NRSG 301

complications of CVAD

-infxn

-phlebitis/ thrombophlebitis

-occlusion

-fluid overload

-arterial puncture

-hemorrhage

-extravasation

-air/catheter embolus

-pneumo/hemothorax

-cathether migration (if >2cm diff- report & DNU)

PICC maintenance

-drsg change Q7days & PRN

-flush at least Q12hrs/Qshift or Q24hrs w/ home care

power picc

-purple PICC

-18 gauge lumens (usually)

-*can inject contrast (max rate 5mL/sec)

non-tunneled lines

-short term/emergent Tx

-jugular (int/ext), subclavian, femoral

-used less than 1 wk

-sutured in place

-req's heparin flush if non-valved

tunneled lines

-use >1 month - indefinitely

-subclavian vein

-*dacron duff

-once healed, no drsg needed at home

IVAD

-LT IV Tx (i.e. intermittent meds, chemo)

-line in distal 1/3 of SVC

-decreased risk of infxn

-requires huber needle to be accessed

IVAD maintenance

-assess for dislodging: neck/ear pain, gurgling, palpitations, free mvmnt of port, swelling, diff accessing

-flushes Q8 wks

-req's heparin flush

hemo lines

-tunneled line

-subclavian or jugular

-usually for temporary access (i.e. emergent or waiting for AVF to heal)

-*uncuffed <3mos - emergent

-cuffed >3mos - LT

TPN through a CVAD

-*req's in-line filter

-needs a dedicated line

-usually white port = TPN

CVP monitoring

-pressure measured in SVC, near R atrium

-normal CPV= ~3-8 cmH2O

most common reasons for VAD occlusions

1. thrombotic (58%)

2. chemical (drug precipitate) (42%)

3. mechanical

PICC blood draw policies

-always change cap afterwards

-must discard 6mL before drawing labs UNLESS taking C&S

-done if peripheral veins inaccessible, hemorrhage risk, needle phobia, pt refusal

-20mL flush post-b draw

-incr'd risk of infxn & occlusion

-*prime needleless cap before attaching*

-**DNU heparinized CVADs for b draw**

benefits to PICC b draw

-decr'd risk of hematoma from puncture

-vein preservation

-decr'd pain/anxiety

PICC blood draw methods (3)

1. stop infusion for 2 mins & remove tubing/cap and attach directly to lumen (best practice)

2. attach vacutainer to needleless cap and draw then change needleless cap

3. stop infusion for 2 mins, attach 10mL syringe to needleless cap then attach vacutainer to syringe, change cap

PICC drsg change complications

-migration

-bleeding at site

-infxn

-accidental removal

PICC drsg change steps

1. clean technique to peel drsg, expose securement device & remove & clean area

2. aseptic to apply new device & remove remaining drsg (using forceps)

3. sterile to complete rest

NOTE: if 1st drsg change, may notice statseal disc- must remove

NOTE: change TSM drsg Q7days but gauze Q2days

PICC removal

-remove catheter slowly in 2-3cm increments (avoids venospasm)

-if resistance felt, stop adn apply heat for 15mins to upper arm/shoulder

-place large TSM with sterile gauze over top *keep insertion sterile*

-apply pressure for 5-10mins, keep pt lying for 30mins

Jugular or subclavian CVAD removal

-pos'n in trendelenberg/flat NO pillows

-get pt to take deep breath and hold

-withdraw & apply pressure w/ sterile gauze for 5-10 mins

-keep pt lying flat for 30mins

NOTE: if any resistance felt, stop, tape in place & report to MRP

dysuria

difficult or painful urination

oliguria

decreased/low urine output

causes of urinary retention

-strictures, clots, kidney stones

-BPH

-Trauma

-Tumor

-Pregnancy

-Anxiety

-Infection or scar tissue

-Nerve disorders

-Postoperative complications

-Meds (anticholinergics, antipsychs, antihistamines, opioids, anesthetics)

indications for catheterization

-perioperative use

-acute urinary retention/bladder obstruction

-need for accurate ins/outs in critically-ill pts

-to assist healing of open wounds near perineum/sacrum for incontinent

-prolonged immobilization

-end of life comfort care

HOUDINI (IH indications for urinary catheterization)

H- hematuria

O- obstruction

U- urologic surgery

D- decubitis ulcer (open sacral/perineal on incontinent person)

I- I&O for critically ill

N- no code/comfort care

I- immobility

urinary catheterization

-check orders PRN

-assess for iodine & latex allergies NOTE: iodine can sting excoriated skin

-supine pos'n male, dorsal recumb. female

-pericare pre- and post-insertion

-*if >700mL retention, pinch catheter to avoid spasms/collapse

-keep bag below waist

-secure w/ stat lock

if catheter not inserting

-get pt to relax, cough/laugh, deep breathing

-insert w/ twisting motion

-increase lubrication

-lidocaine PRN

-try coude-tip (if XY)

-ensure urethra located (may be inside vagina on anterior wall for some pts)

-leave old catheter in place, get new supplies & try again

IF STILL not working: remove & clean supplies, ensure pt comfort, docu attempts, contact MRP

foley insertion documentation

-time

-type & size

-volume of SW to inflate balloon (DNU NS because will leak out overtime)

-colour, clarity, amount of urine

-pt's tolerance

-presence of drainage

-if specimen collected

catheterization complications

-CA-UTI (w/in 48hrs catheter insertion)

-urethral trauma

indwelling foley removal

-check orders PRN

-blue pad, peri care & inform pt

-check balloon volume

-deflate balloon w/ syringe

-remove gently

-post-pericare, encourage fluids, **monitor post-removal void

post-foley removal documentation

-time

-condition of balloon & catheter tip

-volume removed from balloon

-pt's tolerance

-if specimen collected

if catheter ballon won't deflate

-ensure no kinks

-check amount of fluid put into ballon previously

-try to inflate again then deflate

-notify MRP

-over 1-2 days, continue trying to deflate --> urologist

foley urine collection

-clamp below port for 30 mins

-cleanse port & attach syringe

-withdraw min 30mL sample

-disconnect, place in specimen container & send

-*UNCLAMP

nephrostomy def'n & indications

surgically inserted tube to remove urine directly from renal pelvis

-removal of renal calculi

-decompression of obstruction

-maintain/improve renal fnctn

-if ureteral obstruction

-trauma

nephrostomy complications

-kidney infxn (dull flank pain, fever, chills, urine changes)

-skin breakdown

-sepsis

nephrostomy monitoring

-urea

-creatinine

-lytes

-potentially GFR

suprapubic catheter def'n & indications

catheter surgically inserted thru abdo wall into bladder to collect urine

-urethral anatomical issues

-pelvic organ prolapse

-SCI, trauma

-lower body paralysis

-MS

-LT catheter use

-acute prostatitis

suprapubic care

same as foley + drsg around insertion site until healed

urostomy care

for when bladder cannot store urine (i.e. trauma, fistula)

-same as changing ostomy

-*IF STENTS: keep sterile (bc directly into kidney)

-stents should be INTO bag

-wipe stents w/ sterile 4x4 to remove mucous

-diff collection port than ostomy

CBI def'n & tips

often used post TURP/trauma to ensure clots removed from bladder

-3-way catheter

-ensure NS bags do not run dry (have 2 bags hanging at all times)

-regulate flow w/ roller clamp (if red= incr flow, if clear decr flow)

-gradually reduce as bleeding diminishes

CBI system

-closed sterile system

-two 3L NS bags

-night bag

-bucket that drains nightbag

open intermittent irrigation

*incr infxn risk

-non-luer lock syringe

-use minimum 30mL sterile saline & 60mL syringe (have sterile basin w/ sterile saline)

-ensure same fluid return

-may repeat up to 4x

closed intermittent irrigation

-luer lock syringe attaches to port of catheter

-keep tubing clamped under the port

-instill 30mL sterile saline ensure 30mL returns

-repeat up to 4 times

what happens if no fluid return during CBI/intermittent irrigation

Ensure no kinks in tubing/catheter, proper bag placement- fully open roller clamp if running, consider trying manual irrigation. May indicate:

-blockage of catheter

-large clot

-bladder spasms

Palpate/assess abdo for signs of these problems. Contact MRP.

#1 reason for pleural effusion

-CHF

transudative pleural effusion

occurs d/t incr'd pressure on b vessels that pushes fluid into pleural space; protein-poor fluid

i.e. CHF, cirrhosis (bc decr'd pma proteins), CHD

exudative pleural effusion

incr'd permeability of capillaries from inflammation, infxn, malignancy; protein-rich fluid

i.e. CHF, post-CABG, pneumonia/TB, lung CA, trauma

causes of pneumothorax

CLOSED:

-spontaneous

-high pressures from venting

-injury to lung: broken ribs, subclav. CVAD insertion

OPEN:

-penetrating chest trauma (sucking wound)

NOTE req's vented drsg (occlusive 3-sided)

s/s pneumothorax

-pleuritic CP

-incr RR & effort, dyspnea

-decr mvmnt and breath sounds on affected side

-rising pulse, falling BP

-cool mottled skin

-subcut emphysema (trauma, large bore)

-*tracheal deviation away from affected side (late)

tension pneumothorax + s/s

-type of pneumothorax in which air that enters the chest cavity is prevented from escaping, causing incr'd pressure build up

-absent lung/breath sounds on affected side

-tracheal deviation (late)

-JVD

-incr'd resp difficulty

-dropping BP

3-sided occlusive drsg & contact MRP immediately

hemothorax

-a collection of blood in the pleural cavity usually d/t surgery or trauma

chest tube sizes

-8-12Fr infants/children

-16-20Fr children/young adultls

-24-32Fr most adults

-36-40 large adults

small bore/pigtail catheters

-less drainage than large bore

-more comfortable

-has stopcock clamp NEEDS to stay open

-removal req's Drs order

CT assessments

-start at pt: resp, cardiac & pain assessments

-air leaks

-suction set to correctly

-check drainage

-ensure stopcock/system open & draining

-check for loops

-bedside safety equipment (2 kelly clamps, tape, sterile gauze)

how to know if there's an air leak in a chest tube

-continuous bubbling in water seal chamber

what happens if suction is too high?

can risk:

-damaging lung tissue

-re-expansion pulmonary edema

what parts of CT collection device to check?

-water seal chamber: check for tidalling on inspiration/expiration (ok); check for continuous bubbling in bottom portion (air leak)

-check amount, colour, clarity of drainage

-IF suctioning: orange bellows visible & moving; suction set to correct rate; suction port & tubing connected properly

nrsg considerations for CT pt

-focused resp & cardiac, pain

-VS Q4H

-encourage DB & C Q1-2H (& splint if incision) - check system Q2H

-sit in semi-fowlers

subcutaneous emphysema

-crackling sensation felt on palpation of the skin, caused by the presence of air in soft tissues

-indicates CT either misplaced and putting air into tissues or air leaking out from lung into tissues

s/s cardiac tamponade (mediastinal CT)

-muffled or distant heart tones

-lower BP (d/t b loss)

-irreg pulse/dysrhythmias

CT: what to watch for

-sudden incr >100mL/hr or decr in drainage

-incr in frank blood/drainage appearance changes

-subcut emphysema (delineate w/ marker)

-change in resp status/effort

-changes to ambulation

-incr'd need for O2 to maintain sats

CT documentation

-bubbling

-fluctuation

-drainage

-any complics

-full cardioresp assmnt

-pain

-pt teaching, DB&C

if CT disconnects

-tell pt to cough/bear down (reduces risk of air entry)

-double clamp cross-wise

-swab tubing ends & re-attach

-re-tape

-unclamp

if CT gets pulled out

-don clean gloves

-gloved hand over insertion

-call for help

-apply 3-sided drsg

-assess pt

-call doctor

only times to clamp a CT

-briefly when reconnecting tubes

-briefly when changing drainage system

-briefly when checking for air leak

-if ordered/trialing removal

IF CLAMPED TOO LONG --> tension pneumothorax (if air is issue) or delays pt's recovery (if fluid issue)

P-EGGY drain

-can check for airleaks in air leak chamber w/ 1mL SW

-squeeze chamber to create negative pressure

-for low draining CTs/for pt d/c w/ CT

-withdraw fluid w/ sterile syringe & docu amount, colour

small bore drsg change

-Q5-7days & PRN

-sterile procedure

-chlorhex w/ 70% alcohol swabs

-TSM

-securement device

large bore drsg change

-Q48-72hrs & PRN

-sterile procedure

-wide occlusive tape

-sterile NS

-4x4 drain sponges, 4x4 gauze (PRN)

-absorbent cover drsg

pleurodesis

-putting sclerosing agent into pleural space by creating scar tissue that holds to prevent persistent pleural effusions

-done usually if pleura keep separating

OSA

-epsiodes of apnea or hypopnea (partial collapse) of upper airway w/ associated decrease in O2 sats or arousal from sleep

-CPAP/BiPAP is Tx

CPAP

-continuous positive airway pressure

-helps to prevent upper airway collapse caused by OSA

-mask seals mouth/nose

-most ppl d/c CPAP d/t discomfort, claustrophobia

BiPAP

-bilevel positive airway pressure

-less invasive/more comfortable than CPAP

decortication

-removal of thick fiborus membrane from visceral pleura

when to call the MRP about a CT

-new onset/worsening subcutaneous emphysema

-new onset purulent drainage, foul odor

-new onset inflammation

-CT gets dislodged

suture care

-keep cover drsg on for 24-48hrs post-op

-kept in place 5-14 post-op (deps on orders)

staple care

-keep drsg on for 24-48hrs post-op

-kept in place 7-14 days (deps on orders)

dehiscence Tx

partial or total separation of wound layers

-stop suture/staple removal

-steri-strip

-redress

-call surgeon

evisceration Tx

extrusion of organs thru cavity of open wound; blood supply COMP'D

-stop removing sutures/staples

-cover w/ saline-soaked gauze

-do NOT repos'n organs, call surgeon ASAP

potential suture/staple complications

-dehiscence (splitting open)

-evisceration (splitting + organs out)

-unable to remove sutures/staples

-pain

-infxn

pt education: sutures/staples

-may shower 72 hrs post-op

-no bathing/soaking for 4-6 wks, keep clean & dry

-DON'T strain incision area

-clean hands when touching incision

-do not remove steri-strips

-watch for s/s of infxn

-rest, fluids, nutrition, ambulation

suture/staple assessment + removal

assess for:

-redness, echymosis

-edema

-drainage

-approximation of skin

-# of sutures/staples

-remove every 2nd closure, then remove remaining & cover w/ steri-strips

-if opening starts, stop + cover w/ steri strip(s) & cover drsg, notify surgeon

*NOTE: KEEP every closure & count at end*

wound irrigation

-irrigation tip & 30mL syringe & pos'n etc. 2.5cm (wide) above or 1cm into wound (small opening)

-irrigate w/ 100mL NS/SW etc. or until clear returns

*NOTE: DON'T irrigate a wound >15cm deep or no known end point*

sinus tract

-cavity/channel under wound -> potential for infection/abscess

-"tunnelling"

undermining

-extends into subcutaneous tissue under skin

-not fully visible ... tissue damage can be larger

-casued by infxn, PI, poor WC

benefits of wound packing

-XS moisture & drainage absorbed

-protects wound from trauma from mvmnt

-prevents closure at top of wound & encourages healing "bottom up"

wound packing principles

-1 piece @ time

-use largest poss packing

-ONLY use enough to fill space-> no bulge/stretch

-packing to cover only wound bed, NOT good skin

keep packing count

*DON'T pack wounds >15cm depth/no known end point unless ordered*

*EACH wound req's own WC plan sheet*

VAC therapy contraindications

-insufficient vascularity

-necrotic wounds

-untreated osteomyelitis

-malignancy in wound

->20-25% non-viable tissue

-no known depth, fistulas

-allergy

-high bleed risk

VAC compications

-infxn/sepsis

-foam retention

-tissue adherence

-bleeding

-pain

VAC therapy

-vacuum-assisted closure for wound healing

-uses neg pressure and moisture

-FOR: acute/traumatic, abdo, cardiothroacic, ortho, chronic wounds or burns

benefits to VAC therapy

-good wound bed, granu tissue growth, incr epithel.

-incr local vascularity

-decr bact colonization

-accurate drainage

-optimal moisture

-cost-effective

Prevena vs Pico

Prevena:

-125mmHg

-used for 2-7 days min.

-single use

Pico:

-80mmHg

-change Q3-4 D (up to 7)

-single use

-shower proof drsg

absorbent WC prods

-allevyn w/ mep border

-alginates

-aquacel

-silvercel

-mesalt

-mesorb

-gauze

non-adherent WC prods

-mepitel

-adaptic

-allevyn

-alldress

-inadine

-restore Ag

-iodasorb (paste)

5 rights of clinical reasoning

-right cues

-right action

-right pt

-right reason

-right time

preventing FTR (4)

1. surveillance - most important!!

2. timely ident. of complics

3. taking action

4. activating team response

neuro bell curve

Restless

Anxious

Irritable

Agitated

Confused

Combative

Lethargic

Unresponsive

respiratory bell curve

-20

-24

-30

-increasing 40s

-4-10

-Apnea

cardiac bell curve

->100 bpm

-PVC

-Shape

-Couplets

-Patterns

-Runs V Tach

-V tach

-V fib

-Asystole

4 major obstacles in FTR

1. failure to recog deterioration

2. failure to communicate and escalate concerns

3. failure to assess pt

4. failure to diag and Tx pt appropriately

mgmt of acute resp failure

-supplemental O2 (NP 1-6, SM 5-10, NRB to 15L/min)

-improve ventilation & gas exch (BiPAP, intubation)

-give meds to Tx cause (bronchodil, steroids, analgesics, abx etc)

shockable rhythms

-vtach

-vfib

-everything else w/o pulse = pulseless electrical activity

-if NO pulse, AED cannot shock

ventricles req to fnctn (4)

1. oxygenation

2. perfusion

3. lytes

4. acid-base balance