mL N/S in a greater than or equal to 10 mL syringe (per lumen)
3. Alcohol swabs
CODE C.2
PROCEDURE
2. Don PPE.
3. Cleanse needleless access adapter vigorously with alcohol swab using 15 second scrub (let dry).
5. Release clamp and aspirate slowly for blood return, only until flashback appears.
7. Remove syringe.
8. Clamp lumen.
9. Document.
NURSING ALERT:
For pediatrics, refer to Appendix A. Follow steps 10-13 below with heparin as required.
10. Cleanse adapter vigorously with alcohol swab using 15 second scrub (let dry).
11. Access needleless access adapter with heparin filled syringe (for pediatrics).
15. Document.
NURSING ALERT:
CODE C.2
EQUIPMENT
1. PPE
2. Alcohol swabs
3. Infusion pump
4. Primed IV set with solution(s) as ordered
5. 10 mL N/S in a greater than or equal to 10 mL syringe (per lumen)
PROCEDURE
2. Don PPE.
3. Cleanse needleless access adapter vigorously with alcohol swab using a 15 second scrub
(let dry).
5. Release clamp and aspirate slowly for blood, only until flashback appears.
7. Remove syringe.
8. Cleanse needleless access adapter vigorously with alcohol swab using 15 second scrub
(let dry).
11. Document.
CODE C.2
F. DRESSING CHANGE
NOTE: Assess dressing daily; replace dressing when it becomes damp, loosened or
soiled. Transparent semi permeable dressing is recommended for site
visualization; change every 7 days and PRN. Sterile gauze dressing changed
every 2 days and PRN.
EQUIPMENT
6. Alcohol swabs
7. Transparent semi permeable dressing (#319299)
8. Sterile normal saline (as required)
9. 2x2 sterile gauze (as required)
PROCEDURE
CODE C.2
4. Position patient supine with head turned away from dressing site (as appropriate).
6. Inspect insertion and suture site for redness, inflammation, tenderness or drainage.
8. Remove gloves.
NOTE: If CVC catheter is encrusted with blood or exudate, apply saline soaked gauze
to remove prior to cleaning with chlorhexidine.
11.2 Cleanse length of exposed catheter with same ChloraPrep® swab. Let dry 2-3
minutes.
13. Document.
CODE C.2
G. BLOOD SAMPLING
NURSING ALERT:
EQUIPMENT
1. PPE
2. Blood specimen tubes and labels (plus discard tube 3-5 mL; 7 mL from introducer)
NOTE: Refer to test compendium in laboratory services manual on RQHR Intranet for
appropriate blood tubes.
http://rhdintranet/lab/public/Manuals/Laboratory%20Services%20Manual.htm
PROCEDURE
NURSING ALERT:
In a multi-lumen catheter use proximal lumen for blood sampling when possible.
If continuous infusion in place, stop infusion through all lumens, flush and wait for 1 minute
before drawing discard.
3. Don PPE.
CODE C.2
5. Cleanse needleless access adapter vigorously with an alcohol swab using 15 second scrub
(let dry).
6. Change needleless access adapter (if drawing blood cultures). Refer to Section C.
NOTE: If unable to aspirate blood, see related nursing alert in section C. If still
unable to aspirate sample, attempt blood sampling from another lumen if
possible or notify lab to obtain samples via venipuncture. Notify MRP and
document.
9. Flush lumen with attached N/S using vigorous push-pause technique and wait 1 minute.
11. Insert blood specimen tube (3-5 mL adult) for discard and remove when filled.
NOTE: Blood cultures should be collected via venipuncture unless ruling out CVC as
source of infection. Change needleless access adapter prior to blood culture
sampling from CVC and use discard as part of first sample. Draw one set
from CVC and have lab draw one set via venipuncture.
12. Insert appropriate blood specimen tubes in appropriate order and obtain samples, filling each
sample to fill line.
13. Invert tubes gently 5 times immediately following obtaining each sample.
14. Remove Vacutainer® Luer-Lok™ access device and discard in sharps container.
CODE C.2
NOTE: Discard blood transfer device and blood discard in sharps container.
15. Cleanse needleless access adapter vigorously with alcohol swab using 15 second scrub (let
dry).
16. Attach greater than or equal to 10 mL pre-filled N/S syringe and flush with 20 mL using a
vigorous push-pause technique (10 – 20 mL for Pediatrics).
18. Cleanse adapter vigorously with alcohol swab using 15 second scrub (let dry).
20. Label specimen tubes in presence of patient at time of collection and send to lab
immediately.
NOTE: For pediatrics, if coagulation studies drawn, indicate on requisition if CVC was
heparinized.
21. Document.
H. REMOVAL
NURSING ALERT:
Removal of short term CVC and/or introducer may be performed by RN or RPNs educated
in this skill.
Removal of MLIC and introducer together can be performed by any RN once there is an
order to discontinue introducer. This is performed together simultaneously. For removal
process follow the steps outlined below in Section H.
Ensure that patient has peripheral IV access prior to line removal, if applicable.
An occlusive dressing is required to provide a complete seal to prevent air embolism and
infection.
Routine tip cultures are not performed unless removal for suspected infection or sepsis, per
MRP order.
If catheter tip is to be sent for C&S, corresponding blood cultures must be drawn prior to
removal (1 set drawn via venipuncture and 1 set drawn from CVC).
CODE C.2
EQUIPMENT
1. PPE
2. Mask
3. Non-sterile gloves
4. Sterile dressing set
5. Sterile gloves (if catheter tip C&S is going to be sent)
6. Sterile towel (if not in dressing set)
7. Chlorhexidine 2% with 70% alcohol (3 mL ChloraPrep®) (Clear #310410) (Orange tint
available if needed, usually used on insertion - #310411)
8. Stitch cutter (#310085)
9. 2x2 gauze
10. Sterile Petroleum Jelly (single use packet) (#312115) Occlusive dressing
11. Transparent semi permeable dressing (#319299)
12. C & S swab (if signs of infection present)
13. Sterile specimen container if tip is to be sent for culture
PROCEDURE
2. Review lab data for platelet count, PT, PTT, INR and notify physician of abnormalities prior
to removal.
9. Set up sterile field adding occlusive dressing, stitch cutter and ChloraPrep® applicator.
10. Inspect insertion and suture site for redness, inflammation tenderness or drainage.
11. Have patient turn his/her head away from catheter site (if removing an internal jugular or
subclavian catheter).
CODE C.2
15.2 Cleanse length of exposed catheter with same ChloraPrep® swab. Let entire area dry
2-3 minutes.
17. Place gauze over catheter insertion site with non-dominant hand.
NOTE: If catheter tip is not intact, call MRP immediately and document.
19. Apply direct pressure over insertion site immediately with gauze.
20. Continue to apply pressure for a minimum of 3-5 minutes or until bleeding stops.
NOTE: If coagulation results are abnormal, it may be necessary to apply pressure to site
for longer duration.
21. Apply occlusive dressing: 2x2 gauze with sterile petroleum jelly and transparent dressing.
22. Instruct patient to remain in supine position (or low Fowlers if supine is not tolerated) for 30
minutes after removal.
NOTE: For removal from femoral site, patient is to lie flat x 2 hrs following. Do not allow
hip flexion during this period. Assess dressing for bleeding.
CODE C.2
23. Document date and time of catheter removal, assessment of site and application of occlusive
dressing.
24. Assess site for signs of bleeding or hematoma every 15 min x2, every 30 min x2 and then 1
hour later.
26. Remove initial dressing in 24 hrs. Reapply dressing every 24 hrs until site is healed.
NURSING ALERT:
Removal of single lumen infusion catheter (SLIC) or multi lumen infusion catheter (MLIC)
from introducer is the responsibility of RNs/Physicians within ICU/CCU/PACU only.
Removal of SLIC/MLIC and introducer is performed simultaneously when both devices are
to be removed. Refer to Section H of this procedure if removal of both devices is required.
All SLICs must be removed from introducer prior to transfer out of ICU/CCU.
An MLIC may remain in introducer when patient is transferred out of ICU/CCU/PACU.
EQUIPMENT
1. PPE
2. Mask
3. Non-sterile gloves
4. Sterile gloves
5. Sterile dressing set
6. Chlorhexidine 2% with 70% alcohol (3 mL ChloraPrep®)(Clear #310410) (Orange tint
available if needed, usually used on insertion - #310411)
7. Moisture proof absorbent pad (blue pad)
8. Obturator cap for hemostasis valve
9. Transparent semi permeable dressing (#319299)
PROCEDURE
CODE C.2
NURSING ALERT:
9. Set up sterile field adding obturator cap, ChloraPrep® and transparent semi permeable
dressing.
10. Remove dressing if required to gain access to the locking mechanism of introducer.
NOTE: Forceps from dressing bundle can be used to maintain sterility of one hand
removing SLIC/MLIC
NOTE: One finger must remain sterile to cover hemostasis valve once SLIC/MLIC
removed.
18. Perform site care if dressing was removed to gain access to SLIC/MLIC. (Refer to Section F
DRESSING CHANGE).
19. Document.
CODE C.2
REFERENCES
Canadian Vascular Access Association (2013) Vascular Access Journal of the Canadian
Vascular Access Association. Volume 7 Supplement 1. www.cvaa.info.
Centers for Disease Control, (2011). Guidelines for the prevention of intravascular catheter-
related infections, 2011. Atlanta, GA: CDC.
Davis, M.B. (2013). Pediatric Central Venous Catheter Management: A review of Current Practice.
JAVA Vol 18 No 2 p. 93-98.
Hadaway, L. (2008). Targeting therapy with central venous access devices. Nursing, 38(6), 34-40.
Infusion Nurses Society. (2016). Infusion nursing standards of practice. Norwood, MA:
Lippincott, Williams & Wilkins.
Infusion Nurses Society. (2016). Policies and procedures for infusion nursing. Norwood, MA:
Infusion Nurses Society.
McGee, W., Headley, J., & Frazier, J. (Eds.). (2010). Quick guide to cardiopulmonary care (2nd
ed.). Irvine, CA: Edwards Lifesciences LLC.
Regina Qu'Appelle Health Region Laboratory Services. (2016). Lab services manual.
Wiegand, D. (2017). AACN Procedure Manual for High Acuity, Progressive, and Critical Care
(7th ed.). St. Louis, MO: Elsevier Saunders.
Revised by: Tracey Wilson, Lindsay Dusselier, Jana Lowey, Lisa Roland, Kim Hunt
Date: May 2017 (Wording Clarifications – Oct.2018 – A. Payne, K. Hunt)
CVAD’s inserted for purpose of hemodialysis are used exclusively for that purpose, therefore
without the express written consent of the nephrologist those lines may not be used.
Hemodialysis lines generally contain a much stronger heparin concentration. Heparin in the
CVAD used for hemodialysis should be withdrawn and discarded, not flushed through catheter
and into patients cardiovascular system.
Code: C.2
Author: Pediatrics
Date: Reviewed May 2002; February 2008, January 2009, August 2010, January 2012
Page 19 of 21
APPENDIX B
IV Tubing Changes
Code: C.2
Author: Pediatrics
Date: Reviewed May 2002; February 2008, January 2009, August 2010, January 2012
Page 20 of 21
APPENDIX C
3. To ensure good adhesion, clip excess hair where the dressing will be placed. Do not shave the skin
because of the potential for microabrasions.
4. Make sure skin is free of soaps, detergents, and lotions. Allow all preps and protectants to dry
thoroughly before applying the dressing. Wet preps and soap residues can cause irritation if trapped
under the dressing. Additionally, adhesive products do not adhere well to wet or oily surfaces.
5. Do not stretch the Tegaderm™ dressing during application. Applying an adhesive product with tension
can produce mechanical trauma to the skin. Stretching can also cause adhesion failure.
6. The adhesive of Tegaderm™ dressing is pressure-sensitive. To ensure best adhesion, always apply firm
pressure to the dressing from the center out to the edges.
7. To tailor a dressing for a special application, use sterile scissors to cut the dressing into desired shapes or
sizes before removing the printed liner. For best results and ease of application, cut the pieces so that a
portion of the frame remains on at least two sides.
8. For subclavian and jugular sites, apply the dressing with the patient’s head turned away and neck
extended as expected in normal movement. This helps prevent contamination of the site from
respiratory secretions and stress on the dressing when the patient moves.
Removal Hints
Support the skin when removing Tegaderm™ dressing. For removal from I.V. sites, also stabilize the catheter
to prevent dislodgment. Use one of the following removal techniques based on your patient’s skin condition
and your own personal preference:
Gently grasp one edge and slowly peel the dressing from the skin in the direction of hair growth. Try
to peel the dressing back over itself, rather than pulling it up from the skin.
or
Grasp one edge of the dressing and gently pull it straight out to stretch and release adhesion.
or
Apply an adhesive remover suitable for use on skin to the adhesive edge while gently peeling from
the skin.
*To aid in lifting a dressing edge, secure a piece of surgical tape to one corner and rub firmly. Use the tape as
a tab to help you slowly peel back the dressing.
Code: C.2
Author: Pediatrics
Date: Reviewed May 2002; February 2008, January 2009, August 2010, January 2012
Page 21 of 21