CNUR 305

IV catheter selection

**Best practice** Choose the smallest needle gauge for treatment (smaller gauge for larger veins = least trauma) •18, 20, 22 gauge generally used •The larger the gauge...the smaller the needle 18 g has stronger cathelon and is not as short- advance part blown part of vein with more ease because it is not as bendy

IV cannulation techniques

**Best practice** ONLY two attempts per nurse •Don PPE: clean gloves and goggles •Prepare equipment and apply tourniquet •Select vein •Swab skin vigorously for 30 sec with chlorhexidine in a crosshatch method and allow to dry •Insert: bevel up at 15 - 30° angle •IV Insertion Procedure •Immediately dispose of sharps •Dress with a semi-permeable, transparent dressing & label with date & initials

Nursing assessment and care of IV

**Best practice** Sites are only changed when needed - not as a routine practice •Daily reassessment of the need for IV therapy •Frequent assessment for complications (every 1-2 hours in hospital) •Patient comfort and ongoing education •Confirm correct infusion rate and solution •IV sites placed during less than ideal circumstances, i.e. trauma, must be re-sited within 48 hours Leave IV if it is working Can remove dressing very carefully without removing catheter Frequent assessment especially if something is running

Indications for CVADs

1.Central veins are larger and faster flowing 2.Allow for multiple or rapid infusions 3.Permit painless blood sampling (less peripheral veni-punctures) 4.Better suited for prolonged infusions or therapies 5.Appropriate for drugs or fluids that are irritants (has potential to cause chemical phlebitis if given peripherally). 6.Indicated for drugs that are vesicants (drugs that can cause blistering and tissue necrosis if it leaves the vein and enters the tissue). 7.Some can be used to monitor central venous pressure (CVP). This is the pressure in the right atrium to determine fluid volume (range 0-10 cm H20).

What is a CVAD?

1.An intravenous device inserted into the central venous circulation 2.Majority are inserted in the upper body, either directly or indirectly so that the catheter tip sits in the superior vena cava 3.If femoral vein is accessed, the tip sits in the inferior vena cava

Preventing central line associated infections

1.CLABSI is the most significant cause of healthcare-associated infections! 2.Strict ASEPSIS AT ALL TIMES! 3.Cleanse insertion site with ChlorAprep (adult patients) 4.Use proper flushing technique 5.Proper technique for dressing changes and adherence to time frames 6.Needleless adapters on ALL access ports 7.Avoid taking a BP or attempting venipuncture whenever possible on the arm that has a PICC line 8.Do not use CVAD until tip placement has been confirmed by physician post xray

Albumin

25% •Liver disease/peritonitis •Post-op liver resection •Lg. volume paracentesis 5% •Therapeutic plasma exchange •Thermal injury > 50% 100 mL of 25% albumin expands plasma volume by 450-500 mL •Does not require a filter •Tubing requires a venting system to decrease foaming and pressure in lines •Compatible with most isotonic solutions- usually ran with normal saline. •Can be delivered more rapidly than other products up to 5 mL per minute (5%) or 2 mL/min (25%) •Must be infused within 4 hours from time taken from lab. •Not given for volume resuscitation/ hypovolemia •Cerebral Ischemia •Dialysis patients •Patients who cannot tolerate lg. increases in circulating volume.

CVAD complication: Air embolus

Air enters the vasculature during: •Insertion •Tubing or adapter connection changes •Breech in the system •Accidental catheter removal •Breakage •Faulty catheter •Edema at catheter insertion site •Pain in arm or along vein •Erythema •Edema of arm, face, neck on same side as catheter •Tachycardia •Immediately clamp catheter •Cover catheter exit site •Assess vital signs & SaO2 •Administer oxygen prn •Position patient left side, head down •Notify health care provider •Continue to monitor patient

Flushing the CVAD line

Always begin with hand hygiene Flush before and after each use, *when assessing line Vigorous cleanse of needless adaptor - cleanse with alcohol Use a minimum of a 10 mL syringe Aspirate back until blood returned Use pulsatile push-pause technique (only use gently pressure with tunneled catheters) Instill at least 10 mL of normal saline Clamp lumen (if applicable) PICC line- •Every 7 days and after each access for meds (if no IV infusing) •Flush all lumens •10 mL sterile normal saline •20 mL normal saline after TPN, blood products or blood sampling Short term CVAD-•Every 24 hours and after each access for meds (if no IV infusing) •Flush all lumens •10 mL sterile normal saline •20 mL normal saline after TPN, blood products or blood sampling u

Nursing management after line insertion- CVAD

Assess and monitor site for bleeding Dressing secure and intact X-ray used to confirm placement prior to use Documentation: Type, size, location, placement confirmation If PICC, document length according to agency policy Progress notes has all the info

Tunnelled Intravascular Catheter (TIC)

Catheter "tunnels" from venous insertion site, through subcutaneous tissue, exits on chest wall Tip sits in superior vena cava Anchored by a dacron cuff Single or multi-lumen Long term access Common brands: Hickman, Groshong, Broviac catheters Placement confirmed by x-ray prior to use -radiopaque, made of silicone which is physiologically more compatible (less incidence of thrombosis or irritation to lining of vein) -has a cuff, usually made of Dacron. The purpose of the cuff is to encourage tissue growth within the tunnel. This growth usually occurs by 7-10 days. The tissue anchors the catheter in place and also acts to keep bacteria out of venous circulation

Hyper/hypoglycemia PN

Causes •Abrupt stoppage in infusion •Additional D5W infusion •Abnormal response to dextrose in PN solution Signs & Symptoms Hyper- excessive thirst & urination, blurred vision, headache, hunger, weakness, fatigue, confusion Hypo- Unsteady gait, headache, hunger, tremors, diaphoresis, cold, clammy skin, moody, slurred speech Nursing Management •Decrease infusion rate slowly •Ensure D5W is infusing if PN is decreased or stopped abruptly •Serial BGM •Notify physician if changes to rate/solution is required

PN infection/sepsis

Causes •Considered the # 1 complication •Due to direct intravenous access •Immuno-suppressed patient •Often due to hyperglycemia •Inadequate aseptic technique •Age >80 years Signs & Symptoms Local- Redness, tenderness, warmth, purulent drainage to insertion site Sepsis- tachycardia, hypotension, elevated/decreased temperature, decreased u/o, decreased LOC, labored breathing, chills, lethargy, increased WBCs. Nursing Management -Meticulous aseptic technique when changing/handling PN & patient -Frequent inspection of IV access -Use clear transparent dressing -Monitor vital signs and blood work per protocol -Abiding by nursing protocol in relation to dressing changes, technique and tubing replacement -Report signs and symptoms immediately Clear dressing so you can see it

CVAD- No Flashback When Aspirating or Fluid Wont Infuse

Check if any clamps are closed Assess insertion site - any kinks visible Repositioning arm. Try raising patient's arm above head Ask patient to cough, breathe deeply, take a deep breath & hold or perform the Valsalva maneuver Remove dressing to more closely examine catheter & site If multi-lumen, attempt to access other lumens Consider obtaining order for CathFlo- •CathFlo is an Alteplase fibrinolytic agent that can be instilled into a line that doesn't flush well or one where you can not get flash back •A physician's order is required •Infusions should be stopped during fibrinolytic dwell time (when possible) to optimize effects •Follow local agency specific policy/procedure May be asked to lock it with heparin

Chloride

Chloride : Range 98 - 106 mmol/L Helps maintain proper blood volume Helps maintain blood pressure Helps maintain fluid balance in and out of cells Hyperchloremia: Result of renal acidosis, respiratory alkalosis (due to CO2 levels), high Na levels, severe diarrhea Hyperchloremia treatment: Treat the underlying cause (too much saline then reduce or dehydration is treated with saline or correct Ph imbalance) Hypochloremia: Result of CHF, prolonged diarrhea and vomiting, metabolic acidosis Hypochloremia treatment: Treat the underlying cause (too much saline then reduce or dehydration is treated with saline or correct pH imbalance)

requirements prior to blood transfusion

Consent for transfusion •Informed consent is a standard blood safety requirement in Canada Should be obtained by treating primary health care provider •Must include: •Benefits versus risks •Description of blood component •Patients have the right to refuse- must be clearly documented Do not need consent- Dr. can order if pt is unconscious, and it is an emergency- trauma Jehovah's Witness, get consent within 24 hours of infusion •Verify presence of prescription from primary health care provider •Obtain history of transfusions/reactions •For patients at high risk of reaction, it may be necessary to administer pre-medications 30 minutes in advance •Ensure ABO & Rh typing; antibody screening (cross-match) •The presence of a Transfusion Report on the chart will confirm the patient's blood type •Call the transfusions lab to prepare the required blood product Dr makes order, unit clerk processes, sends it to lab, lab calls unit clerk and unit clerk lets us know to get it- service aids may be responsible for it •Ensure patent IV Access •IV access is required. Rapid infusions will require a larger IV gauge •Flush existing IV lines and resite if necessary •Ensure dedicated IV access •Vital signs •Must be taken and documented 30 min prior to transfusion Cannot run two products through the same lock- 18 gauge •Prime Blood Administration tubing- saline in adults but not with babies •Use strict aseptic technique when handling products and tubing •Use 0.9% sodium chloride to prime all tubing •Must use a blood filter (for most products) •Completely saturate the filter prior to infusion •Be prepared before the transfusion arrives on the unit: •Length of time that blood products can remain at room temperature before being initiated varies by agency policy, usually 30 minutes •The transfusions lab will notify the unit when the blood product is available for dispensing •Any individual "trained" to carry blood products can retrieve the transfusion •When the blood product arrives, inspect for the presence of leaks, clots, or unusual coloring •Patient Teaching •Inform when transfusion is beginning •Instruct patient to remain in his room •Explain procedure and expectations •Inform patient of potential side effects or adverse reactions •Instruct patient when to call for assistance •With second licensed nurse... AT THE BEDSIDE •Using the Transfusion Report, blood unit label, and Transfusion Record Tag: •Verify patient identification using 2 identifiers •Confirm blood product matches transfusion order and is compatible with the patient's blood type •Ensure that the #s on the blood unit label and the Transfusion Record tag match •Confirm blood component expiration date and time •Ensure that both nurses sign the tag; affix one copy to the chart

Creatinine

End product of muscle metabolism Filtered in the glomerulus Not reabsorbed in the tubules Male - 53-106 mcmol/L Female - 44-97 mcmol/L Elevated creatinine shows kidney damage while low shows possible overhydration. •High levels of creatinine usually mean low glomerular filtration rate. •Urine output- poor, urea and creatinine may be in range- out of range= kidney damage •Write out one liners, write assessment out before and then go in and check, and adjust •Distance running- increase muscles, Advil, rhabdo, dark urine

CVC (non-tunnelled)

Directly inserted in subclavian or internal jugular vein Tip sits in superior vena cava Single or multi-lumen Highest incidence of central line associated blood stream infection (CLABSI) Short term use Placement confirmed by x-ray prior to use unless it's femoral -Highest incidence of CLABSI (central line associated blood stream infections) -appropriate for rapid IV fluids, CVP measurement, vasoactive drugs, TPN

Components of Blood/blood products

Each donation of whole blood is separated into 4 components: •Red blood Cells •Plasma •Platelets •Cryoprecipitate What Lab values could indicate the need for each of these products: •Red blood Cells: HG/HCT vrs NA and Albulmin •Plasma: INR, PT aPTT •Platelets: Platelet needs such as bleeding or drugs (Low Molecular weight Heparin) •Albumin: Albimin lab: Not usual for volume replacement unless from nephrologist. Usual for Burns and liver disease. Dehydration and fluid overload affect hgb, hct- number of red blood cells, heparin rather than LMW heparin- stop for 15 min, drastic change in levels Platelets- septic shock- antibiotics and fluid Albumin- major puller, decrease diet and blood loss RBC: 4.2-5.4 x1012/L Female 4.7-6.1 x1012/L Male HgB: 120-160g/L Female 140-180g/L Male Platelets: 150 - 400 x 109/L PT: 11-12.5 seconds aPTT: 30-40 seconds PTT: 60-70 seconds Albumin: 35-50g/L

Urea

End-product of protein metabolism Filtered in the glomerulus Eliminated in the urine ↑ BUN ↓glomerular function Impacted by muscle mass Normal Urea - 3.6-7.1 mmol/L BUN to Creatinine Ratio: Normal BUN to Creatinine ratio: •10:1 to 15:1

Implanted port (IVAD)

Functions like long-term catheter but no external parts Catheter surgically tunnelled under skin to subclavian or jugular vein Tip sits in superior vena cava Distal catheter end attaches to port that is implanted under skin Placement confirmed by x-ray prior to use nurse must have written documentation from physician that the placement is confirmed and port can be accessed -accessed by a special non-coring needle through the skin into a self-sealing septum made of silicone -compatible with virtually all drugs and fluids -can be left in place for years -decreased infection risk because no external exit site where microorganisms can invade

Nursing care for central lines

If it's a PICC line, measure the line according to agency policy Avoid use of acetone and adhesive removers Keep sharp instruments away from the catheter RQHR: infusion pump is required unless continuously visualized Avoid taking a BP on the arm with a PICC- Unless unavoidable

Types of fluid resuscitation

Isotonic - same osmolality is the same on each side of the membrane so a balanced state is maintained between intracellular and extracellular compartments when using isotonic solutions, balance Hypotonic - lower concentration of particles in intracellular than extracellular spaces. Typically used for treatment of cellular dehydration but must be used with caution as overuse will cause the cells to burst, move fluid into cells not vascular space Hypertonic solutions contain higher concentration of particles than the ICF and ECF. This causes a shift of fluids from IC and EC spaces. Used in treatment of water intoxication (caused by over-administration of electrolyte free solution, over use of hypotonic solutions, increased ADH, or renal failure)., pull fluid into vascular space

Central line removal

Lines should be removed when: •No-longer needed or medically indicated (need should be assessed daily) •Patient is stable and does not require hemodynamic monitoring •Suspected or confirmed CLABSI •When unresolved complications exist get out as soon as you can

Treatment for fluid volume deficits

Main strategy is to identify and control source of fluid loss. Replace by oral, enteral, or IV dependent on the severity of the deficit and acuity of the patient. Treatment with isotonic solutions is key in management. Patient is getting better if: gaining weight or has stabilized,Urine output is increasing, I & O are balanced, Mucous membranes are moist, LOC intact, VS normal and Labs are normalizing: Crystalloids are predominately based on a solution of sterile water with added electrolytes to approximate the mineral content of human plasma (i.e. N/S, ringers lactate) Colloids are often based on crystalloid solutions, thus containing water and electrolytes, but have the added component of a colloidal substance that does not freely diffuse across a semipermeable membrane. (i.e. pentastarch, dextran, albumin, etc.)For albumin the colloid is albumin No clear consensus if colloids vs crystalloids is better for volume resuscitation.

PN vs Enteral feeding

PN- •Only used if contraindications to enteral feeding exist. •Administered through a vascular access device •Less risk of aspiration, diarrhea and gastric reflux •Less risk of incorrect tube placement •More expensive •Requires strict aseptic technique when handling EF- •Preferred route of nutrition administration when possible •Administered directly into GI tract •Less expensive •Less serious complications •Maintains/protects mucosal structures and functions of the GI tract •Decreases activation of inflammatory process in GI tract. •Commonly interrupted or stopped •Often will not receive total prescribed amount •HOB needs to be elevated > 30 degrees at all times Commonly interrupted or stopped due to diagnostic procedures, hemodialysis, NPO status, surgery, PT/OT, therefore will often not received the total amount of solution that is ordered. Additional reasons for not receiving the whole amount include GI intolerance, excessive gastric residuals (greater than 200ml on two separate occasions- Aspen (2016), plugged feeding tubes (especially the smaller bore tubes), continuous flushes required, slow advancement of infusion rates, dilution of enteral formulas that is no longer best practice, however still performed. Both can be administered at home

Assessment of the line- CVAD

Proper hand hygiene prior to line access/handling Assess every time line is accessed Minimum of Q shift and PRN Assess around site for warmth, tenderness, discomfort, redness, edema and drainage Assess non-sutured, securement device

Magnesium

Range 0.74 - 1.07 mmol/L Ensures sodium and potassium transportation across cell membranes Crucial to many biochemical reactions Role in nerve cell conduction Hypermagnesemia: Usually only occurs with increased magnesium (intake of milk of magnesia or Maalox) uptake and renal failure In pregnant ladies one of the treatments for eclampsia is magnesium Can cause hypotension, flushing of face, urine retention, nausea, poor reflexes, and coma) Hypermagnesemia treatment: Avoiding ingestion of items with increased magnesium (intake of milk of magnesia or Maalox, green vegetables, oranges, chocolate) IV calcium gluconate If kidneys are okay then IV fluids to encourage diuresis Hypomagnesemia Causes are limited intake or increased gastro intestinal or renal losses Can be a cause of prolonged use of TPN Resembles hypocalcemia resulting in Chvosteks(twitching facial muscles can be identified by tapping the skin over a facial muscle) and Trousseau's sign(carpal spasm identified with blood pressure cuff inflation), deep tendon reflex losses, dysrhythmias (torsades), associated with digitalis toxicity, vertigo and seizures Hypomagnesemia treatment: Increased dietary intake IV magnesium

Phosphate

Range 0.97 - 1.45 mmol/L Essential component of bones and teeth Vital to normal neuromuscular function Required for energy in production of A T P Contributes to protein, fat, and carbohydrate metabolism Assists in maintenance of acid-base balance Hyperphosphatemia: Common with acute or chronic renal failure Other causes: Chemotherapy, large intake of milk or other phosphate containing foods, and large intake of vitamin D Can cause calcium deposits into soft tissue instead of bone, tetany, neuromuscular irritability Hyperphosphatemia treatment: Restrict foods etc. with high phosporour content Adequate hydration Can cause calcium deposits into soft tissue instead of bone, tetany, neuromuscular irritability Hypophosphatemia: Seen in malnourished patients, alcohol withdrawal, phosphate binding antacids, during parental nutrition. Poor energy levels (reduction in ATP Can cause arrythmias and muscle weakness Hypophosphatemia Treatment: IV/oral admin of sodium or potassium phosphate

Sodium

Range 135 -145 mmol/L Responsible for water balance Required for normal transmission of impulses across muscle and nerve cells through sodium-potassium pump mechanism Role in maintaining acid-base balance Changes in sodium levels alter water balance Can increase acidity Hypernatremia: Water loss (dehydration)or sodium gain (hypertonic saline administration, adrenal tumor causing increased aldosterone) Primary prevention is thirst First indicator is urine output- damage, increased urea and creatinine Can lead to seizures or coma Hypernatremia Treatment: IV fluids (iso tonic) Treat the underlying cause (DKA) Hyponatremia: Water excess (dilutional hyponatremia) or losses of Na containing fluids (too much NS) Usual issue is dilutional hyponatremia Can lead to seizures and coma Hyponatremia Treatment: Fluid Restriction If the risk is severe then hypertonic solutions are used (3% Sodium Chloride Intravascular- in pipes, pull more water in if too much sodium= dehydration Surgery- NS contributed to high levels of sodium, resistance to push against I/O, foleys Too quick of an overcorrection can result in seizures, coma, and death (etc.). Therefore, only extreme measures are corrected quickly if the risk of seizures, coma, and death (etc.) are present.

Calcium

Range 2.25 - 2.75 mmol/L Maintain strong bones Required for muscle and nerve transmissions Hypercalcemia: Usually from overactice parathyroid glands, cancer, ingestion of too much vitamin D or calcium supplements Cause excess thirst and diuresis, nausea, and vomiting, and constipation, confuision and lethargy, cardiac arrythmia, palpitations, and fainting Hypercalcemia treatment: decreased dietary intake, medications (Calcitonin) bisphosphonates (IV osteoporosis drugs), prednisone (for high levels of vit D), IV fluids and diuretics. Hypocalcemia: Injured parathyroid glands, auto immune dysfunction, inadequate Vit D, Magnesium depletion Resulting in Chvosteks (twitching facial muscles can be identified by tapping the skin over a facial muscle) and Trousseau's sign(carpal spasm identified with blood pressure cuff inflation), Seizures, cardiac arrythmias (prolonged QT interval), confusion, and psychosis Hypercalcemia treatment: Iv calcium gluconate for acute needs Vitamin D treatment for control in days to weeks

Potassium

Range 3.5 - 5 mmol/L** Required for nerve function and muscle contraction Required for normal transmission of impulses across muscle and nerve cells through sodium-potassium pump mechanism Role in maintaining acid-base balance Hyperkalemia: Common cause is renal failure. Other massive cell destruction , rapid infusion of aged blood, and in patients with severe infections, medications (ACE and aldosterone) metabolic acidosis Cardiac conduction issues (peaked T waves, leading to heart block through PR enlongation), cramping legs Hyperkalemia Treatment: •Eliminating oral and parental potassium intake •Increasing the elimination of potassium through diuretics (Lasix), dialysis, Kayexalate (sodium polystyrene sulphonate)-binds to potassium- poop out •Forcing potassium from ECF to ICF through IV insulin or sodium bicarb to correct acidosis •Calcium gluconate or chloride can treat the membrane effects reversing the effects of cell excitability (stabilize cardiac rhythms)- not first line IV insulin works faster- temporarily move and buy time, peak 30-1 hr of SQ- IV needs it faster- into ICF- then give gluconate- chloride- lose arm, life over limb, then diuretics Do not want heart problems Acidosis hurts the kidney 5.6-6.0 and symptomatic Hypokalemia: Common in losses via kidneys (diuresis or GI tract (diarrhea and vomiting) Shifts from ECF to ICF (See hypernatremia treatment) Rarely due to deficiency in diet Magnesium depletion can cause potassium lows due to the renin-angiotensinigen pathway with the release of aldosterone (spirolactone medication has this affect) Cardiac arrythmias (Peaked P waves, flattened T waves, and U waves become present Mediations such as digoxin Untreated hypokalemia causes diuresis and the inability to concentrate urine Hypokalemia treatment: Oral and IV potassium Severity determines monitoring needs as well as if they are symptomatic

Refeeding syndrome

Rapid feeds following a prolonged period of malnutrition, •Dramatic shift in electrolytes (decreased PO4, Mg, K) •Begins 24-48h following start of feed/infusion •Shifting of H20, glucose and electrolytes resp distress, weakness, cardiac failure, rhabdomyolysis, coma, seizures, •PREVENTION is key! •Slowly titrate PN infusion to goal rate •Titration should take about 4-7 days •Closely monitor electrolytes, weigh, vital signs •Strict Is & Os •Correct any electrolyte abnormalities

Types of parenteral nutrition

TPN- •Requires a central venous access device for administration •Less risk of thrombophlebitis & vessel damage. •Dextrose content >10% (usually 20-50%) •Protein content > 5% •Allows for higher infusion rates, PICC, needs to be easier on the veins, loose the line- not necessarily okay to hook it up to peripherally- can call Dr. or pharmacy Peripheral PN- •Must have specially-designed solution •Dextrose content 10% or less •Protein content < 5% •Only for short term •Patient does not require high protein/calorie •Unable to establish central venous access •Medication label will state peripheral administration, switch solution to be on food, can add more nutrients

Dressing and adapter change CVAD

Use Transparent, semi-permeable dressing Change Gauze dressings q48h & PRN using strict aseptic technique Change Non-Gauze dressings q7days & PRN using strict aseptic technique Needleless adaptors- change **Q 7 days & PRN Changing- 1.Begin with hand hygiene and don appropriate PPE - including mask) 2.Prepare new needleless adapter by priming with NS 3.Vigorously cleanse the adapter connection for 15 seconds 4.Allow to dry; remove & discard 5.Attach new pre-flushed adapter with 10 mL normal saline syringe in place 6.Release clamp (if appropriate) and aspirate slowly for blood until flashback 7.Flush with10 mL NS using push/pause technique 8.Remove syringe and reconnect infusion or clamp (if applicable) 9.Document Dressing- 1.Hand hygiene and don appropriate PPE (including mask) 2.Remove old dressing, inspect area 3.Remove gloves & repeat hand hygiene 4.Establish sterile field, don sterile gloves 5.Cleanse skin using ChloraPrep (2% Chlorhexidine with 70% alcohol) 6.Cleanse using a crosshatch (back and forth) motion with friction in two different directions for total of 30 sec 7.Cleanse length of exposed catheter 8.Let it air dry (never fan or blow to speed-up drying time) 9.Apply new transparent semi-permeable dressing 10.Document

Indications for IV therapy

Why do patients require IV therapy? •Maintain and restore fluid balance •Maintain and restore electrolyte balance •Maintain and restore acid-base balance •Restore intravascular volume •Provide vascular access for administration of medications •Provide nutrition Typically, patients who require IV therapy for more than 6 days may need a CVAD.

vascular access for hemodialysis

uTemporary double lumen CVC for immediate dialysis therapy uReplaced with tunnelled catheter (as pictured) if long term dialysis required uUsed as a bridge for long term therapy while patient awaits placement of arteriovenous fistula or graft best practice guidelines recommend that non-dialysis nurses do not draw blood from these lines, do not administer medications into these lines or flush these lines. In RQHR, the nurses on the units do not change these dressings either. Line care & management is done by specially trained hemodialysis nurses. Hard to miss- very large Right outside of the neck, or femoral area, looks like it is wrapped in gauge

Principles of PN administration

«Always review nursing procedures/agency policy prior to administration «PN must infuse through a pump «PN infusions interrupted > 4 hours must be discarded «Physician's orders should include a total fluid intake (TFI) «Amino acid/dextrose solutions are ALWAYS administered with filtered tubing «Strict aseptic technique must be used when handling solution and priming tubing «Baseline lab work and patient's weight are required prior to initiating PN «PN requirements are reassessed daily Not done by gravity New bag- pharmacy needs to make a new one, typically are not made for the same day Can be adjusted everyday

Nursing management prior to administering PN

«Establish if PN solution is run centrally or peripherally «Ensure patency of line «Remove amino acid/dextrose solution from refrigerator at least 1 hour prior to infusion «2 RNs/LPNs must verify and sign for solution on MAR in accordance with the RQHR High Alert Medications - Independent Double Check Procedure: «Ensure PN label matches PN prescription. «Check expiration date of PN solution «Inspect solutions «Observe solution for cloudiness, particles, leaks or cracks «Prime tubing «Calculate and monitor the TFI «Apply the10 Rights of Medication Administration If label doesn't match - send it back TFI- total fluid intake- calculations for fluid Treat like medication

Stopping/changing PN

«PN infusion should never be interrupted abruptly «Physician's orders are required to make changes to the PN solution/rate «PN tubing & solution should be changed every 24 hours (lipids q12h!) «Aseptic technique is imperative «Administer D5W if PN is interrupted Change tube every few (4) days to prevent infection •Changing tubing/solution per agency protocol using strict aseptic technique •Documentation •Discard used supplies appropriately •Follow up with blood work and blood glucose

Administration of PN

«PN infusions should be gradually increased «NEVER adjust rate without reviewing procedure AND primary health care provider's orders «D5W solution is infused until PN at infusion goal or if PN is stopped «Blood work must be drawn per PN protocol/physician's orders «Use STRICT aseptic technique when attaching tubing to vascular access device: •Don clean gloves •Scrub connections with 70% alcohol for at least 15 seconds «Ensure serial assessments of: «blood glucose levels «vascular access sites «Lab work «patient weights «vital signs (QID) «Detailed physical assessments «Strict intake and output «Ensure additional IV access for medications «Documentation TPN- check sugar qshift, TPN can cause higher blood sugars on patients that are not diabetic Cannot run certain things together in certain lumen Additional access- do not want to stop TPN that many times

Transfusion reactions

•Acute Hemolytic Transfusion Reaction •Febrile Reaction •Most common reaction •Allergic Reactions (minor and major) •Anaphylaxis is rare •Hypotension •Transfusion-associated circulatory overload (TACO)- too much fluid •Transfusion-related acute lung injury (TRALI) •Bacteremia and sepsis babies- give lasix in the middle main categories: allergic, febrile, and hemolytic Plus Taco: Allergic: •Mild: facial flushing, hive, rash •Severe: anxiety, wheezing, dyspnea, hypotension • Febrile: Fever, chills, anxiety, headache, tachycardia, tachypnea Temperature (< 39), or mild reaction (IE: facial flushing, hives, rash, itching) - with direction from primary health care provider- can medicate in between and cautiously restart transfusion within the 4 hour window Hemolytic: Low back pain, apprehension, chest pain, hemoglobinuria, hypotension, tachypnea TACO: most common cause of death STOP as soon as any reaction happens •STOP THE INFUSION and disconnect blood tubing •Maintain IV access using a new primary IV set •Obtain a set of vital signs •Verify patient identification and blood product label •Notify primary health care provider •Remain with patient •Administer medications/treatment as prescribed by PHCP •Immediately document reaction and report event to the hospital's transfusion services

Acute vs chronic GI bleeds

•Acute: sudden onset and/or hypovolemia •Chronic GI Bleeds have many presentations from the more obvious: present as reoccurring episodes of melena or hematochezia or occult blood. To the less obvious: have no signs or symptoms, present with anemia, fatigue, dyspnea, syncope, low RBC and Hg, iron deficiency etc., over months

Clinical indications for chest tubes

•Air or fluid accumulating in the lungs can be from external (penetrating or blunt trauma) or internal reasons (bleb rupture, baro trauma, biopsy, inflammatory exudate) •These injuries can result in pneumothorax and/or hemopneumothorax (although they usually occur together). •Due to opposite pressures in the thorax (negative pressure to allow expansion) and lungs (want to collapse naturally) the lungs are assisted to stay expanded by negative pressures surrounding the lung and internal positive pressures. •Loss of pressures whether caused by external or internal injury results in the accumulation of air or fluid inside the lung (pneumothorax, hemopneumothorax, pleural effusions, and exudate from inflammatory conditions).

Osmolality

•Amount of concentration of solute in body water •Reflects hydration •Used as approximation of extracellular fluid status •Normal range: •Serum: 280-300 mOsm/kg •Urine: 100-1300mmol/KG •Sodium is main contributor in serum •Urea is main component in urine •Indicator of renal function •When the renal function is normal the serum and urine osmolarity go the same direction (one rises and the other rises). If there is impairment then then the urine osmolarity can become more concentrated (higher) than the blood). •Anuria is less than 100ml/day •Oliguira is less than 500ml in 24 hours so if someone is in this face this is an expected amount of urine and we are hoping to improve it or maybe the damage is already done and we are happy with the little amount of urine we have!

Indicators for PN

•Any contraindication to enteral feeding •Severe diarrhea and vomiting •Complicated abdominal surgeries or trauma •GI disease: •Obstruction •Fistulas •Ischemia •Paralytic ileus •Severe malabsorption •Short bowel syndrome •Required rest to GI tract •NPO > 7 days •Infants with immature GI tracts •Severe anorexia •Chemotherapy •Hypermetabolic states •Burns, sepsis, trauma

Nursing Assessments for trachs

•Assess respiratory system every shift & PRN: •Airway Patency •Respiratory Rate •Accessory Muscle Use •Oxygen Saturation •Oxygen Requirements •Auscultation of Lungs •Colour •Level of Consciousness Breathing through neck Bag over stoma of trach •Assess tracheostomy insertion site including: •Bleeding, drainage, infection, edema, redness, pain • •Assess tracheostomy secretions for: •Quantity, consistency, color, & odor Assess like a wound Yellow secretions- infection Normal secretions- clear/white, not super thick

Vein selection for cannulation

•Begin distally •Non-dominant hand •Patient preference •Vein characteristics •Easily Palpable •Straight •Soft •Spongy •Large in size IVDU may not have good veins- ask where they think we should put it AVOID-•Any extremity with an AV fistula graft •Any extremity affected by a CVA •Any extremity affected by a mastectomy •Vein characteristics •Burns, ulcers, rashes or open areas •Joints •Inner aspect of wrist •Veins that are too small for good flow •Below an existing phlebitis •Avoid the lower extremities unless absolutely necessary, inner wrist- emergency, painful

Complications of airway management

•Bleeding •Arterial erosion •Tube dislodgement •Obstruction •Aspiration •Tracheal stenosis •Laryngeal nerve damage •Swallowing dysfunction •Pneumothorax •Air embolism •Weak voice

Red Blood Cells

•Bleeding or anemia •Patients with S & S of impaired tissue oxygen delivery - Tachycardia - Shortness of Breath - Dizziness •Must be filtered with at least a 170 micron sized filter •Must be compatible with type of RBC and Rh factor •Must be infused within 4 hours from the time blood is removed from lab. •Not given solely for volume replacement •Not given solely based on hemoglobin/hematocrit without addressing other physiological or surgical factors

IV complications

•Bruising and pain •Piercing the back wall •Missing the vein •Rolling veins •Valves •Erythema (redness), pain, burning, warmth, and edema • Phlebitis Intervention: •remove IV, cold compress, NSAIDs • •Methods to prevent: •Avoid cannulation in veins in the feet (increases the frequency of phlebitis and infection) •Do not replace IV catheters more frequently than every 72 - 96 hours (duration of catheterization increases the risk) •Use the smallest gauge catheter possible - risk of phlebitis is increased when a large-gauge catheter is used. •Certain medications increase the risk (i.e. KCl, phenytoin) Extravasation: The damage cause by the efflux of solutions from a vessel into surrounding tissue spaces during IV infusion. Can extend to involve nerves, tendons, joints and can continue for months after the initial injury. If treatment is delayed, surgical debridement, skin grafting, and even amputation may be the consequences. Etiology: dorsum of hand/feet; antecubital fossa and near joints or joint spaces; where there is little soft tissue protection for underlying structures; limbs with local vascular problems such as lymphedema may have poor venous flow causing pooling; antineoplastic agents Mechanical: during initial catheter insertion or while the catheter is in place, i.e. patient activity Physiologic: preexisting or emerging vein problems, i.e. PVD, diabetes as well has history of venipuncture and multiple IV insertions Pharmacologic: cytotoxic chemo or non-cytotoxic drugs such as calcium chloride, amphotericin B, acyclovir, digoxin, etc. Most occur at night and often go unnoticed Presentation: pain, erythema, swelling, tenderness...which progresses to blanching, blistering, and skin discoloration (mottling/darkening of the skin; ulceration usually 1 - 2 weeks later). Treatment: •STOP the infusion •Notify the physician who can attempt to aspirate the IV cannula and in some cases, the surrounding tissue •Discontinue the IV •Drug antidotes may be injected into the surrounding tissue by the physician •Elevate the affected limb in order to aid in reabsorption of the infiltrate •Ice packs may provide pain relief •Hot packs increase local vasodilation, diluting the extravasated drug •NOTE: There is no standardized treatment in the acute stage Prevention: • Select veins carefully prior to cannulation •Flush with steile NS to ensure patency •Be attentive to occlusion alarms •Secure catheter properly and assess site q1-2h • Special attention to high risk patients and those receiving IV medications • Select veins in the non -dominant limb to prevent movement related dislodgement •Advocate for CVAD placement for highly irritating, hyperosmolar or vesicant drugs Usually people tell you that it hurts- may flush with NS, may tough it out, always listen to what the patient says What will this look like on assessment? Erythema Pus (late sign) Warmth Induration Pain Venous thrombosis Systemic Infection: fever, malaise, tachycardia, nausea, vomiting, chills Intervention: Discontinue the IV, cold pack (never heat) Treat according to symptoms, i.e. blood cultures may be required if fever present, obtain CBC, treat fever with acetaminophen, antibiotics maybe started Prevention: •Ensure strict aseptic technique during insertion •Avoid insertion in lower extremities •Change emergency IV lines within 48 hours •Ensure dressing is secure •Patient and staff hand washing •Cleanse ports for 15 seconds prior to access

PN ADLs

•Can be provided at home •Can have very negative impact on quality of life both in and out of hospital •Financial implications •Can perpetuate feelings of embarrassment, isolation, or depression •Negative implications on mobility/mobilization

4 main types of CVADs

•Central venous catheters (CVC) or non-tunnelled catheters •Tunnelled intravascular catheters (TIC) •Peripherally inserted central catheters (PICC) •Implanted ports

Fluid leaking at the catheter site- CVAD

•Check if any clamps are closed •Assess patient - ? any signs of distress •Remove dressing to better observe catheter & site •Notify health care provider •Obtain order for x-ray to check catheter placement

Tubing disconnected from catheter

•Clamp catheter closest to patient, if available •Apply sterile syringe to catheter hub to close the system •Assess & monitor patient - ?any signs of distress •If IV infusing, prime all new tubing - DO NOT reconnect contaminated tubing •Continue to monitor patient for any distress

plasma

•Coagulopathies r/t liver disease •Deficiency of coagulation factors •Massive transfusions requirements •Reverses effect of warfarin •Sepsis (with DIC) •Treatment of TTP •Must be filtered with at least a 170 micron sized filter •Dosage based on body weight •Must be compatible with ABO typing- but do not need to be identical. •Requires thawing prior to administration •Rh factor is irrelevant •Can be delivered more rapidly than other products •Not given for volume replacement solely •Not given for a singular deficiencies of coagulation factors •Not given when other (better) treatment options are available

Platelets

•Control of Bleeding •Prevention of bleeding •Thrombocytopenia •Platelet dysfunction from: - Congenital issue - Medications - Following cardio- pulmonary bypass •Must be filtered with at least a 170 micron sized filter •New filter required after each transfusion •Must be compatible with ABO typing- but do not need to be identical. •Rh factor is irrelevant •Not usually effective in patients with diseases of rapid platelet destruction, unless experiencing life-threatening blood loss.

Nursing management PN don'ts

•DO NOT initiate PN until placement of central line access has been confirmed •DO NOT use line designated for PN for anything else •DO NOT let PN hang for > 24 hours (12 hours for lipids!) •DO NOT add ANYTHING to the PN solution •DO NOT increase the rate if infusion is behind •DO NOT infuse solution formulated for central lines in peripheral lines for ANY length of time •DO NOT leave solution out of fridge for > 60 minutes prior to infusion Cannot just crank up fluid

Treatment of pneumo/hemothorax

•Depends on the severity and the cause. •If the patient is stable with minimal air accumulation then no treatment may be needed as it will be left to resolve spontaneously or possible use of a small bore needle with syringe for drainage or placement of a Heimlich valve. •Larger air/fluid accumulations with a pnuemo or hemo thorax usually results in a chest tube connected to a water seal drainage system. •Emergency management usually results in a large bore needle placed in the anterior midclavicular line in the second intercostal space.

Requirements after a blood transfusion

•Discontinue the infusion •Flush line with normal saline until clear •Document completion of transfusion •Continue to monitor patient for 6 hours following transfusion. •Provide written notification to patient regarding transfusion Page that says you received blood during this stay- goes home and needs to sign the paper- with discharge paper

Nursing interventions with a trach

•Ensure pt. is receiving air/oxygen humidified with sterile water •Provide oral care**: •Brush teeth q shift •Swab oral cavity Q2-4h and PRN •Ensure oral mucosa is moist at all times •Perform trach care Q12h and PRN Oral care- be very thorough Trach care- remove ties, cannula, wash •When airway protective reflexes are absent & GI tract intact, enteral nutrition is preferred •Small bore nasogastric feeding tube (i.e. Dobhoff) •PEG or PEJ tubes • •Patients can eat with a tracheostomy when: •Speech Language Pathologist (SLP) has assessed no swallowing dysfunctions •Usually demonstrated by a fluoroscopic video swallowing assessment (VSA) •Swallowing may feel different, SLP works with patient to teach & monitor •Enteral route preferred over IV route •Medications are administered via enteral feeding tube •Collaborate with pharmacy to determine if the patient's medications are available in a liquid form •Remember that some medications are not supplied in a liquid form and also cannot be crushed. Therefore, work with pharmacy and the physician to find alternatives •Liquid medications have a high osmolarity, which can predispose the patient to diarrhea •Must ensure that there are no interactions between the enteral feeding formula and each drug •i.e. must hold tube feeding for 2 hours before and after administering medications such as warfarin, levothyroxine •List available in the RQHR enteral feeding procedure Crush meds- work with pharmacy and physician to find solutions, some may be dissolved, ensure you have all meds and plan what you are doing with each med Time consuming

Fenestrated trach tube

•Fenestrations permit air flow •Allows patient to breath through upper airway and to speak •Improves effectiveness of cough •Cuffed or uncuffed •Long term use

Fluid balance

•Fluid and electrolyte balance: NA, Albumin big fluid drivers but you need to account for blood loss therefore you need HCT and HG. Also you need to account for anemia (generaly RBC feature counts or iron etc.) in blood loss and how fast it occurs. cup theory, These are rules of thumb to help you visualize dehydration, anemia, and blood loss IV fluid- get right into intravascular space Anemic- not enough protein in the diet

Trach safety checklist

•Functional suction equipment & catheters •Functional oxygen equipment •Ambu bag •Identical size & type of patient's trach tube •Identical tube type but one size smaller •Extra disposable inner cannula (if applicable) Have a trach one side smaller- if it comes out, hole closes a little- fast Takes a week to heal completely Always check suction- turn down Able to adjust oxygen Ambu bag- different size masks, remove mask so mask is not put on mouth

Fluid Imbalance

•Incorrect infusion rate •Positive fluid balance •Not adhering to TFI •Common in elderly patients and children •Underlying health conditions (i.e. HF) Signs of fluid excess: increased BP, bounding pulse, JVD, crackles to lung fields, hypoxia, hypoxemia •Establish TFI (per orders) •Ensure correct infusion rate •Monitor Is & Os •Monitor weights/vital signs •Resp & cardio assessments •Encourage ambulation, DB & C exercises •Provide 02 prn •Raise HOB •Administer ordered diuretics

Complications of PN

•Infection/Sepsis •Refeeding syndrome •Hyper/hypoglycemia •Fluid Imbalance •Electrolyte/metabolic imbalance •Extravasation of PN solution •Hepatic Dysfunction •Venous thrombosis •Pneumothorax Hepatic dysfunction- long term use, skin may be yellow or green

Collaborative care for GI bleeds

•Initial and ongoing patient assessment •Oxygen, fluid resuscitation with crystalloid solutions, and then anticipate transfusion of blood (slower than crystalloid reaction but still important) •Medications: Ranitidine IV is common •Identify cause of bleeding, symptoms through endoscopy •Correct underlying problem: Medications, endoscopic intervention, angiotherapy, surgery. Blood takes longer to thaw, match, transfuse, NS usually Antibiotics- may be prophylactically

Requirements during a blood transfusion

•Initiate infusion •Begin infusion rate of RBCs/Platelets/Plasma at 50 mL/hr for first 15 minutes •Reassess patient 15 minutes after blood enters the vein •Rationale? •Increase infusion to prescribed rate or over a maximum of 4 hours •Times for reassessing patient vary per health region •Document entire procedure timely and accurately Pick up any adverse reactions, so blood is not running super fast Reactions when blood reaches patient blood= reaction quickly

PICC

•Inserted peripherally via cephalic or basilic arm vein, usually above the antecubital fossa •Tip sits in superior vena cava •Single or multi-lumen •Long term use •Placement confirmed by x-ray prior to use Multi lumen are more convenient- ICU or really sick, do not have to worry about medication interaction Single lumen may have extra ports attached Label each port- be aware of what is going on in each port Lumen marked "power injectable" Can withstand high pressure that regular PICC lines cannot Permits injection of contrast dye via power infuser or blood through blood transfuser Passive valve system - no clamps required Placement confirmed by x-ray prior to use Purple colour Also used for: Blood draws Blood products IV infusions/IV meds

Types of pneumothorax

•Is the accumulation of air that if unresolved can lead to the collapse of the lung. •Closed pneumothorax has not external wound and the most common is spontaneous pneumothorax (rupture of small blebs for unknown reasons). Men who are tall and skinny are more likely to develop this type of pneumothorax. •Open Pneumothorax is when air enters through an external wound. It is covered with a non-porous dressing taped on all side but one to allow the air to escape but not re enter the chest from the external wound. •Is the accumulation of air that if unresolved can lead to the collapse of the lung. •Closed pneumothorax has not external wound and the most common is spontaneous pneumothorax (rupture of small blebs for unknown reasons). Men who are tall and skinny are more likely to develop this type of pneumothorax. •Open Pneumothorax is when air enters through an external wound. It is covered with a non-porous dressing taped on all side but one to allow the air to escape but not re enter the chest from the external wound. If you close the wound entirely you could create a tension pneumothorax. •A tension pnuemothorax is caused by high tensions inside the pleural cavity that results in cardiac output compromise because of decreased venous return. In the late stages you will also see tracheal deviation with the mediastinal shift.

CVAD complications: hemo/pneumothorax

•Lung or blood vessel punctured during insertion •Perforated catheter= solution into chest area •Chest pain radiating to back •Dyspnea •Cyanosis, hypoxia •↓ chest wall movement •↓ or absent breath sounds on affected lung field •Assess vital signs & SaO2 •Stop IV fluid if infusing •Start oxygen therapy •Notify health care provider •May need to prepare for chest tube insertion •Continue to monitor patient

Upper GI bleeds

•More than 90% of Upper GI Bleeds are caused by peptic ulcers. Other causes include erosive gastritis, Mallory-Weis tears (tear of lining wear esophagus meats stomach), or esophagogastric varices •Symptoms range from syncope, angina, dyspepsia to increased weakness and fatigue. Alcoholism Dyspepsia can mimick a heart attack, reflux can happen varices- balloon down throat to stomach and is blown up to put pressure on the bleed, lots of blood, painful- no time to stabilize, nacrotics decrease BP •Most common cause is peptic ulcer disease from NSAID use and infection H. Pylori. •Incidence is decreasing due to better prophylaxis treatment and declining H. Pylori infection. •Other risk factors include family Hx, smoking, antiplatelet use •Pain is the most common symptom for peptic ulcers usually located in the epigastric area. •Duodenal ulcer location: Pain is usually reduced by eating which closes the pyloric sphincter) but reoccurs in 2-3 hours. •Diagnosis usually discovered from history and confirmed with fiber-optic scope. Usually follow up includes diagnostics for infection from H. Pylori •Drugs as treatment can include Antibiotics for the infection (H. Pylori), Proton Pump Inhibitors (reduce acid) also H2agonists (ex Ranitidine, famotidine, cimetidine) and antacids (Tums). •Crystalloid infusions and then blood transfusions for large amount of bleeding. Surgery only for severe bleeding or perforation. •Other treatments: Eliminating foods that cause distress (limited evidence for eating spicy foods).

Lower GI bleed

•Most common presenting symptom in LOWER GI bleeds is Hematochezia which an occur anywhere in the GI tract •Blood in the stool •The most common cases resolve spontaneously however, 5-50% of patients will require surgery. Diverticular Bleeding with rupture: •Bleeding or inflammation of outpouching in descending colon wall. •Surgically treated or angiogram (to give vasopressin) • Inflammatory Bowel Disease: •Ulcerative colitis in mucosa and submucosa, or Crohns' disease (extends to serosa). •Managed with corticosteroid and amino-salicylate medication, surgery • •Neoplasms, polyps: Bleeding massive or slow, surgical removal indicated Lyes and nutreints are decreased, polyps are banded, biopsy Continuous bleeding is bad, decrease hgb- fatigue, headache, cauterized AVM: •Bleeding often slow, hidden, associated with cardiac, low flow states aging •Treatment usually embolization or vasopressin • Ischemic bowel disease: •Blood circulation to bowel is blocked. •Treatment: restore blood supply to ischemic area, fluid resuscitation, ↑ cardiac output, antibiotics, surgery to prevent death.

Electrolyte/metabolic imbalance

•Not adhering to electrolyte blood work protocol •Renal dysfunction that leads to varying responses to PN solution. Potassium- arrhythmias, irritability, anxiety, fatigue, cramping, nausea, leg cramps, weakness Calcium- fatigue, depression, anxiety, numbness, tingling, seizures, hyperactive reflexes, ECG changes, lethargy, weakness, depressed memory, nausea & vomiting, coma, dysrhythmias •Verify baseline electrolyte levels •Adhere to PN protocol for drawing electrolytes •Monitor Is & Os •Serial BGM •Ensure accurate PN rate of infusion •Monitor for signs of electrolyte imbalances •Carefully correct electrolyte imbalances

preparation for IV therapy

•Obtain an order from the primary care provider •Administration set/ Infusion pump •Patient teaching •Patient positioning & preparation •Adequate room/lighting •PPE •Intravenous catheters, chlorhexidine and alcohol swabs, transparent semi-permeable dressing, tourniquet, and tape best practice Chlorhexidine for skin prep Alcohol swabs inanimate objects IV meds- assumed that they need an IV- they never will write "insert IV"

Single Lumen Trach tube

•Only an outer cannula •Outer cannula has 15 mm universal adapter •Can be cuffed or uncuffed •Lumen of outer cannula cannot be cleaned •Used for patients with long or thick necks

Bedside monitoring of respiratory function and devices-Assessment of pulmonary gas exchange

•Physical Assessment (Auscultation etc.) •History •Pulmonary function tests •Estimation of intrapulmonary shunt •Arterial Blood Gases •Pulse Oximetry •End-tidal C O 2 •Arterial Line

small bore chest tubes

•Pigtail catheters (curly ends) or strait smaller catheters are less traumatic but can become frequently plugged or kinked (therefore, not good with hemothorax issues The "Heimlich chest drain valve is a specially designed flutter valve that is used in place of a chest drainage unit for small, uncomplicated pneumothorax with little or no drainage and no need for suction. The valve allows for escape of air but prevents the re-entry of air into the pleural space"

CVAD complication: Localized infection

•Poor or inconsistent asepsis •Wet or soiled dressings left on catheter site •Immuno-suppression •Redness, warmth, tenderness, swelling at catheter insertion site •Possible purulent drainage •Redness, tenderness, swelling in tissues surrounding catheter site •Fever, chills Assess and monitor patient -Remove dressing and obtain a C & S swab -Apply new dressing (aseptically!) -Notify health care provider -May obtain order for antibiotics -Continue to monitor for worsening of infection (indicators of sepsis!) emphasize that central venous access devices are the most significant cause of health care associated infections and blood stream infections. Cannot stress enough the importance of strict vigilant asepsis for all aspects of central venous catheter care and equipment NOTE: patients may develop inflammation and redness following insertion of PICCs. This is due to trauma and can be treated with NSAIDs and heat. It is transient and doesn't indicate phlebitis or infection. May need order for swab

Weaning and Decannulation

•Process managed by physician & RT with close nursing assessment & monitoring •Often starts with "down-sizing" the trach tube, so more respiratory effort gradually done by the mouth & nose •Capping Trials •Once trach tube removed, stoma covered with occlusive dressing •Will continue to drain for several days •Usually heals closed in a week Capping trials- 1-2 hours, gradually increase and make them breathe on their own

CVAD complications: sepsis

•Progression of localized catheter site infection •Poor or inconsistent asepsis •Frequent access (long term use) •Concurrent infection •Fever/chills •Increased WBCs •Malaise, N & V possible •↑ heart and respiratory rates •Changes in mental status •May or may not see signs of infection at catheter site •Assess vital signs & SaO2 •Activate sepsis protocol •Notify health care provider •Obtain orders for blood cultures (central & peripheral sites) •Initiate antibiotics as ordered •Closely monitor patient - watch for progression to septic shock Best to run an infusion of IV fluid at TKO in order to minimize line access in patients requiring frequent IV medications. Antibiotics ASAP Do blood culture first- catch the infection Get off the line, call the lab

Nursing assessment for chest tubes

•Q: What should you do if the chest tube becomes dislodged from the patient? •A: Use a non-porous dressing (orange waterproof tape) taped on three sides to the external wound on the patients chest. •Q: What should you do if the chest tube becomes dislodged from the chest tube drainage system? •A: If you are unable to reconnect it then you would place the end in a cup of sterile water. Keep all tubing loosely coiled below chest level. Tubing should drop straight from bed or chair to drainage unit. Do not let it be compressed. 2. Keep all connections between chest tubes, drainage tubing, and drainage collector tight, and tape at connections. 3. Observe for air fluctuations (tidalling) and bubbling in the water-seal chamber. • If no tidalling is observed (rising with inspiration and falling with expiration in the spontaneously breathing patient), the drainage system is blocked, the lungs are re-expanded, or the system is attached to suction. • If bubbling increases, there may be an air leak in the drainage system or a leak from the patient (bronchopleural leak). 4. If the chest tube is connected to suction, disconnect from wall suction to check for tidalling. 5. Suspect a system leak when bubbling is continuous. • To determine the source of the air leak, momentarily clamp the tubing successively from the chest tube insertion site to the drainage set, observing for the bubbling to cease. When bubbling ceases, the leak is above the clamp. • Retape tubing connections. • If leak continues, notify physician. It may be necessary to replace the drainage apparatus or to secure the chest tube with an air-occlusive dressing. 6. High fluid levels in the water seal indicate residual negative pressure. • The chest system may need to be vented by using the high negativity release valve available on the drainage system to release residual pressure from the system. • Do not lower water-seal column when wall suction is not operating or when patient is on gravity drainage. DO NOT MILK THE TUBE TO GET RID OF CLOT, make sure it is bubbling, 60 second check- ensure everything is connected and look at the dressing, do not clamp the tube unless ordered- testing to see if the patient can tolerate it without the tube, or stop drainage from happening too fast, check with doctor about dressing change Palpate for crepitus, emphysema- feels like rice krispies

Trach care documentation

•Respiratory status •Amount, consistency, color and odor of secretions •Stoma and skin condition •Complications and nursing action taken •Patient tolerance of procedure

safety procedures for chest tubes

•Respiratory status •colour, respiratory rate, depth, rhythm, use of accessory muscles, 02 saturation •Assess Pain •Assess for manifestations of ↓ or absent breath sounds, significant bleeding (>100 mL/hr), chest drainage site infection (drainage, erythema, fever, ↑ white blood cell count), or poor wound healing, and subcutaneous emphysema at chest tube site. •Encourage mobility, db & c, and incentive spirometry. •Ensure connections are secured (taped) •Dressing •Palpate around the site for crepitus (subcutaneous emphysema) •dry and intact •Observe for Signs of infection •Drainage •Ensure tube patency •Monitor the Amount of drainage with every patient encounter and at the end of each shift and prn •Functional suction equipment (if required) • •Functional oxygen equipment • •Ambu-bag (if not in the room you must have one easy to acquire and use)

IV principles

•Selection of the appropriate vascular access device (VAD) is a multidisciplinary process that should involve the client •Always considered the prescribed therapy, duration of treatment, vascular condition, age, history when selecting the appropriate VAD •Patients who require IV therapy more than 6 days should be considered for a central venous access device •Do not use peripheral IVs for continuous vesicant therapy, TPN, or high osmolarity solutions - unless an emergency

Acute upper GI bleeds: non-ulcer aetiologies

•Several major sources are stress, gastritis, varices, and Mallory-Weis tears •Stress ulcers: deep lesions treated with H2 receptor blockers and PPI's •Acute Erosive or Hemorrhagic Gastritis (common with alcoholics, NSAID use, H. Pylori,, acute stress) : Inflammation of gastric mucosa usually treated with H2 receptor blockers and PPI's or surgery if severe bleeding occurs. Alcoholics Rip esophagus off of stomach Stress- meditation, massive implications Esophageal and Gastric Varices: •Upper GI bleeding associated with cirrhosis, portal hypertension. •Bleeding from Esophagogastric varices is usually large and acute. •Cirrhossis is usually a result of alcohol abuse. Fatty liver- diet, alcohol Albumin- late stage renal crisis ordered by specialist • Mallory-Weis Tears: •Small laceration at the gatroesouphageal junction. •Cause thought to be forceful vomiting in 30% of cases •A history of alcohol abuse makes these patiensHigh risk. •Diagnosis usually through endoscopy as well as treatment with thermocoagulation. May need to cauterize with scope •Arteriovenous Malformation: • •Small blood vessel that has a tendency to bleed. •Cause unknown •Reoccurring bleeding is normal. • Most commonly diagnosed with a endoscopy and treatment is for the underlying causes and possible sclerotherapy. Weakening in blood vesslel, brown outpouch, can rupture, in had stomach, vessles, very dangerous, a lot of blood is moving through Frank Not bright red on lower GI bleed- bile has mixed, unless it went through extrememly fast or superficial Look at whole picture- labs and VS

Clinical manifestations of pneumonia/hemothorax

•Small pnuemo/hemothorax may result in mild tachycardia, dyspnea, and mild chest discomfort (may be the only manifestations). •Large pnuemo/hemothorax may result in shock , dyspnea, respiratory distress, and death if not resolved which usually involves the insertion of a chest tube. Can auscultate- hear nothing- emergency

Suctioning a trach

•Sterile procedure •80-120 mmHg •Suction only on removal •Each suction <10 seconds •Appropriate size catheter •Pre-oxygenate for 1 min prn •Allow 3-4 breaths or rest between suction passes •Assess need for pre-oxygenation •NEVER instill saline or water before suctioning •Max suction passes/treatment = 4 Suction on way out Pt cannot breathe while your suction May cough or gag Pt's understand its going to happen- scary- its not normal Pt specific- listen for report If they need oxygen and you did not give time- sats drop, decreased oxygen, increased anxiety

Trach care

•Sterile procedure •Perform Q12H & PRN •Stoma must be kept clean & free of crusting •No petroleum products or powders near stoma •Only use pre-cut gauze or dressing •RQHR utilizes antimicrobial gauze dressings •Changing trach ties ALWAYS requires 2 people Do it twice Two people- prevent it from being dislodged

Common indications for blood transfusion

•Surgical blood loss •Trauma/injury •Anemia •Gastro-intestinal bleeding •Cancer •Organ dysfunction •Infections •Bleeding disorders

PN teaching

•Teach patient the need for PN, risks, benefits and complications •Management of PN (especially at home) will include an interdisciplinary approach to optimize therapy and minimize/eliminate complications •Cultural considerations- what happens during periods of fasting? •Clarify issues and concerns •Advantages and burdens of PN •Complications & risks must be discussed with patient & family members •Ethical decisions home care, follow up

Parenteral Nutrition

•The administration of nutrients through a vascular access device. •Indicated as a substitute for oral/enteral feedings •A sterile, chemical, hypertonic solution •An intricate combination of protein, carbohydrates, fat, minerals, and electrolytes •Individualized •Can be a short or long term therapy Used in the setting of GI dysfunction or patient's who are severely catabolic PN should be reserved and initiated only after the first 7 days of hospitalization when enteral nutrition is not available Patient's unique requirements- based greatly on patient's weight, ideal body weight, current blood work, liver function, kidney function, degree of stress and fluid requirements

Chest tubes

•The purpose of chest tubes and pleural drainage is to remove air and fluid from the plural space to restore normal pressures and allow the lung to re-expand. •The chest tubes locations change depending what the reason for the tube is meant to do: I.Placed higher if removing air (anterior over second intercostal space) II.Placed lower if removing blood (posteriorly by the eight or ninth intercostal space) Pleural space is full of air and fluid, puts pressure on lung and lung can collapse Trauma- creates hole, specific procedure Surgery Infection Blebs- smoke, hereditary, pocket of air or fluid that ruptures and distributes fluid into space •The removal of air and fluid from the plural space can be done actively (with suction) or passively (without suction). •It may be short term for aspiration of fluid and/or air or longer term for the treatment of a pneumothorax or hemopneumothorax.Actively- tube and chamber with suction ordered by Dr. Or has a little tube, where air can go out but not back in

methods of vein dilation

•Tourniquet •Gravity •Gentle tapping •Encourage the patient to clench and unclench the fist •Application of warmth for 10-15 min •BP cuff (up to 30 mmHg) Alcohol swab to area, push pressure to swab, blanche the skin, see shadow

oxygenation and humidification with trachs

•Trach mask or "collar" •Can be attached to humidification with 35-50% oxygen (8-12L) -sometimes called a "cold pot" •Nebulized medications can also be delivered by trach nebulizer mask Beneficial- secretions, keep secretions moist and moving to suction them out, NEB over trach mask/ cradle

Airway management

•Tracheotomy = surgical incision into trachea for the purpose of establishing an airway •Tracheostomy = the resulting stoma or opening •Tracheostomy Tube = tube inserted into the tracheostomy to maintain patency of airway Cuff can be inflated- balloon completely occludes the trachea, prevent aspiration, positive pressure ventilation- better seal Inner cannula can come out to clean May be permanent or just for acute illness Flange right against pt skin May have option for syringe to inflate if needed Cannula- plastic or metal, disposable, temperature sensitive Trachs may be cuffed or uncured

What is parenteral?

•Usually 2 separate solutions administered concurrently - must be administered with an infusion pump •Lipid emulsions •Fat content •A prepared solution •White, milky in color •Amino Acid/dextrose solution •Includes minerals, electrolytes, vitamins, dextrose; provides macronutrients for energy •Usually clear yellow in color •Contents can be adjusted daily •Medications may be added •Insulin, heparin, etc.

CVAD complication: Thrombosis

•Vein irritation - long term use •Irritating solutions/medsAltered hematopoietic status of patientPre-existing limb edemaSluggish flow of IV fluids •Edema at catheter insertion site •Pain in arm or along vein •Erythema •Edema of arm, face, neck on same side as catheter •Tachycardia •Notify health care provider •Obtain order for diagnostic to verify thrombosis •Assess & monitor patient •Warm compresses locally •Possible thrombolytic drug infusion (specially certified practitioner Diagnosis is CT Be aware of signs and symptoms, let them make the decision Chart

IV pt teaching and documentation

•What do patient's need to know? •Documentation •Date/time of IV insertion •Size of catheter •Site •# attempts •Type/rate of infusion - if applicable •Patient's response to therapy •Teaching •Signature When to call for help-phebilits, thrombus, embolus, pain, redness, burning, swelling Show them that you are taking the needle out- just left a little piece of plastic Pump rings off- ring call bell Default to nurses notes- may document on IV flow sheet

Fluid balance assessment

•What will assist with fluid balance assessment? •History- •Disease •Recent surgery •Medications •Dietary Restrictions- vegan- low protein •Intake and Output• Vital Signs-•Temperature •Respirations •Blood pressure •Pulse Vital Signs - elevated temperature can cause increased loss of fluid through diaphoresis, increased metabolism, and lungs (d/t tachypnea) - tachycardia can be associated with decreased intravascular volume, hypo magnesium, and hypokalemia. Bradycardia can be related to increased level of these electrolytes. Additionally, electrolyte imbalances can cause cardiac dysrhythmias - respirations - potassium and magnesium imbalances can cause respiratory muscle weakness. Severe acid based balances can affect breathing patterns (think back to CNUR 204). PND can indicate pulmonary edema (common in heart failure). - arterial blood pressure and pulse will give valuable information about fluid volume status. Orthostatic BPs are commonly used to determine dehydration, blood loss, and effects of anti-hypertensives. Orthostatic hypotension is defined as drop of 20mmHg or increase of more than 20 bpm Last BM!! PRN meds •Physical Assessment Laboratory Data Meds, warm and sugar water= bacteria (lungs) •Palpation •Cap refill •Accumulation of fluid •Inspection •weight- 1 L- 1 lb •Auscultation •Heart- s3-s4 if fluid overload, hypovolemia- hypotension and tachycardia, friction rub= pericardial effusion •Lungs- pulmonary edema, crackles •Percussion- ascites •Urine •Volume •Concentration •Laboratory