HYPERALIMENTATION & CENTRAL VENOUS CATHETERS

NURSING 108

ECCMajuvy L. Sulse MSN, CCRN

Objective

• Use safe and accurate techniques when caring for clients who are receiving Hyperalimentation and who have central venous catheters

HYPERALIMENTATION

Parenteral Nutrition-delivery/introduction of nutrients, including amino acids, lipids, carbohydrates, vitamins, minerals and water, through a venous access device (VAD) directly into the intravascular fluid required for metabolic functioning of the body.

Components of TPN

• Calories– Carbohydrates-100-150 g/day– Fat (emulsions)-10%, 20%, 30% (1 cal/ml)

• Soybean or safflower triglycerides with eggs as emulsifier.• 2.5g/kg/day• Administered slowly over 12-24 hours

• Protein– Amino acids

– Daily requirement-45-65 g– 1-1.5g/kg/day

• Trace elements• Vitamins

Components of TPN

• Electrolytes– Na:1-2 mEq/kg– K: 1-2 mEq/Kg– Mg: 8-20mEq– Ca: 10-15mEq– Phosphate: 20-40mmol

CLINICAL INDICATIONS

• Paralytic Ileus• Intestinal obstruction• Acute pancreatitis• Malabsorption/malnutrition• Persistent vomiting/ Severe diarrhea• Fistula• Inflammatory bowel disease• Severe anorexia nervosa

Methods of Delivery

Peripheral Parenteral Nutrition (PPN)Lesser concentrated glucose solution with amino acids, vitamins, minerals & lipids given through a PERIPHERAL vein

Total Parenteral Nutrition (TPN)Combines glucose (20-70%), amino acids, vitamins, & minerals via a CENTRAL lineLipids 10%-20% emulsion composed of triglycerides, egg phospholipids, glycerol, & watermay be given intermittently or mixed with the TPN thru a central line

Nursing Management • VS monitored every 4-8 hours or as per facility policy• Strict I & O• Ensure that the correct infusion rate is delivered.• Blood levels of glucose, electrolytes, BUN, CBC &

hepatic profile depending on patient status and protocol • Blood glucose testing at bedside as per

protocol/physician’s order• Daily weights• Monitor peripheral or central lines for signs & symptoms

of infection.• Aseptic dressings change as per facility protocol• Patient education or significant others

Administration of Parenteral nutrition• Ensure correct order from healthcare provider• Remove TPN from refrigerator at least 1 hr before

hanging• Inspect fluid for presence of cracking or creaming• Wash hands• Use strict sterile technique, attach tubing with filter (0.22

micro Millipore for non fat emulsion solution & 1.2 micron with fat emulsion solutions) to PN bag and purge air

• Close all clamps on new tubing. Insert tubing into volume control infuser

• If VAD has a clamp at proximal end, clamp tubing. If no clamp is available on central VAD, instruct the patient to Valsalva manuever while new tubing is connected. Connect tube to hub of VAD

Administration of Parenteral nutrition

• Monitor administration hourly, assessing for the integrity of fluid, patient tolerance & complications.

• If new TPN solution is not available, hang D10W• Document tubing change & fluid administration,

observations, complications & any treatment given• If to be discharged with TPN, teach patient & family

regarding proper storage, handling and administration of TPN

• NOTE: TPN solution, Tubing & Filter are changed every 24 hours or as per hospital policy

Central Venous Access Devices• Placement of flexible catheter into

a client’s central veins most commonly SVC

• Purpose– Long term IV therapy– Long term antibiotic therapy– Blood/ blood product transfusions– Administration of total parenteral

nutrition– Measure direct pressure readings

(CVP)– Chemotherapy– Enhancing diagnostic agents

Central Venous Access Devices• Peripherally inserted central catheters

(PICC)• Single or double lumen polymer

about 45-60 cm gauge 24-16

• Done under sterile conditions by physician or trained RN

• Local anesthetic is used

• Inserted above antecubital fossa- usually basilic (preferred) or cephalic veins with tip at distal 3rd of SVC

• Sterile dressings covers the site

• X-ray confirms placement of tip before line is used

• Used for long-term IV/ TPN therapy

• May remain in place 6-12 monthsPICC

Central Venous Access Devices

• Nontunneled percutaneous catheters• Inserted to SVC or Jugular vein• Short term use• 15-20 cm long dual or triple lumens• Contraindications: ICP, respiratory conditions, spinal

curvatures, trauma/surgery/radiation on neck & chest

• Tunneled Central catheters• Frequent & long term therapy• Dacron Cuff placed inside the subcutaneous tissue,

granulation occurs anchoring the catheter and providing barrier to microrganisms

Tunneled Central catheters

Catheters cont’d

• Central venous pressure catheter (CVP)• Same as PICC but done by physician only• Subclavian, External jugular, femoral

Double Lumen CVPTriple Lumen CVP

Catheters cont’d

• Implanted infusion ports• Consists of a catheter placed

into a desired vein and the other end connected to a port placed surgically in a subcutaneous pocket on a chest wall

• Port consists of metal sheath with self sealing silicone septum

• Accessed via the septum by Huber-point needle that is deflected to avoid coring of the septum

Implanted infusion ports

Nursing Responsibilities

• Maintenance of CV lines-observe for signs & symptoms of infection

• To change Central venous catheter as directed by MD/protocol:

• Obtain equipment• Explain procedure to patient• Place in patient comfortable supine with head

turned away from site• Wash hands• Don gloves & carefully remove old dressing• Inspect insertion site for complications

Nursing Responsibilities• Clean insertion site with each alcohol swab at

insertion site and moving outward in a circular pattern

• Repeat using povidone-iodine swab/Chlorhexidine• Allow to dry• Apply new transparent dressing• Loop and tape tubing to the skin but do not tape

over the dressing• Document dressing change and observation of

insertion site• Teach patient/family instruction regarding sterile

dressing change and report signs of infection, fluid extravasation & phlebitis and inform nursing personnel

Complications of TPN

• METABOLIC• Fluid overload• Hyperglycemia/hypoglycemia/ hyperosmolar states• Biliary complications• Hyperlipidemia• Electrolyte & vitamin excesses or deficiencies

• INFECTIOUS• Catheter sepsis-staph aureus & epidermis, fungus, gram +

and/or gram-

• Mechanical• Air embolus, hemothorax, pneumothorax, hydrothorax,

chylothorax, thrombosis, phlebitis, dislodgement of tube, brachial plexus injury

Nursing Diagnosis

• Imbalanced nutrition: less than body requirements

• Risk for Infection

• Risk for Impaired skin integrity

• Risk for fluid volume overload