1/22/2016. Disclaimer. Disclaimer

Transcription

1 Disclaimer Omnicare, Inc., as a provider of Infusion Pharmacy Services, is committed to the establishment and maintenance of the highest quality of care in infusion therapy services. This Infusion Therapy Education Program has been developed entirely by Omnicare Infusion Services. This program is not meant to be used alone or to replace the practicum necessary at the patient s bedside with an experienced clinician preceptor. This preceptorship is needed to develop the skill set required to properly perform and administer infusion therapy competently. Determining and documenting competency is the responsibility of your employer. Disclaimer Skills validation checklists are available in the Omnicare Nurses Infusion Manual and electronically on Omniview, Omnicare s web portal. The nature of infusion therapy requires frequent updates. It is the responsibility of the healthcare professionals involved with infusion management to remain current in his/her practice. 1

2 Disclaimer The practitioner is responsible for the exercise of independent skill and judgment in the implementation of this information in the clinical setting. This educational program is not intended to replace good professional judgment by the healthcare provider nor is it intended to supersede the necessity for clinically sound prerogatives of a healthcare organization. This education program was developed with reference to standards of care and practice guidelines set forth by organizations such as The Joint Commission, the Centers for Disease Control, the Infusion Nurses Society, the Agency for Healthcare Research and Quality, and the Institute for Safe Medication Practices, and USP Choosing the most appropriate vascular access device for the therapy will result in better clinical outcomes for the patient Important Considerations When Selecting a Vascular Access Device meds of extreme phs Catheter Types Non extreme ph 900 Non extreme ph 900 2

3 Features of Midlines and CVADs Valved vs. Non-Valved Catheters Vascular access devices may be valved or non-valved. Valved catheters are manufactured with pressure sensitive valves integral to the catheter. Midlines and all central vascular access devices may be valved or non-valved. 3

4 Valved Catheters Closed-ended valved catheter: Groshong Slit valve near distal tip of catheter Three way pressure sensitive valve No heparin needed No clamp Valved Catheters Open-ended valved catheter: PAS-V, SOLO Pressure sensitive valve is in hub No heparin needed No clamp Non-Valved Catheters Distal tip open No pressure sensitive valve Requires heparin to prevent backflow of blood into catheter, causing clot formation Non-valved catheters usually have clamps and must be clamped at all times when not in use! 4

5 Power Injectable Catheters Power injectable catheters are designed to withstand the high pressures associated with procedures requiring the use of contrast media. Power rated catheters are manufactured using stronger grade plastics that allow for infusion of solutions at rapid rates of up to 5 ml/second and compatible with pressures of up to 300 PSIs required during contrast enhanced CTs. Power Injectable Catheters (cont) PICCs, implanted ports, tunneled and non-tunneled catheters may be rated for power injection External catheters rated for power injection may have a purple hub, purple catheter and/or purple clamps to help identify them as power injectable. Caution: not all power rated catheters are purple. Other brands have the power rated clearly labeled on the hub or other external part of the catheter. Power Injectable Catheters Power rated implanted ports may have raised tabs that can be palpated on the septum to identify them as power rated ports In the LTC setting, catheters that are rated for power injections are maintained and utilized the same as non-power rated catheters Regardless of power rating, follow prescribed flushing/locking protocols for catheters according to catheter classification Power injectable catheters may be valved or non-valved. Follow prescribed flush based on catheter type. 5

6 Power Injectable Catheters Power injectable catheters may be single or multi-lumen. The lumens able to be used for power injections will be marked. Infusion of solutions or medications in power rated catheters shall not exceed manufacturer s recommendations for the medications or solution being infused. For example: Vancomycin 1 Gram in 250 ml of normal saline infused through a power injectable catheter would still be infused over 90 minutes. With all vascular access devices, information from the referring institution is the best way to identify the type and brand of the catheter. Power Injectable Catheters Midline Catheters Midline catheters may be made of silicone or polyurethane. Midlines may be inserted in the basilic, cephalic or brachial vein. The midline catheter is then advanced into the larger vessels of the upper arm with the distal tip terminating below the axillary vein, but still in peripheral circulation. 6

7 Midline Catheters Are between 8-20 cm long (3-8 ) May be single or multi-lumen Require physician/lip order for placement and reinsertion Informed, written consent is needed Midline Catheters extreme ph Midline Catheters Indications Therapies expected to last 1-4 weeks May be used for therapies appropriate for peripheral administration Limited vascular access Nurse/physician/LIP/patient preference 7

8 Midline Catheters Care and Maintenance Change stabilization dressing/securement device 24 hours after insertion, on admission, then every week and prn (every 2 days if gauze dressing) Always use sterile technique during dressing changes If separate securement device is present, must be changed with every dressing change Change needleless connector on admission, every 96 hours, prn, and after blood transfusion Blood draws not recommended Midline Catheters Flushing/locking protocol: If medication is incompatible with saline, consult with infusion pharmacist for alternate flushing protocol (i.e., D 5 W) Midline Catheters Tips When Utilizing Midlines for Infusion Therapy Always use aseptic technique when caring for or accessing catheter Flush immediately after intermittent infusion to prevent catheter occlusion Use only appropriate flushing devices for flushing midline No BPs or blood draws on arm with midline Measure external catheter length upon insertion, and/or admission, weekly with dressing change and prn If external catheter length increases, do not attempt to re-insert catheter Midline measurement should be clearly documented in patient s chart 8

9 Midline Catheters Tips When Utilizing Midlines for Infusion Therapy Thrombus may cause swelling of arm starting in the fingertips Midline insertion should be considered on the first day of therapy Midline insertion is not a STAT or emergency procedure Mechanical phlebitis can occur up to 72 hours post-insertion Mechanical phlebitis should be treated first, rather than immediately removing catheter Prevention of mechanical phlebitis: Warm compresses for 20 min QID x 2 days Elevate extremity Exercise arm gently Midline Catheters 9

10 Central (CVAD) Infusion catheters which are inserted into and dwell in the major vessels of the body with the tip terminating in the superior vena cava (SVC) or inferior vena cava (IVC). Common to all CVADs May be valved or non-valved May be single or multi-lumen Physician/LIP order is required for placement and reinsertion Informed written consent is needed Central (CVAD) Central (CVAD) Indications Poor peripheral access Therapies expected to last for several weeks, several months, or several years Phlebogenic/vesicant solutions/medications (e.g., Total Parenteral Nutrition, Chemotherapy) Medical history contraindicating ongoing or intermittent peripheral venipuncture Medical conditions requiring frequent venous access Emergency access 10

11 Central (CVAD) Central (CVAD) Contraindications Thrombosis of subclavian, innominate or superior vena cava (SVC) Anomalies of the central venous vascular structures Central (CVAD) Classification of Central 4 classifications Peripherally Inserted Central Catheter (PICC) Non-Tunneled Catheter Tunneled Catheter Implanted Venous Access Device Port Many different brand names Nurses must learn to identify by classification Nurses must identify if catheter is valved or non-valved 11

12 Central (CVAD) Multiple Lumen Catheters Each lumen is a separate catheter and must be maintained individually Allows for simultaneous administration of multiple solutions/medications Allows for simultaneous administration of incompatible solutions/medications Central (CVAD) Considerations Blood draws allowed with physician/lip order (for catheters 4 fr or larger) Flush immediately after intermittent infusion to prevent clotting Maintain positive pressure when flushing All CVADs should be secured to prevent migration, or advancement Peripherally Inserted Central Catheter (PICC) A PICC is a long, thin, flexible (silicone or polyurethane) catheter which is inserted into a peripheral vein with the tip confirmed in the SVC. May be placed at bedside by PICC qualified RN or in Interventional Radiology Veins of choice for insertion: basilic, cephalic, brachial, or medial cubital vein Requires accurate, in depth patient assessment prior to placement 2008 SHEA/IDSA Practice Recommendation: Do not routinely replace 2016 INS Standards of Practice: No recommendation for dwell time Selective devices may be rated for power injection 12

13 Peripherally Inserted Central Catheter (PICC) Contraindicated for patients with history of dialysis shunt/fistula Avoid forearm and upper arm veins in patients with chronic kidney disease stage 4 or 5, unless approved by patient s nephrologist, or physician/lip if no nephrologist involved in care Peripherally Inserted Central Catheter (PICC) Where is the tip supposed to be? According to national guidelines, the tip of a PICC must terminate in the superior vena cava, not in the right atrium, subclavian, or innominate (brachiocephalic) vein If not in the SVC, the tip is malpositioned and should be adjusted. Adjustments are done under fluoroscopy or by a PICC qualified nurse. Tips in the subclavian and innominate veins have a higher risk of thrombophlebitis development Tips in the atrium can lead to arrhythmias Peripherally Inserted Central Catheter (PICC) 13

14 Peripherally Inserted Central Catheter (PICC) Care and Maintenance Change stabilization dressing/securement device 24 hours after insertion, on admission, then every week and prn (every 2 days if gauze dressing) Always use sterile technique during dressing changes If separate securement device is present, must be changed with every dressing change Change needleless connector on admission, every 96 hours, prn, and after blood transfusion Peripherally Inserted Central Catheter (PICC) Flushing/locking protocol: If medication is incompatible with saline, consult with infusion pharmacist for alternate flushing protocol (i.e., D 5 W) Peripherally Inserted Central Catheter (PICC) Tips When Utilizing PICCs for Infusion Therapy Do not administer medications through a PICC until tip placement is confirmed Maintain catheter patency per flushing/locking protocol while awaiting tip confirmation Always use aseptic technique when caring for, or accessing, catheter No BPs or blood draws on arm with PICC 14

15 Peripherally Inserted Central Catheter (PICC) Tips When Utilizing PICCs for Infusion Therapy (cont) Measure external catheter length upon insertion and/or admission, with weekly dressing change and prn If external catheter length increases, do not attempt to re-insert catheter PICC measurement should be clearly documented in patient s chart Peripherally Inserted Central Catheter (PICC) Tips When Utilizing PICCs for Infusion Therapy (cont) Thrombus may cause swelling of arm starting in fingertips Insertion should be considered on the first day of therapy PICC insertion is not a STAT or emergency procedure Mechanical phlebitis can occur up to 72 hours post-insertion Peripherally Inserted Central Catheter (PICC) Tips When Utilizing PICCs for Infusion Therapy (cont) Mechanical phlebitis should be treated first, rather than immediately removing catheter Prevention and treatment of mechanical phlebitis: Warm packs for 20 min QID x 2 days Elevate extremity Exercise arm gently 15

16 Non-Tunneled CVAD A non-tunneled central vascular access device is a catheter that is percutaneously inserted directly into a central vein with tip confirmed in the SVC. Stiffer rigid polyurethane material Often sutured in place Shorter dwell time High infection rate Non-valved catheters should have a clamp on external portion of catheter Non-Tunneled CVAD Veins used for insertion: subclavian, internal jugular, femoral If external catheter length increases, do NOT attempt to reinsert Copy of chest x-ray confirming tip location must be in medical record prior to initial use in facility. If migration occurs, repeat chest x-ray must be done to confirm new tip location prior to use. 16

17 Non-Tunneled CVAD Care and Maintenance Change stabilization dressing/securement device on admission then every week and prn (every 2 days if gauze dressing) Flushing/locking protocol: If medication is incompatible with saline, consult with infusion pharmacist for alternate flushing protocol (i.e., D 5 W) Tunneled CVAD A tunneled central vascular access device is a catheter that is inserted into the subclavian or internal jugular vein with the tip confirmed in the SVC and is then tunneled through subcutaneous tissue and exits below catheter insertion site. Surgical procedure Dacron cuff in tunnel allows granulation tissue to form, creating an anchor and barrier to prevent/resist bacterial migration Suture removal days post insertion Tunneled CVAD Initial post insertion assessment must include monitoring both the insertion and exit sites Copy of chest x-ray confirming tip location must be in medical record prior to initial use in facility. If migration occurs, repeat chest x-ray must be done to confirm new tip location prior to use. 17

18 Tunneled CVAD Care and Maintenance Change stabilization dressing/securement device on admission, every week and prn (every 2 days/gauze) Always use sterile technique during dressing changes If separate securement device is present, must be changed with every dressing change Change needleless connector on admission, every 96 hours, prn, and after blood transfusion Tunneled CVAD Care and Maintenance Measure external catheter length upon insertion and/or admission, with weekly dressing change and prn If external catheter length increases, do not attempt to re-insert catheter Tunneled CVAD Flushing/locking protocol: If medication is incompatible with saline, consult with infusion pharmacist for alternate flushing protocol (i.e., D 5 W) 18

19 Tunneled CVAD Removal of a Tunneled Catheter is a Medical Act! Performed by physician/lip Small incision over cuff may be necessary for removal Implanted Venous Port An implanted venous port is a catheter that is surgically placed into a blood vessel and is attached to a reservoir. The tip terminates in the superior vena cava (SVC). The reservoir is placed under the skin and has a self-sealing septum, or diaphragm. The port is accessed using a percutaneous needle directly through the skin and septum. Venous ports may be implanted in the chest or upper extremity. Once placed, a port is completely covered by skin with no exposed parts. Implanted Venous Port Stainless steel, titanium, or plastic reservoir with silicone septum connected to silastic catheter Self sealing septum allows multiple punctures Available in single or dual ports. A dual lumen port has two separate septums, reservoirs, and catheters. Most ports are placed in the chest and sutured into a subcutaneous pocket created by the surgeon located superficially above the breast tissue, although smaller ports may be implanted into the arm (e.g., P.A.S. Port and X-Port ). If a patient has an implanted port in their arm, blood pressure cuffs and tourniquets should be avoided on the affected arm. 19

20 Implanted Venous Port All ports require accessing/flushing/locking to maintain patency Insertion and removal requires surgical intervention Requires access with non-coring needle (e.g., Huber, Miniloc, SafeStep ) Less alteration in body image Less interference with normal ADLs No dressing required when not in use Long term use (years) Implanted Venous Port Low maintenance when patient not on active infusion therapy Some implanted ports are rated for power injection. Since power injections are not done in the LTC setting, these ports may be accessed with regular, safety non-coring needles. Implanted Venous Port Care and Maintenance Copy of chest x-ray confirming tip location must be in medical record prior to initial use in the facility If accessed: Change non-coring needle and dressing every week Change dressing on admission, weekly and prn during active infusion therapy (every 2 days if gauze dressing) 20

21 Implanted Venous Port Care and Maintenance Always use sterile technique during non-coring needle/dressing changes Flush/lock every month when not receiving infusion therapy, or per physician/lip orders Implanted Venous Port Care and Maintenance Flushing/locking protocol: Implanted Venous Port Care and Maintenance If medication is incompatible with saline, consult with infusion pharmacist for alternate flushing protocol (i.e., D 5 W) The nurse administering the locking must assess the patient for any condition that may require a change in concentration and/or volume of heparin Flush and lock immediately after intermittent infusion to prevent catheter occlusion 21

22 Implanted Venous Port Port Specific Complications Port malposition May be seen after there has been trauma to the port body. One of the major complications that is seen when this occurs is the port flipping over inside its subcutaneous pocket. The nurse will not be able to access the port as the needle will be hitting the bottom (back) of the port reservoir. Should this occur, surgical intervention is needed. If the non-coring needle becomes partially removed from the port body during active therapy, do NOT attempt to push the needle back into the septum of the port. Instead, de-access and re-access per facility policy. Implanted Venous Port Port Specific Complications Port erosion May occur as a result of a misplaced non-coring needle; improper needle length selection, or as a result from a malnourished patient in negative nitrogen balance. Implanted Venous Port Port Specific Complications Extravasation A partially dislodged needle is the most common reason for extravasation. Always assess the needle placement and dressing integrity, especially when vesicants are infusing. In addition, verify the presence of a brisk blood return. If swelling is noted during an infusion, or patient has pain over port during an infusion, promptly stop the medication, assess the patient and follow physician/lip order for extravasation, as needed. 22

23 Implanted Venous Port Port Specific Complications Twiddler s syndrome This is a rare complication that can occur due to the resident s consistent manipulation of the port s body. This manipulation loosens, or breaks, the sutures which were holding the implanted port s body into the subcutaneous pocket. Implanted Venous Port Assessments to be performed before accessing the port: Verify orders: for accessing/de-accessing; flushing solutions/amounts/frequency; blood draws Ensure that the skin over the port is not inflamed, or showing s/s of infection. Do not access if symptoms present, and follow up with physician/lip. Gently assess the mobility of the port Assess the depth of the port body to aid in determining the needle length needed Accessing an Implanted Port Always use sterile technique during port access Perform hand hygiene Gather supplies on a clean work surface Open Port Access Kit Don masks 23

24 Accessing an Implanted Port (cont) Add needleless connector and sterile normal saline syringe to sterile field Don sterile gloves Prep site Attach needleless connector to non-coring needle and prime with normal saline Stabilize port between thumb and forefinger Insert non-coring needle into septum of port, pressing firmly until needle touches the back of the port Never rock or arc needle during insertion Do not rotate or turn needle once accessed Use proper length and gauge of non-coring needle Verify needle placement by aspirating for blood return prior to initiating infusion Secure needle in place with transparent dressing to prevent dislodging Coordinate change of non-coring needle with dressing change every 7 days when port is accessed 24

25 Tips for De-accessing Flush port with appropriate flush/lock solution prior to deaccessing Always wear gloves when de-accessing a port Stabilize port with thumb and forefinger while de-accessing Remove needle slowly with a straight motion. Activate safety feature per manufacturer s instructions. Maintenance of Dressing Change Change stabilization dressing/securement device on admission, every week and prn (every 2 days if gauze dressing) Always use sterile technique during dressing change Perform hand hygiene and don clean gloves and mask Maintenance of Dressing Change Remove old dressing/securement device Perform hand hygiene at patient s bedside using appropriate cleansing agent. Don sterile gloves. 25

26 Maintenance of Dressing Change Cleanse site Allow to air dry according to manufacturer s instructions (will take longer on hairy areas) Apply new securement device/stabilization dressing Measure external length of catheter, and mid-upper arm circumference (one indicator of thrombus formation) Document dressing change Maintenance of Needleless Connector Change Change needleless connector on admission, every 96 hours, prn, after blood draws, and daily with parenteral nutrition. Note: Needleless connector should be changed whenever blood enters the needleless connector. Always prime needleless connector prior to connecting to catheter All lumens must have needleless connector changed at least every 96 hours Maintenance of Needleless Connector Change Vigorously scrub connection with alcohol between hub and needleless connector prior to needleless connector change Clamp catheter if appropriate Remove old needleless connector. ONLY cleanse open hub of CVAD with alcohol if visible exudate/blood present. Attach new needleless connector to catheter hub Document needleless connector change 26

27 Midline/PICC/Non-Tunneled CVAD Removal Physician/LIP order required May be removed by a qualified nurse per state regulation and facility policy Locate catheter pre-insertion length documented on insertion note. If not available, must obtain specific physician/lip order to remove catheter without knowledge of length. Midline/PICC/Non-Tunneled CVAD Removal Place patient in supine position so that the IV insertion site is below the level of the heart Don masks. Perform hand hygiene. Don clean gloves. Carefully remove stabilization dressing/securement device Perform hand hygiene. Don sterile gloves. Cleanse insertion site Midline/PICC/Non-Tunneled CVAD Removal Remove sutures if present Apply antimicrobial ointment to sterile gauze Have patient perform Valsalva maneuver, or take a deep breath and hold during removal. Slowly pull catheter in short strokes until removed. Do not stretch catheter! Apply gauze dressing with sterile antimicrobial ointment over insertion site and apply pressure until bleeding stops 27

28 Midline/PICC/Non-Tunneled CVAD Removal Apply transparent dressing over gauze dressing Measure catheter and compare to length inserted Instruct patient to remain in supine position for 30 minutes Monitor site for bleeding through the dressing; every 15 minutes x 2; every hour x 2 Midline/PICC/Non-Tunneled CVAD Removal Document: Reason for removal Total catheter length Site assessment Interventions Leave dressing in place for 24 hours. Inspect and redress site daily until site has epithelialized. Stuck Catheter If resistance is met during removal, STOP! Reposition arm and attempt to remove catheter If still unsuccessful, tape catheter loosely in place with sterile tape. Apple new sterile dressing. Apply warm compress for minutes to dilate vein Attempt again to remove catheter If resistance is met, notify physician/lip 28

29 Blood Sampling From Central A physician/lip order is required for blood sampling May only be performed by licensed nurse per state regulation and facility policy Catheters/lumens smaller than 4 fr (18g) may be unreliable for blood draws Blood Sampling From Central On multi-lumen catheters, the largest lumen is preferred for blood withdrawal after all infusions have been stopped. If all lumens are of equal size, and one is not red or brown, any lumen may be used. Blood Sampling From Central Stop all infusions for at least one minute prior to blood draw. Disconnect the administration set and cover the end with a sterile end cap. Prior to blood sampling, all infusions are stopped for at least one minute. When a multi-lumen catheter is present, all infusions must be stopped but only disconnect the administration set connected to the lumen that will be used for blood withdrawal. 29

30 Blood Sampling From Central To avoid thrombotic and infection complications, waste blood must NOT be reinfused Therapeutic drug levels may be specifically ordered to be drawn peripherally Always check with the laboratory for the correct order in which to draw the necessary lab work. The order of the draw may affect the results. Certain medications cannot be flushed through the CVAD (e.g., pain management and inotropics) Blood Sampling From Central When drawing a sample for blood cultures: DO NOT discard the blood from the first (aspirated) draw. Fill the blood culture tube with aspirated blood from first draw. (Refer to Procedure 5.7 CVAD Culture) Avoid drawing blood from a heparinized CVAD for coagulation studies Vacutainer system or syringe may be used to withdraw blood from a CVAD Blood Sampling From Central The use of a syringe needle to transfer venous blood to a blood collection tube or blood culture bottle is an OSHA prohibited practice. The BD Vacutainer Blood Transfer Device is a single use device to reduce the risk of blood transfer related needle stick injuries while maintaining the specimen integrity. Flush the catheter with 10 ml of NS prior to blood withdrawal to confirm catheter patency and to remove any drug within the catheter before the blood to be discarded is withdrawn 30

31 Blood Sampling From Central Approximately 5 ml of blood is withdrawn and discarded prior to drawing blood for lab sample Smaller waste volumes are used for neonates, children, and frail patients as ordered After blood withdrawal: Flush catheter with 10 ml NS to remove any residual blood Blood Sampling From Central Change primed, needleless connector. Flush with remaining 10 ml NS. Lock per protocol for vascular access device If difficulty in obtaining sample: Have the patient sit up, lie down, turn from side to side, or ask the patient to cough and reattempt to draw Caution: this may also indicate a problem with the catheter s position If still unable to draw sample using a vacutainer, try using a syringe instead To obtain blood sample from a venous port, access the port with a larger, safety non-coring needle (20g) and verify placement by aspirating blood from catheter 31

32 Vascular Access Device Decision Tree Hemodialysis/Apheresis Catheters Hemodialysis Hemodialysis is a method for removing waste products such as potassium and urea as well as free water from the blood when kidney function is inadequate (e.g., renal failure). Hemodialysis/Apheresis Catheters Apheresis Apheresis is the process of temporarily removing blood from the body and separating it into its components. Blood is made up red and white blood cells, platelets, and plasma Some diseases are caused by excessive numbers of these cells and by abnormalities of the proteins and other substances dissolved in the plasma During the apheresis process the unwanted component(s) can be discarded before returning the other components to the body 32

33 Hemodialysis/Apheresis Catheters Hemodialysis/apheresis catheters are often large-bore, dual lumen tunneled catheters. Short term catheters are often made of polyurethane, and long term catheters of silicone. Apheresis may also be accomplished via large bore short peripheral catheters. Hemodialysis/Apheresis Catheters Hemodialysis/apheresis catheters must be clearly marked with tape, or a printed label: Hemodialysis (or Apheresis) Catheter Do Not Access Without Permission Hemodialysis/Apheresis Catheters Care and Maintenance The facility nurse s role in the care of the catheter is: Ensuring clamps are closed, if present Monitoring the integrity of the patient s dressing and needleless connectors. Dressings are routinely changed during the patient s dialysis treatments. If the dressing becomes wet, loose, or soiled, and the dialysis nurse is not available, the licensed nurse may change the dressing. A sterile dressing change must be done as soon as possible. Follow dialysis center s instructions for emergency care and maintenance. Notifying the patient s hemodialysis nurse/nephrologist/lip if complications occur 33

34 Hemodialysis/Apheresis Catheters Care and Maintenance Because of the large diameter necessary to accommodate the flow rates for hemodialysis and apheresis, flushing/locking protocols are different from other central vascular access devices. Hemodialysis/apheresis catheters are usually locked with higher heparin concentrations to avoid the development of intraluminal thrombosis. The volume used is usually equal to the internal volume of each specific lumen. This high concentration of heparin is withdrawn prior to flushing with next use to prevent heparin bolus. Specific orders must be obtained if the nephrologist/dialysis center wants the catheter flushed/locked and/or dressing changed in the post-acute care setting. Hemodialysis/Apheresis Catheters Assessment Any bleeding or drainage at catheter site must be reported to the nephrologist, hematologist, oncologist or dialysis center immediately A smooth edged clamp must remain with the patient at all times In the event of catheter fracture or breakage: Immediately clamp the catheter as close to the chest wall as possible Position patient in bed on left side in Trendelenburg (head down) Notify appropriate physician/lip Arrange for immediate transport to acute care facility for catheter assessment/repair Next Step Complete Exam Print/Save Certificate of Completion Schedule practicum with your employer 34

35 35