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Therapeutic II > Exam 1 - TPN, Specimen Collection, Central Lines > Flashcards

Exam 1 - TPN, Specimen Collection, Central Lines Flashcards

1
Q

reasons a pt would need TPN (11)

A
  • can’t ingest, absorb, or digest via GI tract
  • severe malnourishment
  • negative nitrogen balance
  • impaired GI tract
  • acute pancreatitis
  • Gi bleeding
  • exacerbations of Crohn’s Disease
  • severe burns or trauma
  • sever liver or renal disease
  • radiation enteritis
  • terminal illness
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2
Q

examples of impaired GI tract

A
  • ileus
  • surgery
  • fistulas
  • short “gut” bowel syndrome
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3
Q

what makes up the components of TPN nutrition

A
  • amino acids
  • glucose
  • fat emulsion (lipids/intralipids)
  • vitamins
  • electrolytes
  • minerals
  • trace elements
  • water
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4
Q

what is the normal glucose concentration in TPN for adults

A

10%

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5
Q

with more serious conditions and depending on what the patient can tolerate what is the alternate concentration of glucose in TPN

A

15-25%

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6
Q

what two ways can lipids be included with TPN

A

combined or infused separately

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7
Q

if the glucose concentration of TPN is greater than 10% how should the TPN be administered

A

via central or PICC line

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8
Q

TPN infusions are administered via

A

dedicated port or central line

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9
Q

how is TPN mix created

A

customized by the pharmacy using aseptic technique

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10
Q

for how long is TPN usually infused over

A

24 hours, but can also be cyclic

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11
Q

how often are the lipids and tubing for TPN changed

A

every 24 hours

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12
Q

are medications able to be added to TPN infusion bags by the nurse

A

NEVER

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13
Q

are TPN and lipid infusions a closed or open system

A

closed

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14
Q

can anything be piggybacked or infused into the TPN IV tubing

A

no

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15
Q

what must be done with TPN until 30 min prior to be infused

A

it must be kept refrigerated

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16
Q

what should be infused should the TPN be unavailable for any reason and why

A

IV solution of 10% dextrose and water to prevent rebound hypoglycemia

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17
Q

what is D10W

A

10% dextrose and water

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18
Q

what kind of filter is needed with TPN infusions

A

0.22 micron filter

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19
Q

how are lipids infused and do they need to be refrigerated

A

separate from TPN via peripheral IV catheter and does not require refrigeration

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20
Q

what should be monitored with TPN infusions

A
  • blood glucose
  • assess site for infection
  • signs and symptoms of infection/sepsis
  • signs of hyperglycemia
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21
Q

if blood glucose becomes too high while receiving TPN what should be administered

A

insulin

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22
Q

the no-no’s regarding TPN infusion

A
  • do not store at room temp
  • do not add any medications to TPN bag
  • do not give an secondary medications through the TPN
  • do not give any other medications in the same central catheter lumen as TPN solution
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23
Q

what should the TPN bag be examined for before administering

A

turbidity, precipitation, cloudiness, any cracks or holes

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24
Q

should the TPN bag not be administered if there is any cloudiness, turbidity, precipitation or any holes or cracks

A

do not use it

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25
Q

what should the RN check on the pharmacy label and prescriber order for TPN

A
  • pt name
  • medical record # or birthdate
  • solution contents (every line)
  • expiration date and time
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26
Q

what should be done prior to hanging TPN bag

A

check label and sign off on TPN order

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27
Q

the date and time should be put on what when doing TPN solutions

A

the solution ad the tubing

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28
Q

what type of tubing should be used for TPN

A

needleless tubing

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29
Q

where should the primed and needleless tubing for TPN be connected to

A

patient’s IV catheter

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30
Q

how often should TPN infusion rate be checked

A

every hour

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31
Q

what complications should be monitored when infusing TPN

A
  • fluid volume excess
  • hyperglycemia
  • hypoglycemia
  • osmotic diuresis and fluid volume deficit
  • electrolyte imbalances
  • signs of infection
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32
Q

what should the central and peripheral IV be assessed for during TPN

A

infection, phlebitis, pain, and purulent drainage

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33
Q

what is number one priority for pt with central lines and receiving TPN

A

preventing infection

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34
Q

potential nursing diagnoses for TPN (7)

A
  • risk for infection
  • risk for hypoglycemia (less than 60 mg/dl)
  • risk for hyperglycemia (more than 200 mg/dl)
  • risk for fluid volume overload
  • risk for fluid volume deficit
  • risk for electrolyte imbalance
  • risk for hypertriglyceridemia
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35
Q

causes of hyperglycemia when administering TPN

A
  • too rapid infusion
  • infection/sepsis
  • medication induced
  • co-existing diabetes mellitus
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36
Q

what do you give for hyperglycemia during TPN

A

insulin

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37
Q

what do you give for hypoglycemia during TPN

A

D10W or 50% dextrose solution if perscribed

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38
Q

what can cause hypoglycemia during TPN

A
  • abrupt decrease in TPN infusion rate

- abrupt discontinuation of TPN

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39
Q

signs and symptoms of fluid overload during TPN

A

tachycardia, hypotension, distended neck veins, weight gain, lung crackles

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40
Q

treatment for risk of fluid overload during TPN

A

maintain strict I and O’s and daily weight

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41
Q

signs and symptoms of fluid volume deficit during TPN

A

decreased urine output, patient thirsty, decreased skin turgor, tachycardia, orthostatic hypotension

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42
Q

treatment for risk of fluid deficit during TPN

A

I’s and O’s and daily weight

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43
Q

signs and symptoms of electrolyte imbalance during TPN

A

muscle weakness, lethargy, cramps, muscle twitching, cardiac rhythm changes

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44
Q

treatment for risk of electrolyte imbalance during TPN

A

monitor serum electrolyte levels and report abnormal levels to provider

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45
Q

treatment for hypertriglyceridemia during TPN

A

infuse lipids as ordered, obtain weekly serum triglyceride levels, use caution when administering meds that are lipid based

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46
Q

system of double checks for specimen collection

A
  1. 1st person signs with first initial and last name on label and requisition, and dates and times
  2. 2nd person checks accuracy of pt, matching label and requisition then initials requisition
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47
Q

what can effect specimen accuracy

A
  • specimen contamination
  • delay in sending specimens
  • inappropriate container or culture media
  • mislabeled or incorrectly identified
  • no I.D. on source of specimen
  • no report of meds that pt is taking that affect specimen analysis
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48
Q

what cultures can be obtained using sterile swab

A

throat, wound, body cavity, fistula, rectal, vaginal

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49
Q

reason for wound/fistula culture

A

identify infectious agent in wound drainage

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50
Q

reason for sputum culture

A

identification of bacterial, viral, fungal infections and acid-fast bacillus for mycobacterium tuberculosis

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51
Q

reason for culture for body cavity or fluid

A

signs and symptoms of inflammation and infection

52
Q

reason for cultures of stool

A

identification of bacterial, fungal, parasitic infections, ova and parasites, currently c.diff

53
Q

reason for throat culture

A

presence of strep

54
Q

reason for urine analysis

A

presence of UTI, also checks endocrine, kidney function, pH, color specific gravity, test for ketones, protein, glucose, red cell casts or white cells for infection or inflammation

55
Q

common organisms from throat cultures

A

strep

56
Q

common orgs from wound cultures

A

staph, strep, pseudomonas, klebsiella

57
Q

common orgs from rectal cultures

A

vancomycin resistant enterococcus, c-diff

58
Q

common orgs from vaginal cultures

A

various bacteria, chlamydia

59
Q

common orgs from nose and skin cultures

A

MRSA

60
Q

when swabbing wound do not swab where

A

outer edge or crusts near skin

61
Q

directions to patient for urine stream collection

A
  1. wash hands
  2. open 3 towelettes
  3. open container lid side up, don’t touch rim
  4. girls - cleanse each side labia from to back, separate towel for each
    boys- swiping motion away from meatus
  5. void a little urine, stop catch in cup
62
Q

when should a 24 hr urine stream usually begin

A

first thing in the morning

63
Q

what is usually the purpose of 24 hr urine collection

A

for total protein and creatinine clearance

64
Q

during a 24 hr urine collection does the first void count towards the collection

A

no the first void gets discarded

65
Q

when does time start for 24 hr urine collection

A

after the first void

66
Q

when does the 24 hr end during a 24 hr urine collection

A

up until the last void before the end of 24 hrs

67
Q

what are the instructions if a urine gets discarded during 24 hr urine collection

A

advise the patient to get a new container and begin again tomorrow if at home, but if in hospital you can begin after that last void

68
Q

is it okay to end a 24 hr urine collection in the middle of the night

A

no

69
Q

does a urinalysis include a test for culture and sensitivity

A

no

70
Q

can urinalysis identify organisms

A

no, but it can point to presence of organism

71
Q

indications for stool specimen

A

stool, culture, fecal fat content, occult blood testing, presence of ova and parasites

72
Q

if checking stool for ova or parasites what must be done with the sample

A

fresh stool sample must be sent to lab immediately, no later than 30 minutes, and not refrigerated

73
Q

fecal fat content is tested by

A

collecting stool for 24, 48, or 72 hr period

74
Q

how to obtain fecal culture

A

sterile swab or sterile specimen cup

75
Q

how to test for occult blood in stool

A

gualac (wooden stick), small amount of stool on each test site

76
Q

venipuncture is a ______ procedure using _______ gloves

A

sterile…. clean

77
Q

in most adults what is the most suitable site for venipuncture

A

antecubital veins

78
Q

what is something to keep in mind when drawing multiple tubes of blood

A

the order of the tubes is important especially if certain tubes have products in them to test different things

79
Q

what kind of needles are used for peds for venipuncture

A

butterfly needle and syringe or vacutainer and adaptor w/ butterfly if vein small

80
Q

order of venipuncture blood draw (7 steps)

A
  1. apply tourniquet
  2. palpate vein
  3. release tourniquet and use antiseptic
  4. reapply tourniquet
  5. Insert needle and obtain specimen
  6. release tourniquet and remove needle covering site with pad
  7. Label specimens and discard needle in sharps
81
Q

what does CVAD stand for

A

central venous access device

82
Q

what are the 4 types of CVADs

A
  1. non-tunneled catheters
  2. tunneled catheters
  3. implanted vascular device
  4. peripherally inserted central catheters
83
Q

what is a tunneled catheter (CVAD)

A

tunnels under the skin and then threaded into central vein

84
Q

what is an implanted vascular device

A

device under the skin with catheter going into a central vein

85
Q

what is a peripherally inserted central catheter

A

threaded through a peripheral vein and into the central circulation/vein

86
Q

what are indications for CVAD insertion

A
  • infusion of concentrated solutions
  • vasoactive medications
  • blood products
  • poor or limited peripheral venous access
  • long term meds, chemo or other irritating solutions
  • hemodialysis
87
Q

what is the main principle of the groshong catheter

A

it has a three way valve which acts to reduce the risk of air embolisms, blood reflux, and clotting

88
Q

groshong catheter - negative pressure opens valve _____ permitting blood aspiration

A

inward

89
Q

groshong catheter - positive pressure opens valve _______ allowing infusion

A

outward

90
Q

neutral pressure valve remains _______ reducing risk of air embolism, blood reflux, and clotting

A

closed

91
Q

what kinds of catheters do not require heparin

A

closed-ended catheters

92
Q

what are the two names of tunneled catheters

A

hickman and broviac

93
Q

what is catheter tunneling

A

the positioning of a portion of the catheter within the sub Q tissue between the vein access and the exit site

94
Q

what is the benefit of a tunneled catheter

A

provides stability and protect against endovascular infection

95
Q

complications from central venous access catheters

A
  • thrombosis
  • infection (acute or delayed)
  • air embolism
96
Q

non-tunneled catheters can also be called

A

multi-lumen catheters

97
Q

where are multi lumen catheters placed

A
  • subclavian or internal jugular vein
98
Q

for peds where can multi-lumen catheter be placed

A

in groin

99
Q

what is the purpose for a multi lumen catheter

A
  • administer large volumes and multiple fluids
  • vasoactive meds, antibiotics, blood products, TPN
  • obtain blood samples
100
Q

general indication for a PICC line

A

kept over a long period of time

101
Q

what can a PICC line be used for

A
  • antibiotics
  • hydration
  • pain management
  • infusion of hyperosmolar/hypertonic solutions
  • blood transfusion
  • hyperalimentation (TPN)
  • certain chemotherapies
  • home inotropic therapy
102
Q

advantages of PICCs

A
  • can be used in acute or home care
  • freedom of movement
  • small and flexible
  • can be used in young and old
  • can be used for fluid or blood draws
103
Q

indications for a dialysis catheter

A
  • pt with acute renal failure
  • pt with an overdose
  • pt requiring maturation of dialysis fistula or graft
  • bridge to transplantation
  • permanent access in patients who have no dialysis sites
104
Q

what is the disadvantage of dialysis catheters

A

they are hard to maintain over a long period of time, especially with infection or septicemia

105
Q

other terms for implantable venous access device (IVAD)

A

port-a-cath

medi-port

106
Q

indications for IVAD

A
  • access site for blood samples

- cyclic therapies (chemo, antibiotics

107
Q

IVAD can handle both _____injections and ______ infusions

A

bolus….continuous

108
Q

signs and symptoms of CVAC related thrombosis

A
  • swelling, warmth, tenderness of extremity beyond the insertion site
  • cyanosis of face
  • development of collateral vessels (extra vessels)
109
Q

how is CVAC related thrombosis diagnosed

A

ultrasound, venogram, CT angiography

110
Q

signs and symptoms of CVAC related infection

A
  • fever, increased WBC, erythema, tenderness at catheter site or purulent drainage
111
Q

CVAC acute infection occurs when and is often due to

A

3-5 days after insertion, due to contamination during insertion procedure

112
Q

CVAC delayed infection occurs when and is often due to what

A

more than 5 days after placement of device ad usually due to staph aureus

113
Q

CVAC related air embolism is what

A

entry of air into vasculature during insertion, while catheter in place or during removal

114
Q

signs and symptoms of CVAC air embolism

A
  • respiratory distress
  • increased HR
  • cyanosis
  • decreased BP
  • sudden change in LOC
  • pt complain of back, shoulder pain
  • churning murmur over precordium upon auscultation
115
Q

management of air embolism from CVAC

A
  • admin oxygen
  • pinch off catheter
  • cover any open or disconnected catheter ports
  • place patient on left side (Trendelenberg position)
116
Q

what is trendelenberg position

A

placing patient on left side to keep air in right atirum

117
Q

“bundle” aspects of central line care

A
  • daily assess for need of catheter
  • aseptic technique
  • site care
  • maintain occlusive dressing (sterile)
  • minimize breaks in line
  • scrub all hubs
  • timely tube changes
118
Q

when should central line dressings be changed

A
  • every 7 days if covered by tegaderm

- if loose, wet or non-occlusive

119
Q

what type of syringe should be used for central lines

A

10mL or larger

120
Q

dressing of central line should cover what in the center

A

the insertion site and suture wings

121
Q

what does occlusive mean

A

completely closed off tegaderm

122
Q

hand hygiene for central line care

A

wash hands before handling tubing and use clean gloves

123
Q

always remove transparent dressing ______ insertion site to avoid yanking it out

A

toward

124
Q

how long should site be scrubbed when changing central line dressing

A

30 seconds

125
Q

during central line dressing change mask should be worn by

A

yourself and the patient

126
Q

what should you bring with you if there is drainage around central line site

A

sterile swab and extra sterile gloves

127
Q

what is important to think of before and after central line dressing change

A

height of bed and side rail

Therapeutic II (6 decks)

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