Dementia Patient Disrupting Catheters and how a Vascular Access Clinician overcame this obstacle and placed and secured Central Catheter Lines is the focus of this Nurse Clinicians in Action. Nurse Clinicians in Action is a spotlight series featuring some of the interesting cases that Vascular Wellness clinicians have treated. These cases generally involve challenging situations or intriguing patient history and may involve more than one Vascular Wellness clinician as our clinicians have the ability to consult each other, including the on-call clinician whose serves as a clinical escalation path, via real-time HIPPA compliant communication. The diversity of these situations is why we believe that our clinicians, as a group, are the most experienced and best trained and supported vascular access providers and why our clients trust us to provide superior care to our mutual patients.
Dementia Patient Disrupting Catheters – The Clinical Case
Dementia Patient Disrupting Catheters case took place in a hospital step-down unit (SDU), a care ward that provides an intermediate level of care between an intensive care unit (ICU) and a standard ward. The Dementia Patient needed central venous pressure (CVP) monitoring (one of the most accurate methods of blood pressure monitoring that can only be achieved with a central line) and was likely to also need dialysis. In addition, the Dementia Patient suffered from mild dementia and had a history of not following medical directions.
Dementia Patient Disrupting Catheters – Diagnosis and Treatment
The Vascular Wellness clinician, along with the patient’s ICU doctor, agreed that a Small Bore Internal Jugular (IJ) line was the best clinical option to both achieve CVP monitoring and upper arm vein preservation for likely future dialysis treatment. Understanding the patient’s proclivity to pull or tug at the line from reviewing his medical history, the Vascular Wellness clinician recommended the use of safety mittens to help prevent the patient from disrupting the line. Safety mittens are soft mittens used to contain the hand and are used as a first type of hand restraint. Based on that recommendation, safely mittens were placed on the patient’s hands.
Unfortunately, the safety mittens did not prevent the patient from interfering with the line and the medical team was unable to perform the required CVP monitoring. As the next step, the Vascular Wellness clinician and doctor agreed that the clinician would place another IJ but this time, on the left side because (i) they wanted to minimize the potential for side effects that can result from sticking the same vein twice and (b) they thought the other side would be harder for the patient to reach. The left side is the less preferred side as it is not a direct route to the Superior Vena Cava (SVC). While the Vascular Wellness clinician expertly placed the line on the left side, it failed to solve the problem as once again, the patient pulled the line despite the safety mittens. At this point, at the recommendation of the Vascular Wellness clinician, the doctor decided that they should place soft restraints on the patient’s hands. Once done, a third IJ was placed along with directions for additional patient monitoring, and through this tenacity, the problem was solved. The doctor and patient were happy and relieved that medical care was now able to be provided.
As anticipated, the doctor ordered dialysis treatment just a few days later, and two Vas Caths for Dialysis were needed. Knowing the history and empathetic to the patient’s issues with catheters around the neck area (which would be in the Internal Jugular vein), the Vascular Wellness clinician placed a Vas Cath in the Femoral vein of each leg. The patient had no issue with the Femoral lines and successfully received the needed dialysis. The doctor, patient, and patient family were grateful for the Vascular Wellness clinician’s skill set, flexibility, and determination to place the right line and taking the time to consider all the factors. Shortly thereafter, the doctor sent the clinician a thank you note along with a small gift.
Dementia Patient Disrupting Catheters case helps explain how the placement of a Central Venous Catheter is not a benign medical procedure and does come with risks and the risks compound through additional needle and line insertions (both successful and unsuccessful attempts). These risks include bleeding, blood clots, DVT’s and infections and the ability to minimize sticks and place the right line at the right time is incredibly important. Vascular Wellness clinicians have done thousands of placements and typically achieve access the first time with no unnecessary sticks or bruising due to training focused on vein visualization via the Ultrasound (US) machine and the sheer volume and diversity of procedures done by each clinician. Further, by having the tools of US Guided PIVs, Midlines, PICCs, Small Bore lines such as Internal Jugular lines (IJs) and Femoral lines (Fems), and Large Bore lines including Vas Caths and Quad Lumens, Vascular Wellness is able to create clinically appropriate access in virtually all patients. These two factors, along with a consultative approach with the treating physician, are just a few reasons why Vascular Wellness improves patient outcomes, reduces costs, and strengthens infection control.