Care of patient with CVP Lines

A B
TYPE OF CVP
1. Preferred site of CVP insertion:
2. M/C site of insertion for TPN administration:
3. M/C site with least risk of infection:
4. M/C site with high risk of infection & DVT:
5. M/C site in emergency:
6. High Risk of Pneumothorax:
7. Patient Position while inserting the CVP line through Jugular or
subclavian vein:
8. M/C of insertion of PICC line:
9. Technique used to insert the CVAC:
10.Solution used for cleaning insertion site:
CVP LUMEN
CVC Lumen

Median Lumen,
18 G

Proximal lumen
18 G

Distal Lumen
16 G
1. Which Lumen is used for CVP Monitoring
2. Which Lumen is used for routine patient intervention
3. Which lumen is used for TPN administration
1. Transparent dressing change after every ……………
2. Gauze Dressing change after every -----------
3. After removing the CVAD the site should be covered
with transparent dressing for up ………hours
 CVP Line flushing

▪ Purpose of Flushing:
▪ Which ml syringe used for flushing:
▪ Which solution used for flushing:
▪ Method used for flushing:
▪ How frequently one should flush the lumen is not in use:
Blood sampling from CVP line
Administering medication through CVP line
Measuring CVP through manometer
• If transducer is too high will have falsely ….BP
readings.
• If the transducer is too low will have falsely
………BP readings.
 Increase CVP level indicates Decrease CVP level
indicates
▪ Fluid overload ▪ Hypovolemia
▪ Right heart failure ▪ Shock
▪ Cardiac tamponade
▪ Pleural effusion
▪ Tension pneumothorax
Which of the following is classified as a tunneled catheter?

a. Hickman
b. Groshong
c. Broviac
d. All of the above
A client with known heparin-induced thrombocytopenia (HIT) is
undergoing chemotherapy and is having a central venous access
device placed. Which of the following types of central venous access
device does the nurse know BEST minimizes the risk of HIT-related
complication?

(1) A Hickman does not contain valves and is routinely flushed with
heparin.
(2) A Broviac does not contain valves and is routinely flushed with
heparin.
(3) A Groshong is a valved catheter that does not require heparin
flushing.
(4) A port does not contain valves and is routinely flushed with
heparin.
What change occurs in the CVP reading if the transducer placed too
high?

a. High reading
b. Low reading
c. No change occur in the reading
d. Abnormal reading
A client experienced a pneumothorax after the
placement of a central venous pressure line. Which of
the following supports a diagnosis of pneumothorax?

1. Sudden, sharp pain on the affected side.

2. Tracheal deviation toward the affected side.
3. Bradypnea and elevated blood pressure.
4. Presence of crackles and wheezes.
A client with pancreatic cancer, who has been bed-bound for 3 weeks, has just
returned from having a left subclavian, long-term, tunneled catheter inserted for
administration of analgesics. The nurse has not yet received radiographic results
for confirmation of placement. The client becomes restless and dyspneic and has
chest pain radiating to the middle of the back. Physical assessment reveals
tachycardia and absent breath sounds in the left lung. The nurse should further
assess the client for:
1. An air embolus.
2. A pneumothorax.
3. A pulmonary embolus.
4. A myocardial infarction.
The nurse should ensure that which of the following is placed when
the client is to receive intravascular therapy for more than 6 days?

1. Short peripheral catheter.

2. Central venous access in the femoral vein.
3. Steel needle in the subclavian vein.
4. Peripherally inserted central catheter (PICC)
The most common preventable complication associated with
CVP insertion?

a. Central Line infection

b. Thrombosis of vein
c. Pneumothorax
d. Haemothorax
What does the PICC stand for?

a. Peripherally injected central catheter

b. Peripherally inserted central catheter
c. Placed inverted central catheter
d. Precisely implanted central catheter
The CVP value should be checked by the nursing officer
at?

a. Mid inspiration
b. Mid expiration
c. End of maximum inspiration
d. End of maximum expiration
A blood sample is to be obtained through the CVC. Which
action should the nurse take before entering the system?

a. Scrub the needleless connector with an antiseptic and allow it

to dry.
b. Scrub the sterile access device and allow it to dry.
c. Scrub the sterile syringe and wipe it dry with sterile gauze.
d. Scrub the needleless connector with an antiseptic and wipe it
dry with sterile gauze.
The nurse is caring for a client who has a peripherally inserted
central catheter (PICC) in place to receive antibiotics. As the
nurse prepares to change the dressing of the PICC, how should
the nurse position the client?

A. sitting upright, with the arm extended from the body over the
head
B. lying flat, with the arm extended from the body below heart level
C. sitting upright, with the arm flexed at the elbow below heart level
D. lying flat, with the arm extended from the body above heart level
A patient with a CVAD suddenly develops dyspnea,
tachycardia, and hypotension. Into which position should the
nurse place the patient?

1. Trendelenburg.
2. Lying flat on right side.
3. On left side with head down.
4. High-Fowler's
 Complications

Immediate Early Late

• Arrythmia • pneumothorax • Infection
• Accidental arterial • catheter blockage • Thrombosis
puncture • Catheter fracture
• haemothorax
• haematoma
• thoracic duct injury
• air embolus
CHEST TUBE
Collection Chamber
Water seal chamber
SUCTION CHAMBER
While inserting ICD drain in the axillary line, all of the
following structures are perforated, except:

a. Parietal pleura
b. Pulmonary visceral pleura
c. External intercostal
d. Internal intercostal
The nurse is caring for a patient with a chest tube. The nurse
knows that the drainage system is working correctly if she
Observes?

1. Continuous bubbling in the water seal chamber.

2. Intermittent bubbling in the water seal chamber.
3. Excessive bubbling appears in the dry suction chamber.
4. Titling is absent in the water seal chamber.
The nurse caring for a client with a closed chest drainage system
notes that the fluctuation (tidaling) in the water-seal
compartment has stopped. On the basis of this assessment
finding, the nurse would suspect which occurrence?

1.The tube indicate air leak.

2.Suction needs to be increased.
3.Suction needs to be decreased.
4.The chest tubes are obstructed.
The post-operative nurse receives a patient with chest
tube from the Operation Theatre. Two hours later when
the nurse checks the chest tube drainage collection
chamber it was completely empty. Which action the
nurse should perform in such situation?

a. Clamp the chest tube

b. Milking of chest tube
c. Turn the patient from side to side
d. Keep the chest tube drainage on the patient’s bed
A patient is receiving positive pressure mechanical
ventilation and has a chest tube. When assessing the
water seal chamber what do you expect to find?

a. The water in the chamber will increase during inspiration

and decrease during expiration.
b. There will be continuous bubbling noted in the chamber.
c. The water in the chamber will decrease during inspiration
and increase during expiration.
d. The water in the chamber will not move.
While helping a patient with a chest tube
reposition in the bed, the chest tube catheter
becomes dislodged from the insertion site What is
your immediate nursing intervention?

a. Stay with the patient and monitor their vital signs

while another nurse notifies the physician.
b. Place a sterile dressing over the site and tape it on
three sides and notify the physician.
c. Attempt to re-insert the tube.
d. Keep the site open to air and notify the physician.
Identify the highlighted part of a given below image?
MANNISOTA TUBE
▪ Routine ETT before tube insertion
▪ inflate gastric balloon using 50mL increments up to 250 -
300ml for SBT or 450-500ml for Minnesota tube
▪ inflation of oesophageal balloon usually is not required (if
required inflate to < or equal to 45mmHg
▪ Esophageal balloon should not be inflated for more than 6
hours.
▪ 500 to 1 kg traction can be used to stop the bleeding.
The health care provider (HCP) arrives on the nursing unit and
deflates the esophageal balloon. Which assessment finding by the
nurse is the most important and should be reported to the HCP
immediately?

1. Hematemesis
2. Bloody diarrhea
3. Swelling of the abdomen
4. An elevated temperature and a rise in blood pressure
A nurse is preparing to care for a female client with esophageal
varices who just had a Sengstaken-Blakemore tube inserted. The
nurse gathers supplies, knowing that which of the following items
must be kept at the bedside at all times?

a. An obturator
b. Kelly clamp
c. An irrigation set
d. A pair of scissors
Nurse Reena is ICU 1 head nurse and during her morning shift
she received a handover report from the emergency nurse who
will be transferring a patient to ICU. The patient has a
Sengstaken-Blackmore Tube. While taking the handover about
the Sengstaken-Blackmore tube which among the following is
incorrect?

a. It is a three-lumen gastric tube

b. one lumen to inflate gastric balloon
c. second lumen to inflate esophageal balloon
d. third lumen is for esophageal suction port
Today’s Target
Colour coding of Gas cylinder
Oxygen
Cylinder
Nitrogen
Carbon
Dioxide
Helium
PISS
Which oxygen device delivers precise amounts of oxygen?

a) Venturi mask
b) Non-rebreather mask
c) Nasal cannula
d) Simple face mask
Which oxygen device delivers the highest concentration of oxygen?

a) Venturi mask
b) Non-rebreather mask
c) Nasal cannula
d) Simple face mask
Devices and flow rate (L/min) FiO2 achieved
Nasal cannula (1-6 L/min) 24-44 %
Oxygen mask (6-8 L/min) 44-60 %
Mask with reservoir bag (10 -15L/min) 60-80 %
Mask with non-rebreathing Reservoir bag (6-10 >90 %
L/min)
Venturi Mask (6-10 L/min) 24-60 %
▪ High Flow Device: Venturi mask
▪ High concentration mask: NRM
▪ COPD: Venture>>>Nasal prong
▪ Red orifice venture mask deliver: 40% FiO2
BLOOD SAMPLING
 Common Site for Blood Sample

Superficial veins of the upper limb

➢ Median cubital vein
➢ Cephalic vein
➢ Basilic vein
 Site to avoid

❖Extensive scarring from burns or surgery

❖Hematoma
❖ Intravenous therapy/Blood Transfusions –
❖IV Cannula, Fistula or Vascular Graft –
❖Edematous extremities – tissue fluid accumulation
can alter test results.
❖Sites with noticeable skin conditions, such as eczema
or infection.
 Articles Requiredc

Vacutainer Needle
Vacutainer Needle Holder
 Different Vacutainer

Blood Culture Tube

Light Blue Top vacutainer
Clot Activator (Red)
EDTA (Lavender)
Glucose (Grey)
 Important Points

▪Label at Bedside
▪Use sterile technique for Blood culture
▪Ideal Position is supine
▪Perform inversion if required
▪Place the tourniquet above the site
▪While inserting the needle, make sure hub should be up
▪When blood comes in, loosen the tourniquet
▪Apply pressure after taking the needle’s out
▪Secure the puncture site with an adhesive dressing
The doctor order for blood sample testing for blood corpuscles
and plasma. As an assigned nurse which of the following
vacutainer the nurse will not use to collect the blood sample?

a. Vacutainer containing calcium bicarbonate

b. Vacutainer containing heparin
c. Vacutainer containing EDTA
d. Vacutainer containing sodium oxalate
ETT & TT CARE
ONE LINER
SIZE OF ETT

• CUFFED ETT =AGE/4 + 3.5

• UNCUFFED ETT=AGE/4+4
▪ Position while ETT intubating:
▪ Position while ETT extubating:
▪ Position while ETT suctioning:
DEPTH OF ETT
Method to confirm the placement
High Pressure and Low Pressure Alarm
1. ETT Insertion is called:
2. TT Removal is called:
3. Bevel of ETT is on which side:
4. ETT is inserted from which side of oral cavity:
5. ETT size represented in which unit:
6. ETT Size estimation formula:
7. ETT Cuff pressure & Measuring Device:
8. ETT standard Size of proximal adapter:
9. Best method to confirm placement of ETT:
10. Most accurate method to confirm ETT Placement:
11. Patient Position while intubating:
12. Colorimetric CO2 detector device change colour from ----- to -----.
suctioning
Mouth before Nose suctioning
Suction Pressure

Age Portable Suction Wall mounted

category machine Pressure
Infant 2-5 50-90 mmHg
Children 5-10 90-110 mmhg
Adult 10-15 100-120 mmhg
SUCTION CATHETER SIZE
ETT Suctioning

▪ HOB @ 30 degree
▪ Pre-oxygenate at-least ………..second (6 breath in 5 second count
with ambu-bag)
▪ Pre-flush and Post flush the suction catheter
▪ Suctioning Duration:
▪ Open suction catheter:……………..technique
▪ Closed Suction Catheter:……………technique
▪ While inserting the suction catheter never apply pressure
▪ Bradycardia during suctioning occur when……..
The nurse is preparing to suction a client with an endotracheal
tube. After ventilating, which is the correct sequence of actions
for the nurse to follow during suctioning?

a. Apply suction, insert a sterile catheter, and withdraw while rotating

the catheter.
b. Insert a sterile catheter, begin to withdraw, apply suction, and
continue to withdraw while rotating the catheter.
c. Apply suction, insert a sterile catheter, and withdraw without
rotating the catheter.
d. Insert a sterile catheter, begin to withdraw, apply suction, and
continue to withdraw without rotating the catheter
TRACHEOSTOMY TUBE
▪ TT Performed at the level of:
TYPE OF TT
 Tracheostomy Tube

Inner cannula
Cuff
inflation Cuff Pilot
line balloon

Obturator

Flange
ONE LINER TT
Velcro Strap
A client has just arrived in the PACU following a successful
tracheostomy procedure. Which nursing action must be taken
first?

A. Suction as needed
B. Clean the tracheostomy inner cannula and stoma
C. Listen to lung sounds
D. Change the tracheostomy dressing as needed
A patient with a tracheostomy has a new order for a fenestrated
tracheostomy tube. Which action should the nurse include in the
plan of care in collaboration with the speech therapist?

a. Leave the tracheostomy inner cannula inserted at all times.

b. Place the decannulation cap in the tube before cuff deflation.
c. Assess the ability to swallow before using the fenestrated tube.
d. Inflate the tracheostomy cuff during use of the fenestrated tube.
SBT
A client is 24 hours postoperative after a tracheostomy has
been performed. The nurse finds the client cyanotic, with the
tracheostomy tube lying on his chest. Which action by the
nurse takes priority?

a. Auscultate breath sounds bilaterally.

b. Ventilate with a resuscitation bag and mask.
c. Call a code or the Rapid Response Team.
d. Insert a new obturator into the neck.
The nurse determines that a client with a tracheostomy tube
needs suctioning if which finding is noted?

1.Rhonchi are auscultated.

2.Pleural friction rub is heard.
3.Fine crackles are auscultated.
4.Pulse oximetry reading is 96%.
A patient with endotracheal tube in place has dry mucous
membrane and lips related to the tube and partial open mouth.
which method is best use to provide oral care

a. Cleanse the mouth with glycerin swab

b. Provide alcohol based mouth rinse and oral suction
c. Rinse with hydrogen peroxide and water mixture
d. Use oral swabs with normal saline for rinsing
The healthcare provider is caring for a patient on a
ventilator with an endotracheal tube in place. What
assessment data indicate the tube has migrated
too far down the trachea?

1- A high pressure alarm sounds

2- Decreased breath sounds on the left side of the
chest
3- Low pressure alarm sounds
4- Increased crackles auscultation bilaterally