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NURS2520 Health Assessment II

NURS2520 Health Assessment II. TPN/Central Line Care. Objective One Demonstrate safe administration and discontinuation of TPN. Parenteral Nutrition. * Parenteral nutrition = intravenous delivery of nutrition via central venous catheter (CVC)

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NURS2520 Health Assessment II

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  1. NURS2520Health Assessment II TPN/Central Line Care

  2. Objective OneDemonstrate safe administration and discontinuation of TPN

  3. Parenteral Nutrition *Parenteral nutrition = intravenous delivery of nutrition via central venous catheter (CVC) • Indicated for clients who can not ingest food or fluids through the GI tract • Types of parenteral nutrition include partial or total • Partial parenteral nutrition (PPN) is indicated for clients who can meet some of their nutritional requirements orally (i.e. shortened small bowel due to injury/disease) • Total parenteral nutrition (TPN) is required for severely malnourished clients, clients with severe and extensive burns or other trauma, and for GI recovery • Administered via central line into high-flow vein to prevent vessel damage due to hypertonicity

  4. Total Parenteral Nutrition • Contains amino acids, vitamins, minerals, and trace elements • Can be modified to meet nutritional needs of client • High in glucose • 10-50% dextrose in water • Start infusion slowly to prevent hyperglycemia • Less than 30-60 mL/h • Most TPN solutions contain insulin to aid in absorption • Do not increase rate without an order as this can cause osmotic diuresis and dehydration • Clients on TPN must receive concurrent weekly infusions of lipids w/fatty acids and triglycerides

  5. TPN (cont’d) • Prepared under strict asepsis procedures • Use surgical aseptic technique when changing TPN solution and tubing • Do not use TPN infusion line for administering other medications/solutions to prevent contamination • Formula bottles should hang for no longer than 12 hours to prevent complications • TPN formula adjusted based on client’s status • Weight • Lab values (electrolytes, blood sugar, albumin, BUN, creatinine) • TPN therapy must be discontinued gradually (up to 48 hours) to prevent sudden drop in blood sugar

  6. Objective TwoDemonstrate a sterile central dressing change and changing central line caps

  7. Central Line Dressing Change • Supine position with client’s head turned away from CVC site • Don gloves and mask; place mask on client • Remove and dispose of old central line dressing and gloves • Inspect site • Remove and dispose of mask • Access sterile CVC dressing change kit • Apply sterile gloves and mask • Cleanse site with 2% chlorhexidine moving in a spiral direction; allow to dry • Maintain sterility

  8. CVC Dressing Change (cont’d) • Apply dressing • Sterile gauze • Sterile, transparent, semipermeable dressing • Change CVC dressing every 7 days • Replace dressing if damp, loosened, or visibly soiled • For PICC line, check position with each dressing change to ensure proper placement • If PICC line position has changed more than 1-2 cm since insertion, may need to x-ray chest for placement *Changing central line caps -- • Prime new sterile caps with saline via sterile syringe • Assure all lumen are clamped • Clean existing caps with alcohol prior to removal

  9. Changing Central Line Caps (cont’d) • Clamp or kink central line prior to removing caps to prevent air from entering the line • Remove first central line cap and replace with primed cap, maintaining sterility; repeat for all caps, ensuring each is secure • Flush central line per institutional protocol to maintain patency and prevent occlusion • Never use syringe with a barrel capacity of less than 10mL • Smaller syringes generate more pressure than larger ones, potentially damaging the line • Flush with at least 10mL normal saline (NS) whenever the central line is irrigated • Use push-pause flushing method to remove particles that adhere to the catheter lumen

  10. Objective ThreeDiscuss safe administration of intralipids

  11. *Intralipids are a source of essential fatty acids and energy • Fat emulsion must be included in longer-term TPN therapy in order to deliver adequate calories and high levels of essential fatty acids • Typically initiated within 1 week of TPN therapy • Change tubing every 12 hours • Infuse or discard emulsion within 12 hours of hanging the container • Begin infusion slowly, increasing daily based on client’s tolerance • Potential for adverse reaction, fat embolus w/rapid infusion

  12. Objective FourDemonstrate safety and sterility in discontinuing a central line

  13. *Removal of nontunneled, noncuffed central lines is an aseptic technique that can be performed by the RN • Place client in recumbent position • Remove dressing and any securing devices from the central line insertion site • Instruct client to perform the Valsalva maneuver • Air is prevented from entering the catheter wound and pathway while client is bearing down • Remove the catheter and apply pressure to the site • Immediately apply antiseptic ointment and sterile occlusive dressing • Client remains recumbent and inactive for 30 minutes • Measure catheter length, document integrity

  14. Objective FiveIdentify types of central lines, safety issues, and cares

  15. *Indications for placement of a central venous access device (CVAD) include -- • Inadequate peripheral vascular access • Need for frequent vascular access • Hypertonic/hyperosmolar infusions • Infusion of irritating or vesicant drugs • Rapid absorption and blood/tissue perfusion • Long-term IV therapy *Contraindications for CVAD placement -- • Altered skin integrity, • Anomalies of the central vasculature, superior vena cava syndrome • Cancer at the base of the neck or the apex of the lung • Immunosuppression, septicemia

  16. *Main types of CVADs -- • Nontunneled catheters • Tunneled catheters • Peripherally inserted central catheters (PICC) • Implanted ports • Nontunneled catheters are inserted into the superior vena cava via percutaneous stick through the subclavian or jugular vein • Single or multilumen • May be referred to as a percutaneous central venous catheter • Example is a Hohn catheter • Catheter size ranges from 24 gauge and 3 ½ inches to 14 gauge and 12 inches

  17. Tunneled catheters are inserted via percutaneous cutdown under anesthesia • Insertion and removal performed by a physician • Catheter tip is placed in the superior vena cava while the other end is tunneled subcutaneously to an incisional exit site on the trunk of the body • Single or multilumen • Dacron cuff near exit site anchors catheter in place, acts a securing device, and serves as a microbial barrier • Left in place for indefinite period of time • Examples are the Broviac, Hickman, and Groshong

  18. PICCs are typically placed in the basilic vein due to diameter and straighter path to the superior vena cava • Single or multilumen • May be placed by RN • Usual dwelling time is 1-12 weeks (can stay much longer) • Decreases risk of CVC complications *A midline catheter (MLC) is a percutaneously inserted IV line that is placed between the antecubital fossa and the head of the clavicle, then advanced into the larger vessels below the axilla • Dwelling time is 1 to 6 weeks • Can deliver most infusates except caustic drugs and TPN that need the dilution capabilities of the superior vena cava • May be placed by RN

  19. An implanted port, or vascular access port (VAP), is surgically inserted into a subcutaneous pocket under the skin without any portion of the system exiting the body • Single or double injection port • Connected to a catheter positioned in the superior vena cava • Port access must be with a noncoring needle to avoid damaging the system • Huber needle • Port-a-Cath Gripper needle • Useful for long-term infusion therapy; should not be accessed more than every 1-3 weeks • Eliminates need for exit site care/dressing changes or regular flushing if not in use; reduces risk for infection • Contraindicated in patients with septicemia or bacteremia

  20. *Risks/complications of CVADs -- • Pneumothorax (due to close proximity to lung apex) • Laceration of the subclavian artery • Difficult to control bleeding because this is a noncompressible vessel • Hemothorax • Migration of the catheter tip across the sinoatrial (SA) node • Dysrhythmia • May become trapped in the tricuspid valve • Permanent damage of the valve • Requires valve replacement • Air or catheter embolism • Catheter pinch-off = the anatomic compression of a CVAD between the clavicle and first rib • Intermittent occlusion of central line • Catheter fracture

  21. http://www.youtube.com/watch?v=ud8EWOQYqP0

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