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Patient Education
Improving health through education
Taking Care of your Home T.P.N.
Please visit the UHN Patient Education website for more health information: www.uhn.ca\patient\health_info.
© 2007 University Health Network. All rights reserved.
This information is to be used for informational purposes only and is not intended as a substitute for professional
medical advice, diagnosis or treatment. Please consult your health care provider for advice about a specific
medical condition. A single copy of these materials may be reprinted for non-commercial personal use only.
Author: Olivia Saqui
Created: 03/2007
Form: D-5377
C034-D
Table of Contents
Introduction..............................................................................................3
Teaching Program....................................................................................4
The Central Venous Catheter...................................................................6
Principles of Aseptic Technique...............................................................9
Handwashing Technique..........................................................................11
The Total Parenteral Nutrition (T.P.N.) Solution.....................................14
• Preparing the T.P.N. Solution . .....................................................18
• Setting up the infusion pump .......................................................23
• Starting the T.P.N. infusion ..........................................................25
• When the T.P.N. infusion is complete . ........................................27
Problems You May Encounter During Infusion.......................................28
Heparin-Lock or “Capping Off”..............................................................29
• Changing the Adapter Cap . .........................................................33
Central Venous Catheter Dressing...........................................................37
Possible Problems Associated with CVC and Home T.P.N.....................44
The Effects of Home T.P.N. on Lifestyle.................................................50
Discharge Planning and Follow-up Care.................................................54
T.P.N. Team Contact Numbers.................................................................56
Introduction
Most of us meet our nutritional needs when we eat food. Normal digestion happens when
food is broken down in the stomach, then absorbed by your bowel. These absorbed products
are carried to the rest of your body by your blood. Nutrition can help to heal your body.
However, sometimes a person cannot eat any or enough food because of an illness. For
example, the stomach or bowel may not be working normally because of surgery. When this
occurs, and you are unable to eat, you can get nutrition in a different way. One way is Total
Parenteral Nutrition (T.P.N.).
What is T.P.N.?
Total Parenteral Nutrition (T.P.N.) is a special liquid food mixture, which we give you
through an intravenous (IV) catheter. T.P.N. looks similar to a regular IV but we use
different fluid. The mixture contains proteins, carbohydrates, fats, vitamins and minerals.
T.P.N. does not go into your stomach or bowel. It goes directly into your bloodstream
through the IV tube that we put in a big vein (usually in your chest). The development
of T.P.N. has helped patients who require prolonged nutritional support. It has been used
successfully in the hospital and at home for many years. With home T.P.N., patients can
leave the hospital and be active in their community.
Your doctor and nurse have found that you will benefit from T.P.N. They are certain that you
and/or your family are physically able to understand and do the procedures for T.P.N. The
T.P.N. nurse will help you to learn the procedures in this booklet. This manual gives you the
information and guidelines that you need to take care of yourself at home while on T.P.N.
The Teaching Program
We want to make sure that you understand and are able to take care of yourself and your T.P.N.
We will develop a teaching plan that suits your needs and the way you like to learn. You will
have one-to-one teaching sessions with the T.P.N. nurse. You will actively participate as we
teach you. We will be with you when you practice your T.P.N. skills before you go home. You
can use this manual as a reference while you are in the hospital and at home.
Teaching a “Back-Up” Person
In addition to teaching you, we recommend that you find a back up person for us to teach.
This person may be a family member or close friend who will be able to help if you have
problems. You are responsible for your own care. However, it is important to have another
person available for support, reinforcement and help when you need it.
Discharge Criteria
Your discharge planning begins when you enter the teaching program and continues until
you are at home. You and your T.P.N. team plan your discharge. To ensure you are ready for
discharge, you must be able to do the following:
• Show that you understand the principles of T.P.N. and how it relates to you.
• Demonstrate the correct aseptic and technical skills required to use the T.P.N. system
at home.
• Show that you know what to do if you have a problem.
• Display an emotional and psychological adjustment to this new way of life.
You and the T.P.N. nurse set the discharge date during your learning program. The date that is
chosen depends on your progress, your medical condition and pharmacy’s ability to prepare
your solutions and supplies.
The T.P.N. Team
As a Home T.P.N. patient, you have access to the T.P.N. team. You will meet the team while
you are in hospital. We are available to support and help you if you have any problems or
emergencies. We will encourage you to talk about your concerns, fears and feelings about
being on T.P.N. Our team is made up of a:
• Doctor
• Nurse
• Dietitian
• Pharmacist
The Central Venous Catheter
A central venous catheter (CVC) is a thin, hollow, flexible tube. It is specially designed to
be in place for a long time. Your surgeon or radiologist puts this catheter in so that you can
safely receive the T.P.N. at home instead of in the hospital.
A Tunneled CVC or “Hickman”
A tunneled catheter is a long-term CVC with part of the catheter placed under the skin
(“tunneled”). It is also known as “Hickman” catheter (diagram below).
• Hickman catheters have a “cuff” that helps anchor the catheter to the tissue under the
skin; it is more difficult to pull the Hickman out if there is a portion running under the
skin. It also helps as a barrier to infection.
• Tunneling makes the Hickman exit site separate from the entrance site, which may lessen
the chance of infection.
• Hickman catheters are very strong and can last for years with good care.
• Hickman catheters have a screw adapter on one end that is hooked up directly to your
T.P.N. tubing.
• Hickman catheters come in different types and sizes. The type of catheter you have will
depend on your own needs.
The diagram below shows you the main blood vessel that the doctor uses to put your Hickman in.
Inserting your Hickman
• You will be awake for the procedure, which takes about 30-45 minutes. We will
freeze the areas on your chest where the catheter will go in and come out.
• The doctor makes a small cut under your collarbone. This is where the catheter goes
in. It is called the insertion site.
• The doctor makes another cut further down your chest. This is where the catheter
comes out. It is called the exit site.
• The doctor makes a tunnel joining the two cuts under the skin.
• The catheter is passed through this tunnel.
• The catheter is then threaded through until the tip is resting in a large vein just outside
the heart called the superior vena cava.
• Once the catheter is in place, the cuts are closed with 2 or 3 stitches.
• The stitches under your collarbone will be taken out in 7 – 10 days. The stitches at the
exit site will stay in place for about 4-6 weeks to give the cuff enough time to attach to
the tissue under your skin.
A “PICC”
Another type of CVC is a PICC, which stands for Peripherally Inserted Central Catheter.
• It is inserted in a peripheral (arm) vein and threaded up into a large vein in the chest.
• The PICC exit the skin near the vein in which it is placed.
• There will be a small portion of the PICC with a cap on the outside of your skin; this
is where your T.P.N. infusions will be connected.
• Compared with the Hickman, PICCs can be faster to insert, as there is no tunnel to
make.
• Although most people need PICCs for only a few weeks or months, PICCs can last for
years if taken care of properly.
The diagram below shows you where the PICC line is placed.
About your CVC:
 The catheter tip rests in a large vein just outside the heart called the superior vena cava.
 Catheter designs come in single or double lumen (it is also available in triple
lumen design).
 There is a cap at the end of the catheter where your T.P.N. tubing will be attached.
 The catheter will need to be flushed at the end of each infusion to prevent clogging.
 The adapter cap is changed routinely as well the dressing.
Principles Of Aseptic Technique
T.P.N. has one major risk — the possibility of infection. This is because:
• Your catheter will stay in your body for a long time
• The T.P.N. solution that you will receive may support the growth of bacteria.
• If you have a fistula, ileostomy, colostomy, or gastrostomy tube, you may have bacteria
transfer to your catheter site.
Infection happens when harmful bacteria grows in your body. When you are on T.P.N., you
may get an infection if some of these bacteria get into your catheter. We will talk about
symptoms and treatment later. What is most important is to prevent infection. You can do
this by using Aspectic Technique.
Aseptic technique is the key to success and prevention of infections.
Remember these principles:
1. Work in a clean, quiet, dust free area. Use a space that does not have other activities
going on. This reduces the risk of microorganisms that are moving in the air from
contaminating your sterile equipment.
2. Clean your countertop or working surface with alcohol or disinfectant. This will reduce
the number of microorganisms on the working surface also helping to reduce the risk
of contamination.
3. Wear a mask if you have a cold. The mesh fibres of the mask trap microorganisms and
reduce the risk of transfer from your mouth or nose to sterile objects.
Only wear a mask once then discard. The fibres of the mask have limited capacity.
4. Use good handwashing technique before you handle or do care on any part of your
T.P.N. system. We include instructions in this manual on Handwashing.
Remember to clean from your fingertips to your elbows. Use a vigorous scrubbing
action. The friction will help to remove microorganisms from your hands.
5. Hold all sterile equipment above your waist level. This keeps your equipment in your
sight and helps to ensure your equipment does not get contaminated.
6. Anything that is sterile becomes contaminated when it comes in contact with an
unsterile object.
7. Do not talk, cough, sneeze or reach over a sterile area or object.
This will prevent your equipment from getting contaminated by droplets from your nose
or mouth or particles from your arm.
8. Cover any sterile needles that you are not going to use right away. This prevents them
from being exposed to the air for a long time.
9. Vigorously wipe the tops of all vials with an alcohol swab before you insert the needle.
This takes away any microorganisms and prevents your equipment from getting
contaminated.
10. Vigorously wipe the connections on all tubing with an alcohol swab before you
disconnect the tubing. This reduces the number of microorganisms on the outer surface
of the connections and decreases the risk of microorganisms going inside the tubing.
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Handwashing Technique
Handwashing is the single most important thing that you can do to prevent the spread of
infection. Your hands can transfer microorganisms from contaminated objects to sterile or
clean ones.
To remove most of the microorganisms and dirt from your hands, you need to wash your
hands for 2 minutes under warm running water using an antibacterial skin cleanser and
vigorous scrubbing.
Important Things to Remember:
• We ask you to use chlorhexidine 2% antibacterial skin cleanser because it is a
detergent and a disinfectant.
• Lather lifts the soil and bacteria. Rub your hands together vigorously to work
up lather.
• Use warm, running water. This increases the cleansing action of chlorhexidine.
• Use friction to clean each finger, palms, wrists and forearms. Friction helps to get rid
of microorganisms.
• Remove all your jewelry. If you cannot remove your rings, move them up and down as
you wash your fingers. Organisms thrive in the dark, moist area underneath your rings.
• Clean under your fingernails with a clean nail file. Do not use a nailbrush because it
may injure your skin causing bacteria to enter and become a source of infection.
• Repeated handwashing removes additional microorganisms.
• After you have completed your aseptic procedure, wash your hands again. Then apply
lotion to your skin to prevent dryness and cracking.
The hand washing instructions on the next page will show you step by step how to clean
your hands as you prepare for an aseptic procedure.
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Handwashing Procedure
Gather:
• Chlorhexidine 2% antibacterial skin cleanser
• Clean nail file
• Paper towel
Steps:
1. Turn on the water. Regulate the temperature and leave the
water running throughout your handwashing procedure.
2. Wet your hands and forearms under the running water and
apply chlorhexidine soap; 2 pumps are usually enough.
3. Clean your nails with the nail file.
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4. Wash your hands rubbing vigorously in a circular motion.
Clean each individual finger, then the palms of your hands,
back of your hands, wrists and then up the elbows.
Never go back to an area that you have just washed.
5. Rinse the soap from your fingertips to your forearms always
keeping your hands pointing up.
Reapply chlorhexidine 2%. Wash your fingers and
hands again.
Rinse your hands again keeping your fingers pointed up.
6. Dry your hands with a paper towel.
Start with your hands and then move up towards your elbow. Dry one arm at a time.
7. Turn taps off with the used paper towel.
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The T.P.N. Solution
Your T.P.N. bag is divided into two chambers. The milky, white solution in the upper
chamber is the fat emulsion (lipid) component of your T.P.N. The clear solution in the
bottom chamber contains the amino acid (protein) and dextrose (carbohydrate) part of your
T.P.N. A rigid plastic rod sits over a rubber strip. This separates the two chambers. There
are also 2 ports on the bag – one for additives and one for when you administer your T.P.N.
The second one is covered with a snap-tab to keep it sterile. T.P.N. solution is kept in a
separate refrigerator.
When you use your solution, look at it closely to make sure that the rod and strip are
securely in place. You do not want these 2 solutions mixing together while in storage up
until when ready to use it.
• If the clear solution looks murky or milky in any way, do not use this solution.
The divider may have been disturbed during shipping/handling or while in storage.
• Get another bag.
• Report the defective bag to the supplier in the morning.
The Contents of Your T.P.N.
Fat Emulsion (lipid)
- Provides essential fatty acids that are important in health maintenance.
- Provides calories for energy.
Amino Acid (protein)
- Provides heat and energy for the body.
- Protein is essential for growth, the building of new tissue, and the repair of injured or
broken-down tissue.
Dextrose (carbohydrates)
- Provides energy.
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Additives
Vitamins, heparin and other certain medications are stable in your T.P.N. solution for
24 hours after they have been added. So the manufacturer does not add these when
making your T.P.N. You need to add these medications on the day that you will use
the bag of T.P.N.
Heparin
- stimulates the release and/or activates an enzyme, which helps your body to absorb
the lipids.
Multi 12™
- is a multivitamin that gives you Vitamins A, B, C, D, E, niacinamide, biotin, and folic
acid. Vitamins are essential for normal metabolism, growth and development of the
body, and maintenance of health. You will add this to your T.P.N. everyday.
Vitamin K
- helps to eliminate prolonged bleeding. You will add this vitamin once per week. If
you are taking blood thinner medications like Coumadin, you will not take Vitamin K.
We will give you a calendar that shows your daily and weekly routines. It will include the
names and amounts of the additives that you will put in your T.P.N.
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Equipment Used for Infusing your T.P.N.
Baxter™ Basic Solution Set
- a disposable, sterile tubing set. It has a 1.2-micron filter to remove bacteria and
prevent particles and air bubbles from passing through.
Flo-gard 6201™ Volumetric Infusion Pump
- an electronic pump attached to a pole. It will safely and accurately infuse your T.P.N.
When Can I Mix My solutions?
Timing is important when mixing additives. Here are some important points to remember.
• The additives are not stable in the T.P.N. bag for longer than 24 hours.
• Your T.P.N. will infuse over night for about 12 hours.
• You can take your bag out of the refrigerator 8 - 12 hours before you connect it. This
gives the T.P.N. solution plenty of time to warm up to room temperature. Warming
your solution is important because the T.P.N. solution has less air bubbles in it. The
cooler the bag, the more air bubbles there are. This means that more air bubbles will
go through the tubing. You cannot speed up the warming process by putting your
T.P.N. solution into direct sunlight or in the microwave. This breaks down the protein
in your solution.
Storage of T.P.N. bags
• Refrigerate your new shipment of T.P.N. immediately.
• Store your solutions in a separate refrigerator. This will decrease the chances of
contamination.
• Do not stack more than 3 bags on top of each other.
• Do not remove the plastic rod dividers until you are ready to use it.
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Cyclic T.P.N.
In the hospital your T.P.N. solutions are infused over a 24-hour period. During this time, we
do blood work to see how your body is responding to the solutions. We adjust your T.P.N.
whenever necessary. Blood work is done to evaluate your body’s response to the solutions
and adjustments are made as necessary.
T.P.N. has a high concentration of dextrose (a type of sugar). When you go home, we do not
want you to have a high blood sugar reaction. To prevent this from happening, the amount of
time that you are on T.P.N. will be slowly decreased. Gradually reducing your infusion time
allows your body to get used to the high sugar load going in over a shorter time. Eventually,
you will be on T.P.N. for only 12 hours per day. This is called the “cyclic T.P.N.”.
At home, you will give yourself the T.P.N. for 12 hours overnight. In the morning, you will
disconnect the T.P.N. This gives you the freedom to go to work or school, shop or do most
anything you want. Occasionally, you might need to start your T.P.N. earlier or later than
usual. If you do, remember not to change the infusion rate and the time it takes to infuse.
Do not try to speed up your T.P.N. This can be dangerous.
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Preparing The T.P.N. Solution
Preferably, prepare the T.P.N. bag with the additives in the morning.
Gather:
• T.P.N. bag
• Syringes—3 ml, 5 ml, 10 ml—follow the checklist provided
•25 gauge needles
• T.P.N. additives – follow the checklist provided
• Pre-loaded Hepalean-lok™ syringe
• Alcohol swabs
• Baxter™ Basic Solution Set
• I.V. pole
Steps:
1. Clean and disinfect your work area.
2. Gather your equipment.
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3. Wash your hands well.
4. Remove your T.P.N. solution from the dark
plastic bag.
5. Draw up all the additives that you need.
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6. Change all the long needles on the syringes to
25 short gauge needles.
7. Wipe the medication port with an alcohol swab.
8. Remove the needle cover of the syringe.
Insert the needle into the medication port.
Inject the medication.
9. Withdraw the needle from the port.
Dispose the used needle into the sharps
container.
10. Repeat steps 7, 8 and 9 until you have put in all
the additives into the T.P.N. bag.
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Complete the preparation of the T.P.N. bag in the evening just shortly before going to bed.
Here is what you need to do:
11. Wash your hands.
12. On the T.P.N. bag, hold the longer exposed end of
rubber strip firmly.
Pull or “peel” it away from the rigid plastic rod.
The two chambers have now combined to become
one bag.
13. Gently shake the bag.
The solution should look completely white with a
slight hint of yellow because of the vitamins.
If your solution has streaks or oily layers, do not
use the bag. Call the supplier in the morning to report.
Prepare a new bag.
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Priming the T.P.N. Tubing
To prime the T.P.N. tubing:
1. Remove the tubing from its package.
Close the roller clamp on the tubing.
2. Remove the cover and insert the spike of the
tubing into the T.P.N. bag.
3. Fill the drip chamber to half way.
4. Do not invert the filter. Put the filter in the upright
position.
Prime the filter completely until no more fluid drips from
the drip chamber.
22
5. Open the roller clamp and tap the filter to get rid of
any air bubbles that got in during priming.
6. Prime the tubing set completely.
Purge all the air.
7. Close the roller clamp completely.
Setting up the T.P.N. infusion pump
8. To do this:
a. Lift the pump door latch and put it in the
horizontal position.
Pull the door open.
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b. Press the red safety clamp to the right.
You will hear a click.
c. Put the dark blue slide clamp on the tubing set
into the pump slot.
Make sure that it is fully inserted into the slot.
It should not stick out at all.
If the blue slide clamp is not in properly, the
pump will not start and an alarm will sound.
d. Load the tubing straight through the
guide channel.
Start at the bottom and move to the top.
Make sure that the tubing is straight and that
the tubing is touching the pumping mechanism
(the white pumping "fingers").
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e. At the top of the pump, place your finger over
the curved area of tubing guide channel.
Gently pull the tubing to make sure it is laying
around the curve and that it is laying flat against
the pumping "fingers".
f. Close the pump door. You will hear two clicks.
Connecting the T.P.N. to your CVC
9. Before starting the infusion, connect the T.P.N.
tubing to your CVC. To do this:
g. Clean the Clearlink adapter cap on your
catheter with an alcohol swab.
Connect the T.P.N. tubing to the clean adapter
cap on your catheter.
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h. Open your catheter clamp.
Open the roller clamp on the tubing.
10.Prior to starting the T.P.N. infusion you must program
the pump. To do this:
a. Turn the pump on by pressing the ON-OFF/
CHARGE keypad. Wait for a few seconds until all
indicator lights go on and the alarm sounds.
Note:
Plug or Battery indicator will light up depending on which source you are using.
b. Set the flow rate by pressing the PRI RATE keypad.
Enter the flow rate that you will use in the numbered
keypad.
Your T.P.N. nurse will tell you the rate in millilitres
per hour.
c. Set the volume to be infused by pressing PRI VTBI
keypad. Enter the desired fluid volume on the
numbered keypad. Your T.P.N. nurse will tell you
the volume in millilitres.
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d. Check all settings that they are correct.
Press the top PRI START keypad to begin the
infusion. The green PUMPING LED light and a
moving bar appears next to the flow rate setting.
Look for drops in the drip chamber of the tubing
to make sure the fluid is flowing.
When your infusion is complete:
When your pump has delivered the volume that you set, it will sound an alert tone. It switches
the pump to a slower rate - KVO (Keep Vein Open). The rate will be 5 ml/hour. Once the
volume has been infused, you can disconnect the T.P.N. and follow the Heparin Lock procedure.
To disconnect from the pump:
1. Turn the pump off.
2. Close the clamp on your catheter.
3. Follow the Heparin Lock procedure on page 30.
After the Heparin Lock procedure, as part of your clean up remove the used tubing from
pump as follows:
1. Open the pump door.
2. Press the tubing slide clamp fully into its slot.
3. Press the SAFETY CLAMP tab to the right.
4. Take the tubing out of the pump and dispose.
5. Turn the pump off using the ON/OFF/CHARGE keypad.
Important:
Keep your pump plugged at all times to keep your battery charged. When the battery is fully
charged, your pump will run on battery for up to 6 hours.
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Problems that may happen during your infusion
Problem
Air in the tubing
(Pump screen will
show "Air")
What To Do
1. Close the roller clamp of the tubing.
2. Turn off pump.
3. Open the pump door.
4. Press the tubing slide clamp fully into its slot.
5. Press the SAFETY CLAMP to the right.
6. Remove tubing from pump.
7. Open the tubing slide clamp.
8. Open the roller clamp slowly to let the bubbles run to the filter.
9. When bubbles enter the filter, close the roller clamp.
10.Re-insert tubing slide clamp fully into its slot again.
11.Load the tubing through the guide channel from bottom to top.
12.Ensure that the tubing is loaded straight.
13.Close the pump door.
14..Open the roller clamp.
15.Turn the pump on.
16.Press PRI START.
Occlusion
• Look carefully at your tubing for a kink. Straighten the tubing.
• Kinks along the
tubing or catheter
• Closed clamp
• Check and make sure all clamps are open.
• Sluggish or
clotted catheter
• Flush the catheter with 3 ml normal saline.
• If you are able to flush the 3 ml normal saline, then flush your
catheter with another 10 ml normal saline. Resume your infusion.
• If you are not able to inject the 3 ml normal saline, call the doctor or
home care nurse or T.P.N. nurse.
Leaking due to:
• A loose
connection
Tighten all connections.
• A crack on the
tubing
Change the tubing and call the supplier.
• A pinhole on the
Clamp your catheter above the pinhole. Wrap the affected site with
catheter
gauze and tape. Call the T.P.N. nurse for catheter repair.
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Heparin Lock (“Capping Off”)
When you are home, it will usually take 12 hours for your infusion to go through. This
gives you the ability to do activities through the day. To prevent your catheter from clotting
when you are not infusing your T.P.N. solution, you need to inject Heparin into the catheter.
Equipment Used For Heparin Lock:
• Hepalean-Lok™ (100 U.S.P. Units/ml) pre-loaded syringe
We use Heparin because it is an anti-coagulant. It prevents blood from clotting in
your line until you hook up to the next infusion.
• Sodium Chloride (Normal Saline) pre-loaded syringe
This solution clears your catheter after your T.P.N. or medication has been infused.
It is an isotonic solution.
• Clearlink™ Adapter Cap
This cap covers the opening or hub of your catheter. You will change the cap every
week or whenever is necessary through the week.
• Alcohol Swabs
You will use alcohol swabs to clean things such as the clearlink adapter etc. You will
also wipe all tubing connections before breaking the connections.
Important Notes
Even if you do not have T.P.N. every day, it is important for you to follow the heparin lock
routine every day. This will prevent problems when you do infuse your T.P.N.
If you have a double-lumen catheter and one of the ports is not in use (dormant port), follow
the heparin lock routine weekly using the same procedure.
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Heparin Lock Procedure
(Capping off)
Gather:
• Alcohol swabs
• Sodium Chloride pre-loaded syringe (10 ml)
• Hepalean-Lok™ pre-loaded syringe (100 units/ml) 5 ml
To cap off:
1. Clean and disinfect your work area.
2. Gather your equipment.
3. Wash your hands well using Chlorhexidine
antiseptic solution.
30
4. Turn off the infusion pump.
Clamp your catheter.
5. Vigorously wipe the connection between the
adapter cap and tubing with an alcohol swab.
6. Disconnect the tubing from the adapter cap.
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7. Vigorously wipe the adapter.
8. Attach the sodium chloride pre-loaded syringe to
the adapter cap. Open the clamp on your catheter.
9. Inject the sodium chloride solution slowly using
the push-pause technique.
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10. Remove the syringe from the adapter cap.
11. Repeat Steps 7, 8, 9 and 10 with the
Hepalean-lock™ pre-loaded syringe.
Changing the Clearlink™ Adapter Cap
If you need to change your adapter cap, do this when you are capping off after your infusion.
You will add these steps:
Gather:
New Clearlink™ adapter cap
Steps:
1. Open Clearlink™ package.
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2. Swab the female luer end of Clearlink™ cap
with an alcohol swab.
3. Attach a sodium chloride pre-loaded syringe.
4. Flush the Clearlink™ with a little bit of
sodium chloride, just enough to fill the space.
Set aside.
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5. Make sure your catheter clamp is closed.
6. Wipe the connection between your catheter and the
Clearlink™ with an alcohol swab.
Remove the Clearlink™ adapter from your catheter.
7. Take the protective cap off the new Clearlink™.
Attach to your catheter the new Clearlink™ adapter
with the sodium chloride syringe.
8. Unclamp your catheter.
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9. Flush your catheter with the remainder of the
sodium chloride using push-pause technique.
10. Now flush your catheter with Heparin using
push-pause technique like you did with the
sodium chloride.
11. Clamp your catheter.
Please note:
Do not clamp your catheter while you are flushing. Clamp your catheter after you remove
the last syringe.
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Central Venous Catheter Dressing
Intact skin is one of the best ways to prevent infection. The point where the catheter leaves
your skin is the exit site. This is a break in skin integrity. You need to carefully clean and
dress the exit site to stop bacteria from growing and causing an infection.
You need to change your dressing weekly and/or whenever it is loose, soiled or damp.
If you are monitoring your catheter exit site because of an infection, you need to change your
dressing every day. The symptoms of exit site infection are redness, pus drainage, swelling
and tenderness.
If your dressing is no longer sealed, you must change it as soon as possible. Your dressing
may not be sealed for various reasons, such as:
• Tape catching on your clothing
• Drainage from the catheter site
• Perspiration especially during the warm weather
Please note:
You may need to change your dressing more often during the summer months.
Things to watch for when you change your catheter dressing:
1. Drainage
If you have redness or drainage around your catheter exit site, call your doctor or T.P.N.
nurse for further instructions.
Please note the type, amount and odor of the discharge.
The site will need to be swabbed and tested for bacteria.
Your doctor may order for you to take an antibiotic until this problem resolves.
When you have drainage from your catheter site, you need to change your dressing every
day and monitor how your site looks.
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2. Redness along the catheter tunnel
If redness develops along the catheter tunnel area, look for drainage from the exit site.
Check your temperature.
Call your doctor or T.P.N. nurse after you finish doing your dressing change.
3. Skin reaction
You may get a skin rash or irritation from the dressing.
If you get a rash, call your T.P.N. nurse. She may arrange for you to use a different type
of dressing.
4. Line migration
The dacron cuff on your Hickman is there to prevent the catheter from slipping out.
The cuff adheres (sticks to) your subcutaneous tissue.
For the first 4 - 6 weeks after you get your catheter, do not pull or tug on your catheter.
Check to see if your catheter has moved. Measure and record the length often.
The length should always be the same as the first time you measured it when it was inserted.
If your catheter is longer, call your doctor or T.P.N. nurse as soon as possible. You will need
a chest x-ray to check the position of your catheter.
After your x-ray, your doctor will tell you if you need to have it replaced.
Equipment Used for Catheter Dressing
Tegaderm™
- A transparent adhesive dressing.
Chlorhexidine-Alcohol Swabstick
- This swabstick contains an antiseptic cleansing which will remove bacteria and help to
protect against microorganisms.
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Catheter Dressing Procedure
Gather:
• Chlorhexidine-alcohol swabsticks (3)
• Tegaderm™ dressing
• tape
1. Clean and disinfect your work area.
2. Gather your equipment.
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3. Wash your hands using Chlorhexidine skin cleanser.
4. Remove the old dressing.
Look for signs and symptoms of infection at the
exit site (for example: redness, swelling, pus
discharge).
If you have any of these symptoms, finish your
dressing change and call your nurse or doctor to
report what you found at your exit site.
5. Wash your hands again.
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6. Open the package of chlorhexidine®-alcohol
swabsticks.
Using 1 side of the stick, clean your skin in a
circular motion until you have cleaned a circle that
is 4 inches in diameter.
7. Turn the stick over and clean the skin again.
8. Repeat steps 6 and 7 using a new swabstick.
9. With the 3rd swabstick, clean the top of the
catheter down 4 inches from the exit site.
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10. Turn the stick over and repeat on the underside
of the catheter.
11. Allow your catheter and skin to dry.
While your catheter is drying, remove the new
dressing from the package.
Peel the paper liner off so that the adhesive
surface is exposed.
12. Apply the clean dressing over your catheter so
that the catheter exit site is in the centre.
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13. Smooth the dressing from the catheter toward
the edges.
14. Loop any excess catheter.
Tape the catheter pointing upward in a
comfortable position.
Do not tape the catheter on top of the dressing.
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Possible Problems Associated with CVC and Home T.P.N.
Infection
Infection is the most common problem associated with Home T.P.N. It often happens because
you have not followed aseptic principles or technique. Infections are caused by germs getting
in or around a CVC and can become a serious problem if not treated promptly. There are two
types of infection:
Type of Infection
What to do
1. Local Infection
If you have these symptoms, tell your doctor
A local infection happens in a specific area,
or T.P.N. nurse immediately. You and your
such as your bladder, throat, ear, etc.
T.P.N. team need to treat these symptoms.
A local infection can occur in your catheter
exit site or tunnel area. With a local
infection, you will have signs and symptoms
including:
• Redness
• Tenderness
• Drainage
• Swelling at the catheter exit site or
along the tunnel area.
2. Systemic Infection
If you have these symptoms, call your doctor
A systemic infection happens when
immediately or go to the nearest hospital
microorganisms enter your bloodstream and emergency department.
make you sick. Systemic infections can
happen if a local infection spreads or if you
get harmful microorganisms in your catheter.
The signs and symptoms of a systemic
infection include:
• Fever
• Chills
• Weakness, and/or
• Tired, achy feeling
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Remember
You must notify your doctor immediately if you have signs or symptoms of systemic
infection. If you are unable to contact your doctor, go to the nearest emergency department.
Failing to get medical attention immediately may lead to serious illness. You may go into
septic shock.
Treatment
We must treat the infection immediately.
The team will do a number of tests including:
• Blood culture - peripheral (from your arm) and retrograde (from your catheter)
• Swabs from your catheter exit site, throat, nose and other sites
• Urine culture
• Sputum culture
These specimens will tell your health care team if you have microorganisms causing your
infection. If harmful microorganisms are present, the laboratory will determine which
antibiotic should be used.
Treatment with antibiotics will start immediately. You will stay in the hospital until your
symptoms improve. You may go home on antibiotics. Your catheter may or may not
be replaced.
CVC Blockage
A “blockage” or occlusion can mean that you cannot flush, infuse T.P.N. or draw blood from
the catheter. Here are a few common causes for blockage:
• Blood clots in the CVC or in the vein around your catheter. Clots can plug up your
catheter making T.P.N. infusion or flushing difficult. This may be caused by a “fibrin
sheath”, which is tissue your body may deposit on the catheter.
• Mechanical blockage or malpositions, can happen when the CVC is in the wrong place
in the blood vessel, is kinked or pinched, or has broken. This could also happen if your
CVC has accidentally come out part of the way or been pushed in too far.
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• Residue or “precipitate build-up” inside the CVC. This can happen if medications interact
with one another and leave behind a residue, or if your CVC is not flushed properly.
○ Signs:

Difficult to infuse TPN or flush your catheter.

Unable to get blood out.

Pump alarm shows “occlusion”.
○ What to do:

Call your doctor or nurse. If unable to contact go to the nearest emergency
department.

For blood clots or “fibrin sheath” - this can be treated with “clot busting” drugs
given through your CVC, which help dissolve the clot or sheath.

For malpositioned CVC - sometimes the catheter can be repositioned to
restore function.

Sometimes, the catheter may need replacement.
CVC Tip Movement
It is possible that the tip (the end portion) of your CVC can change location within
your body. This can happen if you have too much vomiting, coughing, and sneezing or
hiccupping or vigorous arm movement.
○ Signs:

Pain or discomfort, feeling of coldness or fullness near your CVC or in the
shoulder, jaw, ear or neck area.

You can hear flushing or have pain when CVC is used.
○ What to do:

Call you doctor or nurse for instructions. If unable to contact go to nearest
emergency department.
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Catheter Migration
It is possible that the catheter might move or slip out if it gets accidentally pulled or
stretched and the “cuff” becomes unstable.
○ Signs:

The part of your CVC that is outside your body seems longer than usual.
○ What to do:

Check your CVC to make sure the section outside your body does not seem longer
than usual. Initially after your CVC is inserted, measure and record the length of
the external portion of the catheter as a starting point.

If it does seem longer, it may have partially come out of the vein where it is inserted.

Secure the CVC with a dressing or tape.

Call your doctor or nurse immediately. If unable to contact, go to the nearest
emergency department.
External Catheter Breakage
It is unusual for your CVC to break or tear; but it can happen. Catheter breakage can be
caused by using sharp objects around the catheter; too much twisting of the catheter when
changing caps, extreme force when flushing, or catching the outer part of CVC (for example
on clothing) resulting in the catheter being pulled or stretched.
To avoid this from happening:
1. Do not use unnecessary force when flushing.
2. Avoid using sharp objects such as scissors near the CVC
3. Avoid twisting the CVC.
4. Protect all external parts of the CVC so nothing is dangling.
○ Signs:

Dressing is wet due to fluid (sometimes blood) leaking out when infusing or flushing.
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○ What to do:

Place a clamp above the break, close to your skin (ask your nurse for an extra
clamp to use in an emergency).

Call your doctor or nurse. If unable to contact go to the nearest emergency
department.

Some catheters can be repaired, while others may need to be replaced.
Internal Catheter Breakage
It is very rare for the internal part of your CVC to break. If it happens the CVC will need to
be removed and replaced.
○ Signs:

Your CVC is not working properly.

Your heart rate is beating irregularly, and you may feel short of breath for no
obvious reason.
○ What to do:

Call you doctor or nurse immediately for instructions. If unable to contact go to
nearest emergency department.
Air Embolism
An air embolism is an air bubble in your blood stream. It is dangerous because if a large amount
of air enters your vein, it can damage your heart, brain or lungs and cause serious side effects.
To avoid this from happening:
1. Completely flush all the air out of your tubing before you use it.
2. Clamp your catheter whenever your line is open (e.g. changing your clearlink adapter
cap). This will help protect air from getting into your catheter.
3. Your T.P.N. infusion pump has been designed to detect air bubbles in the tubing and stop
pumping if there is air in the tubing.
○ Signs:

Chest pain

Shortness of breath

Coughing.
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○ What to do:

Clamp your catheter immediately

Lie on your left side

Call your doctor or have someone call for you immediately.
Fluid Overload
Fluid overload happens when you receive a large volume of your T.P.N. or IV solution over a
short time. If this happens, your circulatory system may not be able to handle the extra fluid.
○ Signs:

Rapid weight gain

Swollen arms and legs

Shortness of breath.
○ What to do:

Call your doctor or nurse immediately.
Any patient who has been malnourished for any length of time may have low serum (blood)
protein levels. You may have edema (swelling) in your arms and legs. As your nutrition
improves, this “refeeding edema” will subside.
Dehydration
Dehydration happens when your output is more than your intake of fluids.
This can happen if you do not drink enough fluids or you are losing fluids through
vomiting, diarrhea, ostomy etc. These situations can be caused by hot weather,
gastroenteritis, flu, ingestion of alcohol, etc.
○ Signs:

Thirst

Dry mouth

Poor skin elasticity

Weakness or dizziness.
○ What to do:

Call your doctor or nurse immediately.

You need more fluid through your CVC which can be done at home.
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How T.P.N. Changes your Lifestyle
Meals
Eating is a normal function of everyday life. It is a big part of how we socialize and gather
with family. When you cannot eat, you miss the routines of meals, the ability of using food
to relieve boredom, anger or frustration. Patients miss and crave food. In early stages of
your T.P.N., you may feel depressed. This improves as you and your family learn to cope
with this new situation.
Most female T.P.N. patients continue their role as “cook”. Many patients sit with their
families at mealtime and may even begin their infusion.
Bathing
You can bathe or shower as you did before. Do not get your catheter dressing wet. The
T.P.N. nurse will show you ways of preventing this from happening.
Sleep
Since you will infuse your T.P.N. during the night, you might wake up 2 or 3 times through
the night to urinate. Most patients do not have trouble getting back to sleep but do feel
tired through the day. You might need to take a nap during the day. If you continue to have
trouble sleeping, let your doctor know.
When patients first start on T.P.N., they are often concerned about the equipment, their
catheter and making sure everything is working well. You will get more comfortable with
the whole process over time. Initially, when you are getting up to urinate, check your
equipment so that you feel more comfortable.
Oral Hygiene
You need to practice good oral hygiene at all times. Brush your teeth 3 – 4 times per day.
Use mouthwash and dental floss regularly. Exercise and massage your gums regularly.
Good oral hygiene prevents bacteria from building up in your mouth and causing infections
such as cankers or parotitis.
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See your dentist regularly.
When you have dental work, you need to take antibiotics before you have the work done.
This includes cleanings, fillings, tooth extractions and root canals.
Exercise
Most patients can return to their normal exercise routine. Ask your doctor if you can exercise.
In general, exercise builds and maintains muscle mass. Exercise prevents fat deposits. You will
need to gradually increase your exercise activities. You may find that you can do more since
your last illness or you may feel more limitations than before you started on T.P.N.
You can do most activities and sports. Do not play contact sports such as football, etc.
Employment
One important objective of the Home T.P.N. program is to allow a person to resume a normal
lifestyle. This includes working. We encourage you to return to work as soon as you are
physically and emotionally able. When you return to work, you need to adjust your T.P.N.
schedule to accommodate your work schedule.
Body Image and Sexual Activity
You have received care for a major illness. You may have scars on your body and may not
like the look of your permanent catheter. This can affect how you feel about yourself. You
may lack self-respect and have a low self-esteem. These feelings are normal as you get used
to your T.P.N. You may not be comfortable with your body.
Some of our patients are single or they are younger. They have spent a large part of their
life in hospital or at home. These patients have concerns about being isolated and socially
unacceptable. We work with these patients to improve self-esteem.
All these feelings may affect your attitude and your interest in sexual activity. Some patients
fear that excessive motion and various positions will dislodge their catheter. Then they worry
about timing. They feel that lovemaking must now be “scheduled”, lacking spontaneity.
We encourage you to express your feelings. Our team is here to help you.
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We also encourage you to experiment during sex to find a comfortable time for you and your
partner. You can adapt your sexual activity to include your catheter. Many patients choose
to have intercourse when they are not “hooked up” to the T.P.N.
Entertainment
We encourage you to stay in touch with what is going on in the world.
You can start by listening to the radio, watching TV, read the newspaper or talk on
the telephone.
When you feel well, stay in touch with your loved ones, friends and colleagues. You can
adapt your T.P.N. schedule to suit your social needs. For example, if you want to go out for
the evening, you can hook up your T.P.N. later that evening.
Travel
When you feel comfortable with the home T.P.N. procedures and routines, you can plan
different types of vacations. It will take time to organize your trip but it is possible.
If you plan a vacation, talk to your doctor. He or she needs to approve your travel.
Tell your travel agent or airline/train etc of your health situation.
You need to request a letter approving your travel plans.
Talk to your T.P.N. nurse for assistance with planning.
Tell your supplier about your travel plans in advance. They will also help you to prepare.
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Emotional and Psychological Adjustment to Home T.P.N.
It takes a lot to adapt to your home T.P.N. Gradually, you will feel well again and will
develop the technical skills to care of your T.P.N. system. You wtill then see that you have
psychosocial changes that you need to make.
Your experience in the hospital and your recovery are unique to you. You will have a wide
range of feelings and show different emotions because of your home program. It is important
to talk about these feelings to help you deal with any issues that you are having. Your
team is ready to help you. You may be coping well. Or you may feel angry or depressed.
Whatever your emotions are, talk to your health care team. Like you, they want to see you
be successful on Home T.P.N.
We use several resources to help you understand and cope with your feelings.
We use:
• A veteran Home T.P.N. patient. You can exchange ideas and concerns, suggestions
and methods for coping.
• A nurse and doctor. Our role is to listen and counsel you, to help you understand things
and clear up any misconceptions, to answer your questions and give you support.
Your Home T.P.N. impacts your family as well. The system may overwhelm them. They
may be afraid of the changes they need to make. It will take time for them to understand
how your Home T.P.N. affects them. It is important for you and your family to talk about
these concerns. We are here to help you and your family to adapt to your new situation.
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Discharge and Follow-up
Before you leave the hospital, your team will complete the plans with you to have Home T.P.N.
1. CCAC (Community Care Access Centre)
When you are ready to go home, the CCAC coordinator will visit you. The coordinator
will talk to you about what you need at home. He or she will arrange a visiting nurse to
come to your home every day, twice a day for a few weeks.
The CCAC coordinator can also arrange for other services if you need them.
This includes:
• Homemaking
• Physiotherapy
• Lab technician
• Equipment rental
• Other things to make your adjustment to home easier.
2. ____________
__________ is the company that will provide your T.P.N. supplies. A Customer Service
Representative (CSR) will contact you at home once you are more settled to your home
routine to review the ordering process for your T.P.N. solutions and supplies.
The __________ CSR will tell you when you can expect to receive your Home T.P.N. supply.
__________ needs 1 – 2 weeks to make your solutions and do quality testing.
Remember: you must keep your solutions in a separate refrigerator. If you need a
refrigerator to store your solutions, the T.P.N. nurse can arrange this. When you get your
refrigerator, plug it in for 24 hours before you start to use it.
3. Ordering T.P.N. Supply
Your first batch of T.P.N. supply will be ordered and delivered before you go home. After
two weeks of being home, a CSR will contact you and review the process of ordering
future T.P.N. supply. A sample of T.P.N. supply order form is at the end of the manual.
At any time if you notice you are nearly running out of a certain item, contact your CSR
and they deliver what you need as soon as possible.
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Follow-up Care
While you are on T.P.N., we will monitor your health in relation to the T.P.N. We will need
you to do several things:
Blood Tests
While you are on T.P.N., you will need to have blood tests frequently. The blood test
results help your doctor make the T.P.N. formula to meet your nutritional needs. These
tests really help us ensure that your T.P.N. is working for you.
Please make sure that your blood test is done before you go to your T.P.N.
clinic appointment.
T.P.N. Clinic Appointment
The Home T.P.N. clinic is usually held on Tuesday afternoons. You will come to an
appointment within the first 4 weeks after your discharge.
At your appointment, you can talk with your T.P.N. team about concerns or problems that
you are having. Your doctor will also talk to you about your blood test results.
After your first appointment, your T.P.N. doctor will tell you when you need to come
back for another appointment. The length of time between appointments depends on
your needs.
Return Admissions
If you are re-admitted to hospital, please bring a 2 – 3 day supply of T.P.N. solutions with
you. This will ensure that you are getting the usual solution while you are hospitalized.
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Contacting our Team
Your team is here to answer your questions and deal with your concerns.
Team Member
Telephone Number
Dr. Johane Allard
(416) 340-5159
Olivia Saqui (Nurse)
(416) 340-4018
Mary Baun or Millie Yeung (Pharmacist)
(416) 340-4800 Ext. 5306
Lydia Fairholm (Dietitian)
(416) 340-4800 Ext. 8578
T.P.N. Clinic Address:
Toronto General Hospital
10 North Wing
585 University Avenue
Toronto, Ontario
M5G 2N2
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