1. Basic procedures in healthcare 1 (SOL / VCA81)
TOPICS:
9a) Peripheral venous cannulation
9b) Central venous cannulation
9c) Implantable venous port

2. 9a) Peripheral venous cannulation (PVC)
indication
PVC insertion site
PVC care
Possible complications in inserting
PVC removing
thrombophlebitis, phlebothrombosis
Maddon classification (for thrombophlebitis grades)

3. peripheral venous catheter - individual parts
9a) Peripheral venous cannulation (PVC)
stab and accessibility of peripheral veins in order to intravenous administration,
PVC (used abbreviation).
indication: - infusion, - transfusion, - parenteral nutrition, - drug application i. v., - administration of contrast solution before an examination, - blood sampling for diagnostic purposes.
peripheral venous catheter - individual parts

4. 9a) Peripheral venous cannulation (PVC)
PVC insertion site
back of the hand or forearm (if possible, the on non-dominant patient´s hands because of his / her comfort),
vena jugulars,
area over the inner ankle,
instep,
in kids – veins on the head.
peripheral venous cannulation

5. 9a) Peripheral venous cannulation (PVC)
Tools
disposable gloves,
sterile covering,
disinfection (Septoderm),
cellulose squares,
vomit bowl,
(mull swabs),
swab,
adhesive plaster,
tourniquet,
plastic plugs for connection tube closure,
connecting (extension) tube, *
marker / pen,
syringe with 0,9% NaCl ( ml),
waste container for sharp material * it can be used „mandren“, combi cap, or needleless connectors
intravenous cannula (i. v. cannula), – different sizes

6. tools for PVC

7. 9a) Peripheral venous cannulation (PVC)
Procedure
check the patient's medical records,
disinfect the hands,
wash connecting tube with 0,9% NaCl ( ml in syringe),
leave the syringe on the one end of this tube and do not take off the cap from the other one!
check patient´s identity + explain the procedure,
chose the appropriate site for insertion i. v. cannula (without haematomas, edema… ),
put a swab under the patient´s limb,
put on the disposable gloves,
prepare needed tools near to you, but never on patient´s bed,

8. 9a) Peripheral venous cannulation (PVC)
Procedure
attach and tighten the tourniquet 5-10 cm above the puncture site,
disinfect the skin,
grip cannula firmly („three-point grip“),
pull the skin off downward direction from the injection site,
inject the skin with i. v. cannula at an angle of 15-30°, (angle depends on the depth location of a vein)
check it – when properly puncture the vein blood appears in signalling chamber in the cannula,
hold insertion cannula needle in the place and introduce only the plastic part of cannula into the vein,
introduce the whole plastic cannula (up to its transition in a part of hard plastic),
loosen the tourniquet,

9. 9a) Peripheral venous cannulation (PVC)
Procedure
put cellulose swabs under the i. v. cannula to catch any flowing blood,
squeeze the vein above the puncture site and pull the insertion needle,
never return the insertion needle back to cannula!!!
screw the pre-wash connecting tube in the end of i. v. cannula,
remove cellulose swabs,
perform aspiration and subsequent flushing of i. v. cannula,
fix the i. v. cannula with sterile covering,
mark sterile dressing of cannula with the date and time of introduction,
„break“ the connecting tube and close its end with plastic cap,

10. 9a) Peripheral venous cannulation (PVC)
Procedure
wrap the connecting tube loosely and fasten it to the patient´s hand with adhesive plaster,
eventually bandage with gauze bandage (e. g. in restless kids and confused patients),
clean the tools.

11. 9a) Peripheral venous cannulation (PVC)
Videos with…
… description of peripheral venous cannulas
time: 1:03
… PVC insertion procedure
time: 5:00

12. 9a) Peripheral venous cannulation (PVC)
Specifics of care of the patient with PVC
1. monitoring - PVC, - around the injection site (redness, edema… ), - patent´s body temperature, - PVC can be inserted in a vein max. 72 hrs. - exceptionally 5-7 days, but only if there are NO complication and if it allows the producer's recommendations, - a physician record the extended period of PVC in the patient´s medical record.
2. asking the patient - soreness at the injection site, - burning or stinging during the administration of infusion therapy and i. v. injections through PVC. *

13. 9a) Peripheral venous cannulation (PVC)
Specifics of care of the patient with PVC
3. covering exchange
- individual - it depends on the kind of coverage and the producer's recommendations.
covering of PVC

14. 9a) Peripheral venous cannulation (PVC)
Possible complications in PVC inserting
allergic reactions to disinfect, adhesive plaster,
paravenous insertion followed by haematoma onset and edema,
infection,
phlebitis (thrombophlebitis, phlebothrombosis),
embolism (air, blood clot),
damage to the innervation,
hitting the artery. *

15. 9a) Peripheral venous cannulation (PVC)
Thrombophlebitis
inflammation of the superficial veins (possible PVC complication),
symptoms: palpation and spontaneous tenderness over the affected vein, redness, mild edema, induration due to the current vein thrombosis.
Maddon classification – thrombophlebitis grade specification * 0 – no pain or reaction around 1. grade – only pain, no reaction around 2. grade – pain and redness 3. grade – pain, redness, edema, painful streak over a vein 4. grade – pus, edema, redness, painful streak over a vein
* Source: VŠPJ – Hodnotící a měřící škály pro nelékařské profese [online] [cit ]. Available from: C3%AD%20%C5%A1k%C3%A1ly%20pro%20nel%C3%A9ka%C5%99sk%C3%A9%20profese%20-%20Lada%20Cetlov%C3% A1%20a%20kol..pdf

16. thrombophlebitis in inserted PVC

17. 9a) Peripheral venous cannulation (PVC)
Phlebothrombosis
deep vein inflammation associated with the formation of blood clots (possible PVC complication, when PVC is administered in lower limbs),
symptoms: edema of the limbs with painful tension, livid colour and general symptoms (↑ body temperature, ↑ pulse).
phlebothrombosis

18. 9a) Peripheral venous cannulation (PVC)
Other complications
haematoma: solution  compression, pressure bandage, Heparoid (ung.)
extravasation (seepage or leak of agents into tissues)  necrosis - symptoms: slowed infusion, resistance to bolus application of i. v. injection… - risk in: ATB, vasoconstrictor drugs - solution  interrupt of infusion therapy, removal of the cannula, pressure bandage in the area of swelling, cold tiles application

19. 9a) Peripheral venous cannulation (PVC)
PVC removing
Tools:
disposable gloves,
vomit bowl,
disinfection (Septoderm),
cellulose swabs,
adhesive plaster.

20. 9a) Peripheral venous cannulation (PVC)
PVC removing - procedure
prepare the tools,
disinfect the hands,
put disposable gloves on,
inform the patient about the procedure,
prepare adhesive plaster,
prepare cellulose swabs,
hold the cannula on the place with one hand,
peel the skin from the covering with the other hand,
if the covering is loosen take prepared cellulose swab and put them on the insertion site,

21. 9a) Peripheral venous cannulation (PVC)
PVC removing procedure
pull out the cannula while firmly hold the cellulose swabs,
fix the cellulose swabs with adhesive plaster,
clean the tools.
removing PVC

22. 9b) Central venous cannulation (CVC)
indication
CVC insertion site
catheter insertion
CVC care
possible complications after insertion

23. 9b) Central venous cannulation (CVC)
access to the central venous system,
in local anaesthesia, it is introduced to some of the larger veins, while one it‘s end is located in the upper / inferior vena cava, the other end opens the skin's surface,
CVC (used abbreviation),
indication: - administration of parenteral nutrition, - administration of drugs (antineoplastic agents, ATB, immunosuppressive… ), - chemotherapy, - transfusion, - very bad state of veins on the periphery, - repeated blood sampling, - measurement of central venous pressure (CVP), - the possibility of applying drugs that would otherwise irritated the thin peripheral veins and could cause them nonbacterial inflammation and thrombosis.

24. 9b) Central venous cannulation (CVC)
Insertion site
vena subclavia,
vena jugularis externa et interna,
vena basilica et mediana,
vena femoralis.

25. 9b) Central venous cannulation (CVC)
CVC insertion
by a doctor, nurse assists,
catheters are divided into one-way, two-way, three-way and antimicrobial (for high risk patients with antimicrobial correction).

26. 9b) Central venous cannulation (CVC)
CVC care
catheter must be treated according to a predetermined written protocol (the standard of nursing care), which must respond to a specific type of catheter,
bandages and manipulation must be carried out strictly aseptically.
after CVC insertion

27. 9b) Central venous cannulation (CVC)
CVC dressing tools
face mask,
disposable gloves,
sterile gloves,
sterile swabs,
alcohol disinfection,
disinfectant solution, (according to the standard of nursing care)
sterile covering,
adhesive plaster,
vomit bowl.
transparent covering

28. 9b) Central venous cannulation (CVC)
CVC dressing procedure
disinfect the hands,
perform the dressing in collaboration with other health professionals to ensure antisepsis (when working alone, prepare sterile area or tools so we keep sterile environment during the whole procedure),
inform the patient about the procedure,
position the patient to the appropriate position (semi sitting),
put disposable gloves on,
put the face mask on,
gently remove the old bandage (we start at the top and continue downward – we must be very gentle to not injure the patient´s skin or pull out the catheter),

29. 9b) Central venous cannulation (CVC)
CVC dressing procedure
take off disposable gloves after removing the bandage,
disinfect the hands again,
put on sterile gloves,
check carefully insertion site of the catheter,
take a swab with alcohol disinfection,
put the swab on the catheter insertion site and start wash it spirally and one stroke (spirals clockwise while away from the catheter outlet),
change the swabs according to need and continue to proceed the same way until circuit of at least 8 cm is not clean,

30. 9b) Central venous cannulation (CVC)
CVC dressing procedure
never return to the catheter insertion site with the swab which has already touched any part of the skin,
clean the same area in the same way twice,
check each used swab with your sight – if there are not any pathological traces of impurities,
once we have cleaned the skin with alcohol disinfectant, we repeat everything once again, but with disinfectant solution according to the relevant nursing standard,
disinfecting solution should be let to dry properly, (therefore adhere to the specified expiration)
after drying, we put sterile adhesive plaster on the catheter insertion site,
at each dressing change, we must also examine the position, the sufficiency of fixation and the length of the external portion of the catheter,

31. 9b) Central venous cannulation (CVC)
CVC dressing procedure
all these details are recorded in the medical documentation, including information on the status of catheter patency,
first hours (after catheter insertion) it is the preferred a fixation bandage in form of non-transparent porous breathable cover,
after 2 days, it is chosen another procedure according to the appearance of the output location of the catheter, which includes a choice of disinfectant, types of coverage and frequency of dressing changes,
disinfectant solution must not be in conflict with the catheter producer's recommendations (could lead to deterioration of the surface of the catheter),
the frequency of dressing changes depends on the standard of nursing care, recommendations from the producer of the catheter or the individual needs of each patient,
we change also Posiflow modules, infusion sets, etc. during CVC dressing procedure.

32. exchange of CVC covering

33. 9b) Central venous cannulation (CVC)
Video with…
… CVC dressing
time: 4:40

34. 9b) Central venous cannulation (CVC)
Possible complications of CVC
skin infection around CVC – redness, skin formation - solution: Framykoin, Inadine, Betadine ung. or sol.
disorder of skin integrity around CVC (resulting from ↑ skin sensitivity - mostly after radiotherapy) - solution: Greasy tulle, nothing to be paste on the given place
CVC pulling out (due to loosening of securing stitch or inconsiderate treatment of CVC) - solution: RTG checking, proper fixation
CVC obstruction - solution: report a physician, the physician determines next steps
CVC extraction - solution: IMMEDIATE applying of sterile swabs, which we push on the insertion site and we call the physician IMMEDIATELLY *

35. 9b) Central venous cannulation (CVC)
Other possible complications of CVC
artery puncture
pneumothorax *

36. 9c) Implantable venous port
indication
care of implantable venous port

37. 9c) Implantable venous port
closed system, which consists of a catheter (introduced into a central vein) and port (small chamber), to which the catheter is firmly connected,
port: - small chamber placed under the skin, usually on the front side of chest, it is well palpable), - silicone membrane can withstand about punctures,
indication: - chemotherapy, - long-term parenteral nutrition, - long-term ATB therapy, analgesics, - another portion of i. v. therapy.
implantable venous port

38. 9c) Implantable venous port
Port care – Huber needle puncture
disinfect the hand before the manipulation,
prepare a sterile table with tools (face sterile mask, sterile swab, Huber needle, sterile gloves, disinfectant solution, adhesive plaster, syringe with saline),
work with a face mask and sterile gloves,
give the mask face to the patient as well,
disinfect the area above the port properly,
pulp the port and fix it between the 2 fingers,
hold the Huber needle in one hand and perpendicular to the port membrane,
push the needle onto the membrane (do not twist it!!!),
aspire blood into the syringe,
rinse the port with saline,

39. 9c) Implantable venous port
Port care
apply the medication or infusion slowly,
underlay needle sterilely, cover it and fix with adhesive plaster,
application to the port must be continuous,
in case of interruption, flush it with of heparin cap,
the port is usually flushed 1x per month,
every drug application (or blood sampling) finish with flushing of 20 ml of saline and after that 5 ml of heparin cap (5 000 j / 100 ml),
syringe smaller than 10 ml cannot be used when taking care of the port,
an inspection X-ray with spraying the port must be made before the first series of chemotherapy.

40. description of implantable venous port with Huber needle

41. 9c) Implantable venous port
Video with…
… implantable venous port dressing

42. 9c) Implantable venous port
Port care – Huber needle removal
disinfect the hand before the manipulation,
prepare a sterile table with tools (face sterile mask, sterile swab, sterile gloves, disinfectant solution, adhesive plaster, syringe with heparin cap),
work with a face mask and sterile gloves,
disinfect the port around,
when pulling out push the port to the chest wall,
the needle is drawn upwards and in the direction perpendicular to the port,
AT THE SAME TIME we have to apply the heparin cap (if we do not, blood can be sucked back into the port),
after pulling out the needle, disinfect the insertion site and cover it sterilely.

43. Revision List the most common indications for the PVC inserting.
Which sites are suitable for the PVC inserting in adults?
In what time frame do we change PVC covering at the patient?
What is Madon classification for?
What is phlebothrombosis?
Describe the procedure for the removal of PVC.
What does PVC or CVC mean?
List the tools you need for CVC dressing.
What complications may occur after the CVC insertion?
What is an implantable venous port for?
What is the Huber needle for?

44. Reference:
BRAUN, B. Ošetřovatelská péče o centrální žilní katetr v podmínkách JIP a ARO [online] [cit ]. Dostupné z:
CETLOVÁ, L., DRAHOŠOVÁ, L., TOČÍKOVÁ I. Hodnotící a měřící škály pro nelékařské profese [online] [cit ]. Dostupné z: %AD%20a%20m%C4%9B%C5%99%C3%ADc%C3%AD%20%C5%A1k%C3%A1ly%20pro%20nel%C3%A9k a%C5%99sk%C3%A9%20profese%20-%20Lada%20Cetlov%C3%A1%20a%20kol..pdf
DONOR, Z. S. Péče o CŽK [online] [cit ]. Dostupné z:
KOMÍNEK, V. Péče o periferní žilní vstupy na vybraných pracovištích FN Brno [online] [cit ]. Dostupné z:
LF3 – CUNI. Studijní materiály – Implantabilní venózní port [online] [cit ]. Dostupné z: materialy/CNSKZO2/studijni-materialy/Implantabilnx_venxznx_port.pdf
LF3 – CUNI. Studijní materiály – Centrální žilní katetr [online] [cit ]. Dostupné z: materialy/CNSKZO2/studijni-materialy/Centrxlnx_xilnx_katxtr.pdf
VELKÝ LÉKAŘSKÝ SLOVNÍK [online] [cit ]. Dostupné z:
WIKISKRIPTA. Zajištění žilního přístupu [online] [cit ]. Dostupné z: index.php/Zaji%C5%A1t%C4%9Bn%C3%AD_%C5%BEiln%C3%ADho_p%C5%99%C3%Adstupu
PICTURES * (if it is not stated differently): pinterest.com, google.com