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) 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 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

Place client in recumbent position *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

*Contraindications for CVAD placement -- *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 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

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

*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

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