Bowel Elimination Study Guide PDF

chapters 38, 39, 41 & 30 Bowel Elimination Gastrointestinal Tract goes from the mouth to anus and sometimes called the - alimentary tract or canal organs involved - stomach, small intestine, large intestine ◦ Stomach - located upper portion of abdomen ‣ stores food, secr...

chapters 38, 39, 41 & 30 Bowel Elimination Gastrointestinal Tract goes from the mouth to anus and sometimes called the - alimentary tract or canal organs involved - stomach, small intestine, large intestine ◦ Stomach - located upper portion of abdomen ‣ stores food, secretes digestive juices, churns food and propels digested food (chyme) to small intestine ‣ pyloric sphincter - muscular ring that regulates opening from stomach to small intestine, regulating chyme ◦ small intestine ‣ three secretions: duodenum, jejunum, ileum ‣ secretes enzymes that digest proteins and carbohydrates ‣ digestive secretions from liver and pancreas enter small intestine in duodenum ‣ digestion of food and absorption of nutrients to bloodstream ◦ large intestine - absorption of water, formation of feces, and expulsion of feces ‣ ileocecal valve - prevents materials from entering large intestine too soon or from going back into small intestine ‣ lower part of GI tract; extends from ileocecal valve to anus ‣ ascending colon (right side), traverse colon & descending colon (left side), sigmoid colon, rectum, anus ‣ feces are waste o=product that has reached the end of the colon; excreted feces is called stool ‣ defecation is the process of bowel elimination - peristalsis is the movement intestines propulsion of feces Defecation controlled by medulla and spinal cord parasympathetic stimulation causing internal anal sphincter to relax colon to contract - moves feces to rectum  external anal sphincter is voluntary controlled valsalva maneuver is when one bears down - can cause increase abdominal pressure and thoracic pressure ◦ leading decrease in blood to atria and ventricles (lowers cardiac output) ◦ once bearing down stops the pressure release - a larger than normal amount of blood returns ◦ can cause decrease in HR and syncope (bearing down contraindicated in someone with cardiac condition and elderly ) Age related differences infants - bottle or breastfed impacts quantity, consistency and odor toddler - internal and external sphincters develop fully leading to voluntary control of defecation. training can occur when physically able to voluntary control, can communicate. physiologic ability is the priority for training to occur regression can occur with shaming, hospitalization, scolding or if parent/ caregiver shows disgust school age/ adolescent. adult patterns can vary - do not encourage use of laxative or enemas older adult - constipation is a common issue - rectal receptors have a decrease in response to stretching, decrease in urge ◦ fecal impaction occur with prolonged retention and hardening of feces Promoting Normal Bowel Function pattern and position - time of day, privacy and time diet - foods in high fiber and sufficient fluid intake 2L to 3L per day regular exercise promotes gastrointestinal motility (bedrest or poor mobility increases risk of constipation) lifestyle - normal versus embarrassment - preoccupation with bowel movements - hygiene or concern with cleanliness, daily schedule, occupation, activities pathologic conditions - change in stool can be one of the first clinical manifestations of disease abnormal pattern or stool could be an indication of malabsorption issue, cancers, GI conditions, medication side effect, intestinal blockage, infection Considerations: surgical procedures and anesthesia can promote decrease motility and lead to paralytic ileus pain management can lead to constipation do thorough assessment: usually pattern and consistency, possible aides used, changes in bowel patterns noted, problems or pain with elimination, presence of abnormal or artificial orifices (ostomy) - questions related to differences Bristol Stool Chart Type 1 - separate hard lumps, like nuts; hard to pass Type 2- sausage shaped but lumpy Type 3- like sausage but with cracks on the surface Type 4 - like sausage or snake, smooth and soft Type 5- soft blobs with clear cut edges; passed easily Type 6- fluffy pieces with ragged edges; a mushy stool Type 7- watery, no solid pieces; entirely liquid Diagnostic Studies - education bowel preparation may be needed barium or IV contrast - allergy can the patient eat and drink what type of consent is needed awake or anesthesia required what to expect? - invasive versus noninvasive, pain or discomfort or none expected Diagnostic Studies stool collection - use a "hat", send to the lab timely - medical asepsis for collection - do not include urine in sample - if visible blood  or mucus or pus; send with specimen culture: should be obtained prior to starting therapy - if medication already indicated this should be included in lab slip occult blood: blood that is not visible in stool - test can indicate presence of blood - may indicate cancers, GI bleeding, inflammatory bowel disease - can be done at the bedside, home or lab setting timed specimens - larger container to collect all stool during that period Diagnostic Tests esophagogastroduodenoscopy (EGD) colonoscopy sigmoidoscopy upper gastrointestinal and small bowel series (UGI) barium enema abdominal ultrasound magnetic resonance imagining (MRI) abdominal CT scan Treatment of Constipation: laxatives Bulk forming - stool absorbs water, increase colonic distention and stimulates peristalsis Osmotic polyethylene glycol (PEG) - promotes secretion of water in colon Stimulant - increases intestinal motility and colonic secretions Softener - decrease the tension between water and fat and lubricate the stool Lubricants - slow down absorption of water in the colon, softens the stool so easier to pass Treatment of diarrhea passing of more than three loose stools per day  frequency and consistency of stools used to determine usually associated with intestinal cramping may have nausea and vomiting fluid and electrolyte loss is common, especially impacted infants, young children and older adults if electrolytes and fluid balance not addressed timely can lead to life threatening complications seepage of stool can be indication of obstruction or impaction antidiarrheal medications are available - be sure to understand cause prior to use - anti-motility medications (loperamide & diphenoxylate hydrochloride ) eliminate cause and treat symptoms replacement of fluids, may need to be intravenous if can't tolerate hand hygiene chronic diarrhea (3 -4 weeks) may be related to inflammatory bowel disease, IBS, malabsorption, tumor, parasitic infection electrolyte replacement Enemas tap water (hypotonic) 500 to 1 liter of fluid 15 minutes to take effect ◦ softens stool and increases peristalsis normal saline (isotonic) 500 to 1 liter 15 minutes to take effect ◦ softens stool and increase peristalsis soaps studs 500 to 1 liter of fluid 10-15 minutes for effect ◦ irritates intestine, stimulates peristalsis, soften stools hypertonic 70 - 130 ml 5-10 minutes for effect ◦ draws fluid out of interstitial space to colon, stimulates peristalsis (fleet enema) oil 150 to 130 ml 30 minutes to effect ◦ lubricates stool, often used as a retention enema - hold solution for 30-60 minutes Other agents suppositories - melt with body temp; can deliver medication or used for constipation oral solutions - colyte (polyethyl glycol solution PEG) used as a cleansing for tests for surgery ; clear bowel for visualizations ; usually begins one hour after initial dose ; to be completed in 4-6 hours digital removal (disimpaction) - requires an order, can stimulate the vagus nerve resulting in decrease in heart rate and blood pressure ; very uncomfortable and can cause mucosal damage rectal tube for incontinence or uncontrollable diarrhea - stool must be liquid NG tub for decompression and stomach drainage - GI bleed, paralytic ileus, small bowel obstruction Bowel Diversion - ostomy ostomy - surgically formed opening from the inside of an organ to the outside illeostomy - fecal contents from ileum of small intestine come out through stoma colostomy - formed feces in the colon to be eliminated via stoma can be temporary or permanent Urinary Elimination Anatomy & Physiology nephron where the removal of the end products of metabolism occurs - urea, creatine, uric acid are removed from the blood in the form of urine by the nephrons maintain & regulate fluid balances through respiration and secretion of water & electrolyte once urine is formed in nephrons it empties into kidney pelvis and is transported through ureters to bladder voiding or micturition or urination - is the emptying of the bladder ; controlled by nerve centers in brain and spinal cord urination is mostly involuntary reflex but can learn control ; voluntary control of initiation restraining and interrupting the process injury can lead to voiding by reflex only (autonomic bladder) Voiding Pattern usually bladder holds 150 - 250 ml before sensation to urinate frequency depends on amount of urine production norma;;y do not void during sleeping hours first void is more concentrated - not fresh. accumulation of several hours of kidney output urination is not painful - when distention occurs, this may cause discomfort urinary retention - normal production by no excreted completely by bladder; factors impacting; medications, enlarged prostate, vaginal prolapse Considerations Impacting Urination developmental factors: infants lack voluntary control and minimal ability to concentrate urine (light color and odorless) urinary control typically occurs between 2- 5 years of age - daytime control before nighttime control toilet training typically between 2 - 3 years with girls typically developing control earlier than boys education to parents: don't start if child cannot hold urine for 2 hours and can identify and communicate the need to void. child  needs to be able to sit on a toilet. some cultures begins toilet training at 1 year while others may wait Age related changes ◦ diminished ability for kidney to concentrate urine ◦ decreased bladder muscle tone ◦ decreased bladder contractility ◦ neuromuscular problems or degenerative problems Factors of aging ◦ medications which interfere with bladder function ◦ urination at night may increase due to diminish in kidney concentrating urine ◦ frequency related to decrease muscle tone ◦ retention related to decrease contractility Terms: anuria - does not produce or produces very little urine dysuria - painful urination frequency - the need to urinate more frequently glycosuria - more glucose in the urine than normal nocturia - waking up during the night to urinate oliguria - low urine output polyuria - abnormally large amounts of dilute in urine proteinuria - higher than normal amount of protein in urine pyuria - white blood cells in the urine urgency - sudden, strong need to urinate  hematuria - red blood cells in the urine enuresis - bedwetting Incontinence urinary in continence - the involuntary escape of urine urge incontinence - loss of urine after feeling urgent need to void stress incontinence - loss of urine with movement or activity (coughing, laughing, sneezing) overflow incontinence - urge to urinate but only go small amount; bladder doesn't empty and leaks; do not sense need to void functional incontinence - physical or cognitive reason that impairs getting to bathroom in time mixed incontinence - combination of stress and urge incontinence transient incontinence - leakage caused by a temporary situation (infection, illness, medications) reflex incontinence - bladder muscle contracts and leaks urine without warning or urge (often large quantity) total incontinence - bladder can not store urine; pass urine constantly or frequency leaking Factors Impacting Urination foods & fluids ◦ dehydration: concentrated urine; kidneys reabsorb fluid ◦ overload: large amounts of dilute urine psychosocial ◦ personal/private versus natural act (embarrassment versus void when urge occurs) ◦ stress factors activity / muscle tone ◦ immobility decreases muscle tone and sphincter controls; exercise increases metabolism and urine production & elimination ◦ indwelling catheter - loss of bladder tone Disorders and Disease Impacting Urination polycystic kidney disease (PKD) urinary tract infections (UTI) urinary calculi (kidney stones diabetes mellitus (DM) hypertensions (HTN) gout renal failure (chronic kidney disease {CKD} which leads to end stage renal disease {ESRD}) acute kidney injury (AKI) Impact of medication on urination nephrotoxicity - medications which cause kidney damage diuretics - prevent reabsorption of water and electrolytes in renal tubules anticoagulants - can lead to blood urine phenazopyridine - used for urinary tract discomfort; turns urine orange/red antidepressants can turn urine green/blue antiparkinsonian medication can turn urine brown/black Assessing Urinary Elimination physical assessment: urethral opening (women) dorsal recumbent position; retract inner labia to visualize the meatus history and patterns: open ended questions to discover normal patterns and practices monitor skin for color, turgor, excoriation, hydration status urine color, odor, clarity, pH and specific gravity (density of urine) Bladder scan - ultrasound of bladder to determine volume in bladder supine position  post void residual (PVR) - amount in bladder after voiding > 100 cc indicates ineffective emptying of bladder Promoting urination scheduling and keeping normal scheduling pattern urge void - assist client timely privacy - not normal to void in front of someone positioning - urinal standing if able, sitting position (commode) or HOB elevated (bedpan) hygiene - perineal area and hands Intake and Output can delegate the measurement of urine to unlicensed personnel eye level on flat surface infants - normally 6-8 wet diapers per day can weigh absorbent pads (1g = 1ml) specimen hat ( placed in toilet to capture urine ) Specimen Collections urinalysis: aseptic technique; void into clean bedpan or specimen hat ◦ no tissue, no feces and indicate if menses; should be processed within one hour of voiding clean catch / midstream: patient voids a small amount than continues to void in sterile cup ◦ use antiseptic wipes to clean; consider a sterile specimen sterile specimen: catheterization to obtain urine or through an indwelling catheter via port, using syringe ◦ may need to clam tube for no longer than 30 minutes 24 hour urine: usually on ice; large receptacle; throw out first void and start the clock ◦ communication is critical; do not throw out any urine or must start again Diagnostic Procedures cystoscopy - used to view, diagnose and treat lower urinary tract, interior bladder, urethra conditions ◦ prep: liquids in am, sedation/ analgesics prior, should not be painful, need consent intravenous pyelogram - examine kidney and ureter with contrast ; contrast is IV. diagnose renal disease of urinary tract conditions ◦ NPO 12hrs prior, check allergies (shellfish due to contrast) contraindicated if BUN/CR elevated or pregnant. give laxative or enemas to prevent stool or gas interference retrograde pyelogram - radiographic and endoscopic exam of kidney and ureters; placement of ureteral catheter to level of renal and pelvis ◦ contrast delivered via ureteral catheter and images performed; NPO after MN, contraindicated pregnant, iodine allergy or elevated BUN/CR ◦ laxative / enema, void prior to examination, informed consent renal ultrasound - noninvasive, ultrasound to look at renal parenchyma and renal blood vessel ; looks for masses or infection ◦ informed consent, not needed to restrict fluid or food (check policy) ; pain free CT scan - noninvasive, scanned images of body from various angles with X - ray beam, cross sectional image ◦ informed consent, NPO 8 hours if using contrast, check allergy if using contrast, remove any metal, can take medications up to 2 hours before Indwelling urinary catheter reasons for usage urinary retention obtaining a strile specimen when pateint unable accurate measurment of output (critical illness)  perineal or sacral wounds with incontinent paitent to promote healing some surgical or procedures that require bladder to be empty end of life for comfort prolonged immobility Intermittent catheters gold standard for management of bladder emptying dysfunction & after surgery also called straight catheters drain bladder for shorter period reduce risk of UTIs UTI - E coli most common bacteria (common to GI tract) hospital use sterile technique home use clean technique (spinal cord injury, paralysis, neuro conditions Urologic Stent thin catheter inserted into urinary system to relieve obstructions and offers a path for a urine to flow can be temporary (placed in ureters) or can be permanent (placed in ureters) surgical placement or during cystoscopy do not irrigate a stent monitor for output, color, odor, signs of infection, bleeding, decreased output (could indicate obstruction or nonfunctioning) notify provider - bright red urine, severe pain, change in drainage pattern Ileal Conduit surgical resection of small intestine with transplantation of ureters to small bowel, then small secretion of intestine brought to abdomen wall and urine come out of stoma  used for obstruction, tumors, neurogenic bladder, congenital abnormalities Assessment of a stoma normal: dark pink to red, moist, minimal bleeding if any abnormal: dark purple/ blue or pale size: after 6-8 weeks stabilizes - edema initially but should resolve after several weeks ◦ should come out 1/2 inch to 1 inch from stomach skin around site (peristomal area) clean and dry - should not have irritation or erosion would expect some mucous in urine because of the portion of diversion that comes form GI tract - does not decrease over time intake and output should be monitored monitor resuming of peristalsis after surgery Urostomy Appliance diameter of stoma measure inspection of skin faceplate versus one piece of appliance empty frequently or can attach to drainage bag change bag during times of expected low fluid intake (early morning) to decrease amount of urine production during change Dialysis loss of kidney function two categories of dialysis: hemodialysis and peritoneal dialysis mechanical method of filtering waste from the blood Hemodialysis - requires vascular access devise call AV fistula (arteriovenous fistula) ◦ this is a surgically placed flexible synthetic devise that connects the artery and vein  Peritoneal dialysis (CAPD) - uses the blood vessel in the abdominal lining (peritoneum) that utilize diffusion and osmosis to filter the waste product by using a dialysate fluid to move area or higher concentration (blood) to lower concentration (dialysate) ◦ patient carries the dialysate solution in peritoneal cavity for a determined time period ‣ CAPD education and support system are important self management of catheter site, dwells, medications, and dietary/fluids restriction IV Infusion & Blood Infusion monitoring for dehydration and fluid volume status Assessments: skin turgor, tongue (longitudinal furrow), moisture of oral cavity, tears/saliva production Appearance: skin temperature and look, facial appearance, signs of edema (can be localized or generalized; dependent or nondependent) Weight: same time, same way ( 1 liter of water weighs 2.2 lbs) vital signs ◦ pulse: increased with fluid volume deficit - usually an early sign - quality of pulse is decreased with volume deficit (thready) and increased with volume overload (bounding) ◦ respirations: crackles, moist indicate volume overload ‣ depth and rhyme can indicate respiratory alkalosis or acidosis ◦ blood pressure: decreased systolic > 20 mm HG or decreased diastolic > 10 mm Hg indicate a volume deficit or orthostatic hypotension ◦ temperature: fever increase volume requirements (require additional 500 cc/ day 101-103, up to 1 liter if over 103 sustained) Labs - CBC (complete blood count) Hematocrit is increased in volume deficit Hematocrit is decreased in overload or if acute blood loss Hemoglobin is decreased with anemia, acute blood loss Hemoglobin is increased with hemoconcentration Labs - BUN / CR (blood urea nitrogen and creatinine) increased BUN - renal impairment, heart failure, volume deficit increased CR - renal impairment, heart failure, volume deficit Labs ◦ urine pH & specific gravity ◦ dipstick testing: fresh sample needed ◦ laboratory analysis - fresh sample ◦ normal range pH 4.6-8.2 (low indication metabolic acidosis, diarrhea, DKA; high indication respiratory alkalosis, hypokalemia, CRF) ◦ specific gravity reflects urine concentration - normal range 1.005 - 1.030 if it is high urine is concentrated (dehydration) if it is low urine is dilute (volume excess) Dehydration age - decrease thirst medications and interactions of medications (polypharmacy) renal functioning - decreases cardia functioning - less efficiency, volume intolerance monitor electrolytes Fluid Balance sensible loss - can be measure such as urination insensible loss - cannot be measured or seen such as evaporation from skin generally, intake should be 2600 ml/ day : ingested fluid 1500ml, ingested food 800, metabolic oxidation 300 output should equal intake : kidney 1500ml, skin 600ml, lungs 400ml, gastrointestinal 100ml may not be seen in a 24 hour balance but should equate when assessing over 2-3 days of I /O's intake and output should be monitored every shift with a 24 hour total assessed daily strict I/O may require more frequent assessment of balance Fluid Overload restrict fluids - divide quantity over course of day - more during day, moderate evening, less at night - leave enough for medications and meals days (breakfast and lunch and medications) evening (dinner and medications) nights (PRNs and any early or late medications) eliminate items where unintentional intake could occur (water pitchers, post sign) monitor electrolytes respiratory status oral care, ice chips, swabs Assessing Output urine output ◦ 60 to 120 cc per hour is normal ◦ less than 30 cc per hour is abnormal ◦ greater than 2000 cc per day is called polyuria characteristics of normal urine ◦ clear ◦ pale yellow color ◦ mild odor Assessing Peripheral Intravenous Lines infiltration - swelling, pallor, cool, decrease flow of solution thrombus - (clot) similar to phlebitis but with a cessation of flow of solution  phlebitis - tenderness, redness, warm, slight edema above insertion site extravasation - vesicant solution leaks out of vein and into surrounding tissue Peripheral Lines general guidelines for intravenous: if short term usuage the smaller peripheral line is preferred placement of the line is based on patient smallest gauge devise needed for the prescribed therapy no longer need a line just because usually remove and rotate site every 72-96 hours if functioning fine assessment and clinical judgement is needed when deciding to replace or discontinue Central Lines peripherally inserted central catheter (PICC): placed by specially trained nurses, 1-2 lumens, used for home therapy use when infusing a vesicant, TPN, or chemotherapy - can stay in place for 6-18 months non tunneled percutaneous central venous catheter ( < 14 days in use, 2-4 lumens) use for short term critical patient who are unstable tunneled percutaneous central venous catheter: sutured in place for 7-14 days, Dacron cuff, dressing not required once exit site healed, lower incidence of infection from non tunneled Cath implanted port: low rate of infection, not visible when not in use, non coring needle to access, discomfort when accessing (can use a numbing agent) Infections if questioning infection or sepsis - central line will be removed (culturing of the " tip " and blood cultures would be done) assess for infection at least once a shift, document patency, site appearance, patient tolerance, dressing changes, sterile procedure  patient should where mask during dressing change, measure mid-arm circumference for PIIC line Intravenous Medications Intravenous Medications Administration ◦ delivery is directly into bloodstream ◦ immediate effect ◦ most dangerous route of administration ◦ action can't be slowed and can't remove once administrated ◦ aseptic technique for administration Giving via Intravenous Solution through an infusion of solution is slower and can be done over period of time ◦ advantage in that given over time, if irritant can dilute more or slower infusion ◦ IVPB is an intermittent infusion - uses a pump IV bolus or push - single injection concentrated, usually over a period of time such as 2 minutes but much quicker administration ◦ check with pharmacy or drug manual to determine how long - some antibiotics are over 10 minutes can do an IV push through a free following IV solution infusion to reduce the impact of irritation to the vein Delivery systems volume control devise - med is diluted in small amount of fluid - often used with children, infants, critical or older adults where volume is an issue primary infusion = full piggyback bag secondary infusion = empty piggyback bag IVF Administration used for fluid imbalances  nurse responsible for initiation, monitoring and dis continuation of therapy nurse must critically evaluate order and address any concerns related to amount or type of therapy nurse should evaluate labs, vitals, patient history, vitals IV Infusion: Medications diuretics - can lead to fluid volume deficit and electrolyte deficiency ◦ monitor intake and output ◦ monitor lab values antibiotics - rate of infusion, compatibility with solution ◦ be sure the solution is compatible with any other IV solutions ◦ determine if IV tubing is okay to use with other medications ◦ determine if you can flush with saline after infusion IV Infusion: Electrolytes treat imbalances (hypo) understand expected effect accurate administration (dilution, rate of infusion, solute) adverse reactions risk - potassium is NEVER given IV PUSH ◦ requires careful monitoring not to exceed 1 - mEq/Hr Fluid Balance: type of fluid isotonic - fluid remains in the intravascular compartment without any flow movement across the semipermeable membrane ‣ 0.9% Nacl ‣ lactated ringer  ‣ ringer's solution ‣ 5% dextrose in water hypotonic - less osmolarity than the plasma ◦ intravascular space moves out of the intravascular space to the intracellular fluid (ICF) - cells swell and burst ‣ 0.45% Nacl ‣ 0.33% Nacl ‣ 0.2% Nacl ‣ 2.5% dextrose water hypertonic - greater osmolarity than plasma ◦ water moves out of the cell and drawn to intravascular compartment - cells shrink ‣ 3% Nacl ‣ 5% Nacl ‣ 3% Nacl or 5% Nacl + D/W ‣ > 5% D/W IV Catheter sterile technique careful attention to not cause Cath associated infections insertion with a needle which is removed, and a hollow tubing is left in the vein - needless system monitor IV site minimum each shift check for blood return IV changes depend on institution (every 3 days) flush ling each shift at a minimum (flushes are orders) SL lock 3ml flush < 1 week of treatment  do not use with vesicants, irritants or TPN peripheral venous catheter (SL) - short tubing, used < 1 week infusion ◦ do not use with a vesicant )chemo) or irritant medication (potassium) or parenteral nutrition (TPN) Assessment of the IV temperature of skin at site: cool/infiltrate, warm/phlebitis or infection color of skin: pale or blanched/infiltrate, red and inflammation/ phlebitis or infection pus infection leaking fluid infiltration Infiltration when the IV is no longer on the vein and infusion is now going into surrounding tissue ◦ dislodged or the lock penetrated the vessel ◦ swelling, pallor, coldness, pain around site, decrease in flow rate ◦ check site frequently, change site location, discontinue therapy Phlebitis inflammation of vein - tenderness, redness, warmth, slight edema from insertion site caused by mechanical trauma from catheter, or infusion of solution discontinue infusion, warm compress to site - find alternative site Extravasation leaking of vesicant solution into surrounding tissue Thrombophlebitis blood clot in a vein causing inflammation and infection Midline versus PICC Line  midline peripheral catheter - upper arm (basilic, cephalic or brachial vein) > 3 inches in length ◦ distal tip terminates in basilic, cephalic or brachial vein at or below the axillary level and distal to shoulder PICC line - type of CVAD >20cm in basilic, median cubital brachial or cephalic vein ◦ tip of cath terminates at lower 1/3 SVC near junction of right atrium ◦ placement specially trained RN, inserted at bedside radiology ◦ treatment > 1 week ◦ infusion chemo, TPN, hyperosmolar fluids, blood ◦ measure arm circumference Vascular Access devices non-tunneled percutaneous CVAD - shorter time < 14 days ◦ double or triple lumen ; > 8 cm ◦ internal jugular, subclavian or femoral vein ◦ distal tip in thoracic inferior vena cava tunneled - long term therapy, implanted into internal or external jugular or subclavian vein ◦ 8cm in length, sutured in place with removal of suture in 7-14 days; Dacron cuff, dressing not required once exit site heals ◦ tunneled into subcutaneous tissue for 3-6 inches to the exit site ◦ lower incident of infection than non-tunneled ◦ can draw blood CVAD implanted port long term therapy - can draw blood  low risk Cath associated blood infections requires surgical implanting and removal ◦ confirm placement ◦ obtain blood return prior to use ◦ Huber needle - removed when not in use (non coring needle) ◦ rubber port to a reservoir - flushed consistent with volume of Cath and port - follow hospital protocol Intake and Output fluid overload: complication of IVF administration IVF rate per hour (ml/hr) Blood transfusion giving blood - assessments: IV site (large bore, new line, patency) lungs - monitor for signs of overload vital signs - baseline (15 min prior) if temp 100.5 do not give once you call for blood (blood bank) initiate within 30 minutes blood infuses over 4 hours (maximum) filtered Y tubing preparation only use blood tubing per institution policy blood can be infused on a pump or by gravity only prime with normal saline type and screen is good for 72 hours  repeat CBC ordered to check how effective the transfusion; one to 3 point change; can repeat 15 - 30 min post infusion vented tubing glass bottle requires vented tubing albumin comes in a glass bottle blood tubing - checking the blood two person check must be licenses nurse and read aloud patient name, blood type, RH factor, expiration date, number on bag matches attached tag (may be in computer system) check bag of blood outside room (initial check ) check bag of blood patient's ID Pre - medications can give acetaminophen and diphenhydramine reduces chance for febrile nonhemolytic transfusion reaction or minor allergic reactions may use additional filtration or irradiation o blood furosemide can be given in between units of blood to reduce volume overload inititating the transfusion baseline vitals (within 30 minutes) in line filter or add on filter give within 4 hours pump for transfusions, can give gravity but not done thi sway much normal saline to prime only; only use blood tubing for blood start slow - usually see a reaction in first 15 minutes  vitals at 15 minutes then increase rate if no reaction vitals every 30 minutes or per hospital protocol until transfusion complete vitals an hour after transfusion completed Blood Transfusion compatibility is critical if incompatible can lead to hemolysis & death Blood type: A, B, AB, O cross matching is what is done between two specimens RH factor positive or negative Type O is universal donor (have either A or B antigens) Type AB is universal recipient (no agglutinins to A or B antigens) Blood Donation free from infectious disease donor screening questionnaires and lab test useful in determining risk blood is tested for HIV, Hep B & C, syphilis and others age, weight and height requirements lab and vitals in specific ranges (blood counts, fever) Autologous Transfusion advanced planning blood can be donated every 4-7 days and up to 3 days prior to a surgery frequently used in surgical setting intraoperative blood salvage ( patient's blood is collected in special canisters and rains to allow for autologous transfusion) Types of Blood Products whole blood - risk for volume overload PRBC's - reduces risk for overload, need RBC but not plasma FFP - fresh frozen plasma, emergencies restores coagulation factors and blood volume Albumin - hypovolemic shock, albuminemia, liver failure Cryoprecipitate - bleeding r/t hemophilia, DIC, depleted coagulation factors Gamma globulins - antibody parts of plasma Platelets - bleeding from deficiencies in number or quality of platelets Transfusions high risk medication administration - 2 RN sign off can not be delegated this task to LPN can delegate vital signs but not assessment - frequent vital signs see hospital policy two RN verification of: patient name, MRN, order, informed consent, blood type and cross match, product number, expiration date, and inspect the product for clumps, sediment, clots, bubbles Transfusion Reactions - stop blood transfusion IMMEDIATELY allergic reaction - hives, itching, anaphylaxis febrile reaction - fever, chills, headache, malaise hemolytic reaction - immediate onset facial flushing, fever, chills, headache, low back pain, shoch circulatory overload - dyspnea, dry cough, pulmonary edema bacterial reaction fever, hypertension, dry flushed skin, abdominal pain Considerations gauge of peripheral venous access: 20 to 24 gauge  fresh ling is using peripheral site/blood return in line filters or add on filter slow start to monitor for reactions (first 15 minutes) frequent vital signs required through infusion baseline vitals immediately before starting temp > 100.5 notify provider before initiating not good after 4 hours (bacteria starts to grow) - call for blood only when ready may give acetaminophen, diphenhydramine or furosemide Transfusion reaction intervention stop the infusion notify the provider blood tubing, blood and labels return to blood bank may require antihistamine, antipyretic or antibiotic may require addition lab work treat symptoms