Tubes, Drains, & Lines

A.D.C V.A.N D.I.M.A.L.S

*Admission*: (ex. Admit 57 yo M to Dr. Smith's service) a) Inpatient b) Outpatient c) Observation *Diagnosis:* (ex: diverticulitis, cholelithiasis, appendicitis) a) Medical condition b) NOT surgical procedure *Condition:* Stable, fair, guarded, intubated

VITALS / SPECIAL PARAMETERS

*Vitals:* • Most common (MC): *q 4hrs* • Stable outpatient: q8hrs or q shift Special Parameters: NOTIFY PROVIDER IF--- 1. *Temperature > 101.5 F / 38.5 C* 2. *Urine output < 30 cc/hr* 3. *No urine output in 8 hrs* 4. *SBP >160 mmHg* 5. *Glucose < 60, > 300* 6. *HR < 50 BPM, > 110 BPM*

JACKSON PRATT & HEMOVAC DRAINS

- Surgeon Preference: all areas of surgery - *Placed during procedure & secured w/ Nylon suture (Roman-sandal-tie)* TO REMOVE: 1. *If output < 30 cc of serosanguinous fluid over preceding 24 hrs* 2. Explain the procedure & IT WILL BE PAINFUL! Premedicate if absolutely necessary. 3. Ligate the suture holding drain in place. 4. Open bulb/grenade of JP or suction on hemovac. (take bulb off suction) 5. Pull w/ steady movement & discard. 6. Place dry gauze dressing over opening & secure with tape.

Bariatric Surgery Diets

1. *Bariatric I* - Consists of sugar free fluids, jello, popsicle, broth, water decaf tea, no juice, soda 2. *Bariatric II* - Easily digested, semi-liquid foods in small amts, protein shakes b/w meals 3. *Bariatric III* - Soft or pureed foods, high protein drinks b/w meals 4. *Bariatric IV* - Soft foods (cooked veggies) & soft/ground meats, protein shakes b/w meals

G-TUBE/J-TUBE

Indications: • *Enteral feeding - J Tube* (placed w a catheter) • *Stomach decompression - G Tube* (can also be placed in jejunum) Placement: • Operating Room • Interventional radiology Feeding: • *Start at 10 cc/hr then titrate up by 10 cc to desired rate (40-70cc/hr)* Residual: • Normal < 200 cc (should have less than 200 in the stomach) • If > 200 cc, hold feeding x 2 hrs then recheck, if < 150 cc restart TF (may have to decrease rate if residual going up)

Allergies

Most hospitals have a pharmacist collecting home meds & asking about allergies. - Direct admissions require admitting provider to review meds. NKDA (No Known Drug Allergies) Must list SPECIFIC drug name/class of drugs & SPECIFIC reaction. Not a true allergy: *GI upset, dizziness, headache, tingling, leg edema, constipation, "makes me feel weird."* Significant reactions: *tongue edema, hives, throat closing, facial edema.*

Chemical Pleurodesis

MC Indication: *Malignant/Non-malignant pleural effusion* (rare: pneumothorax) Type of agent: *TPA/Bleomycin* (Talc: most effective) Instillation: 1. Turn Chest Tube off to suction 2. Instill 60 cc of agent for ~5 min (slower = less pain/discomfort) 3. Close CT to drainage or clamp with *Kelly clamp* 4. Instruct nursing staff to unclamp/open CT to drainage in 6 hrs (4hrs) 5. Chest X-Ray ordered 8-12hrs after instillation. Multiple instillations needed for proper trmt - up to 3X Bleomycin - very painful, only need for 4 hours

Post-op special diets

1. *Clear liquids* - Liquids that are clear/transparent in composition. (water, ginger ale, broth, cranberry) 2. *Full liquids* - Food that is liquid at body temperature. (jello, tea, coffee, orange juice) 3. *Thickened liquids* - Nectar/ Honey thickened any type of liquids (Indication: dysphagia) 4. *Low Residue* - Food that contain only moderate amts of fiber (Indication: diet after GI surgery) 5. *Mechanical soft* - Foods of soft composition (Indication: dysphagia, difficulty chewing) 6. *No salt* - *4 g* sodium restriction 7. *Low sodium* - 2 g sodium restriction (Indication: edema, CHF, renal disease, cirrhosis w/ ascites) 8. *Renal* - *50 g protein, 2 g potassium, 2 g sodium* (Indication: renal disease/failure, dialysis) 9. *Cardiac* - Food w/ *low sodium, low cholesterol, low saturated & total fat* (MI, cardiac hx) 10. *Consistent Carbohydrate* - Foods that provide a consistent amt of carbs based on caloric level to allow for optimal glucose control (Indication: DM) 11. *Gluten free* - Foods not processed with gluten (Indication: celiac sprue) 12. Regular - Foods without specific modifications 13. *TPN* - Transparental nutrition, IV admin, written q day (Indication: malnourished pts)

Labs/Special Tests

1. CBC, BMP (CMP), Mg, Phos in am 6/17 2. ECG & AP/Lateral Chest X-Ray for pre-op clearance 3. CT abdomen & pelvis w/ PO contrast for abdominal pain 4. Gallbladder US for RUQ pain 5. Right LE Venous Doppler for LE pain - R/O DVT 6. X-Ray of Pelvis in PACU s/p right total hip replacement 7. MRI of thoracic spine s/p fall

G-J TUBE MAINTENANCE

1. Clogged: instill warm water into tube using a 60cc syringe. Don't force instillation. Let it sit for 5-20 min & then draw back fluid. • Try *pancreolipase w/ Viokace or Clog Zapper tablets* crushed & instilled. 2. "My tube fell out": skin prep, new tube, sterile gloves, suture to secure. • *2-3 weeks for tract to form* • Replace tube w/ foley for G-tube (in the mean time before surgical replacement) • Avoid replacement if J-tube. NEVER inflate balloon (balloon will cause obstruction in jejunum) • If resistance, don't force, may need surgical or IR to replace. • Confirm with *gastrografin X-Ray* before using

Managing Chest Tube Air Leaks

1. Dressing around the chest tube needs to be airtight. 2. Check all tube connections. 3. Intermittent bubbling in the water-seal chamber with respiration is normal. 4. *Continuous bubbling in the water-seal chamber indicates a large leak.* 5. *Excessive movement many cause leaking.*

What should you do if the chest tube falls out?

1. May transport pt off the unit: place to water seal. 2. If chest tube falls out, as quickly as possible place a Vaseline gauze & dry sterile dressing & tegaderm over insertion site. 3. Place pt in 45 degree sitting position. 4. Immediately call thoracic MD or APP covering/on call. 5. Closely monitor vitals & tension pneumothorax symptoms.

Nursing

1. Titrate to keep *O2 sats > 92%* 2. *Sequential Compression Stockings* (SCD's) to bilateral LE while in bed, TED stockings 3. *Incentive Spirometry (Inspirex)* 10X/hr while awake 4. NGT to low wall suction (LWS) 5. Foley to gravity, Strict I & O's, Strain all urine (w/ nephrolithiasis) Irrigate foley q1hr PRN if blood clots 6. *Wet to Dry dressing change 2X daily* 7. Elevate right LE 8. *Posterior Hip* (reclining, crossing legs) / *Anterior Hip precautions* (getting out of bed)

*Water Seal*

Disconnecting chest tube reservoir apparatus from wall suction x 4 hrs when the following criteria is meet: 1. *Resolution of pneumothorax* 2. *Pleural drainage evacuated over 24 hrs < 100cc* 3. *Absence of air leak on Valsalva maneuver or forceful cough* Restart wall suction immediately if not tolerating water seal.

PICC Complications

INFECTION: • Insertion site is red, swollen, with ecchymosis, warm to touch Tx: • Peripheral blood cultures x 2; remove & send tip of catheter for culture, start IV abx BROKEN TIP: • Upon removal, a portion of line is missing. Vascular/IR nightmare!! (check for integrity of line!!) CLOTTED OFF: • *Instill TPA into each lumen*, RN draw/flush q 1hr (let it sit for 1 hour) • Change PICC if not working after 2 attempts.

Nasogastric Tube

Indication: 1. Excessive vomiting 2. Ileus or mechanical bowel obstruction 3. Prevent gastric aspiration 4. Feeding 5. Medication administration Contraindications: 1. Facial/nasal fractures/deformities 2. Known strictures (narrowing) &/or esophageal perforation 3. Hx of gastric bypass surgery 4. Comatose state with unprotected airway

NG Tube Trail Clamping

Indication: • Resolved vomiting • Flatus • Bowel movement • < 150 cc daily output Order: • Clamp NGT x 4 hrs • Unclamp x 1 hr • Is residual < 200 cc x 2 trials • If yes, REMOVE! • If no, revaluate in 24 hrs.

Chest Tube Maintenance

Indication: *Pneumothorax, Pleural Effusion* (most common in surgery setting) Placement: In the OR & IR (interventional radiology) 99% of the time

Chest Tube Removal

Indication: *Resolution of pneumothorax, decreased pleural effusion/drainage.* Process: Before starting prep dressing (Tegaderm, 4x4 gauze, Vaseline gauze) 1. Position pt: sitting up at 45 degrees & slightly angled towards non-effected side 2. If there is a suture, cut suture securing chest tube. 3. If pigtail CT, must cut internal suture holding pigtail rigid. 4. Ask pt to exhale. 5. Remove tube with one steady movement. 6. Immediately place prepped dressing over insertion site. 7. Listen to lung sounds.

Foley catheter

Indications: 1. Accurate output 2. *Lasix treatment* 3. Strict bedrest 4. *Pelvic/femur fracture* 5. Large surgeries 6. Anticipated prolong bedrest. Intra-op: Placed for procedure & removed at the end. Size: • SIZE MATTERS! • *MC standard catheter 16F* (comes in the kit) - range from 12 to 26 French • *MC 3-way CBI (continuous bladder irrigation) 22F, 24F* - range from 16 to 28 • *MC coude (enlarged prostate) 16F* - slightly angled or curved tip on a catheter. Used by men to void w/ enlarged prostate Balloons range from 5mL to 50mL

Nasogastric Tube Placement

Supplies: 16Fr Tube, Lube, Chucks sheet, cup with water & straw 1. Ask pt about deviated septum or nasal surgery, previous hx of NGT. 2. Explain the procedure: instructions for certain ques during placement (RN very helpful) 3. Measure NGT - average pt 50-60 cm distance into stomach. 4. Lubricate & place into the nare, watch for coiling, WATCH FOR PROJECTILE VOMITING! 5. If choking or difficulty breathing, STOP IMMEDIATELY & REMOVE TUBE! 6. Check placement by: seeing bile in the tube, instill gas into stomach OR instill air into stomach & listen with stethoscope. Then place to LWS. 7. Confirm placement with CXR. May need adjustment if poor placement.

PICC line (peripherally inserted central catheter)

Types: Single, *Double, Triple* (MC b/c want several diff lumens in case 1 gets cut off - usually double if pt in house) Indication: 1. Prolonged infusion of IV medication 2. total parenteral nutrition (TPN) - triple is preferred (cannot put meds & TPN in same one) Placement: Interventional Radiology Dressing: • Antimicrobial patch, adhesive device, & transparent dressing Duration: As short as clinically possible, change every 5-7 days if prolonged insertion Risk: • Bleeding, nerve injury (brachial plexus), irregular heartbeat (if advanced too far), blood clot, infection

Risk of Venous Thrombosis w/ a PICC Line

VENOUS THROMBIS: • Risk: *cancer, older, ICU pt, obese, larger PICC size, femoral/jugular vein site* • UE edema, pain to touch, paresthesia, erythema. Tx: • Venous Doppler of UE, start Heparin (other anticoagulation agents) gtts. • Only remove PICC if no improvement of symptoms.

IV FLUIDS:

a) *LR @ 125 cc/hr* b) *NS @ 75 cc/hr* c) *D5 ½NS @ 80 cc/hr*

ACTIVITY

a) AD LIB (as desired), As tolerated b) OOB TO CHAIR c) AMBULATE d) (Strict) BEDREST e) WEIGHT-BEARING • FULL • PARTIAL or 50% • TOE TOUCH or 25%

Continuing Home Medications Post-Op

a) Cardiac - Beta Blockers, ACE's, CCB's, etc. b) Pulmonary/Respiratory - Xopenex, Albuterol, Atrovent c) Thyroid - Levothyroxine d) Psych - Anxiolytics, Depression, Schizophrenia, etc. STOP: 1. Vitamins/Supplements 2. Cholesterol meds 3. Diabetic meds PO/SQ

Diet

a) NPO except for meds, Sips of Clears, Clear liquids, Full liquids, Regular b) Consistent Carbohydrate 75 grams (diabetic) c) Low sodium, Low fat, low potassium d) Nectar thickened liquids (swallowing issues i.e. Stroke, MG)

Medications for Post-Op

a) PO/IV Meds for MILD, MODERATE, SEVERE, BREAKTHROUGH ANTIEMETICS: a) *Zofran* 4 mg IV q4hrs, *Reglan* 10mg q6hrs b) *Phenergan* 25 mg IV q6hrs ANTIBIOTICS: Post-op prophylaxis DVT PROPHYLAXIS: *Heparin, Lovenox, Eliquis* INSOMNIA: *Benadryl, Ambien*

Hypospadias

• Congenital condition • Urethra is located on the underside of the penis. Management: 1. 14F standard foley 2. Coude catheter (start with smaller size) If all else fails, bedside dilation/cystoscopy.

Female Catheter Placement

• If accidentally catheter vagina must use new kit & start over • ALL HANDS-ON DECK! Morbidly obese pts will require retraction assistance from 2 other people. • NEVER INFLATE THE BALLOON UNTIL YOU SEE LIQUID GOLD! • On the surgical floor at bedside, may need to place the bed in Trendelenburg position (head down) for better visualization. • When attempt has failed, call someone for advice or assistance.

Urethral Stenosis Stricture

• MC in males discovered at placement of catheter, rare in females. Causes: 1. Injury during infant circumcision. (23% occurrence after birth) 2. Inflammation or injury when penis rub against diaper after circumcision. 3. Long-term use of foley catheters as adults. Management: Bedside dilation &/or cystoscopy.

Advanced Foley Management

• NEVER remove foley after urological procedure unless specifically instructed by attending. • Manual foley irrigation with sterile water for large clot evacuation. • Bleeding at the meatus or around the foley—WATCH & PRAY! • Traumatic removal: should be replaced to tamponade any bleeding. • Keep catheter in for the least amount of time. D/C POD #1 or 2. • Irritation at urethral meatus—Apply Lidocaine jelly!

Male Catheter Placement

• URO TIP: inject urethra with lubricant. • HUB the catheter even if you see LIQUID GOLD! • When inflating balloon & there is resistance STOP IMMEDIATELY! Insert catheter further. • Gently pull catheter back out until balloon catches the internal meatus.