Lines and Tubes

Purpose of IV/AV lines

Administer drugs and fluids: quick response, high concentration

To collect blood samples: monitor blood gases, alcohol, poison, sugar, etc

3 methods of injection

bolus

gravity infusion

infusion pump

Bolus

injection with hand-held syringe or automatic injection over short period of time

Gravity Infusion

bag of solution connected to tubing and needle

Infusion pump

electronic control of rate and volume of injection

When would an infusion pump alarm

low battery, air or foreign body in line, kinked, solution depleted, disconnected line, infiltration/extravasation

Parenteral solutions

saline - clear fluid

5% dextrose (D5) - clear fluid provides energy and carbs

total parenteral nutrition (TPN) -milky white, replace GI nutrition

vitamins

Standard height

18-20" above injection site

Drip rate

follow order of MD/pharmacy per specific drug amount over period of time

What should you check a solution for

clarity

expiration

container condition

label (correct dose and drug, correct concentration and rout of administration)

Gauge

unit that IV catheters are measured in to describe diameter

Larger the number the smaller the diameter

6 rights to administering meds

right time

right route

right medication

right dose

right patient

right reaction

DOCUMENT!

Extravasation

escape of fluid or blood from a vessel into surrounding tissue (blown vein)

Extravasation signs/symptoms

puffy near injection site

poor infusion

pain at injection site

swelling

cool to touch

pale skin at sight

Extravasation Response

STOP IV

call RN/MD

elevate effected area

warm compress

Phlebitis

inflammation of a vein

Phlebitis signs and symptoms

red line along vein going up the arm

poor infusion

blood backup in line

swollen red vein

pain proximal to puncture sight

phlebitis response

Call RN/MD

elevate effected part

warm compress

discontinue IV

Venous Thrombosis

The formation of blood clots within a vein (stationary clot)

Venous thrombosis signs/symptoms

poor infusion

blood backup in line

redness (but not up the arm like phlebitits)

Venous thrombosis response

call MD and RN

alert for pulmonary embolus

Embolus

blood clot or foreign material travels to narrow site in a vessel, creating occlusion

Types of embolus

Pulmonary emboli (most common)

brain emboli

coronary emboli

Increased risk of embolus

central lines

trauma

valve defects

atherosclerosis

venous stasis

post-op

Embolus signs/symptoms

sudden onset of symptoms

chest pain

dyspnea

rapid pulse

pallor

diaphoresis

clammy skin

Embolus Response

rapid response

contact RN

Infection

systemic or localized infection because of lack of asepsis or poor continued care of IV

Infection signs and symptoms

fever

angry and red appearance of site

elevated WBC

chills or headaches, backaches, nausea

Infection response

Report to RN/MD

discontinue IV

antibiotics

3 Basic types of Upper GI devices

Nasogastric (NG)

Orogastric (OG)

Nasoentric (NE)

Nasogastric (NG)

nose to stomach

Orogastric (OG)

mouth and stomach

Nasoenteric (NE)

nose to small intestine

Purpose of Upper GI devices

feed, give meds (NE tube), remove GI content, connect to suction

2 types of nasogastric tubes

Levin (single lumen)

Salem-sump (double lumen)

Pathway of NG tube

nose -> esophagus -> stomach

What's wrong with this NG tube

the tube is not fully in the stomach

RT role in placement of GI tube

watch for improper placement

radiographic verification

How to find NG tube

find line in the neck and follow it to the stomach and the loop it makes in stomach

NG tube in lung

Alert

NE tubes function

introduce materials into small intestine

minimize reflux, regurgitation, aspiration

NE tube pathway

nose -> esophagus -> stomach -> duodenum

inserted through nose, mouth, or surgical opening

NE tubes other names and info

AKA: Dobbhoff

small lume gets easily blocked

weighted tip to carry it along GI tract

NE tube care during imaging

avoid tension on line

pin tube to clothing

GENTLY brush tube out of xray field

report to RN if concerned placement is incorrect

Colostomy Bag (Lower GI)

connection between colon and external abdominal wall

empties into collection bag

temporary or permanent

Ileostomy

connection between small intestine and external abdominal wall

Ostomy Bag care

don't usually do anything, outpatients can usually care for their own bag

if dislodges, clean and dry area

What is a Tupperware seal for an ostomy bag?

have patient tighten stomach and reapply device (ostomy bag) to create seal

Enema tips

straight or cuffed

some are triple lumen

Tripple lumen enema tips

channels for barium, cuff air, colonic air

3 types of urinary catheters

1) foley catheter

2) ureteral stent

3) nephrostomy tube

Foley catheter

drain bladder

sometimes to introduce contrast to body

can be seen when put a contrast in bladder

don't xray these but can see during pelvis exam

ureteral stent

kidney to bladder

nephrostomy tube

kidney to outside the body

releases pressure from kindeys

CCU and NCU

cardiac care unit

neurological care unit

Reasons for urinary catheterization

unable to use bedpan

trauma (fractured hip)

post-op

irrigation of bladder

chemo

incontinence

input/output documentation

epidural/spinal where patient cannot feel sensation to void

Urinary catheter sizing

french numbers: increase number=increase diameter

Urinary catheter types

Indwelling (foley)

Intermittent/in and out/ straight catheterization (Bardex)

Internal vs external end of catheter

Internal end is in the bladder and secured with balloon cuff

external end attaches to drainage bag

Catheterization precautions

Extreme UTI potential

keep drainage bags BELOW level of bladder but OFF floor

avoid tension on catheter

Nephrostomy

sometimes x-ray for placement

percutaneous (placed in OR) through back into renal pelvis

entrance at kidney from back, exits outside body

Nephrostomy purpose

drain urine or administer meds

Ureteral stent "pig-tail stents"

connects between kidney and bladder

Oxygen (respiratory device) reminders

high pressure in tank

use roller when transporting tank

Endotracheal Tube (ETT)

inserted through mouth or nose

emergency situations for short term breathing

can have rattling noise: notify nurse

RN may suction

Pathway: reach 3-5cm proximal to carina

What happens if ETT gets inserted too far?

goes down right lung, only that side receives air

Tracheostomy

surgical creation of an opening into the trachea through the neck

Pathway: ends halfway between stoma and carina (level of T3)

long term

Carina

Point at which the trachea bifurcates (divides) into the left and right mainstem bronchi

What to do if ETT or tracheotomy tube are dislodged?

immediate code

Ventilator

partial or complete mechanical breathing

DO NOT disconnect

Why do ventilator tubing have corrugated appearance?

to prevent collapse of tube when breathing

What to do if ventilator disconnection alarm sounds?

promptly reattach

Time exposures with breathing cycle of ventilator when taking x-rays

Chest x-ray: full inspiration

Abdomen: full expiration

Ventilator tubing; tracheostomy x-ray

Chest tube

used when lung collapses away from chest wall

large diameter tube inserted into pleural space to drain air or fluid, allowing lung to re-inflate

what causes a lung to collapse

air or fluid in the pleural space

pneumothorax

air in the pleural cavity

hemothorax

blood in the pleural cavity

where to insert chest tube

upper thorax if for collapsed lung

lower thorax if for draining fluid

Chest tube precautions

1) KEEP drainage collector lower than chest level

2) DON'T tip drainage collector

3) AVOID tension on tubing

4) COVER if seal is broken, cover puncture site with airtight seal

How to locate chest tube on xray

start looking on outside of body and trace it in and up

Central venous lines

more permanent and travel longer distances than IVs

PICC line (peripheral inserted central catheter)

type of central venous line

placed near heart (SVC)

Purpose of PICC line

administer medication

long term IV therapy

chemo

PICC line pathway

ends at SVC, just superior to right atrium

How to trace PICC line

find line near shoulder and follow line to the heart

PICC lines pre-manipulation and direction

don't pre-manipulate image because it prevents radiologist from manipulating it themselves

make sure line goes to SVC and not up towards the brain

Portcath

long term IV therapy, chemotherapy

preserves vessel puncture site

surgically placed

may be used in CT for contrast injections

Portcath important locations

special diaphragm disk under skin

special right angle needed to puncture diaphragm

Portcath Pathway

ends just superior to right atrium

Portcath x-ray

Swan Ganz line

only line to go into artery

multiple lumen line

Swan Ganz line purpose

blood gas sample

pressure reading

administer meds

Swan Ganz line pathway

subclavian vein -> SVC -> RA -> RV -> pulmonary artery

ends just past entrance of right pulmonary artery

Pulled central venous line or PICC

patient in steep left lateral trendelenburg position (on left side and drop head down, which keeps air on right side of heart)

Pacemakers

keep heart beating

temporary or permanent

often 2 electrodes (RA and RV)

x-ray after surgery to ensure correct placement

Pacemaker pathway

subclavian vein -> SVC -> RA -> RV -> electrode wedged agains RV wall

automatic implantable cardioverter-defibrillator (AICD)

doesn't fire at all times like pacemaker

corrects arrhythmias

AICD on image

most defibrillators only have one electrode

1) one electrode in SVC or brachiocephalic vein

2) if second is used, apex of RV

Intra-aortic balloon pump (IABP)

temporary treatment used when heart fails b/c working too hard

reduce workload on heart to help heart heal

allows more blood in coronary artery to help heart rest