Postprocedure education for central lines
- No BP's on that arm
- No heavy lifting
- Cleaning once a week
What makes a midline different?
- not central because it doesn’t go into aortic branch
- Similar to Peripheral venous access
- Into basilic to the axilla
What cannot be done with a midline?
- pH can’t be too acidic - be careful with meds
- No blood draws
A CVAD (central venous access device) lands where?
superior vena cava
Why do we use CVAD?
Meds not irritating to veins because it dumps into SVC where there is a large amount of blood
What is done right after insertion of CVAD?
Xray to determine placement
Complications of CVAD placement?
- Thrombus formation
Where is the tunneled and non-tunneled catheter placed?
- Subclavian vein
- Internal Jugular (IJ)
What is special about accessing Ports?
- Must be specially trained
- Use a Huber needle to access
- Porta-cath life is based on the number of punctures
Non-tunneled cath vs. tunneled - why?
Non-tunneled – if patient just needs quick renal replacement therapy (not staying in as long)
What are the protocols for preventing infection with a CVAD?
CLABSI (central line associated bloodstream infections)
Why use a 10 mL syringe to flush any central line?
smaller barrels exert too much pressure which poses a risk for rupturing the catheter
How much do we flush a CVAD?
- 10 mL NS before and after medication administration
- 20 mL NS after blood draw
Name the precautions taken to prevent catheter-related bloodstream infections. Major components of the bundle:
- Hand hygiene
- Maximal barrier precautions upon insertion (sterile - gown, mask, gloves)
- Chlorhexidine skin antisepsis
- Optimal catheter site selection
- Post-placement care
- Daily review of line necessity
Normal HCO3 (bicarb)
K+ with someone in metabolic acidosis
K+ in someone in metabolic alkalosis?
What is metabolic acidosis?
- pH <7.35
- too much acid (H ions) not enough base (HCO3)
What are some causes of metabolic acidosis?
- Starvation diet / low carb diets
- DKA (metabolic) – extremely high glucose that can’t be used – tissues use fat
- Kidney failure (metabolic) – under elimination of H+ ions or underproduction of bicarb (also caused by pancreatitis)
- Hypoxia at tissue level (metabolic) – fever, infection
- Salicylate intoxication (ASA overdose)
- Diarrhea – over elimination of bicarbSevere dehydration
What are some causes of Respiratory Acidosis?
- Hypoventilation (respiratory)
- Airway obstruction
- Alcohol intoxication
- Sleep apnea
- ALS/MS/Muscular Dystrophy
- Guillan Burre
- Pain / Trauma – example fractured ribs
An overproduction of hydrogen ions can result in ?
An underelimination of hydrogen ions (like in kidney failure) can result in ?
An underproduction of bicarbonate (like in kidney failure pancreatitis, liver failure or dehydration) can result in ?
An overelimination of bicarbonate (like in diarrhea) can result in ?
An underelimination of hydrogen ions (like in respiratory depression, airway obstruction, COPD, trauma...) can result in ?
What do we want to assess first in a patient at risk for acidosis?
Cardiac system - acidosis can lead to cardiac arrest from hyperkalemia
Cardiac manifestations (Key features) of acidosis?
- Delayed electrical conduction: (brady to heart block, tall T-waves, widened QRS, prolonged PR
- Thready peripheral pulses
CNS manifestations (Key features) of acidosis?
Depressed activity: lethargy, confusion, stupor, coma
Neuromuscular manifestations (Key features) of acidosis?
- skeletal muscle weakness
- flaccid paralysis
Respiratory manifestations (Key features) of acidosis?
- Kussmaul respiration
- variable respirations
Integumentary manifestations (Key features) of acidosis?
- warm, flushed, dry skin (metabolic acidosis)
- pale to cyanotic and dry skin (respiratory acidosis)
What is Alkalosis?
- pH >7.45
- too much base (HCO3) and not enough acid (H ions)
What are some causes of Metabolic Alkalosis?
- Antacids use
- Vomiting (lose acid)
- Loop Diuretics (number one cause of metabolic alkalosis in hospitals)
- NG suctioning
- Blood transfusions with citrate
What are some causes of Respiratory Alkalosis?
- Hyperventilation – must be careful with mechanical vent patients
- Anytime body not getting enough O2 to tissues – compensation is to breath more times in a minute
An increase of base components (like ingesting antacids, blood transfusion) can cause ?
A decrease of acid components (like in vomiting, NG suctioning, thiazide diuretics, hypercortisolism, or hyperaldosteronism) can cause ?
An excessive loss of carbon dioxide (like in hyperventilation, fear, anxiety, mechanical vent, ASA tox, altitudes, shock, pulmonary problems) can cause ?
CNS manifestations (Key features) of Alkalosis?
- increased activity
- anxiety, irritability, tetany, seizures
- +Chvostek's sign
- +Trousseau's sign
Neuromuscular manifestations (Key features) of Alkalosis?
- muscle cramping and twitching
- skeletal muscle weakness
Cardiovascular manifestations (Key features) of Alkalosis?
- Increased HR
- normal or low BP
- Increased digitalis toxicity
Respiratory manifestations (Key features) of Alkalosis?
- Increased rate and depth of ventilation (in Respiratory alkalosis)
- Decreased respiratory effort associated with skeletal muscle weakness (in metabolic alkalosis)
When assessing a patient with respiratory issues, what are some questions to ask?
- Where do you work
- Meds are you on
- Health problems
- Childhood illnesses
- Lung cancer
air entrapment under the skin – crackling sensation - also called subcutaneous emphysema
Breath sounds over the trachea and larynx. Inspiration < Expiration, harsh and hollow.
Breath sounds heard over bronchi. Inspiration = Expiration, mixture of both sounds
Breath sounds heard over Left lower lung anterior and posterior. Inspiration > Expiration, periphery, alveoli.
Breath sounds like popping, hair being rolled between finders, velcro sounds
- fine crackles
- fine rales
- high-pitched rales
Breath sounds like lower-pitched course rattling sounds caused by fluid or secretions
Breath sounds like Continuous snoring sounds
Breath sounds like grating scratching sounds
pleural friction rub
Name of elevated levels of RBC's often related to excessive production of erythropoietin in response to chronic hypoxic state (COPD, high altitude).
What do we tell patients not to do before PFT's?
- No smoking 6-8 hours before
- No bronchodilators 4-6 hours before
This PFT indicates respiratory muscle strength and ventilatory reserve
- FVC (forced vital capacity)
- reduced in obstructive and restrictive diseases
What does forced vital capacity (FVC) test for?
the maximum amount of air that can be exhaled as quickly as possible after maximum inspiration
This PFT is effort dependent and declines normally with age. It is reduced in certain obstructive and restrictive disorders.
FEV1 (forced expiratory volume in 1 sec)
What does forced expiratory volume in 1 second (FEV1) test for?
maximum amount of air that can be exhaled in the first second of expiration
This PFT indicates hyperinflation or air trapping. Often from obstructive pulmonary disease. Normal or decreased in restrictive pulmonary diseases.
Functional residual capacity (FRC)
What does functional residual capacity (FRC) test for?
Amount of air remaining in the lungs after normal expiration
Cyanosis unresponsive to O2 therapy, chocolate-brown-colored blood, after benzocaine topical anesthetic
- call RRT
- dentures out
What are potential complications of bronchoscopy?
- aspiration - no eating/drinking until gag reflex returns
Why is thoracentesis done?
- get fluid off lungs
- put meds into lungs (usually chemo)
What are complications of thoracentesis?
- bleeding (watch for hemoptysis)
- decreased breath sounds on affected side
What must the patient do following thoracentesis?
lay on unaffected side for one hour
What is the risk associated with lung biopsy?
Two key things to remember with O2 therapy
- Use lowest amount of O2 possible
- Length of tube does not affect how much O2 getting
Important info for O2 via NASAL CANNULA
- Flow rate: 1-6 L
- FiO2: 24-44%
- Varies on how you breath (RR and volume)
- If more than 4 L - need moisture
Important info for O2 via FACE MASK
- Flow rate: at least 5 L
- FiO2: 40-50%
- prevent from rebreathing exhaled air
- must flush out CO2 – remember this
- aware of vomiting
- good seal or not doing any good
Important info for O2 via PARTIAL REBREATHER
- Flow rate: 6-11 L
- FiO2: 60-75%
- Must keep Bag 2/3 full on inspiration and expiration
Important info for O2 via NON-REBREATHER
- Flow rate: 10-15 L
- FiO2: 90%
- Able to bring in maximum amount of O2 – not mixed with any outside air
- One way valve with flaps
- flaps close when taking in O2, must open when exhaling or will suffocate on CO2 (safety issue)
Important info for O2 via VENTURI MASK (HI-FLOW)
- Flow rate: must be 4-10 L
- FiO2: 24-50%
- Adapters allow us to give the Precise amount of O2
- Safety issue: flow must be 4-10 or not giving liter flow enough O2 on this mask, monitor can get caught in bed linens, tubing kinks easily, make sure adapter not covered
S/S of oxygen toxicity
- nonproductive cough
- chest pain beneath sternum
- GI upset
- crackles on ausclutation
- nasal stuffiness
- sore throat
Patients at risk for Oxygen induced hypoventilation?
- these patients run the same PaCO2 all the time
Education for patients and family going home with Oxygen
- No smoking
- Keep away from gas/fire/flammable liquids (acetone)
- Wear cotton
- Make sure everything grounded
- Make sure electrical is in good working order