RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCE,

BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 / NAME OF THE CANDIDATE AND ADDRESS / MS. ANU JACOB KACHAPPILLIL
C/O MR. K.C. JACOB KACHAPPILLIL HOUSE KARAVATTE KURIZU MULANTHURUTHY P.O ERNAKULAM ,682314 KERALA
2 / NAME OF THE INSTITUTION / M.S. RAMAIAH INSTITUTE OF NURSING EDUCATION AND RESEARCH
M.S.R.I.T POST, BANGALORE-560054.
3 / COURSE OF STUDY AND SUBJECT / M Sc. NURSING
MEDICAL SURGICAL NURSING DISSERTATION PROTOCOL.
4 / DATE OF ADMISSION TO COURSE / 10. 06. 2008
5 / TITLE OF THE TOPIC:
ASSESSMENT OF KNOWLEDGE AND PRACTICE OF NURSES REGARDING CARE OF PATIENTS WITH CENTRAL VENOUS CATHETER IN A VIEW TO DEVELOP SELF INSTRUCTIONAL MODULE.

6. BRIEF RESUME OF THE INTENDED WORK

INTRODUCTION

“PREVENTION IS BETTER THAN CURE”

Critical care unit is a hospital facility for provision of intensive nursing and medical care of critically ill patients, characterized by high quality and quantity of continuous nursing and medical supervision and by use of sophisticated monitoring and resuscitative equipments. Critical care nursing is the field of nursing with a focus on the care of the critically ill or unstable patients. Intensive care nurses are required to be comfortable with a wide variety of technology and its uses in the critical care setting. They should be skilled in handling equipments such as hemodynamic and cardiac monitoring systems, mechanical ventilator therapy, intra-aortic balloon pumps (IABP), ventricular assist devices, continuous renal replacement equipments, extracorporeal mechanical oxygenation circuits (ECMO), central venous catheters and many other advanced life support devices.1

Critically ill patients require continuous assessment of their vital organs including cardiovascular system to diagnose and manage their complex medical condition. This is` most commonly achieved by means of direct pressure monitoring systems such as Central venous catheters, pulmonary artery catheters and intra arterial BP monitoring. Central venous catheters are commonly used in critically ill patients as most of them need a long term assess. These catheters has got multiple functions like monitoring pressure of right side of the heart, administration of intra venous fluids, medications and nutrients.2

A central venous catheter is a long fine hollow tube with an opening at each end. One end provides access from outside your body to the other end which is situated in a large vein in the chest. It can remain in position for several months. Insertion of a central venous catheter (CVC) in a human was first reported by Werner Forssman, a surgical intern, who described canalizing his own right atrium via the cephalic vein in 1929. A technique that facilitates catheter placement into lumens and body cavities — the Seldinger technique — was subsequently introduced by Sven-Ivar Seldinger in 1953. Insertion of a CVC using the Seldinger technique has revolutionized medicine by allowing the central venous system to be accessed safely and easily.3

The most common indication of central venous lines are determination of fluid volume status by measurement of pressure in vena cava and right atrium, evaluation of heart as an effective pump, assessment of vascular tension quality, reflection of preload, unavailable peripheral access, conditions necessitating long term access, trauma, burns, high risk surgery, cardiovascular surgery, acute myocardial infarction, poor nutritional status, dehydration etc. Multilumen central venous catheters are now commonly used. They are used for administration of fluids and medications, administration of blood and blood products, total parentral nutrition (TPN), concurrent administration of incompatible medications, venous blood sampling, central venous pressure (CVP) monitoring, chemotherapy, prevents loss of peripheral lines to caustic, erosive or painful drug therapy, reduces necessity of repeated veni puncture. Some patients are able to continue their treatment at home with a central venous catheter in place. People who have a phobia of needles may prefer to have a central venous catheter. The physician threads central venous catheters through subclavian vein, internal jugular vein, antecubital vein or femoral vein into the vena cava just above or within the right atrium.

Improper management of patients with central venous catheters can give rise to various complications like line embolism, thrombosis, infection/sepsis, ischemia of involved limbs, cardiac perforation, pneomothorax, accidental puncture of an artery leading to bleeding, catheter displacement etc. A high reading of CVP indicates congestive heart failure, cardiac tamponade, increased blood volume (over transfusion or over hydration), vasoconstriction, tricuspid valve dysfunction, right ventricular dysfunction (>15 cm H2O), left ventricular dysfunction (>18 mm Hg), constrictive pericarditis, pulmonary hypertension etc. Low reading of CVP indicates hypovolemia (blood loss, diuresis), vasodilatation (drug induced), decreased venous tone, peripheral blood pooling etc.4

Role of nurse in care of patients with central venous catheter is tremendous. Before inserting a central venous catheter nurse has to ensure that patient is not taking any medication to prevent or treat blood clots, such as warfarin, heparin or aspirin. Aspirin has to be avoided one week before inserting the line as this prevents blood clotting normally. Before the procedure, blood samples are taken to ensure that blood count is satisfactory and patient’s blood is able to clot normally. To prevent infection of central venous catheters, nurses have to practice strict aseptic techniques while giving care to patients. Vital signs has to be monitored frequently and assesment of respiratory function is also important. Hand washing has to be done with antimicrobial agents. Central line must be kept clean and dry at the exit site, where it comes out of the chest, and also at the end where the bung is attached. A transparent dressing will cover the exit site while the stitches are in place. Whilst the sutures are in place, the catheter must be dressed weekly, more frequently if the dressing becomes loose or soiled, using full aseptic technique.. Regular flushing of line is necessary to prevent it becoming blocked. Firstly, the stale fluid within the line is withdrawn and thrown away. The line is then flushed with saline and Hepsal which is an anti-clotting agent. If central line is not in continuous use it must remain clamped. 5

Today nursing is considered as a discipline of higher technology coupled with a wealth of complex information. Nurse’s role is to apply that knowledge in an efficient and cost effective manner. It is essential for nursing and medical personnel who are responsible for effective conduct of central venous catheter care, to have clear picture of its techniques, peculiarities, and above all its inherent dangers. They need to have knowledge and skill in care of central venous catheters to prevent development of complications

6.1 NEED FOR THE STUDY

“IT IS NOT HOW MUCH YOU KNOW, BUT

HOW MUCH LOVE YOU PUT IN THE DOING.”

‘MOTHER THERESA’

Central Venous Catheters (CVCs) are now common among critically ill patients. More than five million central lines are inserted each year in the United States alone.6

Health Care Associated Infections (HAIs), previously known as nosocomial infections, are the fourth leading cause of death among hospitalized patients. Data from the Centers for Disease Control and Prevention (CDC, 2004) reports a nosocomial infection rate of 5%, of which 10% are blood stream infections (BSIs), and an attributable mortality rate of 15%.

Four categories of infections are common in intensive care units: Blood stream infections (BSIs), urinary tract infections, lower respiratory tract infections, and pneumonia. Intra vascular devices are the common cause of blood stream infections. Approximately 80,000 catheter related blood stream infections occur in ICUs each year in United States. Catheter related blood stream infections are associated with high rate of morbidity, prolonged hospitalizations, and increased costs. A comparative study done on incidence of blood stream infections associated with peripheral venous catheters and central venous catheters proved that peripheral catheters have rarely been associated with blood stream infections whereas central venous catheters accounts for majority of blood stream infections about 55,000 infections per year in United States. 7

Central venous catheters break the body's natural defence barrier (the skin), and so put the patients at risk of catheter-related infections, of which an estimated 200,000 cases occur worldwide each year. Catheter-related infection is devastating, with increased suffering and risk of death for patients, and increased institutional costs due to the increased length and complexity of hospital admission. 8

Central venous catheterization can be lifesaving but is associated with complication rates of approximately 15%. A study conducted on major complications of central venous catheters found out that infection, accidental puncture of lungs (1 in 200 patients), displacement of catheter tip (very rarely) and Accidental puncture of the artery which may cause bleeding (1 in 100 patients) are the commonest complications of central venous catheters.9

14% of central venous catheters may become colonized in ICU patients resulting in 60,000 cases of bacteremia each year in United States. Because treatment of catheter-related infections is so costly (one infection increases hospital charges by $11,000), prevention is the best strategy.10

A study done at Escort Heart Centre , New Delhi shows that mortality due to central venous catheter related blood stream infection was 22.9% as compared with 0.2% in non central venous catheter related blood stream infection.11

A study done at Rajiv Gandhi Cancer Institute New Delhi proved that major complications of central venous catheters are infection(1.27%), breakage/leakage (0.5%), dislodgement(0.31%) and occlusion(0.06%). 12

A study was conducted to determine intensive care unit (ICU) nurses' knowledge of evidence-based guidelines for preventing central venous catheter (CVC) related infection. 18%knew that central venous catheters should be replaced on indication only. Regarding dressings, 15% knew that these should be changed only when indicated and at least once weekly.14% knew antibiotic ointments are not recommended because they trigger resistance. The recommendation to replace administration sets within 24 hours after administering lipid emulsions was recognized by 85%, but it was known by 5% only that these sets should be replaced every 96 hours when administering neither lipid emulsions nor blood products. The study proved that nurse’s knowledge about care of central venous catheters is not adequate. Professional seniority and the number of intensive care beds in the ICU where nurses work showed not to be associated with better scores on the test.13

A study to assess the nurses knowledge and practice of caring patients with intra venous therapy was done at Celal Bayar University hospital , Turkey . The study was done in two stages. The 1st stage was to determine the knowledge of nurses about using intra venous catheters, intra venous infusion treatment, symptoms and treatment of phlebitis. The 2nd stage involved observation of patients intravenous catheters for signs and symptoms of phlebitis and nursing interventions carried out for the same. The result revealed that nurses have high knowledge levels but their practice was not correlating with their knowledge which was evidenced by 67.24% of patients showing symptoms of phlebitis.14

Numerous studies have been published in support of staff education programs or self instructional module to reduce intravascular catheter-related complications. Pediatric studies of staff education programs have shown that catheter infection rates can be reduced between 23 and 37%. Studies shows that education of nurses and proper care of central venous catheters can reduces infection rates by 41 to 66% in adult ICUs. The reduction of infection rates due to catheter care educational programs also leads to a decline in hospital cost. 15

Prevention is better than cure. The above facts shows that its high time for nurses to improve their knowledge about care of central venous catheters and having knowledge is not adequate but putting it into practice is more important to prevent complications. The personal experience of the student researcher during clinical experience and above literatures regarding nurse’s knowledge and practice of central venous catheter care has inspired the investigator to do this study and to prepare a self instructional module on care of patients with central venous catheters to improve nurse’s knowledge and to improve the quality of nursing care.

6.2 REVIEW OF LITERATURE

The review of literature is traditionally considered as a systematic critical review of the most important published scholarly literature on a particular topic.

According to Polit and Hungler (1999) “Review of literature is a critical summary of research on a topic of interest generally prepared to put a research problem in context or to identified gaps and weakness in prior studies so as to justify a new investigation”.16

Literature review for the present study has been collected and presented under the following headings:-

1.  Literature review on advantages of central venous catheters.

2.  Literature review on complications of central venous catheters

3.  Literature review on prevention of complications of central venous catheters

4.  Literature review on nurse’s knowledge and practice of patient with central venous catheter care.

1. LITERATURE REVIEW ON ADVANTAGES OF CENTRAL VENOUS CATHETERS

A study was conducted on the advantages of peripherally inserted central venous catheters in children with malignancies for the safe administration of medication and to avoid repeated painful venipunctures at Rajiv Gandhi cancer institute New Delhi. A retrospective analysis was done in children with cancer having central venous catheters. Of 127 catheters inserted in 127 children, mean catheter life was 161 days with a total of 18,955 catheter days (for 124 patients, 3 lost to follow-up). Elective removal occurred in 63/101 (62.4%) and catheter removal due to complication rate was 2.41 per 1,000 catheter days. Infection, breakage/leakage, dislodgement, phlebitis, and occlusion rates was 1.27, 0.57, 0.31, 0.06, and 0.06 per 1,000 catheter days, respectively. The study proved that central venous catheters are convenient, cheap, safe, and reliable device for long term intravenous access in children with malignancies.12

A study was conducted to find out the advantages of central venous catheters in malignant patients requiring long term venous assess at All India Institute of Medical Sciences, New Delhi, India. A total of 110 patients with various malignancies requiring long-term venous access were included in the study. Duration of catheter indwelling period ranged from 7 to 365 days with a mean of 120 days. In 90% of the cases the catheter tip was located either in superior vena cava or in right atrium. Total catheter related complications were observed in 37 (34.54%). The study concluded that long term venous access using central venous catheters is the safe and reliable method for administration of chemotherapeutic agents, antibiotics and blood products.17