Exam 2 Lines.pdf

Basic Line Management - Why?  Essential to best patient outcomes  Safety  Appropriateness - Who?  Interprofessional Team Communication  Physicians, PA’s and NP’s  Nursing  PT, OT, SLP, RT  Patient – patient education is very important  Supportive personnel K. Sam 2023 7 Basic Line Ma...

Basic Line Management - Why?  Essential to best patient outcomes  Safety  Appropriateness - Who?  Interprofessional Team Communication  Physicians, PA’s and NP’s  Nursing  PT, OT, SLP, RT  Patient – patient education is very important  Supportive personnel K. Sam 2023 7 Basic Line Management - What?  What?  Types of Lines  Thorough chart review  Check MD orders  Current and discontinued orders  Purposes and Indications for lines and equipment  Insights into patient’s status and acuity  Identify precautions and contraindications  Check parameters relevant to mobility, as needed - Where?  Where?  Location / Site  Attachment or device, if any K. Sam 2023 8 Basic Line Management - How?  Before mobility  Communicate with nursing for patient status, recent vitals, and order clarification as needed  Coordinate time and supportive personnel  Systematic approach in equipment and line handling  Observe environment systematically  E.g., Top to bottom, L to R  Equipment on the wall, on the floor, and on the bed  Physically trace all lines and tubes  From the point of insertion or attachment to the patient to the monitoring equipment (or vice versa, choose the safest option).  Important to understand the effects of mobility can have on each line and on the patient’s systems being monitored  Mentally rehearse mobility activity and organize lines strategically  Examine cardiac monitor; check baseline vitals, especially with cardiopulmonary or neurological devices K. Sam 2023 9 Basic Line Management - How? (cont.)  During mobility  Be cautious, safe, and vigilant in line monitoring  Integrity of all line insertions and attachments  Lines are not impeded and not pulled taut  Communication  Monitoring patient response  HR, rhythm, BP, O2 sat, RPE, pallor, diaphoresis  After mobility     K. Sam 2023 Check patient’s vitals and response to mobility Inspect all lines, sites and equipment Positioning for comfort and pressure relief Notify RN if any lines need to be re-connected, releveled, or re-start after mobility 10 Cardiovascular System BP cuff  Purpose/Indication:   Location:    Provides indirect measure of BP Typically, not used on arm with IV In ICU, cuff usually remains on patient’s arm and is inflated automatically Clinical Implications:  Record blood pressure before, during and after therapy K. Sam 2023 12 Cardiovascular System Pulse oximeter  Purpose:   Location:   Indirectly measures O2 saturation External device applied to fingertip, toes, forehead, bridge of nose, or earlobe Clinical Implications:  Activity may be contraindicated when O2 saturation falls below a certain level. K. Sam 2023 13 Cardiovascular System  Purposes: EKG leads  Indications:  Diagnostic, screening, continuous monitoring of electrical conduction through the heart  Reveal basic anatomy of the heart     Chest pain, palpitation, dizziness, syncope, cyanosis To detect myocardial injury, ischemia, previous infarction Heart conditions and associated symptoms+ To detect pacemaker or defibrillator device malfunction&  Locations:  Surface electrodes. Standard 12-leads for full cardiac assessment, monitoring may be done with fewer leads  Clinical Implications:     Notify RN before mobility if patient is on telemetry Monitor hemodynamic response & exercise tolerance Identify pathological rate and rhythms & adjust/stop PT Identify Red Flags on EKG and declining cardiac status K. Sam 2023 14 Cardiovascular System Sequential Compression Device (SCD)  Purposes/Indications: • To promote venous return • To prevent the risk of DVT in LE due to prolonged bedrest, venous insufficiency, or limited ambulation capacity  Location: LEs  Clinical implications • Compression is graduated, distal to proximal, to return venous blood to heart. • Contraindicated on limb with DVT • Turn off machine and unwrap SCD sleeves for mobilization; Place back and turn on after therapy session K. Sam 2023 15 Cardiovascular System  Purpose/Indication:  Peripheral Intravenous (IV) line  Location:   For administering liquid medications, fluids, electrolytes or blood product transfusions Vein (forearm, back of hand, neck, leg, or foot) Clinical Implications:       Avoid BP cuff on limb with IV Nurse can often disconnect IV for therapy, but some meds must be continuous Do not kink, occlude or place tension on IV Drip bag above insertion site. Notify nursing staff if insertion site is swollen or red If IV becomes displaced during therapy session put pressure on the site to control bleeding and notify nursing staff immediately K. Sam 2023 https://www.icumed.com/products/critical-care/triox-venous-oximetry-catheters/triox-picc 16 Cardiovascular System Venous Line & Catheter  Purpose/Indications:  Allows long term IV administration of medications,+ fluids, blood products directly into the heart  PICC and Port-A-Cath: chemotherapy administration  Hickman/Broviac and Port-A-Cath: multiple blood draw without repeated needle sticks. • Location: Terminating in superior vena cava typically  Clinical Implications: • Keep insertion site dry • Nurse can disconnect IV if medication is not continuous • No mobility / exercise / UE ROM restrictions • Types: • • • • PICC: peripheral, commonly at basilic vein Hickman: internal jugular or subclavian vein Broviac: subclavian vein Port-A-Cath: subclavian vein K. Sam 2023 17 Cardiovascular System Venous Line & Catheter - PICC line Peripherally inserted central venous (PICC) line • Location: • Basilic vein is the most common placement • May also be placed in the cephalic or median cubital vein, terminating in superior vena cava or right atrium • Single, double, triple lumens  Additional Clinical Implications: • Wait for X-ray confirmation of proper placement before mobilization or exercise • Avoid BP on the extremity with PICC line • No mobility / exercise / UE ROM restrictions • No axillary crutches - can occlude the line and can cause thrombus formation (Top) https://www.icumed.com/products/criticalcare/triox-venous-oximetry-catheters/triox-picc (Bottom) https://www.lhsc.on.ca/thoracicsurgery/picc-line-insertion K. Sam 2023 18 Cardiovascular System Venous Line & Catheter Hickman/Broviac    -Hickman/Broviac - Port-A-Cath, MediPort Location: Tunneled central venous catheter typically inserted into internal jugular or subclavian vein May have multiple lumens Cuff helps prevent slippage and the entrance of bacteria Port-A-Cath, MediPort   Location: Port implanted under the skin, typically subclavian, attached to thin catheter  Port is accessed with a special needle Additional Clinical Implication:  (Top 4) https://nursekey.com/central-venous-access-catheter/ (Bottom Right): https://www.shutterstock.com/search/port+a+cath Usually compatible with bathing or swimming K. Sam 2023 19 • Purposes: • Directly measures arterial BP directly and in real-time Cardiovascular System • Indications: Arterial Line (A-line) • Locations: • Obtain blood sample for arterial blood gas (ABG) analysis • Labile BP, hemodynamic instability, titration of vasoactive drugs, frequent arterial blood sampling (e.g. hypoxia), etc • Commonly in radial and femoral arteries, also seen in brachial or dorsalis pedis arteries • Thin catheter inserted into artery and connected via pressure tubing to pressure transducer • Clinical Implications: • Invasive – ICU, peri-op for high-risk patients, critically ill patients • Pressure bag (saline) must remain above level of A-line site • Pressure transducer is placed at the level of right atrium+ • Changes in bed height will alter arterial BP readings • Femoral insertion requires hip flexion ROM up to 60° to 80° • check MD order and facility protocol • Arterial blood carries higher pressure than venous blood • Displacement of an arterial line is a life-threatening emergency because of significant rapid blood loss. • Apply pressure to the insertion site and immediately call for help. K. Sam 2023 http://www.nu2icu.com/nu2icu-haemodynamics/nu2icu-haemodynamic-monitoring-in-icu-arterial-lines-map/ 20 Cardiovascular System Pulmonary artery catheter (= PA line, Swan-Ganz catheter)  Purposes:  Directly measures pressures in R-side of the heart and pulmonary artery; Indirectly measure cardiac output • Indications: • Heart failure, shock, post-MI, pulmonary hypertension, pulmonary edema, after open heart surgery or drug therapy, heart valve disease, cardiomyopathy • Location: • Multi-lumen catheter inserted through internal jugular or subclavian vein, terminating in the pulmonary artery • Clinical Implications: • Physical activity very restricted • Avoid ROM that may disturb the insertion site • Internal jugular insertion: limit head and neck movement • Subclavian insertion: Limit ipsi. shoulder flexion to 90 deg and contra. shoulder minimal functional movement • For femoral insertion: Limit flexion to 70 deg • Dislodging a PA line is a life-threatening emergency! Apply pressure to the insertion site and call for help. K. Sam 2023 (Top) https://quizlet.com/98485028/pa-catheter-monitoring-flash-cards/21 (Bottom) https://slidetodoc.com/pulmonary-hypertension-invasive-monitoring-by-kimberly-napper-pulmonary/ Respiratory System Supplemental Oxygen  Purpose:  O2 is considered a drug when breathed in concentrations greater than atmospheric air  Regulated by FDA - Needs MD prescription  Indications: Hypoxemia, anemia, pulmonary edema, CO poisoning  Clinical Implication: Inflammable; risk of overdose  O2 delivery Devices: 1. 2. 3. 4. 5. 6. Nasal cannula Closed/simple face mask Tracheostomy mask/collar Partial non-rebreather mask Non-rebreather face mask Air entrainment system – Venturi mask  Nebulizer:  Handheld or attached to respiratory tubing  Used to administer pulm medications  Patient responses vary  Some patient may demo improved activity tolerance. Others may become very agitated, making activities more difficult. K. Sam 2023 23 Respiratory System Supplemental Oxygen - Oxygen Delivery Devices 1. Nasal cannula (NC) 2. Closed/simple face mask 3. Tracheostomy mask/collar 4. Non-rebreather face mask 5. Partial non-rebreather mask 6. Air entrainment system – Venturi mask • 2-prong device – most common - deliver low flow O2 (1-2L)  Like a NC in a mask form; mouth breather; Hard to talk / eat  Placed over a tracheostomy – through which O2, humidification or nebulizer is given  Has a reservoir bag & a 1-way valve – the reservoir bag is filled with 100% supplemental O2 – so patient will breathe in 100% O2  For short term help when patient is less stable.  Allow some room air or exhaled air which contains CO2 back to the reservoir bag and allow rebreathing. So O2 concentration is below 100%.  Allow greater O2 flow  Has adaptor or dial - diff adaptor deliver different level and very precise FiO2  Great for COPD patients – not to knock out the hypoxic drive K. Sam 2023 24 Respiratory System Supplemental Oxygen - Home Oxygen Systems  O2 tanks – high pressure  Liquid oxygen – low pressure  Lightweight canister  Some can last for 8 hours  Oxygen concentrators      Separates out oxygen from ambient air Flow generally 2-3 liters/min Can deliver continuous vs pulsed O2 Requires electricity or battery Can be stationary for home use or portable K. Sam 2023 25 https://www.istockphoto.com/photo/oxygen-flow-meter-plugged-in-thegreen-outlet-on-hospital-wall-medical-equipment-gm1195282355-340656933 Respiratory System Non-invasive positive pressure ventilation (NIPPV) - CPAP - BiPAP  Purpose: To decrease work of breathing  Location:  Uses a mask instead of artificial airway - use supplemental O2  provides Positive Airway Pressure (PAP) to help to keep alveoli open and support ventilation  Indications:  To avoid intubation & mechanical ventilation  Often used for obstructive sleep apnea  Type:  CPAP: continuous pressure  BiPAP: Bi-level or 2 level – lower pressure on exhalation K. Sam 2023 26