Editing Nursing Skills and Procedures (section)

=== Central venous access ===
Central venous access devices include nontunneled central catheters, tunneled catheters, implanted ports, and peripherally inserted central catheters. Tip position in the lower superior vena cava must be confirmed radiographically before first use. Central access is required for vesicants, parenteral nutrition, solutions with high osmolarity, and long-term therapy.

Infection prevention bundle: hand hygiene, maximal sterile barrier precautions at insertion, chlorhexidine skin antisepsis with full drying time, optimal site selection with the femoral site avoided in adults, scrubbing the needleless connector for the specified time before each access, sterile dressing changes at defined intervals or whenever the dressing is damp, loose, or soiled, and daily review of whether the line is still necessary. Prompt removal of an unnecessary line is the most effective single measure.

Air embolism prevention during insertion and removal of a central catheter: position the patient supine or in Trendelenburg when the anatomy allows, have the patient perform the Valsalva maneuver or exhale during removal, and apply an occlusive petroleum-based dressing to the exit site afterward, keeping the patient flat briefly. Immediately after subclavian or internal jugular insertion, the nurse assesses for pneumothorax, watching for sudden dyspnea, chest pain, diminished breath sounds on the affected side, and tracheal deviation.

Flushing uses a pulsatile push-pause technique with preservative-free normal saline, and clamping is timed to maintain positive pressure appropriate to the connector type. A blood return should be present before administration; absent return may indicate a fibrin sheath or thrombus and is reported rather than forced. Never use a small syringe such as 1 or 3 mL to force a clot, because the smaller barrel generates dangerously high pressure and can rupture the catheter.