Lab: Central lines, IVPB and TPN

isotonic

• osmolality

• what kind of solution ?

• osmolality is the same as blood (310 mEq/L)

• electrolyte solutions are isotonic (must be diluted with water of they will cause enter RBCs too quickly and cause then to rupture)

• no fluid shift

• used for low blood volume

hypotonic

• electrolyte content is less than 250 mEq/L

• lower osmolality than blood

• causes cells to swell

• uses for cellular dehydration (DKA, hyperosmolar hyperglycemia)

hypertonic solution

• electrolyte content is greater than 375 mEq/L

• causes cells to shrivel

• used for cerebral edema

Fluid Overload

• overloading with fluid

• s/s moist crackles on auscultation of the lungs, cough, restlessness, distended neck veins, edema, weight gain, dyspnea, and rapid, shallow respirations.

• tx: decreasing the IV rate, monitoring vital signs frequently, assessing breath sounds, and placing the patient in a high Fowler position.

Air Embolism

• s/s

• tx? immediately ? position ? assess? administer ?

• air in veins

• s/s: palpitations, dyspnea, continued coughing, jugular venous distention, wheezing, and cyanosis; hypotension; weak, rapid pulse; altered mental status; and chest, shoulder, and low back pain.

• tx: immediately clamping the cannula and replacing a leaking or open infusion system, placing the patient on the left side in the Trendelenburg position, assessing vital signs and breath sounds, and administering oxygen

Phlebitis

• inflammation of a vein

• chemical (from a vessicant), mechanical (catheter issues) or bacterial (infection)

• s/s: reddened, warm area around the insertion site or along the path of the vein, pain or tenderness at the site or along the vein, and swelling.

Infiltration

• unintentional administration of a nonvesicant solution or medication into surrounding tissue.

• s/s: edema around the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate

• tx: the infusion should be stopped, the IV catheter removed, and a sterile dressing applied to the site after careful inspection to determine the extent of infiltration.

• warm compress & elevate arm

• cold compress of hypertonic solution

Extravasation

• administration of vesicant or irritant solution or medication into the surrounding tissue

• s/s: pain, burning, and redness at the site. Blistering, inflammation, and necrosis of tissues can occur.

• 
  

thrombophletis

• presence of a clot plus inflammation in the vein.

• s/s: localized pain, redness, warmth, and swelling around the insertion site or along the path of the vein, immobility of the extremity because of discomfort and swelling, sluggish flow rate, fever, malaise, and leukocytosis

hematoma

• s/s

• tx

• results when blood leaks into tissues surrounding the IV insertion site.

• ecchymosis, immediate swelling at the site, and leakage of blood at the insertion site.

• tx: removing the needle or cannula and applying light pressure with a sterile, dry dressing;

• applying ice for 24 hours to the site to avoid extension of the hematoma;

• elevating the extremity to maximize venous return, if tolerated

where do peripheral Ivs go

• infants ?

• use ?

• hands, feet, forearms, AC

• infants up to 9 months may use scalp veins bc its easier to see

• use shortest length and smallest gauge possible

Central Venous Cases Device

• sites?

• used f0r

• rapidly diluted to?

• newborns ?

• what kinds

• subclavian, jugular vein, femoral vein

• used for high osmolatiy solutions (TPN, chemical, vesicants) inserted at a high flow into a large vessel

• rapidly diluted into isotonic solutions by the blood vessel

• newborns - umbilical cord vein for IV

• types: tunneled, non-tunneld/ PICC/ implanted

Non -tunnled Central Catheter

• lumens ?

• must be ?

• how long can it be used

• do not use until ?

• single, double or triple lumens (labeled medial distal and proximal)

• must be clamped and secured with needle-less adapter or caps so pt does not bleed out

• for short term use / emergency use

• do not use until placement is secured by xray

insertion of central catheters

• inserted at bedside in ICU, ER

• consent needed

• nurses role: monitor ECG, BP, maintain sterility, pt comfort, document

tunneled catheter

• placement ?

• purpose of cuff?

• used for how long

• lumens ?

• some have?

• Inserted into the subclavian vein and advanced until its tip lies n the SVC just above the right atrium.

• The proximal end is then tunneled from the entry site through the subcutaneous tissue of the chest wall and brought out through an exit site on the chest & sutured

• Dacron cuff anchors the catheter in place and serves as a
  barrier to infection

• long term use (years)

• inserted surgically at bedside

• single double or triple lumen

• Some have valves that prevent backflow of blood and air

Peripherally Inserted Central Catheter (PICC)

• how long can it be used

• inserted where ?

• N/I?

• placement ?

• can be used for days to months

• can be inserted at bedside

• NO BP, IV or blood taken from same extremity with a PICC

• placement: basilic or cephalaic vein and cath is threaded to SVC

• infants: Inserted via saphenous vein with tip in the IVC above the diaphragm

implanted port

• what is it

• what kind of needle

• pros and cons

• self sealing septum that allows needles to go through without damage or leakage

• 90 degree needle for entry (huber needle)

• for long term iv therapy

• placed surgically underneath the skin

• more pt freedom and less r/o infection

• more expensive

how can we minimize infection when managing central lines

• hand hygiene (both nurse and pt)

• turn pt head to opposite side when doing dressing changes

• sterile technique

• PPE (gloves, mask, gown)

• chlorohexidine used b/c it dries faster and it reduces the likelihood that the catheter will be inserted before the bacteria have died off

• remove if not needed or if infected (necessity must be reassessed daily)

• antibiotic patches

• caps on ports and when accessing scrub for 15 seconds

TPN

• what is it

• who needs it

• what has already been considered

• Method of providing nutrient to the body via Intravenous route

• Patients who are unable to ingest adequate oral food or fluid within
  7 days

• -severe burns, malnutrition, AIDS, sepsis cancer, bowel surgeries, acute pancreatitis, psychiatric syndromes (anorexia nervosa)

• Have already considered enteral nutrition (tube feeds) b/c of better
  maintenance of gut mucosal integrity and fewer complications

administering TPN

• how much over how long

• compare ?

• what must be assessed ? how often

• what size filter ?

• how long Is TPN good for ?

• tubing ?

• some solutions ? filter?

• must have ?

• 1-3 L of solution is administered over 24 hours

• Compare label with physician‘s order – prepared in pharmacy under hood for sterility

• pt specific - needs are reassessed every day based on blood work and modified daily

• TPN/ PPN needs 0.22-micron-in-line filter

• after 24 hours bag and tubing need to be discarded

• cannot reuse same tubing - high sugar = r/o bacteria

• Some solutions come mixed with TPN/PPN and fats emulsions in one bag with a special filter - Called TNA (3-in-1) – Total Nutrient
  Admixture – use 1.2-micron filter

• must have dedicated port for TPN, not be used for other medications administration

Intravenous fat emulsions

• infused through ?

• over how many hours and how many times a week?

• filter ?

• white bag - not pt specific

• Intravenous fat emulsions may be infused through Y-connector close to the insertion site and below the TPN/PPN filter,

• slowly over 6-12 hours and approx. 2-3 times a week.

• Comes with own 1.2-micron-in-line filter (lipids are bigger molecules)

nursing implications for TPN

• what are the 2 ways we can administer

• what is always needed to administer

• in case of emergency what can we give

• how can hypoglycemia happen ? to avoid ?

• verification of ?

• what needs to be changed/ assessed daily ?

• what needs to be checked regularly ?

• 10% or more dextrose solution administered via central line only

• large Gauged peripheral line may be used for Peripheral Parenteral Nutrition (PPN) of lower osmolality and for shorter use

• infusion pump used always, and check q2-3 hrs to verify rate

• If TPN runs out and pharmacy has not prepared hand D10W (emergency - we don’t want hypoglycemia!)

• never stop abruptly always taper (again hypoglycemia)

• needs 2 nurses verification (same as blood)

• tubing changed daily to avoid bacterial growth

• monitor weight and labs daily to reassess formula of TPN

• glucose checked regularly!

what are we assessing on our pts who are on TPN

• weight

• electrolytes

• caloric intake & hydration

• muscle wasting

• poor tissue healing

• Vomiting and diarrhea

complications of central catheter

• pneumothorax - may accidentally puncture plueral membrane

• monitor O2 sat and respiratory function

• air embolism

• clots - if you face any resistance STOP! can dislodge clot and push into patient

• displaced catheter

• infection / sepsis

• fluid volume overload