HYPERALIMENTATION & CENTRAL VENOUS CATHETERS NURSING 108 ECC Majuvy L. Sulse MSN, CCRN

Objective Use safe and accurate techniques when caring for clients who are receiving Hyperalimentation and who have central venous catheters

HYPERALIMENTATION Parenteral Nutrition- delivery/introduction of nutrients, including amino acids, lipids, carbohydrates, vitamins, minerals and water, through a venous access device (VAD) directly into the intravascular fluid required for metabolic functioning of the body.

Components of TPN Calories –Carbohydrates g/day –Fat (emulsions)-10%, 20%, 30% (1 cal/ml) Soybean or safflower triglycerides with eggs as emulsifier. 2.5g/kg/day Administered slowly over hours Protein –Amino acids –Daily requirement g –1-1.5g/kg/day Trace elements Vitamins

Components of TPN Electrolytes –Na:1-2 mEq/kg –K: 1-2 mEq/Kg –Mg: 8-20mEq –Ca: 10-15mEq –Phosphate: 20-40mmol

CLINICAL INDICATIONS Paralytic Ileus Intestinal obstruction Acute pancreatitis Malabsorption/malnutrition Persistent vomiting/ Severe diarrhea Fistula Inflammatory bowel disease Severe anorexia nervosa

Methods of Delivery Peripheral Parenteral Nutrition (PPN) Lesser concentrated glucose solution with amino acids, vitamins, minerals & lipids given through a PERIPHERAL vein Total Parenteral Nutrition (TPN) Combines glucose (20-70%), amino acids, vitamins, & minerals via a CENTRAL line Lipids 10%-20% emulsion composed of triglycerides, egg phospholipids, glycerol, & water may be given intermittently or mixed with the TPN thru a central line

Nursing Management VS monitored every 4-8 hours or as per facility policy Strict I & O Ensure that the correct infusion rate is delivered. Blood levels of glucose, electrolytes, BUN, CBC & hepatic profile depending on patient status and protocol Blood glucose testing at bedside as per protocol/physician’s order Daily weights Monitor peripheral or central lines for signs & symptoms of infection. Aseptic dressings change as per facility protocol Patient education or significant others

Administration of Parenteral nutrition Ensure correct order from healthcare provider Remove TPN from refrigerator at least 1 hr before hanging Inspect fluid for presence of cracking or creaming Wash hands Use strict sterile technique, attach tubing with filter (0.22 micro Millipore for non fat emulsion solution & 1.2 micron with fat emulsion solutions) to PN bag and purge air Close all clamps on new tubing. Insert tubing into volume control infuser If VAD has a clamp at proximal end, clamp tubing. If no clamp is available on central VAD, instruct the patient to Valsalva manuever while new tubing is connected. Connect tube to hub of VAD

Administration of Parenteral nutrition Monitor administration hourly, assessing for the integrity of fluid, patient tolerance & complications. If new TPN solution is not available, hang D10W Document tubing change & fluid administration, observations, complications & any treatment given If to be discharged with TPN, teach patient & family regarding proper storage, handling and administration of TPN NOTE: TPN solution, Tubing & Filter are changed every 24 hours or as per hospital policy

Central Venous Access Devices Placement of flexible catheter into a client’s central veins most commonly SVC Purpose –Long term IV therapy –Long term antibiotic therapy –Blood/ blood product transfusions –Administration of total parenteral nutrition –Measure direct pressure readings (CVP) –Chemotherapy –Enhancing diagnostic agents

Central Venous Access Devices Peripherally inserted central catheters (PICC) Single or double lumen polymer about cm gauge Done under sterile conditions by physician or trained RN Local anesthetic is used Inserted above antecubital fossa- usually basilic (preferred) or cephalic veins with tip at distal 3rd of SVC Sterile dressings covers the site X-ray confirms placement of tip before line is used Used for long-term IV/ TPN therapy May remain in place 6-12 months PICC

Central Venous Access Devices Nontunneled percutaneous catheters Inserted to SVC or Jugular vein Short term use cm long dual or triple lumens Contraindications: ICP, respiratory conditions, spinal curvatures, trauma/surgery/radiation on neck & chest Tunneled Central catheters Frequent & long term therapy Dacron Cuff placed inside the subcutaneous tissue, granulation occurs anchoring the catheter and providing barrier to microrganisms

Tunneled Central catheters

Catheters cont’d Central venous pressure catheter (CVP) Same as PICC but done by physician only Subclavian, External jugular, femoral Double Lumen CVP Triple Lumen CVP

Catheters cont’d Implanted infusion ports Consists of a catheter placed into a desired vein and the other end connected to a port placed surgically in a subcutaneous pocket on a chest wall Port consists of metal sheath with self sealing silicone septum Accessed via the septum by Huber-point needle that is deflected to avoid coring of the septum

Implanted infusion ports

Nursing Responsibilities Maintenance of CV lines-observe for signs & symptoms of infection To change Central venous catheter as directed by MD/protocol: Obtain equipment Explain procedure to patient Place in patient comfortable supine with head turned away from site Wash hands Don gloves & carefully remove old dressing Inspect insertion site for complications

Nursing Responsibilities Clean insertion site with each alcohol swab at insertion site and moving outward in a circular pattern Repeat using povidone-iodine swab/Chlorhexidine Allow to dry Apply new transparent dressing Loop and tape tubing to the skin but do not tape over the dressing Document dressing change and observation of insertion site Teach patient/family instruction regarding sterile dressing change and report signs of infection, fluid extravasation & phlebitis and inform nursing personnel

Complications of TPN METABOLIC Fluid overload Hyperglycemia/hypoglycemia/ hyperosmolar states Biliary complications Hyperlipidemia Electrolyte & vitamin excesses or deficiencies INFECTIOUS Catheter sepsis-staph aureus & epidermis, fungus, gram + and/or gram- Mechanical Air embolus, hemothorax, pneumothorax, hydrothorax, chylothorax, thrombosis, phlebitis, dislodgement of tube, brachial plexus injury

Nursing Diagnosis Imbalanced nutrition: less than body requirements Risk for Infection Risk for Impaired skin integrity Risk for fluid volume overload