What is the purpose of “tunneling” (inserting the catheter 2-4 inches under the skin) when the surgeon inserts a Hickman central catheter device? Tunneling:

Increases the patient’s comfort level.
Decreases the risk of infection.
Prevents the patient’s clothes from having contact with the catheter
Makes the catheter less visible to other people.

Solution

Decreases the risk of infection.

The actual access to the subclavian vein is still just under the clavicle, but by tunneling the distal portion of the catheter several inches under the skin the risk of migratory infection is reduces compared to a catheter that enters the subclavian vein directly and is not tunneled. The catheter is tunneled to prevent infection.

Kent a new staff nurse asks her preceptor nurse how to obtain a blood sample from a patient with a portacath device. The preceptor nurse teaches the new staff nurse:

The sample will be withdrawn into a syringe attached to the portacath needle and then placed into a vacutainer.
Portacath devices are not used to obtain blood samples because of the risk of clot formation.
The vacutainer will be attached to the portacath needle to obtain a direct sample.
Any needle and syringe may be utilized to obtain the sample.

Solution

The sample will be withdrawn into a syringe attached to the portacath needle and then placed into a vacutainer.

A special port-a-cath needle is used to access the port-a-cath device. A syringe is attached and the sample is obtained. One of the primary reasons for insertion of a portacath device is the need for frequent or long-term blood sampling. A vacutainer will exert too much suction on the central line resulting in collapse of the line. Only special portacath needles should be used to access the portacath device.

What volume of air can safely be infused into a patient with a central venous access device (CVAD)?

It is dependent on the patient’s weight and height.
Air entering the patient through a CVAD will follow circulation to the lungs where it will be absorbed and cause no problems.
It is dependent on comorbidities such as asthma or chronic obstructive lung disease.
None.

Solution

None.

Any air entering the right heart can lead to a pulmonary embolus. All air should be purged from central venous lines; none should enter the patient.

A male patient is to receive a percutaneously inserted central catheter (PICC). He asks the nurse whether the insertion will hurt. How will the nurse reply?

“You will have general anesthesia so you won’t feel anything.”
“It will be inserted rapidly, and any discomfort is fleeting.”
“The insertion site will be anesthetized. Threading the catheter through the vein is not painful.”
“You will receive sedation prior to the procedure.”

Solution

“The insertion site will be anesthetized. Threading the catheter through the vein is not painful.”

Pain related to PICC insertion occurs with puncture of the skin. When inserting PICC lines, the insertion site is anesthetized so no pain is felt. The patient will not receive general anesthesia or sedation. Statement 2 is false. Unnecessary pain should be prevented.

A male patient needs a percutaneously inserted central catheter (PICC) for prolonged IV therapy. He knows it can be inserted without going to the operating room. He mentions that, “at least the doctor won’t be wearing surgical garb, will he?” How will the nurse answer the patient?

“You are correct. It is a minor procedure performed on the unit and does not necessitate surgical attire.”
“To decrease the risk of infection, the doctor inserting the PICC will wear a cap, mask, and sterile gown and gloves.”
“It depends on the doctor’s preference.”
“Most doctors only wear sterile gloves, not a cap, mask, or sterile gown.”

Solution

“To decrease the risk of infection, the doctor inserting the PICC will wear a cap, mask, and sterile gown and gloves.”

Strict aseptic technique including the use of cap, mask, and sterile gown and gloves is require when placing a central venous line including a PICC. Options A, C, and D are incorrect statements. They increase the risk of infection.

Some institutions will not infuse a fat emulsion, such as Intralipid, into central venous access devices (CVAD) because:

Lipid residue may accumulate in the CVAD and occlude the catheter.
If the catheter clogs, there is no treatment other than removal and replacement.
Lipids are necessary only in the most extreme cases to prevent essential fatty acid (EFA) deficiency.
Fat emulsions are very caustic.

Solution

Lipid residue may accumulate in the CVAD and occlude the catheter.

Occlusion occurs with slow infusion rates and concurrent administration of some medications. Lipid occlusions may be treated with 70 percent ethanol or with 0.1 mmol/mL NaOH. Lipids provide essential fatty acids. It is recommended that approximately 4 percent of daily calories be EFAs. A deficiency can quickly develop. Daily essential fatty acids are necessary for constant prostaglandin production. Lipids are almost isotonic with blood.

Some central venous access devices (CVAD) have more than one lumen. These multi lumen catheters:

Have an increased risk of infiltration.
Only work a short while because the small bore clots off.
Are beneficial to patient care but are prohibitively expensive.
Allow different medications or solutions to be administered simultaneously.

Solution

Allow different medications or solutions to be administered simultaneously.

A multilumen catheter contains separate ports and means to administer agents. An agent infusing in one port cannot mix with an agent infusing into another port. Thus, agents that would be incompatible if given together can be given in separate ports simultaneously.

How can central venous access devices (CVADs) be of value in a patient receiving chemotherapy who has stomatitis and severe diarrhea?

The chemotherapy can be rapidly completed allowing the stomatitis and diarrhea to resolve.
Crystalloid can be administered to prevent dehydration.
Concentrated hyperalimentation fluid can be administered through the CVAD.
The chemotherapy dose can be reduced.

Solution

Concentrated hyperalimentation fluid can be administered through the CVAD.

In patients unable to take oral nutrition, parenteral hyperalimentation is an option for providing nutritional support. High concentrations of dextrose, protein, minerals, vitamins, and trace elements can be provided. Dosing is not affected with options a and d. Crystalloid can provide free water but has very little nutritional benefits. Hyperalimentation can provide free water and considerable nutritional benefits.

Central venous access devices are beneficial in pediatric therapy because:

They don’t frighten children.
Use of the arms is not restricted.
They cannot be dislodged.
They are difficult to see.

Solution

Use of the arms is not restricted.

The child can move his extremities and function in a normal fashion. This lessens stress associated with position restriction and promotes normal activity. Fear may not be eliminated. All lines can be dislodged. Even small catheters can be readily seen.

An infection in a central venous access device is not eliminated by giving antibiotics through the catheter. How would bacterial glycocalyx contribute to this?

It protects the bacteria from antibiotic and immunologic destruction.
Glycocalyx neutralizes the antibiotic rendering it ineffective.
It competes with the antibiotic for binding sites on the microbe.
Glycocalyx provides nutrients for microbial growth.

Solution

It competes with the antibiotic for binding sites on the microbe.

Glycocalyx is a viscous polysaccharide or polypeptide slime that covers microbes. It enhances adherence to surfaces, resists phagocytic engulfment by the white blood cells, and prevents antibiotics from contacting the microbe. Glycocalyx does not have the effects in options B-D.

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