Lines, Leads, and Tubes

acute care environment: teamwork

• communicate with the team → pt, physician, PA, nursing stuff, PT, OT, respiratory therapy, SLP

• create a mobility plan

rating level of 1: mobility scale for ICU prerounds

patient ability: PROM, turning at least every 2 hours

typical PT involvement: no, nursing provides mobility

rating level of 2: mobility scale for ICU prerounds

patient ability: level 1 ability + AROM, use of dependent lifts

typical PT involvement: no, nursing provides movement

rating level of 3: mobility scale for ICU prerounds

patient ability: level 2 ability + bed mobility, activity sitting at edge of bed, standing weight shifts, pivot transfers, with or without endotracheal tube

typical PT involvement: yes

rating level of 4: mobility scale for ICU prerounds

patient ability: level 3 ability + pre-gait activities, stepping, transfers, ambulation

typical PT involvement: yes

systematic approach to acute care environment

1. notify nursing staff before entering room

2. communicate with the patient

3. scan environment systematically, visually following all lines and tubes from beginning to end

4. visualize the mobility activity and modify environment as needed

5. group lines in one hand, get help if needed

6. keep the patient informed and monitor responses

7. inspect all lines, tubes, and monitors before leaving

8. notify nursing staff upon leaving the room

three functions of devices

1. send substances into the body

2. take substances out of the body

3. monitor functions and levels in the body

sometimes one device can perform multiple functions

devices assist with bodily functions

• nutrition

• waste excretion

• circulation

• respiration

• neural function

• suction and drainage

nutrition devices

• feediing tubes

• NG tubes

• PEG tubes

how are tubes generally named

generally named for the insertion site and endpoint

feeding tubes

liquid nutrition delivered into the stomach or intestines

NG feeding tubes

= nasogastric feeding tubes

• coming in through nose → going to stomach

• should be stopped and pt. positioned upright for 30 mins before supine activities

  • 1 hour in pediatric patients

  • prevents aspiration

• alert nursing to resume feeding

PEG tube

= Percutaneous Endoscopically (placed in) Gastric

• placed in abdomen

• usually called a G tube

where should gait belt be placed regarding tubes

gait belt should be placed above any abdomen tubing

waste excretion: urinary catheters

• indwelling (foley) catheter and collection bag

• condom catheter and collection bag

• external wicking catheter

• surgical insertion → suprapubic catheter, urostomy, nephrostomy

indwelling (Foley) catheter

• keep collection bag below bladder level

• avoid tension on tubing

• drain urine from tubing before activity

surgical insertion catheters

• keep insertion site dry

• avoid placing gait belt over the insertion site

should you drain the catheters yourself

ONLY if you have talked to the nurse and gotten their permission → they are usually measuring the urine or checking for blood

waste excretion: fecal matter

• colostomy/ileostomy bag

• rectal tube

colostomy/ileostomy bag

• attach directly to large intestine through surgical opening in abdomen

• maintain secure attachment of bag

• keep attachment dry

rectal tube

• inserted into rectum with collection bag

• can be easily dislodged

• keep bag below level of tube

• use “slippery sheet” for mobility activities

when is a line critical

the more central a line is, the more critical its disturbance

cardiac leads

• monitor heart activity

• alarm may sound if lead is dislodged

• between 3 and 12 leads

temporary transvenous pacemaker

• used to regulate heartbeat

• mobility limited

• a disconnected pacemaker can be life threatening!

Intravenous (IV) line

• administering drugs and fluids

• typically, in vein on forearm or back of hand → also neck, leg, foot

• avoid BP cuff on limb with IV

• maintain drip bag above insertion site

• avoid occluding or placing tension on the line

• notify nursing staff if insertion site is swollen or red

Peripherally Inserted Central Catheter (PICC)

• venous line

• inserted in vein of UE, terminating in superior vena cava

• administering drugs and fluids long term

• avoid placing a BP cuff on arm with PICC

• use of axillary crutches may be contraindicated due to occlusion

Hickman/Broviac

• central venous catheter typically inserted into jugular vein, terminating in superior vena cava

• may have multiple lumens

• venous access for administering meds and/or blood sampling for weeks or months → decreases needle sticks

• keep insertion site dry

Port-A-Cath, MediPort

• port placed under the skin, typically subclavian, attached to thin catheter

• threaded into the vena cava

• similar to Hickman/Broviac

• port is accessed with a special needle

• can use to draw blood, administer drugs, blood transfusion

arterial line

• catheter inserted into artery

• connected via pressure tubing to transducer

• measures arterial BP directly

• used to draw blood and deliver meds

• commonly used in brachial, radial, or femoral arteries

• changes in bed height will alter transducer readings

• displacement of an arterial line can be a life-threatening emergency → apply pressure to the insertion site and call for help

restrictions with femoral insertions of arterial lines

hip flexion ROM restricted to 60-80 degrees

pulmonary artery catheter

• aka PA line or Swan-Ganz catheter

• multilumen catheter inserted through large vein, terminating in the pulmonary artery

• measures pressures in heart and pulmonary artery

• Pt.’s physical activity very restricted

• avoid ROM that may disturb the insertion site

• dislodging a PA line can be a life threatening emergency → apply pressure to the insertion site and call for help

pulse oximeter

• external device applied to fingertip or earlobe

• indirectly measures O2 saturation level

• activity may be contraindicated when O2 saturation falls below a certain level

blood oxygen levels 95-100%

normal blood oxygen levels

blood oxygen levels 91-95%

concerning blood oxygen levels

blood oxygen levels <90%

low blood oxygen levels

blood oxygen levels 80-85%

when low oxygen saturation affects your brain

blood oxygen levels 67%

cyanosis

blood pressure cuff

• provides indirect measure of BP

• in ICU, cuff usually remains on pt’s arm and is inflated automatically

• typically, not used on limb with IV

sequential compression devices

• sleeves placed on pt’s legs

• attached to inflation pump

• compression increases, distal to proximal, to return venous blood to heart

• may be removed for mobility activities

• discontinued when pt. is out of bed regularly

respiration

• endotracheal tube

• tracheostomy tube

• O2 mask/nasal cannula

• nebulizer

some function mobility is possible with “trach” in place

endotracheal tube

• inserted through mouth into trachea

• attached to ventilator

• avoid excess head and neck movement

tracheostomy tube

• inserted through neck into trachea

• attached to ventilator

• smaller diameter tube

ventilator

• machine-assisted breathing device connected to tracheal tubing

• different ventilation modes for different pt needs

• some OOB activity is possible, depending on length of tubing

• displacement of endotracheal (ET) tube creates a life-threatening situation for pt.

• check for changes in insertion level of tube before and after activity

O2 mask or nasal cannula

• attached to oxygen source

• nasal cannula: typically 1-2L O2

• non-rebreather mask for higher flow

• check charge on portable O2 containers before use

nebulizer

• handheld or attached to respiratory tubing

• used to administer meds

• pt responses to meds vary → easier breathing, agitation

neural system devices

• intracranial pressure monitor

• ventricular shunt

intracranial pressure monitor

• small catheter connects sensor in epidural space or dural tube to transducer

• measure pressure within brain

• brain very sensitive to pressure changes

• contact nursing before activity

ventricular shunt

• tube surgically placed into ventricle of brain

• shunt excess cerebrospinal fluid (CSF) from brain to jugular vein or abdominal cavity

  • ventriculoperitoneal (VP)

  • ventriculoatrial (VA)

• bed rest for 24 hours after shunt placement

• avoid direct pressure over shunt

• watch for severe headache or nausea upon sitting or standing → report to nursing staff, emergency situation

PCA device

= patient-controlled analgesia device

• pt. uses push-button to deliver pain medication

• through IV via electronic pump

• total amount is controlled to prevent overmedication

• typically results in decreased use of pain meds

• avoid occluding tubing

• coordinate mobility activities with pain control

nasal/oral suction devices

• NG suction tube

• yankauer suction

NG suction tube

• inserted in nasal passages, attached to wall suction pump

• used to remove stomach contents

Yankauer suction

• rigid tube with hook-shaped end, connected to wall suction unit

• used to clear secretions from mouth

• secretions may need to be cleared before initiation of activity

wound drain devices

• jackson-pratt drain

• hemovac

jackson-pratt drain

• tubing from surgical site to suction bulb

• drains and collects excess fluid from surgical site

• drain usually attached to pt’s clothing

• have nursing staff drain before activity if more than half full

hemovav

• tubing from surgical site to collection canister

• drains and collects excess fluid from surgical site

• drain usually attached to patient’s clothing

• for bigger drians

chest cavity suction device

chest tube (CT) (Pleurovac)

• large-bore tube inserted into chest cavity

• drains excess fluid or maintains pulmonary inflation

• tube attached to wall suction unit or water-sealed bedside container

• keep bedside container upright and below insertion site

• accidental removal of chest tube can create a life threatening emergency

hospital care → delirium can occur

• in response to ICU stressors

• exhibiting fatigue, confusion, anxiety, hallucinations

• pts often recover fully, but many experience ongoing symptoms after hospital discharge

home environments

• provide opportunity for meaningful and realistic mobility training

• may have limited resources

• fall prevention

  • good lighting

  • removing obstacles

  • removing or securing loose rugs

• always respect that you are a guest in the pt’s home

housing insecurity

• about 600,000 people in the US experience homelessness on any given night

• complex social conditions

• far-reaching health and mobiltiy implications

• often seen by PT in community clinics