Nursing Measurements Guide
A Guide to Deep Tendon Reflexes
In this lecture, we will go through the different complications of inserting peripheral catheters through different scenarios and questions.
A certified doctor is inserting a peripherally inserted central catheter (PICC) line to a client. As the doctor inserts the central line and tethers it through, the client, all of a sudden, starts to experience shortness of breath and lightheadedness. The cardiac monitor is also showing signs of dysrhythmia.
Based on what the client is manifesting, what should be the nurse’s initial action?
Whether it’s a nurse or doctor inserting the PICC line, what they should do is to stop what they’re doing immediately.
This type of question is an NCLEX® favorite and is even given in nursing school exams. Therefore, it is crucial, first, to become familiar with what a PICC line is and what the complications are in inserting it to a client.
Based on the answer, why do you think the nurse or doctor should stop inserting? What is happening to the client at that moment?
Tethering the Line
When tethering a PICC line or a central line, a catheter is inserted into the vein, and it goes through the superior vena cava, which might extend down and even reach the right atrium. Inside the right atrium is the sinus atrial (SA) node which is considered as the main battery of the heart where electrical impulses are created.
Therefore, if that portion of the right atrium is tickled, the possibility of exciting some cardiac cells which can cause lightheadedness, shortness of breath, and dysrhythmias.
Upon realizing that the client is experiencing dysrhythmia, the doctor or nurse who is inserting the line must immediately pull out the catheter.
For those who are a bit unfamiliar or who need a more detailed discussion of dysrhythmias and who require help in interpreting EKGs, there’s a course on our website regarding those topics. So, you can visit our website and check those out.
As the nurse in charge of a client with PICC, you are responsible for measuring the client’s arm by checking how far the catheter is sticking out of the client’s arm. Usually, the assessment of the length of the PICC line sticking out of the arm is done during the morning shift.
At the beginning of the shift, the PICC line that’s sticking out is around seven centimeters. However, during the middle of the shift, the client starts to complain of lightheadedness, nausea, and shortness of breath. You checked the PICC line, and there are only about three centimeters of the PICC line sticking out.
As the nurse in charge, what are the things that you need to do?
This is another question that usually comes out on your nursing exams and NCLEX®. With this kind of scenario, what the nurse should do are the following:
First, the nurse should assess the client and gather data to be related to the physician. Then, the next step would be to act and call the doctor. Before informing the doctor, make sure that the client is stable and don’t leave them alone. Make sure someone is around once you leave the room to inform the doctor. Also, do not pull out the PICC line by yourself because this would cause more harm than good to the client.
Measure the circumference of the client’s arm to make sure that the arm is not inflamed because if it is, then it would indicate that the client has an infection or irritation that is caused by the PICC line.
At the start of the shift, the first thing that you should do is to measure your client’s arm to assess if there’s any kind of swelling. Usually, the normal measurement would be at least half a centimeter or at least one centimeter higher.
For our next topic, we’ll discuss TPN and IV fluid therapy.