Case Study of Joseph: Prevention and Management of Central Venous Access Device-Associated Bloodstream Infection and Occlusion

This case study discusses the prevention and management of central venous access device-associated bloodstream infection and occlusion in the case of Joseph. It includes evidence-based practices and interventions for reducing the risk of infection and managing occlusion.

Running head: CASE STUDY OF JOSEPH
Case study of Joseph
Name of the student:
Name of the university:
Author note:

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Strong evidences through literatures:
High level of evidences such as randomized controlled trials (RCTs), cohort studies, and
systematic reviews were used in this study for identifying risk factors associated with the CVAD
and the prevention strategy of bloodstream infection and prevention and managing strategy of
occlusion and improve patient outcome (Lopez-Briz et al. 2014 and by Ullman et al. 2015) .
Different key words were used concepts in electronic data based such as CINHAL, MEDLINE,
and EMBASE for identifying key. For this paper, filters were used in electronic data bases for
obtaining high piece of evidence and developed a care plan for Joseph accordingly who was
admitted to the hospital for CVAD blood stream infection.
Introduction:
CVAD (central venous access device) is referred to a device which installed into the
body of the patient who requires severe uptake intravenous fluid (Wilson et al. 2015). It is
inserted in the patient for administrating the hyperosmolar drugs such as Noradrenalin and it is
mainly used for prolonged monitoring of central venous of the patient who are admitted into the
intensive care unit (Kamulegeya et al. 2015). However, it is often observed that the insertion of
CVAD may give rise to a severe infection called central line-associated bloodstream infection.
The case study represents the health condition of Joseph who was admitted to the hospital
because of unresponsiveness. Because of state of unconsciousness, a three-lumen central venous
catheter was inserted into the right subclavian vein of Joseph using surgical technique and
Inotropes in the form of IV noradrenalin administrated. Without proper nursing care, blood
infection can contribute to the maximization of morbidity and mortality rate. The purpose of the

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essay is to develop a nursing care plan for Mr. Joseph. This paper will illustrate the risk factors
associated with the CVAD and the prevention strategy of bloodstream infection and prevention
and managing strategy of occlusion in the following paragraphs.
Central line-associated bloodstream infection (CLABSI):
In the clinical setting, the central venous access device is a life-saving therapy for
treating the patient of an intensive care unit (Fujimoto et al. 2017). However, a considerate
number of cases due to aseptic insertion of CVAD give rise to a bloodstream infection (Bradford
et al. 2014). According to Mermel et al. (2017), it was observed that due to the negligence of
following proper protocol for ICU patients, CVAD becomes a potential source of the nosocomial
infection and bacteraemia. A study by Mermel et al. (2017), suggested that the possibility of
causing bloodstream infection by CVAD insertion is 64 times higher than peripheral cathedral
insertion. Another study by Marschall et al. (2015), highlighted that the potential source of
CVAD bloodstream infection are Staphylococcus aureus, Enterococcus sp, Candida sp.,
Klebsiella pneumonia. S. aureus that colonizes in the catheter tip and when it inserted in the
patient’s body is transmitted to the bloodstream and causes infection. Barcellos et al. (2017),
highlighted that these microbes are present in the subcutaneous layers and nasal mucosa and it
gains the access to the bloodstream due to the catheter insertion. As observed in this cases study,
due to CVAD insertion Joseph experienced bloodstream infection and diagnosis confirmed the
cause of occlusion.
Prevention:

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Adherence to the evidence-based practice and individual interventions proved to be
effective preventive measures for CLABI. This systematic review would be effective for
identifying the effective intervention for the Joseph. Therefore, an article was chosen for the
literature review written by Ullman et al. (2015) where the researchers conducted a systematic
review of the current gap of the CAVD complications. The strength of the study is that the
researchers conducted the prospective study for understanding the higher source of evidence
related to the complication of bloodstream. The review included 24 prospective and 50
retrospective cohort studies where it was undertaken in Europe and North America. The authors
suggested that the bloodstream infection increased with the aseptic handling is the reason behind
causing the infection. Therefore, the authors argued that due to lack of evidence, health
professionals used to perform hand hygiene and appropriate skin anti-septic for prevention but in
recent practice totally implanted device and needless access device should be used for reduction
of the infection. The authors stated that it is cost effective and highly acceptable compared to the
intravascular devices. Moreover, the authors suggested that although totally implanted device
and needless access device is the best practice for reduction of the infection, flushing procedure
and CVAD dressing and securement, and pressure measuring technique are also effective in
reducing the prevalence of infection during the catheter insertion (Ullman et al. 2015).
Therefore, for reduction of infection observed in the case study totally implanted device with the
guidance of health professionals is effective will give the better result. Therefore, for Joseph,
totally implanted device as well as needleless device can be used. The study showed that for
management of the blood infection due to catheter insertion into the patient of intensive care
unit, Chlorhexidine is an effective antimicrobial drug. Registered nurse should monitor the

4CASE STUDY OF JOSEPH
dressing for any changes in the skin integrity or presence of any excaudate for the blood
infection.
The study provided a concise idea of the prevention of the bloodstream infection
developed in the patient (Ullman et al. 2015). However, the study failed to provide data related
to the different dwelling time of catheter insertion in the patient.
Occlusion:
Thrombotic occlusion is a common phenomenon for the patient with the catheter
insertion for the intravenous fluid administration (Sapontis et al. 2015). A study by Lee et al.
(2016), showed that block is one of the common complications of bloodstream infection where
catheter completely block and it cannot be flushed. Therefore, for minimizing the risk of
developing occlusion, nursing practice includes aseptic infusion a flushing technique. A study by
Habara et al. (2016), suggested that risk factors for occlusion is catheter tips, age over 65 years,
previous infection as well as deep insertion of the catheter can give rise to thrombotic occlusion.
However, the occlusion can be thrombotic and obstructive (Dharma et al. 2015). Therefore, it is
crucial to review and analyses a paper which conducted the study on both of the occlusion. The
case study represents the health issues of the Joseph where Joseph developed the bloodstream
infection and due to insertion of the catheter, the area becomes occluded. Hence, in order to
identify the presence of occlusion nurses require identifying the condition if there is an occlusion
due to the thrombosis formation.
Prevention:

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The article that was chosen for the systematic review was written by Lopez-Briz et al.
(2014), where researchers included randomized controlled trials for prevention of the occlusion.
The systematic review conducted to analyses the specific intervention and reestablished the
patency of blocked central venous catheter lumen. The strength of the study is that the study
included a randomized trail control where the primary outcome was measured and the secondary
outcome was measured. The key advantage of the review is that it included corrects studies from
2013 from CINHAL, MEDLINE, and EMBASE by a hand search of the relevant journals. The
study also assessed the potential bias such as adequacy of random sequence generation, binding
outcome assessment for six journals conducting a meta-analysis. In the study, researchers
argued that the catheter should be assessed properly before inserting into the patient’s body for
avoiding the occlusion. It was also observed that in the previous practice, staying loosely fitted
cloth and compression stockings were used for management of the occlusion takes place due to
the catheter insertion and effective prevention method is normal saline water. However, authors
concluded that in the current clinical practice the best preventive measures for preventing
occlusion in an intensive care patient is heparin flushes or antithrombotic agents is suitable for
preventing the occurrence of occlusion (Lopez-Briz et al. 2014). Furthermore, the study also
showed that the chemical interventions such as administration of 0.2 % of the sodium
bicarbonate or 70% ethanol solution are effective in clearing the blockage of the catheter.
Therefore, in order to make an effective prevention plan for Joseph regarding his thrombosis
occlusion, the effective practice urokinase and normal saline water are effective. For
management of occlusion, heparin flushing can be used as nursing intervention since it acts as a
blood thinner for clotting of blood. However, it was also observed that in many cases the use of
anticoagulants may affect other parts of the body. Therefore, in other interventions, the heparin-

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bonded catheter can be used for preventing occlusion of the patient. The study is effective for
understanding the best practice since the study provided the concise idea of both prevention and
maintenance of the occlusion. Therefore, for Joseph, a care plan should be developed where
nurses should consult the doctor for removal of thrombi and anticoagulants should be
incorporated after removal. Moreover, leafy vegetable should be incorporated in the diet plan for
faster healing of Joseph (Nicolotti et al. 2016). Nurses should monitor the improvement from
occlusion and faster healing of the Joseph for physical and mental well being of Joseph.
As observed in this case study of Joseph, area of the skin of joseph was red after the
infection. Zeiner et al. (2018), showed that the local skin injury is the common phenomenon that
observed after infections. Therefore, in order reduce the skin irritation related to infection, anti
histamines as well as tea- tree oil should be administrated to the patient and further
complications should be documented by nurses.
Conclusion:
Thus it can be concluded that, with the assistance of the essay, an individual can obtain
the best evidence to create nursing care which prevents the development of the bloodstream
infection but catheter and occlusion as well as management of the infection. The paper discussed
the case study which represents the centre venous access device-mediated bloodstream infection
and associated occlusion. From the assistance of the literature review, it was observed that totally
implanted device or needleless access device is the best practice for preventing the blood
infection. In order to manage the infection the chlorhexidine administration is effective
compared to standard aseptic handling of catheter insertion. Similarly, in order to prevent

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occlusion, heparin-bonded catheter or sodium bicarbonate flushing process is the best practice in
the current era. For management, it heparin or other anticoagulants can be used.

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