Exam 1 - TPN, Specimen Collection, Central Lines Flashcards
(127 cards)
1
Q
reasons a pt would need TPN (11)
A
- can’t ingest, absorb, or digest via GI tract
- severe malnourishment
- negative nitrogen balance
- impaired GI tract
- acute pancreatitis
- Gi bleeding
- exacerbations of Crohn’s Disease
- severe burns or trauma
- sever liver or renal disease
- radiation enteritis
- terminal illness
2
Q
examples of impaired GI tract
A
- ileus
- surgery
- fistulas
- short “gut” bowel syndrome
3
Q
what makes up the components of TPN nutrition
A
- amino acids
- glucose
- fat emulsion (lipids/intralipids)
- vitamins
- electrolytes
- minerals
- trace elements
- water
4
Q
what is the normal glucose concentration in TPN for adults
A
10%
5
Q
with more serious conditions and depending on what the patient can tolerate what is the alternate concentration of glucose in TPN
A
15-25%
6
Q
what two ways can lipids be included with TPN
A
combined or infused separately
7
Q
if the glucose concentration of TPN is greater than 10% how should the TPN be administered
A
via central or PICC line
8
Q
TPN infusions are administered via
A
dedicated port or central line
9
Q
how is TPN mix created
A
customized by the pharmacy using aseptic technique
10
Q
for how long is TPN usually infused over
A
24 hours, but can also be cyclic
11
Q
how often are the lipids and tubing for TPN changed
A
every 24 hours
12
Q
are medications able to be added to TPN infusion bags by the nurse
A
NEVER
13
Q
are TPN and lipid infusions a closed or open system
A
closed
14
Q
can anything be piggybacked or infused into the TPN IV tubing
A
no
15
Q
what must be done with TPN until 30 min prior to be infused
A
it must be kept refrigerated
16
Q
what should be infused should the TPN be unavailable for any reason and why
A
IV solution of 10% dextrose and water to prevent rebound hypoglycemia
17
Q
what is D10W
A
10% dextrose and water
18
Q
what kind of filter is needed with TPN infusions
A
0.22 micron filter
19
Q
how are lipids infused and do they need to be refrigerated
A
separate from TPN via peripheral IV catheter and does not require refrigeration
20
Q
what should be monitored with TPN infusions
A
- blood glucose
- assess site for infection
- signs and symptoms of infection/sepsis
- signs of hyperglycemia
21
Q
if blood glucose becomes too high while receiving TPN what should be administered
A
insulin
22
Q
the no-no’s regarding TPN infusion
A
- do not store at room temp
- do not add any medications to TPN bag
- do not give an secondary medications through the TPN
- do not give any other medications in the same central catheter lumen as TPN solution
23
Q
what should the TPN bag be examined for before administering
A
turbidity, precipitation, cloudiness, any cracks or holes
24
Q
should the TPN bag not be administered if there is any cloudiness, turbidity, precipitation or any holes or cracks
A
do not use it
25
what should the RN check on the pharmacy label and prescriber order for TPN
- pt name
- medical record # or birthdate
- solution contents (every line)
- expiration date and time
26
what should be done prior to hanging TPN bag
check label and sign off on TPN order
27
the date and time should be put on what when doing TPN solutions
the solution ad the tubing
28
what type of tubing should be used for TPN
needleless tubing
29
where should the primed and needleless tubing for TPN be connected to
patient's IV catheter
30
how often should TPN infusion rate be checked
every hour
31
what complications should be monitored when infusing TPN
- fluid volume excess
- hyperglycemia
- hypoglycemia
- osmotic diuresis and fluid volume deficit
- electrolyte imbalances
- signs of infection
32
what should the central and peripheral IV be assessed for during TPN
infection, phlebitis, pain, and purulent drainage
33
what is number one priority for pt with central lines and receiving TPN
preventing infection
34
potential nursing diagnoses for TPN (7)
- risk for infection
- risk for hypoglycemia (less than 60 mg/dl)
- risk for hyperglycemia (more than 200 mg/dl)
- risk for fluid volume overload
- risk for fluid volume deficit
- risk for electrolyte imbalance
- risk for hypertriglyceridemia
35
causes of hyperglycemia when administering TPN
- too rapid infusion
- infection/sepsis
- medication induced
- co-existing diabetes mellitus
36
what do you give for hyperglycemia during TPN
insulin
37
what do you give for hypoglycemia during TPN
D10W or 50% dextrose solution if perscribed
38
what can cause hypoglycemia during TPN
- abrupt decrease in TPN infusion rate
| - abrupt discontinuation of TPN
39
signs and symptoms of fluid overload during TPN
tachycardia, hypotension, distended neck veins, weight gain, lung crackles
40
treatment for risk of fluid overload during TPN
maintain strict I and O's and daily weight
41
signs and symptoms of fluid volume deficit during TPN
decreased urine output, patient thirsty, decreased skin turgor, tachycardia, orthostatic hypotension
42
treatment for risk of fluid deficit during TPN
I's and O's and daily weight
43
signs and symptoms of electrolyte imbalance during TPN
muscle weakness, lethargy, cramps, muscle twitching, cardiac rhythm changes
44
treatment for risk of electrolyte imbalance during TPN
monitor serum electrolyte levels and report abnormal levels to provider
45
treatment for hypertriglyceridemia during TPN
infuse lipids as ordered, obtain weekly serum triglyceride levels, use caution when administering meds that are lipid based
46
system of double checks for specimen collection
1. 1st person signs with first initial and last name on label and requisition, and dates and times
2. 2nd person checks accuracy of pt, matching label and requisition then initials requisition
47
what can effect specimen accuracy
- specimen contamination
- delay in sending specimens
- inappropriate container or culture media
- mislabeled or incorrectly identified
- no I.D. on source of specimen
- no report of meds that pt is taking that affect specimen analysis
48
what cultures can be obtained using sterile swab
throat, wound, body cavity, fistula, rectal, vaginal
49
reason for wound/fistula culture
identify infectious agent in wound drainage
50
reason for sputum culture
identification of bacterial, viral, fungal infections and acid-fast bacillus for mycobacterium tuberculosis
51
reason for culture for body cavity or fluid
signs and symptoms of inflammation and infection
52
reason for cultures of stool
identification of bacterial, fungal, parasitic infections, ova and parasites, currently c.diff
53
reason for throat culture
presence of strep
54
reason for urine analysis
presence of UTI, also checks endocrine, kidney function, pH, color specific gravity, test for ketones, protein, glucose, red cell casts or white cells for infection or inflammation
55
common organisms from throat cultures
strep
56
common orgs from wound cultures
staph, strep, pseudomonas, klebsiella
57
common orgs from rectal cultures
vancomycin resistant enterococcus, c-diff
58
common orgs from vaginal cultures
various bacteria, chlamydia
59
common orgs from nose and skin cultures
MRSA
60
when swabbing wound do not swab where
outer edge or crusts near skin
61
directions to patient for urine stream collection
1. wash hands
2. open 3 towelettes
3. open container lid side up, don't touch rim
4. girls - cleanse each side labia from to back, separate towel for each
boys- swiping motion away from meatus
5. void a little urine, stop catch in cup
62
when should a 24 hr urine stream usually begin
first thing in the morning
63
what is usually the purpose of 24 hr urine collection
for total protein and creatinine clearance
64
during a 24 hr urine collection does the first void count towards the collection
no the first void gets discarded
65
when does time start for 24 hr urine collection
after the first void
66
when does the 24 hr end during a 24 hr urine collection
up until the last void before the end of 24 hrs
67
what are the instructions if a urine gets discarded during 24 hr urine collection
advise the patient to get a new container and begin again tomorrow if at home, but if in hospital you can begin after that last void
68
is it okay to end a 24 hr urine collection in the middle of the night
no
69
does a urinalysis include a test for culture and sensitivity
no
70
can urinalysis identify organisms
no, but it can point to presence of organism
71
indications for stool specimen
stool, culture, fecal fat content, occult blood testing, presence of ova and parasites
72
if checking stool for ova or parasites what must be done with the sample
fresh stool sample must be sent to lab immediately, no later than 30 minutes, and not refrigerated
73
fecal fat content is tested by
collecting stool for 24, 48, or 72 hr period
74
how to obtain fecal culture
sterile swab or sterile specimen cup
75
how to test for occult blood in stool
gualac (wooden stick), small amount of stool on each test site
76
venipuncture is a ______ procedure using _______ gloves
sterile.... clean
77
in most adults what is the most suitable site for venipuncture
antecubital veins
78
what is something to keep in mind when drawing multiple tubes of blood
the order of the tubes is important especially if certain tubes have products in them to test different things
79
what kind of needles are used for peds for venipuncture
butterfly needle and syringe or vacutainer and adaptor w/ butterfly if vein small
80
order of venipuncture blood draw (7 steps)
1. apply tourniquet
2. palpate vein
3. release tourniquet and use antiseptic
4. reapply tourniquet
5. Insert needle and obtain specimen
6. release tourniquet and remove needle covering site with pad
7. Label specimens and discard needle in sharps
81
what does CVAD stand for
central venous access device
82
what are the 4 types of CVADs
1. non-tunneled catheters
2. tunneled catheters
3. implanted vascular device
4. peripherally inserted central catheters
83
what is a tunneled catheter (CVAD)
tunnels under the skin and then threaded into central vein
84
what is an implanted vascular device
device under the skin with catheter going into a central vein
85
what is a peripherally inserted central catheter
threaded through a peripheral vein and into the central circulation/vein
86
what are indications for CVAD insertion
- infusion of concentrated solutions
- vasoactive medications
- blood products
- poor or limited peripheral venous access
- long term meds, chemo or other irritating solutions
- hemodialysis
87
what is the main principle of the groshong catheter
it has a three way valve which acts to reduce the risk of air embolisms, blood reflux, and clotting
88
groshong catheter - negative pressure opens valve _____ permitting blood aspiration
inward
89
groshong catheter - positive pressure opens valve _______ allowing infusion
outward
90
neutral pressure valve remains _______ reducing risk of air embolism, blood reflux, and clotting
closed
91
what kinds of catheters do not require heparin
closed-ended catheters
92
what are the two names of tunneled catheters
hickman and broviac
93
what is catheter tunneling
the positioning of a portion of the catheter within the sub Q tissue between the vein access and the exit site
94
what is the benefit of a tunneled catheter
provides stability and protect against endovascular infection
95
complications from central venous access catheters
- thrombosis
- infection (acute or delayed)
- air embolism
96
non-tunneled catheters can also be called
multi-lumen catheters
97
where are multi lumen catheters placed
- subclavian or internal jugular vein
98
for peds where can multi-lumen catheter be placed
in groin
99
what is the purpose for a multi lumen catheter
- administer large volumes and multiple fluids
- vasoactive meds, antibiotics, blood products, TPN
- obtain blood samples
100
general indication for a PICC line
kept over a long period of time
101
what can a PICC line be used for
- antibiotics
- hydration
- pain management
- infusion of hyperosmolar/hypertonic solutions
- blood transfusion
- hyperalimentation (TPN)
- certain chemotherapies
- home inotropic therapy
102
advantages of PICCs
- can be used in acute or home care
- freedom of movement
- small and flexible
- can be used in young and old
- can be used for fluid or blood draws
103
indications for a dialysis catheter
- pt with acute renal failure
- pt with an overdose
- pt requiring maturation of dialysis fistula or graft
- bridge to transplantation
- permanent access in patients who have no dialysis sites
104
what is the disadvantage of dialysis catheters
they are hard to maintain over a long period of time, especially with infection or septicemia
105
other terms for implantable venous access device (IVAD)
port-a-cath
| medi-port
106
indications for IVAD
- access site for blood samples
| - cyclic therapies (chemo, antibiotics
107
IVAD can handle both _____injections and ______ infusions
bolus....continuous
108
signs and symptoms of CVAC related thrombosis
- swelling, warmth, tenderness of extremity beyond the insertion site
- cyanosis of face
- development of collateral vessels (extra vessels)
109
how is CVAC related thrombosis diagnosed
ultrasound, venogram, CT angiography
110
signs and symptoms of CVAC related infection
- fever, increased WBC, erythema, tenderness at catheter site or purulent drainage
111
CVAC acute infection occurs when and is often due to
3-5 days after insertion, due to contamination during insertion procedure
112
CVAC delayed infection occurs when and is often due to what
more than 5 days after placement of device ad usually due to staph aureus
113
CVAC related air embolism is what
entry of air into vasculature during insertion, while catheter in place or during removal
114
signs and symptoms of CVAC air embolism
- respiratory distress
- increased HR
- cyanosis
- decreased BP
- sudden change in LOC
- pt complain of back, shoulder pain
- churning murmur over precordium upon auscultation
115
management of air embolism from CVAC
- admin oxygen
- pinch off catheter
- cover any open or disconnected catheter ports
- place patient on left side (Trendelenberg position)
116
what is trendelenberg position
placing patient on left side to keep air in right atirum
117
"bundle" aspects of central line care
- daily assess for need of catheter
- aseptic technique
- site care
- maintain occlusive dressing (sterile)
- minimize breaks in line
- scrub all hubs
- timely tube changes
118
when should central line dressings be changed
- every 7 days if covered by tegaderm
| - if loose, wet or non-occlusive
119
what type of syringe should be used for central lines
10mL or larger
120
dressing of central line should cover what in the center
the insertion site and suture wings
121
what does occlusive mean
completely closed off tegaderm
122
hand hygiene for central line care
wash hands before handling tubing and use clean gloves
123
always remove transparent dressing ______ insertion site to avoid yanking it out
toward
124
how long should site be scrubbed when changing central line dressing
30 seconds
125
during central line dressing change mask should be worn by
yourself and the patient
126
what should you bring with you if there is drainage around central line site
sterile swab and extra sterile gloves
127
what is important to think of before and after central line dressing change
height of bed and side rail
