VA-BC CERTIFICATION STUDY MATERIAL QUESTIONS & ANSWERS 2024!!

List indications for Vascular Access: - ANS 1. Total parenteral nutrition (TPN) 2. Partial parenteral nutrition 3. I.V. fluids and medications 4. Blood and blood components 5. Chemotherapeutic agents 6. Cardiac monitoring 7. Plasmapheresis 8. Aquapherisis 9. Hemodialysis a. Diagnostic testing b. Frequent blood sampling What is the French Scale? - ANS Measurement of the outside size (diameter) of a catheter What is the range of Central venous catheter French sizes? - ANS 1.2fr for Neonates up to 15fr for dialysis catheters As the French size increases, what does the diameter of the catheter do? - ANS It increases What is the gauge scale? - ANS Measurement of the outside size(diameter) of a catheter As the gauge number gets larger, what happens to the catheter size? - ANS It gets smaller. What is the gauge range of IV catheters? - ANS 24ga to 12 ga Why are all I.V. devices manufactured in the USA are required to be radiopaque? - ANS To facilitate location of catheter emboli in the event of shearing or fracture From what two materials are IV catheters made? - ANS Silicone and Polyurethane Which catheter material can be affected by alcohol? - ANS Polyurethane What are the indications for short peripheral catheters? - ANS -Infusions projected for 6 days or less -Non-irritating medications and solutions -Non-vesicant medications and solutions What are contraindications for short peripheral catheters? - ANS -Placement into an arm with fracture, trauma, infection, or compromised circulation -Veins in the arm on the same side of a mastectomy, breast surgery or lymph node dissection -Veins in the arm with an A/V fistula or graft What veins are used for short peripheral catheters? - ANS Metacarpal, cephalic, basilic and accessory veins of the arms How many short peripheral catheter insertion attempts per healthcare provider are allowed? - ANS 2 What additional veins in pediatrics may be used for non-irritating/non-vesicant infusions? - ANS Metacarpal, cephalic or basilic, scalp veins if <18mo What are the indications for a midline catheter? - ANS -Infusions projected for 6 days- 4 weeks -Non-irritating medications and solutions -Non-vesicant medications and solutions What are contraindications for a midline? - ANS -Arms with: A/V fistula, infection, fracture, trauma, or compromised circulation -Chronic Kidney Disease What are the sites and vessel selection for midline catheters? - ANS Basilic or cephalic vein in the antecubital fossa or lower part of the upper arm What product should be used for a midline placement? - ANS A product that is specifically designed and labeled as a peripheral midline catheter What barrier precautions should be considered for midline placement? - ANS Maximun sterile barrer Why should a PICC device NOT be used for midline placement? - ANS Using a PICC device for midline placement will risk confusion related to the type of access device a patient has; places the catheter tip outside the SVC, which is contrary to the manufacturers' DFU related to the intention of the product and risks potential liability for the nurse. What is optimal tip location for a midline catheter? - ANS One inch below the axillary area For midline placement, what alternative veins can be considered in pediatric patients? - ANS Scalp veins Popliteal veins Saphenous veins What are the indications for non-tunneled catheters? - ANS Short term central vein access Emergency central vein access What are the contraindications for non-tunneled catheters? - ANS Neck or chest sites may be excluded for patients with tracheostomies, radical neck dissection, and cervical fracture instability, or unstable airway Inability to position patient, insert or stabilize catheter Avoid insertion on same side as a PICC that passes through the subclavian vein What are the potential vessels for non-tunneled catheters? - ANS A. Jugular veins, external and/or internal B. Subclavian veins C. Femoral veins (least preferred) In patients at greater risk for catheter associated bloodstream infections (CABSI) what typed of PICC or non-tunneled catheters should be considered? - ANS Anti-microbial catheters What type of barrier precautions are required for non-tunneled catheter placement? - ANS Maximun sterile How should a patient be positioned for non-tunneled catheter placement? - ANS slight Trendelenburg position Why is a patient placed in slight Trendelenburg position for non-tunneled catheter placement? - ANS to avoid the possibility of air emboli during the placement procedure In non-tunneled catheter or PICC placement., what should always be avoided when accessing veins? - ANS Blind-stick attempts. Prior to any infusion of non-tunneled catheters, how should tip location be confirmed? - ANS ECG technology or radiograph What must be obtained prior to ANY infusion of a non-tunneled catheter or a PICC line? - ANS A free flowing blood return What is the optimal tip location for a non-tunneled and PICC catheters? - ANS Cavoatrial juncture (CAJ) If inserted through the femoral vein, what the optimal tip location for a non-tunneled and PICC catheters? - ANS Inferior vena cava (IVC) above the level of the diaphragm Why is the femoral vein is commonly used in pediatric critical care units for non-tunneled catheter placement? - ANS Due to ease of insertion in young patients Why may the jugular vein be the preferred point of insertion in very young children for non-tunneled catheters? - ANS To avoid a pneumothorax What are the indications for placement of a PICC line? - ANS -Patients who require central venous access when the duration of the infusions are unknown -Infusion of irritating medications -Infusion of vesicant agents What are the contraindications of PICC line placement? - ANS -Placement into an arm with fracture, trauma, infection, amputations, or compromised circulation -Placement into an arm paralyzed as a result of a CVA may increase the risk of catheter-related thrombosis due to compromised circulation 4 -Chronic kidney disease patients What vessels are selected for PICC line placement? - ANS Basilic, brachial or cephalic vein in the upper arm What barrier precautions are required for PICC placement? - ANS Maximum sterile What areas of tip location should be avoided in PICC line placement? - ANS Avoid catheter tip locations in the upper SVC or midclavicular areas What Alternative veins for PICC lines may be selected in pediatric pts.? - ANS Scalp veins, popliteal veins In pediatric patients, what, if added ,may decrease catheter occlusion? - ANS Heparin (confirm infusatn compatibility) What are the indications for tunneled catheters? - ANS -Infusions that are projected to continue for months or years -Apheresis What are the contraindications for tunneled catheter placement? - ANS -Presence of a bloodstream infection -Severe coagulopathy -Cellulitis (affecting intended insertion site) which vessels are selected for tunneled catheters? - ANS a. Subclavian veins b. Jugular veins c. Femoral veins Where might tunneled catheter exits sites be located? - ANS The chest, upper back, top of thigh, or lower torso What attached to the catheter, will be positioned in the tissue track to secure the catheter? - ANS A stabilizing Dacron cuff After a tunneled catheter placement, how long until the exit site heals? - ANS Two to three weeks. When (upon physician approval) may a tunneled catheter be maintained without a dressing? - ANS Once the cuff has developed tissue attachment and the exit site is healed, In pediatric pts. with tunneled catheters, why do we assess/verify internal catheter tip location as the child grows? - ANS To maintain internal tip in the SVC What are the indications for an implanted port? - ANS Infusions that are projected to continue for months to years What are the contraindications for an implanted port? - ANS -Severe coagulopathy -Severe, uncontrolled sepsis -Burns or cellulitis (affecting the intended insertion site) -Patient who is cachectic, below ideal body weight, or lacking subcutaneous tissue for port implantation What vessels are selected for a "peripheral" implanted port? - ANS Basilic or cephalic vein What vessels are selected for a "central" implanted port? - ANS Subclavian vein Jugular vein Femoral vein Name two things considered when placing an implanted port. - ANS -Comfort related to the location of the implanted venous port -Depth of the implanted port must be shallow enough for the clinician to palpate and insert a non-coring access needle safely to maintain access into the port septum Depending on the vein accessed, where might the port implantation site be located? - ANS Port implantation site may be upper chest or lower abdominal side area How is the port secured inside the patient? - ANS Port is sutured into a subcutaneous pocket under the skin Accessing an implanted port is always what type of procedure? - ANS Sterile procedure What type of needle is used to access an implanted port? - ANS Non-coring needle What are power-injectable catheters? - ANS Power-injectable catheters are made of polyurethane and engineered to withstand high pressure >300 pounds per square inch (PSI) What are power injection catheters used for? - ANS Used for power injection of I.V. contrast media for a computerized tomography (CT) or magnetic resonance imaging (MRI) scan What are indications for an intraosseous device? - ANS As an alternative to venous access in emergency situations What are contraindications for intraosseous placement? - ANS -Trauma or fracture in the area of access -Bone disease What are possible selection sites for IO placement? - ANS Sternum, iliac crest, femur or tibia (away from the growth plate in the tibia) What may be administered through an IO device? - ANS I.V. fluids, blood and medications In emergency situations, in what population are IO devices often used? - ANS Infants and children What are indications for dialysis or apheresis catheters? - ANS Hemodialysis, apheresis for plasma or platelets What are possible vessels selected for dialysis/apheresis catheters? - ANS Jugular, subclavian, or femoral vein Generally, what size are dialysis or apheresis catheters? - ANS Catheter lumen size is generally 13 to 16 gauge Why are dialysis/apheresis catheters more rigid? - ANS To facilitate rapid blood flow Which catheter insertions are surgical precures and required anesthesia? - ANS Implanted ports, tunneled catheters, Dialysis/apheresis catheters. Where is the optimal tip location for a dialysis/apheresis catheter? - ANS Upper right atrium What are indications for an aerial catheter? - ANS Monitoring arterial pressure, arterial blood draws and organ specific infusions What are contraindications for radial artery catheters? - ANS Lack of adequate arterial circulation via the ulnar artery determined by an Allen's Test prior to catheter insertion What vessels are selected for placing arterial catheters? - ANS Radial, brachial, axillary, or femoral vein What is the indication for a Pulmonary artery catheter? - ANS Assessment of cardiac function What are contraindications for a PA catheter? - ANS Mitral stenosis Right heart mass Tricuspid or pulmonary mechanical valves What vessels are preferred for PA catheter placement? - ANS The right subclavian or internal jugular In which type of catheter placement is cardiac monitoring used during insertion? - ANS Pulmonary Artery catheters. What is the indication for an Aquapheresis catheter? - ANS Diuretic resistant CHF (ultrafiltration to remove excess fluid/sodium) What is the contraindication for an aquapheresis catheter? - ANS Lack of an accessible basilic vein in upper arm What vessel is selected for an aquapheresis catheter? - ANS Basilic vein above the antecubital bend For what things are Aquapheresis catheters are not recommended? - ANS Not recommended for infusions of fluids or medications What is the optimal tip location for an aquapheresis catheter? - ANS 1 -2 centimeters below the axilla What vessels are available to use with pediatric umbilical catheters? - ANS 2 umbilical arteries 1 umbilical vein During what time frame may umbilical vessels be accessed? - ANS Up to the 4th day of life. What are appropriate uses of an umbilical catheter located in a VEIN? - ANS -Blood sampling -All infusates What are appropriate uses of an umbilical catheter located in an ARTERY? - ANS -Blood sampling -No TPN or vesicant infusions Site Determination: In evaluating potential sites, what is an important but an often overlooked portion of the CVAD pre-procedural assessment? - ANS Physical exam Site Determination: Prominent superficial veins in the area of planned CVAD may indicate what? - ANS Neighboring or central vein stenosis or thrombosis Site Determination: What should you assess upon physical exam when determining potential CVAD sites? - ANS -Skin turgor with emphasis on skin condition at the planned insertion site -Presence of any skin lesions, scars, edema, ecchymosis, or grafts -Presence or absence of collateral veins -Swelling of the arm, chest, face or neck -Prominent superficial veins Site Determination: Why should you avoid non-compressible or partially compressible target veins? - ANS They denote probable thrombosis Site Determination: What might variance in the vein diameter along the vein pathway do? - ANS Variance in the vein diameter along the vein pathway which may interfere with catheter advancement Site Determination: When assessing to patient for potential CVAD sites why should you look at a recent CXR? - ANS To check for pacemakers or Automatic Implantable Cardioverter Defibrillator (AICD), spinal rods or other implanted devices Skin Preparation: What is an antiseptic? - ANS A chemical agent that inhibits microorganisms on skin or tissue and has an effect of limiting or optimally preventing infection. Skin Preparation: What is a disinfectant? - ANS A chemical agent that destroys microorganisms on inanimate objects Skin Preparation: What is aseptic technique? - ANS -A specific type of aseptic technique where key areas of items to be used for an infusion cannot be touched prior to insertion. -Once a site has been disinfected it can only be touched by the clinician if wearing sterile gloves. -All injection ports on I.V. tubing and end caps on catheter lumens MUST be properly disinfected prior to access Skin Preparation: What are the properties of ideal skin antiseptic agents? - ANS a. Broad spectrum of activity / rapid bactericidal activity b. Persistence or residual properties on the skin c. Maintain its activity in the presence of organic material d. Non-irritating or have low allergic and/or toxic responses e. No or minimal systemic absorption Site Preparation: What factors may affect the activity and effectiveness of an antiseptic solution? - ANS a. Organism's concentration in that specific area of the skin b. Organism's composition c. Concentration of the antimicrobial agent d. If it is combined with other antiseptic agents (e.g. as a tincture with alcohol) e. Duration of organism's exposure to the antimicrobial agent Site Preparation: What are the recommended prep agents? - ANS a. Chlorhexidine gluconate b. Iodophors c. Alcohol d. Surface disinfectant e. Adhesive remover f. Skin protectant Site Preparation: How is Chlorhexidine gluconate applied? - ANS In a back-and-forth motion for a minimum of 30 seconds Site preparation: Against what type of organisms is Chlorhexidine gluconate effective? - ANS gram positive and gram negative Site preparation: With it's strong skin binding properties, what is the residual effect of Chlorhexidine? - ANS Up to 48 hours residual activity Site preparation:: What is a pediatric consideration of Chlorhexidine? - ANS USE WITH CAUTION FOR PREMATURE INFANTS AND CHILDREN < 2 MONTHS OF AGE Site preparation: What are iodophors? - ANS Solutions of iodine in complexes that contain a low amount of free iodine Site preparation: What solutions contain up to l0% of an iodine complex, and provide up to 1% free iodine for skin antisepsis - ANS Povidone iodine (e.g. Betadine™) Site preparation: After the application of povidone iodine, what should NOT be applied? - ANS Alcohol Site preparation: What is effective against gram-positive and gram-negative bacteria, fungi, and viruses; but has minimal effect on bacterial spores? - ANS Tincture of iodine Site preparation: For an antiseptic effect to occur with Iodophors, what must happen? - ANS The antiseptic must have contact with the skin for two minutes or more to release free iodine Site preparation: Once applied, how long is the residual effect of Iodophors? - ANS Approximately two hours Site preparation: if iodine comes into contact with organic matter, such as blood, what happens? - ANS It is neutralized and no longer effective Site preparation: What solutions contain 1% to 2% iodine in an alcohol base? - ANS Tincture of Iodine Site preparation: Why are iodophor solutions usually not used in neonatal and infant populations? - ANS Percutaneous absorption of iodine has been noted in neonates, with hypothyroidism induction in newborns. Site preparation: After Povidone Iodine has dried, what can you do to minimize the effects of skin irritation and dryness? - ANS Remove it with sterile saline wipes. Site preparation: What type and concentration of alcohol is still used extensively in skin antisepsis? - ANS Isopropyl Alcohol in a 70% concentration Site preparation: How does alcohol exert antimicrobial effect? - ANS By denaturing the cell proteins and dissolving the cell lipids Site preparation: On what type of organisms does alcohol have an excellent or good effect? - ANS Gram + and Gram - bacteria fungus virus Site Preparation: What is the residual effect on the skin of alcohol? - ANS Alcohol lacks residual antimicrobial property once the alcohol evaporates Site preparation: Which antiseptic has a volatile or flammable nature until completely dry? - ANS Alcohol Site Preparation: What effect can alcohol have on the skin? - ANS Alcohol irritates and dries the skin What is the purpose of a disinfectant wipe? - ANS To kill bacteria, viruses, and fungi on inanimate objects Surface disinfectant are used on what type of surfaces? - ANS Use on hard, nonporous surfaces and equipment In line placement, when are surface disinfectants used? - ANS prior to setting up sterile field and between patient use What is the purpose of adhesive remover? - ANS Removes sticky residue from tape or dressings b. Allows easy removal of transparent dressings, butterfly stitches and stabilization devices during dressing changes c. Decreases skin trauma and tears d. Do not use directly on insertion site Is it okay to use adhesive remover directly on Insertion site? - ANS No