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Nursing

Venous Access Devices

Peripheral Intravenous (PIV)

The PIV is the most commonly used device to administer intravenous fluids and medications. PIVs are placed in peripheral veins using an intravenous catheter. 

       Advantages

      Disadvantages

  • Easiest vascular access device to insert
  • Lowest risk of device-related systemic infection
  • Least invasive device for children with good peripheral vein access
  • No blood sampling capabilities
  • Peripheral veins are irritated by some medications and Total Parenteral Nutrition (TPN)
 

Central Venous Access Devices (CVAD)

CVAD provide access to the central venous system via the superior vena cava (SVC) or the inferior vena cava (IVC). CVAD are intended for both short term and long term use.

Benefits of CVAD over Peripheral IV's include:

  1. Stability -  depending on the device, some devices can remain in place for weeks to years
  2. Rapid Hemodilution - due to large blood flow through the vena cava, medications and solutions are rapidly diluted and distributed throughout the body
  3. Safety - medications that are vesicants or vessel irritants are more safely administered via a CVAD as there is less risk of extravasation
  4. Blood Sampling - most CVAD allow for blood sampling decreasing the amount of venipuncture for patients requiring frequent blood work
  5. Multilumen Configurations - available as single or multi-lumen which allow incompatible infusions to be delivered simultaneously
  6. Home IV Therapy - CVAD allow patients who are medically stable to receive treatment at home

General CVAD Care

The care of all CVAD is aimed at minimizing the risk of developing a catheter-related infection, maintaining patency of the device, and avoiding accidental dislodgement. Proper care of the device can minimize the risks.

  • All CVAD care begins with a vigorous hand wash
  • Includes standardized dressing, cap and tubing changes
  • Routine assessment of the line necessity and function
  • Standard access procedures

Your preceptor or clinical instructor will introduce you to the CVAD care bundles, a group of evidence-based interventions used together to reduce central line-associated bloodstream infections (CLABSI). 

Nursing students can provide CVAD care only under the direct observation of a nurse AND only if the acquisition of these skills is supported by their academic programme.

Securing CVAD

Ensuring CVAD are properly secured helps prevent accidental dislodgement of the catheter and damage caused from repeated twisting or kinking of the catheter. All CVAD must be well secured externally to the patient's body. 

If during your nursing student placement  you are expected to participate in the care of patients with CVAD, you are required to review the CVAD policies and procedures. Please note that these documents can only be accessed on the hospital internal website.

Types of CVAD

Peripherally Inserted Central Catheters (PICC)

  • enter a peripheral vein and the tip of the line is advanced to the central venous system
  • require ongoing care for heparinization, cap change, dressing change
  • must be protected from water; should not swim or immerse limb while bathing

Tunneled External Catheters

  • commonly referred to as central venous lines (CVL)
  • surgically tunnelled through subcutaneous tissue
  • require ongoing care for heparinization, cap change, dressing change
  • must be protected from water; should not swim or immerse limb while bathing

Subcutaneous Ports

  • totally implanted venous access device
  • portal body is implanted in subcutaneous tissue of anterior chest
  • catheter tunneled to internal jugular vein and tip rests in the superior vena cava
  • accessing requires needle insertion
  • lowest risk of infection among all CVAD as there is no external portion when not in use
  • good for long term, intermittent therapy (e.g., chemotherapy) and for conditions with intermittent access requirements
  • when not in use requires only monthly heparinization
  • when not accessed, no daily care required and no restrictions on most activities (e.g., swimming, sports) as the entire device is internalized

Percutaneous Central Venous Catheters

  • placed directly into the jugular, femoral, or subclavian vein
  • usually sutured
  • often inserted for use in the critical care unit

 

If you are expected to care for patients with CVAD, upon commencing your placement you are required to review:

1) SickKids CVAD policies and procedures. Please note that these documents can only be viewed on the hospital internal Policies and Procedures website. 

2) CLABSI bundle - available on the internal hospital website.

                                             

References: Caring for Children with Central Venous Access Devices: The Hospital for Sick Children, SickKids Learning Institute, 2017.