Download Day 4 PP - Hep Locks, Central Lines, Art Lines

Initiation of Intravenous Therapy
Equipment


Cannula (needle or catheter), tourniquet, alcohol
swabs, skin cleansing solution, tape, dressing
supplies, gloves, tubing, solution container, a pole to
suspend the container, and infusion pump
Prescribed solution or drug


Use the “five rights”: right solution or drug, right dose or
strength, right patient, right route, and right time
Attach tubing to solution container, fill drip chamber
halfway, allow some fluid to run through the tubing
until completely filled with fluid and there are no air
bubbles in the tubing
Site Selection
Should be the least restrictive
 A large vein that is in good condition
 A soft, straight vein is best
 Avoid veins that are hard and bumpy, bruised,
swollen, near previously infected areas, or close to a
recently discontinued site
 Transilluminator or ultrasound can facilitate locating
a vein
 Preferred site is usually patient’s nondominant arm
 Begin with most distal veins, then move proximally **
 Should not be done in an arm that has impaired
circulation or poor lymphatic drainage, as in radical
mastectomy

Procedure







Wash hands thoroughly; explain procedure to patient
Apply tourniquet above venipuncture site to distend
vein
Locate appropriate vein; temporarily remove the
tourniquet
Vigorously cleanse venipuncture site in a circular
pattern first with alcohol and then with a
recommended solution
Allow to air dry after each cleansing step; do not
blow on the site or fan it
Reapply the tourniquet
Perform the venipuncture using Standard Precautions
Procedure cont’d
Carefully insert cannula through the skin and guide it
into the vein in the direction of blood flow (towards
the heart) **
 If first attempt unsuccessful, select another site,
change cannulas, and try again
 When using the catheter over needle, the needle is
threaded only 1/4 inch into the vein
 Then catheter is threaded into vein as needle is
removed
 After threading the cannula into the vein, connect it
to the infusion tubing, and tape it securely but
without restricting circulation
 Dress site with a clear occlusive dressing that allows
inspection of the insertion site or with a sterile
gauze pad

Procedure cont’d


Pain

Venipuncture and cannula placement are painful

Drugs to decrease venipuncture pain include intradermal lidocaine
(Xylocaine), transdermal lidocaine, and prilocaine (EMLA cream)
Documentation

Place a piece of tape on the site dressing with the date and time that the
cannula was inserted as well as the length and gauge of the cannula and
your initials

Label every bag of fluid and tubing with the date and time that it was hung
and the fluid’s expiration date
What is a Heparin lock?
Heparin Locks, or Hep Locks, are small tubes
attached to a catheter, inserted into the arm
and held in place with tape in order to
administer drugs and fluids without injecting
patients multiple times unnecessarily
Emergency situations require an accessible
vein fast; the Hep Lock provides that
accessibility. Medicine may be injected
easily, making life simple for nursing staff and
less painful for patients.
Function of a hep lock
They do not contain heparin, unless used
for a heparin flush
 They are used by nurses to keep open a
vein for easy access in order to administer
drugs, saline, antibiotics or blood.
 An advantage is that medication may be
given without disturbing the patient while
asleep

PREVENTION OF
CENTRAL LINE-ASSOCIATED
BLOODSTREAM INFECTIONS (CLABSI)
Objectives






Know the definition of a central line catheter
Identify the classifications and types of central line catheters
Discuss risk factors and sources of central line associated
bloodstream infections (CLABSI)
Understand management of central lines during and after insertion
Identify clinical signs and symptoms of central line associated
bloodstream infection (CLABSI)
Describe interventions designed to prevent central line associated
bloodstream infections. (CLABSI)
Terms





BSI – bloodstream infection
CDC = Centers for Disease Control &
Epidemiology
CHG – chlorhexidine
CVC = central venous catheter
CLABSI = central line associated bloodstream
infection
General Information




48% of ICU patients have central venous catheters (CVCs),
accounting for 15 million CVC-days per year in ICUs.
The CDC estimates the attributable treatment costs associated
with a bloodstream infection range from $35,000 to
$56,000/infection and increase length of stay by an
average of 7 days.
>250,000 CVC-related infections per year.
Mortality may be up to 35%.
CDC. Guidelines for the prevention of intravascular catheter-related infections. MMWR 2002;51(No. RR-10).
How do central lines cause
bloodstream infections?
Central venous catheters (CVCs) disrupt the
integrity of the skin allowing bacteria and/or
fungi to enter.
 Infection can spread to the bloodstream
(bacteremia)
 Hemodynamic changes and organ dysfunction
(sepsis) may ensue.

CLABSI Definition


A CLABSI is a primary bloodstream infection (BSI) in a
patient that had a central line within the 48-hour period
before the development of the BSI.
For the Infection Preventionist to classify a CLABSI,
nationally accepted criteria from the CDC should be met.
What is a central line?


An intravascular catheter that terminates at or close to the heart or
in one of the great vessels. This line is used for infusion, withdrawal
of blood, or hemodynamic monitoring.
Great Vessels include:
 Aorta
 Superior vena cava
 Inferior vena cava
 Brachiocephalic vein
 Internal jugular vein
 Subclavian vein
 Pulmonary artery
 External iliac vein
 Common femoral vein
 In Neonates count, Umbilical Vein

Note: insertion site and/or type of device does not define a central line.
The following classify as Central Lines
(may not be all inclusive)







...
Subclavian, Femoral or Internal Jugular (single, double,
triple or quad)
Introducer [Cordis]
Swan Ganz catheter
PICC
Hemodialysis Vas-Caths (tunneled and non-tunneled)
Implanted ports (i.e., Port-a-caths)
Umbilical (UVC)
Sources of CLABSI’s



Migration of skin organisms at the insertion site into
the cutaneous catheter tract with colonization of the
catheter tip is the most common route of infection.
Contamination of the catheter hub also contributes to
intraluminal colonization of long-term catheters.
Rarely, contamination of the infused fluid leads to
infection.
Pathogenesis
Clinical Features of Line Sepsis

Nonspecific

Highly Suggestive of Line Sepsis
Fever
 Chills, shaking rigor
 Hypotension, shock
 Hyperventilation
 Gastrointestinal

abdominal pain
Vomiting
Diarrhea






Neurologic


confusion
seizures




Source of sepsis unapparent
Patient unlikely candidate for sepsis
Intravascular line in place (or
recently in place)
Inflammation or purulence at site
Abrupt onset, with shock
Sepsis response to antimicrobial
therapy or dramatic improvement
after removal of device
What can we do to prevent a CLABSI?
Patient/Family Education
Prior to Central Line Insertion



Ensure the patient (and family as needed) are
educated about central line infection prevention prior to
the procedure being performed.
Document the education on the patient’s medical record.
Patient education flyer can be obtained by going to the
Novant Health Intranet PATIENT EDUCATION SITE >>PATIENT
INSTRUCTIONS >>SPECIFIC FACILITY(IES) >>INFECTION CONTROL
>>SPECIFIC PATIENT INSTRUCTION DOCUMENT IN ALPHABETICAL
ORDER
Central Line Bundle Compliance



The central line bundle is a group of evidence based interventions for
patients with intravascular central catheters that, when implemented together,
result in better outcomes than when implemented individually.
The science behind the bundle is so well established that it should be
considered standard of care.
Key Components:
1. hand hygiene
2. maximal barrier precautions (both for the patient and the inserter) when
placing a central line
3. chlorhexidine skin antisepsis
4. optimal catheter site selection (subclavian preferred site)
5. daily assessment of line necessity with prompt removal of unnecessary line
Prior to Insertion
Demand Strict Hand Hygiene
Observe proper hand washing procedures either with
conventional antiseptic-containing soap and water or with
alcohol-based hand rub.
Insertion:

The person inserting the central line should:
Select an optimal catheter site, with subclavian vein
as the preferred site for non-tunneled catheters in
adults (if not contraindicated).
Insertion:
The person inserting
& those assisting
should don maximal
barrier precautions.
Head cover
Mask
Sterile Gloves
Sterile Gown
Maximal Patient Barrier:
 Drape
the patient with the full body drape (head-to-toe).
Maintain a Sterile Field
During the Insertion:
Insertion:
The person inserting the central line should:
Use chlorhexidine skin prep in a back-and-forth friction scrub.
 For the so-called dry sites (subclavian or jugular), prep for at
least 30 seconds – allowing a 30 second dry time.

For the wet sites (femoral or groin), prep for at least 2
minutes with a 1 minute dry time.

Ensure that solution dries completely before attempting to
insert the central line.
Chlorhexidine Alert . . .
Chlorhexidine should not be used on:
 Infants less than 2 months of age
(unless approved by your facility)
or

Anyone with a chlorhexidine sensitivity or allergy.

For those meeting the above alerts, 10% povidone-iodine
or 70% alcohol may be used as an alternative skin prep.

If inserting an umbilical central line, avoid tincture of iodine
because of the potential effect on the neonatal thyroid.
Other iodine-containing products (e.g., povidone-iodine)
can be used.
After Initial Insertion




Apply occlusive sterile dressing per your facility’s
policy.
Use existing order set (if available) or obtain MD
order for a chest x-ray to verify central line catheter
tip placement.
No fluids/medications should be administered via the
line until verification of placement is done unless in an
emergent situation.
After placement has been verified
 Connect
NEW administration sets and fluids to ports
 NEVER connect previously used IV tubing to the new
central venous access line.
Line Necessity



Daily review of central line necessity may prevent delays
in removing lines that are no longer needed.
Many times, central lines remain in place simply because of
their reliable access and because personnel have not
considered removing the line.
However, it is clear that the risk of infection increases over
time as the line remains in place and that the risk of
infection is decreased if removed.
Daily Review of Line Necessity

Every day, ask the following:

Does the patient still need the line?



If yes, can a less risky catheter be used? (e.g., triple lumen to a peripheral)?
If no, can we remove the line today?
A central line may be considered necessary for the following:
 long-term antibiotics,
 multiple IV antibiotics,
 multiple blood / blood products,
 vesicant drugs (Dopamine, Dilantin, Vancomycin) or irritant drugs (Cefoxitin, Fortaz),
 TPN,
 chemotherapy,
 hemodynamic monitoring,
 reliable access (IV fluid therapy, frequent blood draws, pain management).
Dressing Changes



Replace catheter-site dressing if it becomes damp,
loosened, or visibly soiled or when inspection of the
site is necessary.
Dressing changes are to be done based on your
facility’s policy and line type.
Chlorhexidine is the preferred cleansing agent. When
cleansing the dressing site, use chlorhexidine (CHG)
swab or other approved agents per your facility’s
policy.
Dressing Changes (continued)





Do not use topical antibiotic ointment or creams on
insertion sites (except dialysis catheters).
Do not submerge the catheters under water.
Visually inspect site for swelling, erythema or drainage.
If any of these symptoms are present notify physician.
Do not use acetone or adhesive remover to remove old
dressings.
Transparent dressing material will release when
stretched.
Administration Sets

Replace administration sets, including secondary sets & add-on
devices, no more frequently than at 72-hour intervals, unless
CLABSI is suspected or documented.


Exception: Administration sets that have been intermittently
disconnected from the patient (open system) shall be changed
every 24 hours and immediately upon suspected
contamination or when the integrity of the product or system
has been compromised.
Replace tubing used to give blood/blood products after each
unit of blood/blood product is given.
Provide optimal care for
IV Injection Ports



Prior to accessing the port, clean it per the
manufacturer’s guidelines
(10 twists with 70% alcohol) and allow
to air dry before accessing the system.
(No blowing or fanning).
Cap all central line ports when not in use.
Change caps no more frequently than
every 72 hours and at least every 7 days
or according to the manufacturer’s
recommendations.
EXCEPTION: Change the cap when: it has been removed for any reason or any time the
cap appears damaged, is leaking, blood is seen in the catheter without explanation, blood
residue in the cap or when cap has been laid down on a non-sterile surface.
Hemodialysis Catheters


Do not use hemodialysis catheters for blood drawing or
applications other than hemodialysis except during dialysis,
under emergency circumstances or with MD order.
Use povidone-iodine antiseptic ointment
at the hemodialysis catheter exit site
after catheter insertion and at the end
of each dialysis session only if this
ointment does not interact with the
material of the Hemodialysis catheter
per manufacturer’s recommendation.
CENTRAL LINE Care



https://youtu.be/NjoISDHQeyc Dressing Change
https://youtu.be/6rz-UqeEEK0 Flushing the
Catheter
https://youtu.be/BwbEI23DIpE Admin of Meds
Hemodynamic Monitoring
Part I
(ABP, CVP, Ao)
MICU Competencies
2006-2007
41
What is Hemodynamic Monitoring?
• Non-invasive = clinical assessment & NBP
• Direct measurement of arterial pressure
• Invasive hemodynamic monitoring
42
Noninvasive Hemodynamic Monitoring
• Noninvasive BP
• Heart Rate, pulses
• Mental Status
• Skin Temperature
• Capillary Refill
• Urine Output
• Mottling (absent)
43
Proper Fit of a Blood Pressure Cuff
• Width of bladder = 2/3 of upper arm
• Length of bladder encircles 80% arm
• Lower edge of cuff approximately 2.5 cm
above the antecubital space
44
Why A Properly Fitting Cuff?
• Too
small
causes false-high reading
• Too
LARGE causes false-low reading
45
Indications for
Arterial Blood Pressure
• Frequent titration of vasoactive drips
• Unstable blood pressures
• Frequent ABGs or labs
• Unable to obtain Non-invasive BP
46
Supplies to Gather
• Arterial Catheter
• Pressure Tubing
• Pressure Bag
• Flush – 500cc NS
• Pressure Cable
47
Supplies to Gather
• Sterile Gown (2)
• Suture (silk 2.0)
• Sterile Towels (3)
• Chlorhexidine Swabs
• Sterile Gloves
• Mask
48
Leveling and Zeroing
• Leveling
– Before/after insertion
– If patient, bed or transducer move
• Zeroing
– Performed before insertion & readings
• Level and zero at the insertion site
49
Potential Complications
Associated With Arterial Lines
• Hemorrhage
• Air Emboli
• Infection
• Altered Skin Integrity
• Impaired Circulation
50
Documentation
• Insertion procedure note
• ABP readings as ordered
• Neurovascular checks every two hours
(in musculoskeletal assessment of HED)
• Pressure line flush amounts (3ml/hr)
• Tubing and dressing changes
51
Central Venous Pressure Assesses . . .
• Intravascular volume status
• Right ventricular function
• Patient response to drugs &/or fluids
52
Central Venous Pressure (CVP)
• Central line or pulmonary artery catheter
• Normal values = 2 – 8 mm Hg
• Low CVP = hypovolemia or ↓ venous return
• High CVP = over hydration, ↑ venous return,
or right-sided heart failure
53
Leveling and Zeroing
• Leveling
– Before/after insertion
– After patient, bed or transducer move
– Aligns transducer with catheter tip
• Zeroing
– Performed before insertion & readings
• Level and zero transducer at the phlebostatic
axis
54
Phlebostatic Axis
• 4th intercostal space, mid-axillary line
• Level of the atria
(Edwards Lifesciences, n.d.)
55
More on Leveling and Zeroing
• HOB 0 – 60 degrees
• No lateral positioning
• Phlebostatic axis with
any position (dotted line)
(Edwards Lifesciences, n.d.)
56
Dynamic Flush
Dynamic flush ensures the integrity
of the pressure tubing system.
Notice how it ascends - forms a
square pattern - and bounces below
the baseline before returning to
the original waveform.
•Check dynamic flush after zeroing
any pressure tubing system
57
System Maintenance
• Change tubing and fluid bag q 96hrs
• No pressors through CVP port
• Antibiotics, NS boluses, blood, & IV pushes are allowed
through the CVP line
58
Troubleshooting
• Improper set-up and equipment malfunction are the primary
causes for hemodynamic monitoring problems
• Retracing the set-up process or tubing (patient to monitor)
may identify the problem and solution quickly
• Use your staff resources: Help All, Charge Nurse, Educator,
Preceptors, MICU experts
59
Troubleshooting
Damped Waveforms
Pressure bag inflated to 300 mmHg
Reposition extremity or patient
Verify appropriate scale
Flush or aspirate line
Check or replace module or cable
60
Troubleshooting
Inability to obtain/zero waveform
Connections between cable & monitor
Position of stopcocks
Retry zeroing after above adjustments
61
Continuous Airway Pressure (Ao)
• Also known as Paw, Ao
• Purpose:
– Improves accuracy of hemodynamic
waveform measurements
– Identification of end-expiration
• Positive waveform deflections = positive
pressure ventilation
• Negative deflections = spontaneous
inspiratory effort
62
Supplies to Gather
• Pressure Cable
• Pressure Tubing
• Connector
(Edwards Lifesciences, n.d.)
63
Setting up the Ao
• Discard infusion spike end & cap port
• Connect pressure tubing to vent tubing
(using connector opposite heating cable)
• Connect cables
• Zero the tubing (leveling not necessary)
64
Troubleshooting Ao
• Do not prime tubing with fluids!
• Damping will occur with fluid or secretions
• To evacuate any fluids, disconnect pressure tubing from vent
tubing and push air through the pressure tubing with a 10 ml
syringe connected at one end until fluid-free
65
Summary
•Record Ao with CVP
•Read mean CVP at end-expiration as
described. No need read vascular pressure at
any particular time in the cardiac cycle
66
Documentation of CVP
• Include on waveform strip
–
–
–
–
–
–
Position of the HOB
Vasopressors and rates
Amount of PEEP
Scale
CVP measurement
Signature of the nurse
(post in green chart behind graphics tab)
67
References & Resources
Burns, S. M. (2004). Continuous airway pressure monitoring. Critical Care Nurse, 24(6), 70-74.
Chulay, M., & Burns, S. M. (2006). AACN Essentials of critical care. McGraw-Hill: New York.
Edwards. (2006). Pulmonary Artery Catheter Educational Project. http://www.pacep.org
Edwards Lifesciences. (n.d.) Educational videos. www.edwards.com
MICU Routine Practice Guidelines. www.vanderbiltmicu.com
MICU Bedside Resource Books
MICU Education Kits (Red cart in conference room)
MICU Preceptors, Help All Nurses, & Charge Nurses
VUMC policies. http://vumcpolicies.mc.vanderbilt.edu
68
References



http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_
CLABScurrent.pdf
http://www.ihi.org/IHI/Programs/Campaign/Centr
alLineInfection.htm
CDC. Guidelines for the prevention of intravascular
catheter-related infections. MMWR 2002;51(No.
RR-10)
CARE OF THE PATIENT
RECEIVING
BLOOD/BLOOD
COMPONENTS
OBJECTIVE
DEMONSTRATE
SAFE
NURSING INTERVENTIONS IN
BLOOD TRANSFUSIONS
PT EDUCATION

EXPLAIN RISKS AND BENEFITS

WHAT TO EXPECT

WHAT SIGNS/SYMPTOMS TO LOOK FOR

Discuss possible alternatives if unable to accept donation

What Religion will not accept transfusions?

JEHOVAH’s WITNESS
Other Alternatives

Volume Builders

Crystalloids

Artificial Crystalloids


Dextran for example

May cause bleed problems or allergic reactions

THEY ONLY REPLACE VOLUME
DONATIONS

Autologous

Predonation by the client themselves

Client will donate blood 1 unit/week for 3-4 weeks taking FE and/or EPO
Infusion Therapy Risks

Risk factors:

Disease transmission

Hepatitis B 1:140,000

Hepatitis C 1: 225,000

Hepatitis A 1:1 million

HIV 1: 1.5 million

Syphillis 1: 1 million

Bacterial contamination

Acute or delayed transfusion reactions


Mismatched ABO 1: 35,000

Incompatible Death Rate 1:600,000
Circulatory overload
Infusion Therapy Risks

Risk factors:

Disease transmission

Bacterial contamination

Acute or delayed transfusion reactions

Circulatory overload
Infusion Therapy Risks

Each unit of blood currently undergoes tests for nine diseases

Bacterial contamination is very rare, but may occur at any point


Refrigeration helps prevent bacterial growth
Transfusion reactions

Allergic reactions, incompatibilities, anaphylactic response to plasma proteins
Infusion Therapy Hazards

Some risks specific to massive transfusion (replacement of > one blood
volume in 24 hours):

Hypothermia

Hemodilution

Platelet dysfunction

Electrolyte problems

BUT WHICH ONES???

Calcium toxicity: LOW

Iron overload
Infusion Therapy Risks

Noninfectious Serious Hazards

Mistransfusion and ABO/Rh incompatibility

Cardiopulmonary toxicity/circulatory overload

Transfusion-related graft-vs.-host disease

Transfusion-related acute lung injury

Metabolic derangements in pediatric and massive transfusion

Under-transfusion
ADMINISTRATION PROCESS


ASSESS Transfusion history

Previous transfusions, allergies and reactions

Type of transfusion reaction, manifestations, and treatment
GET SET OF BASELINE VITALS
Interventions

Once the blood has been taken from the blood bank, it must be
administered within 30 minutes

The nurse must ensure:

Positive patient identification

Appropriateness of blood component

Blood product inspection

Verification of donor – recipient compatibility

Verification of product expiration date
adminstration of blood


Pt needs 18 or 20 gauge IV needle so cells are not
lysed (destroyed)
Prior to administration, blood needs to be checked
by 2 licensed nurses. Check the expiration date,
name, medical record number, type of blood,
blood band id, pt birthday

Check vitals prior to administration

**blood transfusion must be completed within 4 hours of initiation.

Use blood tubing for administration
Monitor for blood reactions
Monitor vitals continuously during administration


Y-type blood tubing.
Figure 23.2 Sample blood administration record fromMy Nursing
Lab
OBJECTIVE

ASSESS TRANSFUSION REACTIONS AND SAFE INTERVENTIONS
Transfusion Reactions
RX continued

Circulatory overload: dyspnea,
tachycardia, cough, frothy
sputum, cyanosis, increased BP that drops suddenly,
distended neck veins, crackles

High risk are elderly and those with history of CHF

cardio system is unable to manage the additional fluid load

Occurs anytime during transfusion and up to several hours after completion


Occurs if infusing too rapidly or too much quantity
Tx: stop infusion, call for help, be prepared for code, be prepared to administer
oxygen and Lasix
The END
PARENTERAL NUTRITION
Total parenteral nutrition (TPN) is the provision of
intravenous nutrients to patients whose
gastrointestinal (GI) tract is not functioning or cannot
be accessed and to patients whose nutritional needs
cannot be met with oral diets or enteral feeding. The
patient receives a combination of nutrients- crystalline
amino acids, dextrose, electrolytes, vitamins, minerals,
trace elements and lipid/fat emulsion administered
intravenously.
Once limited to critical care areas, TPN is now
present on post surgical floors and medical units,
when feeding by mouth is not possible, when a
person's digestive system cannot absorb nutrients
due to chronic disease, or, alternatively, if a
person's nutritional requirements cannot be met
by enteral feeding (tube feeding) and/or through
oral diet.
WHAT IS TPN?
Total parental nutrition (TPN) is the practice of
nourishing a patient intravenously, bypassing the
usual process of eating and digestion. It is a form of
specialized nutrition, including amino acids,
dextrose, fat emulsion, vitamins, minerals and trace
elements given intravenously.
• It is osmotically active and must be administered
carefully to prevent trauma to the vascular portal of
entry.
• It is administered intravenously and can be
administered through a peripherally inserted central
catheter (PICC), a central venous line (CVC) or a large
peripheral line.
• TPN is ALWAYS administered through an
infusion pump.
The sterile bags of nutrients are infused continuously
through the pump over a 12 hour or 24 hour period to
prevent vascular trauma and metabolic instability.
INDICATIONS FOR TPN ADMINISTRATION
• If there is intolerance to oral intake or enteral feeds and if the
patient is NPO for an extended period of time.
Short-term TPN (7 to 10 days) or long-term TPN (>10 days) is
used to treat patients whose GI tract is not functioning or not
accessible for various reasons.
Indications for TPN administration
PHYSIOLOGICAL CONDITION - Non functional GI tract
CLINICAL MANIFESTATION:
• Massive small bowel resection/ GI surgery
• Paralytic ileus
• Small bowel ileus (dilated bowel with air/fluid levels on CT scan)
• Intestinal obstruction
• Trauma to abdomen, head , neck
• Severe malabsorption
• Intolerance to enteral feeding (protracted nausea/vomiting)
• Bowel infarction/bowel ischemia
• Chemotherapy, radiation therapy, bone marrow transplant
• High output small bowel fistula >500ml/d
• Mechanical small bowel obstruction
Indications for TPN administration
PHYSIOLOGICAL CONDITION – Extended Bowel Rest
• Inflammatory bowel disease exacerbation
• Severe diarrhea
• Moderate to severe pancreatitis
Indications for TPN administration
PHYSIOLOGICAL CONDITION – Preoperative TPN
• Preop bowel rest
• Treatment for comorbid severe malnutrition in patients with nonfunctioning GI tracts
• Severe catabolic patients when GI tract is non-useable for more than
3 to 5 days
COMPOSITION OF TPN SOLUTIONS
TPN is specialized nutrition including amino acids, dextrose, fat
emulsions, vitamins, minerals and trace elements prepared in a
sterile bag for intravenous administration.
2 components: amino acids/dextrose solution and lipid emulsion.
TPN is ordered by the physician depending on the patient’s clinical
history and current metabolic needs.
ACCESS ROUTES FOR TPN ADMINISTRATION
TPN solutions must be carefully administered intravenously because
it is osmotically active and can cause trauma to the vascular portal of
entry.
TPN is best administered through a large vein through a PICC or CVC.
Peripheral IV is the last resort. The risk/benefit decision to use
peripheral parenteral nutrition should include as many phlebitismitigating techniques as possible.
TPN is NOT compatible with any other solutions and must be
administered by itself. An infusion pump must be used to
regulate the administration because it may lead to
hypoglycemia
Parenteral nutrition solutions containing final
concentrations exceeding 10% dextrose should
be administered through a central vascular
access device (CVAD) with the tip located in
the central vasculature, preferably the superior
vena cava right atrium junction for adults.
INS Standards of Practice 2011, pg. S91
FOOD FOR THOUGHT
• Consult religious leaders about continuous infusion of TPN
solution during fasting periods, i.e., Ramadan, Yom Kippur.
Devout followers may insist on fasting.
Follow agency policy and procedures when administering TPN.
Chemotherapy/Biotherapy
Administration
(Pre, Immediate and Post)
Objectives

At the completion of this session the
participant will be able to
◦ Identify components of pre-treatment
assessment
◦ Calculate BSA and confirm
chemotherapy/biotherapy dosage
◦ Describe required family teaching prior to
chemotherapy/biotherapy administration
Objectives

At the completion of this session the
participant will be able to
◦ Describe safety measures to verify
chemotherapy/biotherapy orders
◦ List steps in preparation of
chemotherapy/biotherapy
◦ Identify nursing measures for different
routes of administration
Individual Treatment
Plan



Review the individual treatment plan
for any required pretreatment
laboratory tests, imaging studies or
specialized organ evaluations.
Schedule all required studies
Check the general treatment plan for
any amendments and updates that may
alter therapy. Clarify any discrepancies
Follow institutional policies for verifying
chemotherapy/biotherapy orders
Pretreatment Physiological
Assessment

The following should be assessed and
completed prior to starting
chemotherapy/biotherapy:
◦ Review the individual's experience
with previous
chemotherapy/biotherapy regarding
side effects or toxic effects from the
medications
◦ Review with the child and family the
effectiveness of supportive care with
past chemotherapy/biotherapy
◦ Perform a thorough physical
assessment
Pretreatment Physiological
Assessment
Assess that all pretreatment laboratory
and imaging studies are complete and
within acceptable limits. Ascertain that
results of all pretreatment studies have
been evaluated
 Calculate the patient’s absolute
neutrophil count (ANC) prior to
administering chemotherapy using the
following formula:
 ANC = (% segs + % bands) x total
white blood count
 Verify within institutions ANC parameters
prior to beginning treatment

Pretreatment Physiological
Assessment



Begin the process of physiologic
preparation for
chemotherapy/biotherapy. This will
include hydration and plans for control
of nausea and vomiting
Obtain baseline vital signs
Deliver premedications for supportive
care and schedule at appropriate
intervals
Dosing of
Chemotherapy/Biotherapy
When calculating doses in
pediatrics, the actual body weight
is used
 Chemotherapy/biotherapy doses
are generally calculated using
body surface area. Accuracy of
weight and height measurements
is essential to correct dosing of
chemotherapy/biotherapy

◦ BSA = Ht (cm) X Wt (kg) ÷ 3600, then square
root the result
Dosing of
Chemotherapy/Biotherapy
Milligram/kilogram formulas are used
to calculate chemotherapy/biotherapy
doses in children weighing less than 10
kilograms or who are less than 12
months of age
 Maintenance fluids are calculated using
the BSA. A formula for calculating
fluids is 1500ml/m2/24 hours
 Toxicity from prior therapy may
necessitate dose reductions. Organ
dysfunction may necessitate dose
reduction

Preparation of
Setting

The following should be obtained
before beginning
chemotherapy/biotherapy:
◦
◦
◦
◦
Personal protective equipment (PPE)
Disposal equipment
Chemotherapy spill kit
Emergency drugs and equipment
available
◦ Infusion pump
Preparation of Setting

The following should be
obtained before beginning
chemotherapy:
◦ IV fluids and tubing
◦ Premedications (e.g.,
antiemetics)
◦ Emesis basin
Family Assessment &
Education

Accomplish the following
prior to each
chemotherapy/biotherapy
course:
◦ Identify barriers to learning,
including primary language,
anxiety and illiteracy
◦ Explore with the child and
family any personal
preferences they have
regarding chemotherapy
administration, such as the
time they prefer treatment to
start, any rituals the child
finds helpful and supportive
care
Family Assessment &
Education

Accomplish the following prior to
each chemotherapy course (cont.):
◦ Review the medications to be given.
Include the name of the medication,
administration route, length of therapy
and administration schedule
◦ Discuss potential side effects, when
they might occur and how they may be
managed
◦ Review plans for the management at
home after the
chemotherapy/biotherapy is complete
Principles of
Administration
Comprehensive patient
assessment
 Review/verification of
treatment plan
 Preparation
 Safe handling principles
 Patient/family education
 Follow institutional guidelines

Verification

Patient-Specific Information
◦
◦
◦
◦
Patient identification
Allergies
Current height, weight, BSA
Pre-treatment parameters such as pertinent
lab values that influence dosage
◦ Pre-treatment diagnostic testing results
necessary to begin chemotherapy/biotherapy
cycle
Verification

Chemotherapy Orders & select Biotherapy
Orders per institution
◦ The chemotherapy/Biotherapy order should include: (2
RN Check)
 Patient identification
 Patient-specific measurements (body weight, height,
and body surface area)
 The full generic name of the drug
 The drug dose, dose calculation, dose modification
calculation, route, frequency, administration guidelines
such as duration of infusion and rate of administration
 Required monitoring
 Admixture fluid type, volume and rate
Preparation

Preparation for Administration
◦ Assure test dose and/or pre- medications and
hydration are administered
◦ Protect light-sensitive drugs
◦ Inspect medication prior to administration for
discoloration and particulate matter
◦ Inspect medication label for drug name, dose
and expiration date
Preparation

Preparation for Administration
◦ Assure that the mode of administration is
consistent with knowledge of vesicants and
irritants and matches order, label and protocol
◦ Avoid bringing medications administered by
different routes to the patient’s room at the
same time
◦ Ensure patient/family education completed
Chemotherapy/Biotherapy
Administration

To ensure safe
administration:
◦ Follow institutional
and OSHA guidelines
for
administration/dispos
al
◦ Administer
medications in
accordance with
institutional
medication
and nursing practice
policies
and guidelines
Administration

To ensure safe
administration:
◦ Utilize the 6 rights
of safe
administration:






Right
Right
Right
Right
Right
Right
patient
medication
dose
route
time
fluid/volume
◦ Use leur lock
connections and
safety needles
Administration

Oral
◦ Do not handle without PPE
◦ Tablets should not be crushed and dissolved
outside of a biological safety hood
◦ If an oral dose is vomited, establish
guidelines for repeating the dose with the
ordering clinician
Administration

Oral
◦ Creative measures for helping small children tolerate
oral medications
◦ School-age children and adolescents, who are
responsible for taking their own oral
chemotherapy/biotherapy, should have their doses
verified by an adult
◦ Liquids should be given in an oral type syringe to
deliver an accurate dose of the entire drug and
minimize spills/residue
Administration

Intramuscular/Subcutaneous
◦ Site selection
 Injection into larger muscles is
recommended
 Avoid injection into areas of pre-existing
tenderness and/or ecchymosis or nodules
from prior injections
 Volume for single injection is sitedependent
◦ Smallest gauge needle as appropriate
for child’s size
◦ Ensure age-appropriate preparation and
teaching are completed with the patient
and family
Administration

Intramuscular/Subcutaneous
◦ If the patient is mildly thrombocytopenic,
after the injection, apply pressure directly
to injection site for 5 minutes to prevent
formation of a hematoma
◦ Apply topical anesthetic agent or ice to the
injection site prior to the injection to
minimize pain
◦ Dispose of waste in accordance with OSHA
and institutional policies and guidelines
◦ Rotate the site of injection for subsequent
injections
Administration
Intravenous (IV) access must be established
and patency verified prior to administration
 IV access may be established via:

◦ Peripheral IV catheter
◦ Central venous catheter(CVC)
 External catheters
 Broviac, Hickman, Groshong, PICC
 Implanted ports
 Medi-Port, Port-a-CathTM
Administration

Peripheral IV
◦ Avoid site selection distal to any recent
venipuncture
◦ A new peripheral IV site is
recommended if an already existing
peripheral IV site is older than 24 hours
◦ Areas over joints or bony prominences
and the antecubital fossa should be
avoided
◦ During IVP vesicant administration,
blood return should be verified after
each 0.5cc-1cc injected
Administration

Implanted Central Venous Catheters
◦ Assure the selected site is stabilized just prior to
injection/infusion to avoid accidental needle
punctures and/or accidental drug exposure. For
long-term infusions, tape the site securely, without
obstructing your view of the site, so that signs of
extravasation can be promptly identified
Administration

CVC and continuous infusion
◦ Blood return should be verified
immediately prior to beginning the
infusion
◦ The CVC site should be evaluated for
signs of inflammation and extravasation
of a vesicant infusion every hour
throughout the infusion
◦ Secure IV tubing with leur lock
connections
◦ Use gauze and/or plastic backed drape
beneath connections during access or
de-access procedures
Administration

IV
Administration
Methods
◦ IV Push (IVP)
◦ Bolus infusion
◦ Continuous
infusion
IV Push Administration
IV push therapy is infused in
less than 5 minutes
 Methods

◦ Direct push: Directly infusing
chemotherapy agents into the IV
access device using a syringe
◦ Stop cock method: Using a 3way stop-cock to administer
chemo
Continuous IV
Infusion



Infusions should not be
interrupted unless
absolutely necessary
Infusion pump should be
used
Ensuring drug is infused
in prescribed time
◦ Some protocols allow
for increasing dose by
10%
◦ Other protocols do not
allow for change of
rate
◦ Check with the
prescribing clinician if
infusion will not finish
at prescribed time
Vesicants/Irritants

Vesicants: are a class of drugs,
that when extravasated cause
severe tissue damage and may
lead to necrosis (Jenkins, 1998)
 Irritants: are agents that have
the potential to cause phlebitis
and irritate tissue if extravasated,
they do not cause the degree of
tissue damage and necrosis that
vesicants do
Monitoring for Potential
Side Effects

Flare Reaction
◦ A localized venous inflammatory
reaction in response to an IV agent
◦ Signs and symptoms include pain,
redness at the site and along the vein
length
◦ Treatment/management: Once
extravasation is ruled out, the vein
should be flushed with a compatible
IV fluid and resolution of the redness
should follow
Monitoring for Potential
Side Effects

Hemodynamic monitoring
◦ Monitor hemodynamic status
taking vital signs as indicated
throughout administration
Monitoring for Potential
Side Effects

Fluid status
◦ Monitor fluid status: measure
urine output and urine specific
gravity as needed throughout
administration
◦ Monitor hydration status: oral
intake, skin turgur, mucous
membranes, and tears, assess the
impact of nausea and vomiting on
oral intake
Monitoring for Potential
Side Effects

Specific side effects:
◦ Monitor for the
occurrence of side
effects
◦ Monitor the
effectiveness of the
anti-emetic regimen
Monitoring for Potential Side
Effects – Allergic Reactions
Allergic reactions and anaphylaxis
are hypersensitivity reactions to a
foreign protein that can occur
immediately or within minutes to
hours after exposure to the
offending protein
 The reaction can be localized or
systemic

IgE Mediated vs Non IgE
Mediated
IgE Mediated
 Specific IgE is
produced at
initial exposure
 Reaction occurs
at subsequent
exposures
 Anaphylaxis
Non IgE Mediated
 No prior
sensitization
required
 Reaction can occur
at initial exposure
 Anaphylactoid
◦ Non-Allergic reaction
◦ Allergic Reaction
Chung, C 2008
Signs and Symptoms
Infusion Reaction
Allergic Reaction/Hypersensitivity
 Pruitis/itching
 Rash/desquamation
 Urticaria: hives, welts, wheals
 Rigors/chills
 Headache
 Arthralgia/myalgia
 Fatigue (asthenia, lethargy, mailaise)
 Dizzyness
 Sweating
 Nausea/Vomiting
 Cough, Dyspnea, bronchospasm
 Hypotension/hypertension
Heinz-Josef Lenz, 2007
 Tachycardia

Severe Infusion Reaction
Life threatening and may appear
within minutes of exposure
 Severe bronchospasm, laryngeal
edema, respiratory distress, and/or
cutaneous and gastrointestinal,
leading to hypotensive crisis

Chung, C 2008
Infusion Reactions
Prevention/Prophylaxis
 Acetominophen
 Antihistamines
 Corticosteroids
 H2 antagonist
Management
 Antihistamines
 Corticosteroids
 Epinephrine
 Oxygen
 Vasopressors
 Bronchodilators
Mild to Moderate Reactions
Resume infusion at 50% reduction of
infusion rate once
symptoms are completely resolved
Chung, C 2008
Monitoring for Potential Side
Effects – Allergic Reactions

Nursing interventions
◦ Stop Infusion
◦ Maintain airway, IV access, vital signs
◦ Administer medications promptly in
the event of a reaction:




acetaminophen (Tylenol)
diphenhydramine (Benadryl)
Steroids
epinephrine (Adrenaline, Sus-phrine)
 Know the actual doses of medications that
would be needed specifically for an individual
patient receiving a potentially anaphylactic
medication
Documentation








Date and time
Venipuncture site (central or peripheral)
Venipuncture needle type, gauge, length
Verification of blood return, prior to,
during and after infusion
Drug name, dose, route and volume in ml
Type and amount of IV flush solution
used
Infusion duration
Document per institution guidelines
Documentation








Antiemetic, dose, time
Pre-med, dose, time
Hydration type and
amount
Method of
administration
Adverse reactions/side
effects
Patient tolerance of
chemotherapy/biothera
py
Ability to tolerate fluid
and food
Patient and family
education
Patient and Family Education

Prior to administration and during
administration of
chemotherapy/biotherapy
◦ Name of medications to be given
◦ Administration route and any routespecific step-by-step administration
guidelines
◦ Expected or potential side effects and
when they may occur
◦ Safe handling considerations
Patient and Family Education
Supportive care measures
should be a part of the
education plan
 If a patient is prescribed
growth factors, side effects
and detailed administration
techniques should be
reviewed

Patient and Family Education
Ensure discharge teaching is
completed with the patient and
family, and they have all
necessary medications,
equipment, supplies and disposal
instructions, if the patient is to
receive medications at home
 Patients and family members
should be aware of reportable
symptoms and side effects, as
well as who to contact and the
telephone/pager numbers

Discharge Planning
CVC teaching
 Home care referral
 Review expected or
potential side
effects they may
experience at home
 Chemotherapy/
biotherapy schedule
(calendar)
 Follow-up
appointment

Patient and Family
Outcomes
Accurate and safe
administration of
chemotherapy/
biotherapy
 Effective
management of
nausea and
vomiting
 Effective pain and
symptom
management
 Effective
anticipatory
guidance

Demonstrate the
technical skills
necessary to
provide care at
home
◦ Medication
administration,
central line
catheter care, etc.
 Effective
documentation of
chemotherapy/
biotherapy
administration at
home
