Lines and tubes Flashcards
why is learning about equipment important?
allows therapists to make informed decisions and safe choices
when entering a patient’s room:
1: scan the environment
2: treat all lines and tubes the same
scanning the environment
where do all the lines originate and terminate?
what are the lines for?
how do they impact PT treatment?
1 goal
do NOT pull them out!!!
what type of equipment will I see?
pulmonary cardiac vascular GI Renal urinary neurology integumentary
pulse oximeter
probe emits 2 wavelengths of light and a photo-detector measures the difference between light absorbed during systole & diastole provides estimate of arterial % SaO2
compare manual HR with oximeter HR for accuracy
factors that limit pulse oximeter accuracy
cold fingers nail polish darker skin motion cardiac arrhythmias
oxygen delivery
1: nasal cannulas
2: masks
nasal cannulas
Low flow oxygen system:
-concentration of supplemental O2 is 24-44% (air~21%)
High oxygen flow system
-for pt requiring >6L/min. more comfortable than a mask
masks
increase O2 concentration to 35-55%
document FiO2, not flow rate
partial non-rebreather mask
- mask with O2 bag that offers higher O2
- pt usually more ill
- requires lower flow of O2 for FiO2 need
NRB flow:
6L/min=60%
7L/min=70%
artificial airways
“oropharyngeal airway”
prevents obstruction of airway by moving the tongue anteriorly and facilitates suctioning
1: endotracheal tube (ETT)
2: tracheostomy
mechanical ventilation
either endotracheal tube (ETT) or tracheostomy is indicated to prevent upper airway obstruction, and provide a sealed system for mechanical ventilation
endotracheal tube (ETT)
- tube inserted into trachea through mouth when in respiratory failure
- allows air to easily pass in & out
- used in ICU (and some pulmonary specialty areas)
If ETT is pulled out..
can cause damage to vocal cords.
check breathing and apply O2/artificially breathe for pt until re-intubated
tracheostomy
- surgical procedure where incision is made in tracheal rings and tube inserted
- placed in acute and chronic conditions for more permanent airway
- decreased vocal cord or tracheal injury. usually for prolonged intubation
- consult with SLP on swallowing, etc
- tracheostomy button maintains open stoma and allows direct tracheal suctioning
if tracheostomy is pulled out…
apply O2/artificially breathe for pt until tube is put back in.
Passy Muir Speaking valve (PMSV)
- promotes use of upper airway
- assists with verbal communication and coughing
- must deflate cuff when valve on (or pt can’t breathe)
- SpO2 must be >90% to wear PMSV all day
- speaking valve assessment is only for those on high humidity trach collar
tracheostomy collar
high flow O2 delivery system with high humidity
- humidity warms and moisturizes the air
- FiO2 ranges from 21-100%
can use venturi system for ambulation
4 advantages of artificial airways
- prevent airway obstruction
- protect airway from aspiration
- facilitate suctioning
- provide closed system for mechanical ventilation
5 disadvantages of artificial airways
- cough is less effective-
- reduced ciliary motion
- interferes with communication and nutrition
- bypasses respiratory defense mechanisms
- tracheal stenosis
mechanical ventilation: implications for PT
- ability to participate in PT depends on medical stability and mental status (pts often sedated)
- ventilation is not a contraindication to mobility/therapeutic intervention
- consider that tracheal tubes may irritate airway with mobility so you may need assistance to stabilize tube
if mechanical ventilation is dislodged…
use manual ventilation (ambu bag) to ventilate patient and call for help
ambu bag
- used in ICU or emergency situation
- used to manually ventilate patients, stimulate a cough, supplement O2, and/or increase normal volume of air during a breath
- can be used when ambulating a pt without a portable ventilator or during suction
artificial airways and PT
- can participate in all therapeutic interventions
- usually require emphasis on airway clearance and mobilization
- ensure airway is stable prior to tx
- listen to breath sounds before, during and after tx
- air leaks around trach tube normal during mobility exercises
- note position of tube before, during and after tx. excessive movement of tube should NOT occur; if it does, notify the nurse and D/C tx
chest tubes
=any tube placed in the chest
- sutured into place
- chest drain is a large catheter placed within pleural space, mediastinum or pericardium to remove fluid or air and restore respiratory function.
- mediastinal/pericardial tubes are often placed after open-heart surgery
indications for chest tubes
pneumothorax
hemothorax
pleural effusion
emphysema
chest tube sites
drain sites vary
typically through 4th or 5th rib, in mid or anterior axillary line with site of entry posterior to lateral border of pectoralis major
chest tube implications for PT
- monitor vitals
- watch for bubbling in chambers (more pronounced during coughing and expiration) particularly with movement/ambulation. if bubbling is a “new” occurrence, notify nurse as leak may have occurred- consider portable suction machine
- ensure tube is not kinked or blocked
- pt can participate in all therapy provided drainage system kept below level of insertion site and suction is continued
- encourage position changes, shoulder ROM, ambulation and deep breathing exercises
- if collection bottles fall over, right immediately and notify nurse
EKG/ECG
if abnormal, be sure all leads are connected
if disconnected, snap on.
receiver usually fits in pocket of inpatient gown
EKG monitor displays:
HR RR O2 sat BP EKG
if you don’t have telemetry when ambulating a patient…
use a pulse oximeter or other device to monitor HR and O2
pacemaker
substitues for a defective natural pacer of the heart
epicardial pacemaker
placed during open heart surgery whereby electrodes sewn or screwed into the heart muscle
endocardial pacemaker
generator placed in infraclavicular pocket with pacer leads attached to R atrium and ventricle
temporary pacemaker
used in acute care following cardiac surfer. sewn to outside of heart and wires exit below xiphoid process
automated implantable cardioverter-defibrillator (ICD)
- shocks/defibrillates the heart during lethal arrhythmias (such as V-tach)
- paces the heart with regular or overdrive pacing
- important to know at what HR the device is activated in oder to ensure HR remains >10 BPM below that rate
pacemaker and automated ICD implications for PT
internal pacemaker via subclavian vein and ICD
- usually placed on side of non-dominant UE
- shoulder flexion and abduction limited to 90 degrees
- no extreme shoulder extension
- WB restrictions per MD (may limit use of AD)
- no pressure in axilla should be applied (particularly during assistance with mobility)
- temporary pacers do not increase HR with exercise (RPE should be used instead)
intra-aortic balloon pump
- used in ICU
- catheter with balloon attached is placed in aorta via femoral artery
- increased CO when balloon deflates during systole: increased forward flow with decreases after load
- increased coronary artery and myocardial perfusion: balloon inflates during diastole directing blood flow backwards into coronary arteries
PT implications with IABP
-bestrest: usually only increase head of bed height to <30 degrees to avoid trunk/hip flexion on the side of the catheter (no sitting)
Focus of PT intervention:
- UE and contralateral LE exercises as tolerated (can move ankle and foot of LE with catheter)
- prevention of pulmonary impairments
if intra-aortic balloon pump is dislodged…
quickly apply pressure and get help
Swan Ganz catheter
- for long term use in ICU
- flexible, balloon tipped catheter inserted (by MD) in a large peripheral vein and guided through right side heart to pulmonary artery
swan ganz Katheter measures
=used to evaluate cardiac function and volume status, and monitor response to fluids, diuretics and vasoactive drugs
MEASURES: hemodynamics R arterial pressure pulmonary artery pressure pulmonary artery wedge pressure cardiac output
swan ganz catheter (PAC) normal pressures
R atrium= 0-8 mmHg R ventricle= 8-12 pulmonary artery: systolic= 15-30 pulmonary artery: diastolic= 5-15 pulmonary capillary wedge pressure= 4-15
swan ganz catheter (PAC) PT implications
- don’t mobilize pt if pulmonary capillary wedge pressure is being measured.
- check with skilled professional to determine if OK to get pt up or out of bed
- if cleared for PT, pt can participate in all therapy including positioning, airway clearance, and mobilization provided the pt is stable
- keep transducer level at 4th intercostal space for accurate reading during therapy
- check swan position before and after moving pt
complications of swan ganz
infections line related sepsis thrombus rarely pulmonary infarct pulmonary artery rupture
pigtail catheter
- catheter placed in heart or lung to drain fluid collections (tamponade or pericardial effusion, pleural effusion, etc)
- curved end to prevent puncture during infection
- stopcock to allow controlled drainage of collection
- consider pathology requiring catheter and negative impact on CO, ventilation, or gas exchange before PT tx
arterial lines/catheters
used in acute care for continuous monitoring of BP and drawing blood to monitor arterial blood gases and pH
-catheter in peripheral artery connected to a transducer and pressurized flush device
common sites for arterial lines
radial artery
femoral artery
sometimes brachial or dorsalis pedis
to avoid kinking line, joint may be immobilized
arterial line implications for PT
- WBing is limited and joint movement/ROM near sites of insertion is avoided to prevent dislodging of line
- if pt is stable and line is secure, the pt can participate in all PT interventions including positioning, airway clearance, and bed mobility
- if catheter is in a sheath- pt will be on strict bed rest
- check hospital policies- if femoral line- may be on bedrest (hip ROM limited to 30 deg)
- standing or gait is uncomfortable with dorsal pedis line
- always inspect catheter site prior to mobilization and secure if necessary
arterial line precautions
- if line is pulled, apply pressure to site immediately and call for help
- transducer needs to be level to the 4th intercostal space to give accurate reading. will need to be re-calibrated following change in position
- if transducer is below the heart, displayed BP will be falsely high; if above heart, reading will be falsely low
arterial line complications
bleeding
infection
lack of blood flow to tissues supplied by artery
2 primary types of venous catheters
1: peripheral intravenous (IV)
2: central intravenous
- peripherally inserted central catheter (PICC)
peripheral IV
- inserted into peripheral vein- typically hand or forearm
- allows immediate access for administration of drugs, fluids & blood transfusion into circulatory system
- used to obtain venous blood
- infiltration is common when the IV fluid goes into the tissue instead of the vein
- inserted by a nurse
- lasts 3-5 days
peripheral IV implications for PT
- certain meds must run continuously
- if IV pump alarm sounding-check with nursing
central venous catheter
flexible tube inserted into subclavian, internal or external jugular or femoral vein
-sutured or stapled in place
indications for venous catheter use
- diagnostic info by measuring central venous pressure (CVP) and easy access to blood samples
- administration of meds that are caustic to peripheral veins
- access when no peripheral veins are available
- long term meds or parenteral nutrition (TPN)
- hemodialysis or plasmapheresis
peripherally inserted central catheter (PICC)
- long, slender, small, flexible tube inserted into peripheral vein and advanced until a large vein in the chest
- less invasive, with decreased risks of complication and can remain in place for long periods of time
- alternative to subclavian or femoral lines which have greater infection rates!
- inserted in vein in upper arm and terminates near superior vena cava
venous central catheter implications for PT
do NOT take BP in the arm with a PICC line or attach anything tight on that arm
patient controlled analgesia (PCA) pump
- used for pain control
- medication delivered via IV
- inform nurse if pt not responsive or responsiveness decreased
- only PATIENT should press PCA button
- monitor BP
other lines and tubes
GI Renal urinary neurology integumentary
feeding tubes
total parenteral nutrition (TPN)
nasogastric (NG) tube
Dobhoff (feeding) tube
percutaneous endoscopic gastrostomy/jejunostomy (PEG/PEJ)tube
total parenteral nutrition (TPN)
feeding tube for pt’s who can’t use their GI tract (given through central venous line)
nasogastric (NG) tube
tube inserted via nostril and terminates in the stomach
used to empty stomach of gas and digestive fluids and for feeding
Dobhoff (feeding) tube
tube inserted via nostril and terminates at the beginning of the small intestines.
used for short term feeding for patients who can not chew or swallow but have functioning GI tract
percutaneous endoscopic gastrostomy/jejunostomy (PEG/PEJ) tube
surgical placement of tube in stomach or jejunum for longer term nutrition
NG tube implications for PT
- check before discontinuing suction to ambulate
- do not lie patient flat after feeding
- if pt begins to vomit, reattach NG
Dobhoff (feeding) tube implications for PT
- do not lie patient flat while feeding
- can often disconnect for ambulation/mobility- check with nursing
PEG/PEJ tube implications for PT
- can usually disconnect G/J tube for mobility, but care must be taken to reconnect correctly
- area will be sore and painful following initial placement
colostomy
- fecal matter drains from colon through abdomen (via stoma) and is eliminated into a collection pouch
- indicated with certain diseases, traumas or surgeries (can be temporary)
- careful with gait belt placement
hemodialysis
- removes toxic waist products from blood stream for patients with renal failure to maintain fluid, electrolyte and pH balance
- venous access through central line or ateriovenous (AV) fistula
- usually every other day for 3-4 hours
- continuous venovenous hemofiltration (CVVH)
plasmapheresis
indicated when plasma is unable to carry antibodies and nutrients to tissue and remove wastes
-blood cells are removed/exchanged to manage specific plasma deficiency (remove toxins)
continuous venovenous hemofiltration (CVVH)
removes waste products continuously to eliminate large fluid shifts
hemodialysis & plasmapheresis PT implications
- no BP taken in arm with AV shunt for dialysis
- if on hemodialysis, schedule PT around dialysis
- patient may have low endurance
CVVH PT implications
- treatment depends on medical stability
- depending on location of line, may mobilize
foley catheter
- placed directly into the bladder to assist in evacuation of urine
- do not tip collection canister- used to carefully measure urine output
- secure tubing to thigh before mobilizing to reduce friction at insertion site and decrease risk of UTI. keep tubing away from feet
why should the foley bag be placed below level of bladder?
1: promote drainage
2: prevent backflow
external ventricular drain
=tube placed in ventricle to drain cerebral spinal fluid (CSF) in order to relieve pressure on brain due to acute injury, blockage or infection
-must be leveled at external auditory meatus at all times as it drains via gravity
intracranial pressure monitor
measures pressure surrounding brain
4-15 mmHg normal
external ventricular drain PT implications
- drain must be clamped for any mobility (even changing bed height)
- consult with MD to ensure intracranial pressure is controlled for clamping of drain
- drain must be re-leveled before it’s re-opened after mobility completely
intracranial pressure monitor PT implications
- maintain pressures below 20-25 mmHg unless prescribed by MD
- head of bed should be ~30 degrees with head in neutral
surgical drains
- tubes placed in surgical or infection site to drain fluid
- many operate via a suction mechanism (hemovac, jackson-pratt drain: looks like small grenade placed in wound to remove fluid by creating a vacuum)
- OK to mobilize pt
- good to pin drain to gown
- if drain is full and want to mobilize pt, notify nursing who can assist with emptying
wound vac
- removes slough/exudate from wound, maintains moisture, increases circulation, reduces edema and bacteria
- can carry machine during tx without disconnecting it (watch battery life!)
- if disconnecting, must clamp both ends (keep ends clean by using glove/gauze)
- monitor dressing and seal for breaks
compression boots
- intermittent pneumatic pressure of calves to promote blood flow and reduce DVT risk in pts with limited mobility
- can be removed for ambulation
- if pt is confused, consider alternative method of DVT prevention to reduce fall risk
- if pt. is very edematous, may cause pitting edema so consider adjunct compression therapy
considerations!
- be familiar with hospital/clinic policies
- use an extra person to assist with lines
- always monitor pt’s vital signs and symptoms
