Exam 1 - TPN, Specimen Collection, Central Lines Flashcards
reasons a pt would need TPN (11)
- 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
examples of impaired GI tract
- ileus
- surgery
- fistulas
- short “gut” bowel syndrome
what makes up the components of TPN nutrition
- amino acids
- glucose
- fat emulsion (lipids/intralipids)
- vitamins
- electrolytes
- minerals
- trace elements
- water
what is the normal glucose concentration in TPN for adults
10%
with more serious conditions and depending on what the patient can tolerate what is the alternate concentration of glucose in TPN
15-25%
what two ways can lipids be included with TPN
combined or infused separately
if the glucose concentration of TPN is greater than 10% how should the TPN be administered
via central or PICC line
TPN infusions are administered via
dedicated port or central line
how is TPN mix created
customized by the pharmacy using aseptic technique
for how long is TPN usually infused over
24 hours, but can also be cyclic
how often are the lipids and tubing for TPN changed
every 24 hours
are medications able to be added to TPN infusion bags by the nurse
NEVER
are TPN and lipid infusions a closed or open system
closed
can anything be piggybacked or infused into the TPN IV tubing
no
what must be done with TPN until 30 min prior to be infused
it must be kept refrigerated
what should be infused should the TPN be unavailable for any reason and why
IV solution of 10% dextrose and water to prevent rebound hypoglycemia
what is D10W
10% dextrose and water
what kind of filter is needed with TPN infusions
0.22 micron filter
how are lipids infused and do they need to be refrigerated
separate from TPN via peripheral IV catheter and does not require refrigeration
what should be monitored with TPN infusions
- blood glucose
- assess site for infection
- signs and symptoms of infection/sepsis
- signs of hyperglycemia
if blood glucose becomes too high while receiving TPN what should be administered
insulin
the no-no’s regarding TPN infusion
- 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
what should the TPN bag be examined for before administering
turbidity, precipitation, cloudiness, any cracks or holes
should the TPN bag not be administered if there is any cloudiness, turbidity, precipitation or any holes or cracks
do not use it
what should the RN check on the pharmacy label and prescriber order for TPN
- pt name
- medical record # or birthdate
- solution contents (every line)
- expiration date and time
what should be done prior to hanging TPN bag
check label and sign off on TPN order
the date and time should be put on what when doing TPN solutions
the solution ad the tubing
what type of tubing should be used for TPN
needleless tubing
where should the primed and needleless tubing for TPN be connected to
patient’s IV catheter
how often should TPN infusion rate be checked
every hour
what complications should be monitored when infusing TPN
- fluid volume excess
- hyperglycemia
- hypoglycemia
- osmotic diuresis and fluid volume deficit
- electrolyte imbalances
- signs of infection
what should the central and peripheral IV be assessed for during TPN
infection, phlebitis, pain, and purulent drainage
what is number one priority for pt with central lines and receiving TPN
preventing infection
potential nursing diagnoses for TPN (7)
- 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
causes of hyperglycemia when administering TPN
- too rapid infusion
- infection/sepsis
- medication induced
- co-existing diabetes mellitus
what do you give for hyperglycemia during TPN
insulin
what do you give for hypoglycemia during TPN
D10W or 50% dextrose solution if perscribed
what can cause hypoglycemia during TPN
- abrupt decrease in TPN infusion rate
- abrupt discontinuation of TPN
signs and symptoms of fluid overload during TPN
tachycardia, hypotension, distended neck veins, weight gain, lung crackles
treatment for risk of fluid overload during TPN
maintain strict I and O’s and daily weight
signs and symptoms of fluid volume deficit during TPN
decreased urine output, patient thirsty, decreased skin turgor, tachycardia, orthostatic hypotension
treatment for risk of fluid deficit during TPN
I’s and O’s and daily weight
signs and symptoms of electrolyte imbalance during TPN
muscle weakness, lethargy, cramps, muscle twitching, cardiac rhythm changes
treatment for risk of electrolyte imbalance during TPN
monitor serum electrolyte levels and report abnormal levels to provider
treatment for hypertriglyceridemia during TPN
infuse lipids as ordered, obtain weekly serum triglyceride levels, use caution when administering meds that are lipid based
system of double checks for specimen collection
- 1st person signs with first initial and last name on label and requisition, and dates and times
- 2nd person checks accuracy of pt, matching label and requisition then initials requisition
what can effect specimen accuracy
- 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
what cultures can be obtained using sterile swab
throat, wound, body cavity, fistula, rectal, vaginal
reason for wound/fistula culture
identify infectious agent in wound drainage
reason for sputum culture
identification of bacterial, viral, fungal infections and acid-fast bacillus for mycobacterium tuberculosis
reason for culture for body cavity or fluid
signs and symptoms of inflammation and infection
reason for cultures of stool
identification of bacterial, fungal, parasitic infections, ova and parasites, currently c.diff
reason for throat culture
presence of strep
reason for urine analysis
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
common organisms from throat cultures
strep
common orgs from wound cultures
staph, strep, pseudomonas, klebsiella
common orgs from rectal cultures
vancomycin resistant enterococcus, c-diff
common orgs from vaginal cultures
various bacteria, chlamydia
common orgs from nose and skin cultures
MRSA
when swabbing wound do not swab where
outer edge or crusts near skin
directions to patient for urine stream collection
- wash hands
- open 3 towelettes
- open container lid side up, don’t touch rim
- girls - cleanse each side labia from to back, separate towel for each
boys- swiping motion away from meatus - void a little urine, stop catch in cup
when should a 24 hr urine stream usually begin
first thing in the morning
what is usually the purpose of 24 hr urine collection
for total protein and creatinine clearance
during a 24 hr urine collection does the first void count towards the collection
no the first void gets discarded
when does time start for 24 hr urine collection
after the first void
when does the 24 hr end during a 24 hr urine collection
up until the last void before the end of 24 hrs
what are the instructions if a urine gets discarded during 24 hr urine collection
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
is it okay to end a 24 hr urine collection in the middle of the night
no
does a urinalysis include a test for culture and sensitivity
no
can urinalysis identify organisms
no, but it can point to presence of organism
indications for stool specimen
stool, culture, fecal fat content, occult blood testing, presence of ova and parasites
if checking stool for ova or parasites what must be done with the sample
fresh stool sample must be sent to lab immediately, no later than 30 minutes, and not refrigerated
fecal fat content is tested by
collecting stool for 24, 48, or 72 hr period
how to obtain fecal culture
sterile swab or sterile specimen cup
how to test for occult blood in stool
gualac (wooden stick), small amount of stool on each test site
venipuncture is a ______ procedure using _______ gloves
sterile…. clean
in most adults what is the most suitable site for venipuncture
antecubital veins
what is something to keep in mind when drawing multiple tubes of blood
the order of the tubes is important especially if certain tubes have products in them to test different things
what kind of needles are used for peds for venipuncture
butterfly needle and syringe or vacutainer and adaptor w/ butterfly if vein small
order of venipuncture blood draw (7 steps)
- apply tourniquet
- palpate vein
- release tourniquet and use antiseptic
- reapply tourniquet
- Insert needle and obtain specimen
- release tourniquet and remove needle covering site with pad
- Label specimens and discard needle in sharps
what does CVAD stand for
central venous access device
what are the 4 types of CVADs
- non-tunneled catheters
- tunneled catheters
- implanted vascular device
- peripherally inserted central catheters
what is a tunneled catheter (CVAD)
tunnels under the skin and then threaded into central vein
what is an implanted vascular device
device under the skin with catheter going into a central vein
what is a peripherally inserted central catheter
threaded through a peripheral vein and into the central circulation/vein
what are indications for CVAD insertion
- infusion of concentrated solutions
- vasoactive medications
- blood products
- poor or limited peripheral venous access
- long term meds, chemo or other irritating solutions
- hemodialysis
what is the main principle of the groshong catheter
it has a three way valve which acts to reduce the risk of air embolisms, blood reflux, and clotting
groshong catheter - negative pressure opens valve _____ permitting blood aspiration
inward
groshong catheter - positive pressure opens valve _______ allowing infusion
outward
neutral pressure valve remains _______ reducing risk of air embolism, blood reflux, and clotting
closed
what kinds of catheters do not require heparin
closed-ended catheters
what are the two names of tunneled catheters
hickman and broviac
what is catheter tunneling
the positioning of a portion of the catheter within the sub Q tissue between the vein access and the exit site
what is the benefit of a tunneled catheter
provides stability and protect against endovascular infection
complications from central venous access catheters
- thrombosis
- infection (acute or delayed)
- air embolism
non-tunneled catheters can also be called
multi-lumen catheters
where are multi lumen catheters placed
- subclavian or internal jugular vein
for peds where can multi-lumen catheter be placed
in groin
what is the purpose for a multi lumen catheter
- administer large volumes and multiple fluids
- vasoactive meds, antibiotics, blood products, TPN
- obtain blood samples
general indication for a PICC line
kept over a long period of time
what can a PICC line be used for
- antibiotics
- hydration
- pain management
- infusion of hyperosmolar/hypertonic solutions
- blood transfusion
- hyperalimentation (TPN)
- certain chemotherapies
- home inotropic therapy
advantages of PICCs
- 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
indications for a dialysis catheter
- 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
what is the disadvantage of dialysis catheters
they are hard to maintain over a long period of time, especially with infection or septicemia
other terms for implantable venous access device (IVAD)
port-a-cath
medi-port
indications for IVAD
- access site for blood samples
- cyclic therapies (chemo, antibiotics
IVAD can handle both _____injections and ______ infusions
bolus….continuous
signs and symptoms of CVAC related thrombosis
- swelling, warmth, tenderness of extremity beyond the insertion site
- cyanosis of face
- development of collateral vessels (extra vessels)
how is CVAC related thrombosis diagnosed
ultrasound, venogram, CT angiography
signs and symptoms of CVAC related infection
- fever, increased WBC, erythema, tenderness at catheter site or purulent drainage
CVAC acute infection occurs when and is often due to
3-5 days after insertion, due to contamination during insertion procedure
CVAC delayed infection occurs when and is often due to what
more than 5 days after placement of device ad usually due to staph aureus
CVAC related air embolism is what
entry of air into vasculature during insertion, while catheter in place or during removal
signs and symptoms of CVAC air embolism
- respiratory distress
- increased HR
- cyanosis
- decreased BP
- sudden change in LOC
- pt complain of back, shoulder pain
- churning murmur over precordium upon auscultation
management of air embolism from CVAC
- admin oxygen
- pinch off catheter
- cover any open or disconnected catheter ports
- place patient on left side (Trendelenberg position)
what is trendelenberg position
placing patient on left side to keep air in right atirum
“bundle” aspects of central line care
- daily assess for need of catheter
- aseptic technique
- site care
- maintain occlusive dressing (sterile)
- minimize breaks in line
- scrub all hubs
- timely tube changes
when should central line dressings be changed
- every 7 days if covered by tegaderm
- if loose, wet or non-occlusive
what type of syringe should be used for central lines
10mL or larger
dressing of central line should cover what in the center
the insertion site and suture wings
what does occlusive mean
completely closed off tegaderm
hand hygiene for central line care
wash hands before handling tubing and use clean gloves
always remove transparent dressing ______ insertion site to avoid yanking it out
toward
how long should site be scrubbed when changing central line dressing
30 seconds
during central line dressing change mask should be worn by
yourself and the patient
what should you bring with you if there is drainage around central line site
sterile swab and extra sterile gloves
what is important to think of before and after central line dressing change
height of bed and side rail
