Transcript LPN-C - Faculty Sites

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)
 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
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
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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
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
Objective Two
Demonstrate a sterile
central dressing change and
changing central line caps
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
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
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
Objective Three
Discuss safe administration
of intralipids
*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
Objective Four
Demonstrate safety and
sterility in discontinuing a
central line
*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
Objective Five
Identify types of central
lines, safety issues, and
cares
*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
*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
 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
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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
 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
 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
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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
*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
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Intermittent occlusion of central line
Catheter fracture
 http://www.youtube.com/watch?v=ud8EWOQYqP0