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Catheter/ Vein Path
- Tenderness/ pain
- Redness/ warmth
- Venous cord
- Swelling
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Mechanical Phlebitis
- Inflammation of vein caused by body's response to a foreign material. Not an infectious process
- Primarily occurs during first week (i.e. 3-7 days)
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- Teach patient frequent observation, for tenderness
Prevention:
- Do not baby the arm. Recommend that patient regularly squeeze hand into a fist (may use a soft ball for this)
- At the first sign of tenderness, apply moist heat (warm wet towel in a plastic bag), 20 minutes on and 20 minutes off
- If tenderness does not resolve, apply continuous low heat
- Rate phlebitis according to scale provided in Nursing D & P, C-86-A & B, pg. 2
- Grade II or less: Apply continuous low heat for 2-3 days. Elevate extremity, encourage mild exercise. Arrange for phone follow-up at 24/48 hrs to assess decreasing symptoms
- Grade 3 or more requires q24h visual monitoring
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- Fever/ chills
- Redness, drainage and swelling at site
- Pain/ tenderness at site
- Tachypnea or hypotension
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Infection/ Sepsis
- Immunosuppression
- Failure to maintain aseptic, sterile technique in catheter case
- Contaminated catheter
- Fibrin sheath
- TPN, steroid therapy
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Prevention:
- Aggressive cleansing of insertion site. Do not leave any crusting at insertion site
- Notify physician
- Blood cultures to be drawn
- Swab exit site
- Catheter removal followed by culture of tip
- Antibiotics
- Investigate other causes/ sites of infection
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- Warmth
- Swelling
- Redness
- Pain/ tenderness
- Doesn't follow course of vein
- Spreads in diffuse circular manner
- Extends beyond limits of dressing
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Cellulitis
- A localized exit site infection
- Due to contamination of site
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- Notify physician
- Cellulitis responds well to oral antibiotics or increased site care and may not require removal of catheter (up to discretion of physician)
- If catheter removed, it must be cultured
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- Edema of arm, shoulder, neck/ face
- Distended arm or neck veins
- Pain of arm, shoulder, neck
- Arm turns dusky colour when in dependent position
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Thrombophlebitis
- Deep vein thrombosis of the subclavian vein due to:
- obstruction of blood flow;
- injury to intima wall vein;
- increased blood; or
- viscosity due to dehydration
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- Notify physician
- Verify with venogram
- Use of anticoagulant therapy
- Removal of catheter
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- Redness
- Pruritis
- Encompassed by dressing
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Skin Reaction
- Related to sensitivity to dressing
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Prevention:
- Do not use tinted chlorhexidine as the dye is associated with skin reactions
Intervention/ Guidelines:
- When the skin around the insertion site becomes itchy and/or reddened under the dressing do a patch test on the patient's chest using chlorhexidine 0.5% at one spot, IV 3000 at one spot, and aqueous chlorhexidine 2% at another spot (this will distinguish between sensitivity to chlorhexidine, IV 3000, and alcohol). Check in 24 hours
- If the patient is sensitive to IV 3000, change the dressing to Mepore
- If the patient is sensitive to chlorhexidine (will show sensitivity to both chlorhexidine 0.5% and aqueous chlorhexidine 2%), change the cleansing solution to povidone iodine. If the skin is irritated, rinse off with sterile saline before applying dressing
- If the patient is sensitive to alcohol (will show sensitivity only to chlorhexidine 0.5%), then switch cleansing solution to aqueous chlorhexidine 2%
- If the skin becomes excoriated, cleanse with appropriate agent, make the dressing over the insertion site as small as possible and use a small, sterile adhesive bandage (only is skin is unbroken). Use cortisone cream (requires a prescription) bid, applied thinly with a sterile q tip. Dress with gauze and cling. Home care may need to be involved. Assess q24 hours. Leave adhesive bandage on for 48 hours (as long as skin underneath is unbroken)
- Skin reactions may need a great deal of creative thinking. The principles you are trying to maintain are:
- Reduce the bacterial count on the skin. Chlorhexidine is the most effective agent and chlorhexidine 5% in 70% alcohol is the most effective product
- Cover the insertion site with a barrier. IV 3000 is the most effective dressing
- Maintain the integrity of the skin around the insertion site. Stretch the IV 3000 to remove, do not stretch to apply. Avoid the use of adhesives on damaged skin. If patient seems sensitive to orange border of IV 3000, remove
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- Unable to flush catheter or aspirate blood from catheter
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Blocked Catheter
- Drug precipitate
- Fibrin Sheath
- Blood clot in catheter caused by blood return in catheter due to improper flushing, vomiting, coughing, heavy lifting or strenuous exercise
- Catheter tip or valve against vessel wall or vein valve
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- Assess cause, reposition patient
- For fibrin sheath, make arrangements with PICC nurse to declot according to Directive & Procedure
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- Increased length of external catheter
- Lack of blood return
- Swelling in chest or neck during infusion
- Pain or discomfort during infusion
- Leaking at catheter exit site
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Catheter Migration
- Severe coughing or vomiting
- Physically active patient
- Catheter not securely anchored
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- Assess cause
- Secure anchoring of catheter with steri strips
- Teach patient to observe external length of catheter and report changes
- Notify physician
- X-ray for placement
- Remove catheter if necessary
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- Chest pain
- Dyspnea
- Pallor
- Light headedness
- Tachycardia/ hypotension
- Confusion
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Air Embolism
- Air enters circulatory system and travels to right ventricle through the vena cava
Due to:
- Open tubing while patient vomiting or coughing
- Air accidentally injected due to improper priming of lines
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- Turn patient on left side in trendelenburg position
- Notify physician
- Do vital signs
- 02 as per doctor's orders
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Pain During Infusion
- Damaged or torn catheter from too small a syringe used
- Vasospasm
- Phlebitis (see Trouble Shooting, Appendix 1).
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- Determine location of pain
- Notify physician
- X-ray with contrast median may be required
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