lines, tubes, drains

why is acute care important?

- patients being discharged sooner- require more assistance

- skills can be applied to any setting

- important to understand how effects of hospitalization can impact care in other settings

- important to engage in collaborative practice with other healthcare providers!

key points to remember:

don't pull anything out!

have a plan in mind before moving the patient

ask for help!

have enough slack on lines

nurses are your friends<3

types of lines

peripheral lines and central lines

peripheral lines types

- arterial line or A-line

- intravenous IV line

central lines types

- central venous catheter

- swan-ganz catheter

- peripherally inserted central catheter/PICC

a peripheral line is

lines entering into circulation through any peripheral vessel

short term use

fluids and meds

a central line catheter is threaded through the

- internal jugular vein

- antecubital vein

- basilic vein

- subclavian vein

a central line has a tip usually resting in the ________, is there for _____ of time, more prone to _____

superior vena cava or right atrium; longer periods; infection

a central line is used for

chemotherapy, long term antibiotics, or total parenteral nutrition (TPN fluid that has every nutrient needed)

intravenous line (IV):

placement (duration and placed by)

any accessible vein (arm, leg, foot)

placed by RN

duration 3 days

intravenous line (IV): indication

administration of drugs/fluids

blood transfusions

obtaining venous blood

cannot be used to draw blood

intravenous line (IV): PT role

can usually be heparin locked (heplocked)

should obtain MD order

heplocked

The term "heplocked" usually refers to a "heparin lock", which is a medical term used in intravenous (IV) therapy.

Instead, it's "locked" with a small amount of heparin, an anticoagulant (blood thinner), to keep the IV line from clotting when it's not in use.

This setup allows quick access to the vein if medications need to be given later, without needing to insert a new IV.

It avoids the need to have a patient hooked up to fluids all the time. EASIER manageable ability of PT to move patients

Example: A nurse may say a patient is "heplocked" when the patient has an IV line in place, but no fluids are running, and the line is flushed and sealed with heparin.

arterial line (A-line):

placement (duration)

brachial artery

radial artery

femoral artery

placed by MD

arterial line (A-line): indication

monitors arterial blood pressure

access for ABG

lab data

arterial line (A-line): PT role

cannot be heplocked

transducer placed at the level of left atrium when reading

if femoral A line discontinued, pt cannot be seen/on bed rest for 60-90 minutes

central venous catheter:

placement (duration and placed by)

subclavian

internal jugular

femoral vein into superior vena cava

placed by MD

duration 2-3 weeks

central venous catheter: indication

monitoring central venous pressures

administering drugs

fluids

transfusions

TPN (total parenteral nutrition)

central venous catheter: PT role

NO ROM greater than 90 degrees at shoulder and hip;

no horizontal adduction

do not take BP on side of the line

swan-ganz catheter (PA line or pulmonary artery line)

placement (placed by)

subclavian or internal jugular vein to pulmonary artery

placed by MD

swan-ganz catheter (PA line or pulmonary artery line) indication

monitoring heart pressures

cardiac output

core temperature

pulmonary activity

swan-ganz catheter (PA line or pulmonary artery line) PT role

no ROM greater than 90 degrees at the shoulder

no horizontal adduction

avoid head and neck movements (for subclavian) that may disrupt PA line

peripherally inserted central catheter (PICC)

placement

basilic (most common)

cephalic

median cubital vein to superior or inferior vena cava

peripherally inserted central catheter (PICC) indication

access for long term administration of TPN

meds

fluids

blood products

chemotherapy

peripherally inserted central catheter (PICC) PT role

NO BP taken on involved extremity

what is the purpose of intracranial pressure monitoring? what degree do we keep the head of the bed at?

maintenance of normal cerebral perfusion pressure (CCP) and early identification of increased ICP

keep head of bed at 30 degrees

what is "normal ICP"?

4 to 15 mmHg

what will increase ICP?

lowering the head of the bed

trendelenburg position

lateral neck flexion or extreme hip flexion

valsalva maneuver (hold breath and bearing down)

noxious stimulation (vomit nausea)

pain

stress

coughing

frequent arousal from sleep

what are the values for abnormal ICP/an ICP that causes concern?

15-20 mmHg causes concern

anything greater than 20 mmHg is clearly abnormal and medical intervention is warranted

*keep ICP monitored and in mind when performing exercises- make sure it stays within normal range

ICP bolt (intracranial pressure bolt or subarachnoid bolt)

placement (placed by)

subarachnoid space via burr hole placed by MD

ICP bolt (intracranial pressure bolt or subarachnoid bolt) indication

short term use if cerebral edema prevents use of other devices

ICP bolt (intracranial pressure bolt or subarachnoid bolt) PT role

no out of bed activities-

rarely if ever put in upright position- if so need two people

focus on things that can be done in bed

ventriculostomy aka intraventricular catheter

placement (placed by)

anterior horn of lateral ventricle via burr hole placed by MD

ventriculostomy aka intraventricular catheter indication

drainage or sampling of CSF (cerebrospinal fluid)

monitoring ICP

ventriculostomy aka intraventricular catheter PT role

need to look for color changes

must note color of CSF before during and after treatment

notify nurse if color changes i.e. clear to bloody

CSF should be clear with light pink hue

ventriculostomy is considered

gold standard for measuring ICP

foramen of monro

connects lateral ventricles to third ventricle

have to be careful with ICP regarding?

open or closed catheters-

open (unclamped) allows for release of pressure

closed (clamped) means increasing pressure with movement has no way to be relieved

signs of increased ICP

headache

blurred vision

decrease in alertness

vomiting

changes in mental status: confusion

weakness or problems with moving or talking

be aware! any sudden changes are not normal

monitor symptoms with exercise

oriented x4 means?

able to answer all mental status orientation questions correctly:

person? place? time? situation?

supplemental oxygen:

placement

nasal cannula

face mask

trach mask

ventilator

supplemental oxygen indication

oxygen delivery

supplemental oxygen PT role

ask nurse if patient needs O2 with activity

is portable O2 needed?

how many liters?

does patient desaturate with activity?

check O2 sats PRN

what percentage of oxygen saturation (O2 sats) is considered normal?

normal is above 92%

no ailments or lung disorders

pulse oximeter

placement

ear lobe

finger

toe

forehead

bridge of nose

pulse oximeter indication

measure percentage of hemoglobin saturated with O2 in arterial blood

pulse oximeter PT role

have portable machine PRN to monitor patient

what is hemoglobin?

Hemoglobin is a protein in red blood cells that carries oxygen from the lungs to the body's tissues and returns carbon dioxide from the tissues back to the lungs.

telemetry (ECG)

placement

colored leads that coincide with different locations to monitor HR/RR/ and O2 sats

telemetry indication

continuous monitoring of HR and rhythm and RR

telemetry PT role

talk with nurse or telemetry tech before unhooking any leads and before and after working with pt

nasogastric/orogastric (NG/OG) tube

placement

tube placed in nose or mouth to stomach

placed by RN

nasogastric/orogastric (NG/OG) tube indication

enteral feeding

gastric drainage

decompression of the stomach

nasogastric/orogastric (NG/OG) tube PT role

may be hooked up to wall suction which may limit distance patient can be away from the bed

if clamped; monitor pt for nausea or abdominal distention BC! pressure can pull on attachment sites from the weight of it

put feedings on hold if lying flat

dobhoff tube

placement

mercury weighted tube to be passed with a guide wire thru nose into small intestines

placed by MD or special trained RN

dobhoff tube indication

long term use in a pt who cant orally ingest (surgical, comotose, stroke)

dobhoff tube PT role

don't pull it out!!!!!!

head of bed at least 30 degrees when in use- put feedings on hold if pt needs to lie flat

stop feedings when laying flat

PEG/PEJ tube

placement

percutaneous endoscopic gastronomy

percutaneous endoscopic jejunostomy

surgically placed in the stomach/jejunum

placed by MD

PEG/PEJ tube indication

enteral feeding

small intestine drainage

gastric drainage

PEG/PEJ tube PT role

watch gait belt placement/hand placements

gait belt should be placed above tube

put feedings on hold if pt lay flat

Endotrachial Tube (ET tube)

placement

PVC tube placed in trachea via nose or mouth

placed by MD

INTUBATION! attaches to ventilator

Endotrachial Tube (ET tube) indication

used to relieve airway obstruction

prevent aspiration

facilitate tracheal suction

mechanical ventilation

Endotrachial Tube (ET tube) PT role

should know if patient is weaning

must monitor vitals especially RR

tracheostomy (trach) tube

placement

indication

PT role

PVC tubing placed in trachea thru an opening in the neck (stoma)

placed by MD

tracheostomy (trach) tube indication

mechanical ventilation

prolonged ventilatory support

after laryngectomy

tracheal resection

other head/neck surgeries

tracheostomy (trach) tube PT role

if off ventilator, watch patient for coughing, sputum issue when cover is off

direct line to lung must be suctioned and cleaned

suction (yankauer suction) tube

placement

where needed

suction (yankauer suction) tube indication

used for suction of saliva

mucus

blood

etc

suction (yankauer suction) tube indication PT role

this is your friend so use it!!

physical exercise breaks up mucus

prevents aspiration

chest tube

placement

surgically placed in chest between ribs

placed by MD

chest tube indication

promotes normal intrapleural pressures/mechanics by:

1. removing air/fluid from pleural space

2. prevents re-entry of air/fluid

3. reinflates a collapsed lung

chest tube PT role

- DONT TIP!

- extension tubing if cannot be removed from wall suction

- coughing, deep breathe, and lying on side of insertion can cause discomfort

- if on water seal (removed from suction) can gait train further

- dependent position: tubes lower than insertion so drainage can occur

urinary/foley catheter

placement

bladder

placed by RN

urinary/foley catheter indication

bladder drainage

urinary/foley catheter PT role

must be taken during PT session

communication on amount and color before drainage if needed for easier ambulation

rectal tube/pouch

placement

rectum

by RN

rectal tube/pouch indication

rectal drainage

collect liquid stool

prevent skin breakdown 2 degrees runny stool

rectal tube/pouch PT role

may or may not want to sit patient up 2 degrees to discomfort or dislodging

keep collection bag below level of insertion

colostomy/ileostomy tube

placement

colon is surgically opened and brought to abdominal surface

bag placed by RN after surgery

colostomy/ileostomy tube indication

bowel elimination when colon is obstructed or not functioning

when there is a need for diversion of fecal matter

colostomy/ileostomy tube PT role

watch gait belt/hand placement

may need to be emptied before or after tx

if bag comes off- notify nurse immediately

jackson pratt (JP) drain

placement

placed at surgical site- may have one or many

placed by MD

jackson pratt (JP) drain indication

drainage of local edema/blood

jackson pratt (JP) drain PT role

don't let bulb dangle

secure bulb to gown so doesnt pull

elimates excess fluid of surgical site

constavac drain

placement

indication

PT role

placed at surgical site

drainage of local edema and blood

gravity or suction set up

what is the difference between the constavac and JP drains?

JP is gravity dependent

constavac is not gravity dependent- suctions

JP does mild drainage whilst constavac is a more efficient drainer

incentive spirometer

placement

given to patient at bedside

incentive spirometer indication

to assist with deep breathing in hopes to prevent pulmonary complications during hospital stays

prescription ex. "10x/hour"

incentive spirometer PT role

incentivize them to get to a certain number and keep increasing

encourage patient to use when in bed

sequential compression device (SCD)

placement

inflatable sleeves applied to leg (full or just lower)

prevents blood clotting

"dont like? you have to walk w me!"

sequential compression device (SCD) indication

promotes venous return and prevents DVT

inflates and deflates to encourage circulation

sequential compression device (SCD) PT role

contraindicted in extremity with DVT

dont use over top of open wound or acute cellulitis

2 point vs 4 point

arms or legs 2 limbs constrained

all 4 limbs constrained

restraints

- cloth

- leather

- 2 point

- 4 point

- mitt

posey vests

L'nard boots