Skills: TPN/ PD/ CVP by EGBautista, USI-BSN/ Aug08 T tal Pa!"#t"!al Nut!

iti # $TPN% - Hyperglycemia o %hirst: nausea: headache: *ea;ness - Other name: Hyperalimentation HA - Re!ound Hypoglycemia - Primary method of providing a complete o 7o not eat late at night nutrients o "f there is a!rupt hypoglycaemia: - Refers to the provision of all required nutrients - E clusively !y the "# route $%OP of %P, and infuse "$O%O,"& - $upplements ordinary or tu!e feeding sol8n - %hrough o <luid overload o Peripheral line o &entral line Note: When there is TPN, do not draw blood. &onnected to 'ugular( $u!clavian vein 'ugular is used to enter the P"!it #"al Dialysis $PD% circulatory - =sing peripheral cavity to *ithdra* !lood "ndications: through diffusion or osmosis 0ess ha>ardous than hemodialysis $hort term use - Often the treatment of choice of older adults o )o*el in+ury( surgery o )o*el disease "ndications: o $evere malnutrition Poor cardiac function o ,utritional prep- Prior to surgery Peripheral #ascular disease o .ala!sorption / !o*el cancer <ree lifestyle 0ong term use 0ong distance to hemodialysis o )o*el resection o Prolonged intestinal failure &ontraindications: Hernia ,utritional requirement: $ignificant loin pain Amino acids &olostomy 1lucose O!esity 0ipids )lindness .inerals Psychosis #itamins 7ecrease in 0ung function H23 4 electrolytes %race Elements ,ursing .anagement - )aseline measurements 5#s for sepsis6 - Accurate daily monitoring - &linical O!servation - 7aily *eight - Patient8s $trength - Anthropometric .easurements - Prevention of infection - )asic ,ursing care - &are of equipment 5last priority6 &omplications of %P, - $epsis o 9atch for fever: s*eating: chills: inflammation - Pneumothora - Air em!olism o Perform valsalva maneuver o .anifestations: &yanotic: $O): chest pain: cough - &lotted catheter line - &atheter displacement Equipment - comforta!le chair - *ater sin; - *eighing scale - drip stand - hoo;s - dialysate ? Phases( Procedures @- <ill( "nflo* @-20 of dialysate infused !y graving <"00 into the peritoneal space 5@3-23min6 2- 7*ell <luid d*ells in the cavity for a specified time ?- 7rain( Outflo* <luid then flo*s out of the !ody 7RA",$ !y gravity into a drainage !ag )ag must !e lo*er APeritoneal / may cavities / diffusion 7ialysate additives Heparin o Prevent clotting of catheter tu!ing

Skills: TPN/ PD/ CVP by EGBautista, USI-BSN/ Aug08 Potassium - <inal e changes of the night is left to d*ell o Prevent hypo;alemia through the day 4 drained the ne t evening as the process is repeated Anti!iotic o 1iven *hen peritonitis is present *Potassium & Antibiotic should not be given sabay. %ypes: @2?B&ontinuous Am!ulatory P7 Automated P7 "ntermittent P7 continuous cycle P7 &omplications: @- Peritonitis 2- Pain ?- E it site 4 %unnel infection B- Poor 7ialysate Outflo* H- 7ialysate lea;age Peritonitis - ma+or complication of P7 - causes: connecting site contaminated - .anifestations: o &loudy dialysate outflo* o <ever o A!dominal tenderness o A!dominal pain o 1eneral malaise o ,ausea 4 vomiting Pain - common during inflo* E it site 4 tunnel infection - Predisposing factor o 7ialysate lea;age o Pulling( t*isting of the catheter - .anifestations: o Redness o %enderness o Pain Poor 7ialysate Outflo* - .ain cause: o &onstipation - Other causes: o Jin;ed( clamped connection tu!ing o &lient8s position 5supine: lo*: fo*lers6 o <i!rin clot formation o P7 catheter displacement 7ialysate 0ea;age - occur more often in o!ese( dia!etic clients: older adults on long term steroid therapy

&ontinuous Am!ulatory P7 - client performs self-dialysis !y infusing B 20 e changes of dialysate into the peritoneal cavity - dialysate remains B-C hoursD E days a *ee; - 7*ell Period: o &ontinuous connect system 5straight transfer set6 o 7isconnect system 5F transfer set6 Prone for infection - 7ialysate must !e *arm Automated P7 - used in acute care setting output dialysis center - =ses automated cycling machine - Advantages: o Permits in-house dialysis *hile the client sleeps o incidence of peritonitis is reduced o used to administer large volume of dialysis solution "ntermittent P7 - com!ines osmotic pressure gradients *ith true dialysis - requires e change of 20: o ?3-G3 minutes interval time o @H-23 minutes of drain time - Requires 23-B3 e changes of 20 o ? times a *ee; - &an !e automated or manual - PO%E,%"A0 A7#A,%A1E$ o Progressive removal of H2O 4 ,a o Relatively lo* ris; of inducing hypotension o &orrection of co-e istent hyponatremia !y sieving of ,a into the ultrafiltrate &ontinuous I cycle P7 - uses an automated cycling machine - e changes occur at night *hile the client sleeps

E<<0=E,% &O0OR$: )loody or !lood-tinged o @-2 *ee;s / normal &lear 4 light yello* o 9ell esta!lished P,

Skills: TPN/ PD/ CVP by EGBautista, USI-BSN/ Aug08 )ro*n-colored effluent &omplications: o %here is !o*el pro!lem disorder - carotid artery puncture o )o*er imperforation - Pneumothora $ame color as urine 4 has same glucose - air em!olism concentration - arrhythmia o "mperforated !ladder - perforation of $#&( R-atrium( R-ventricle Opaque( cloudy - infection o pineapple +uice - Pleural effusion o "nfection occur - E travasion of infusate ,ursing care: - Allergic reaction to catheter material K)efore treatment - evaluate !aseline #$ Equipment: - *eigh client - sterile !ag of fluid *ith attached fluid - !aseline la! tests administration set K7uring P7 - "# set solution @- ta;e 4 record #$ q @H-?3 minutes - .anometer 2- assess for signs 4 respiratory distress - $topcoc; ?- chec; dressing around the catheter e it site q ?3 for *etness Position of the Patient: $=P",E B- monitor the prescri!ed d*ell time 4 initiate A "n line *ith the heart outflo* H- monitor !lood glucose levels "nterpretation G- o!serve outflo* pattern - L of a!ove normal E- accurately record the total amount of outflo* o 9ea;ening( failure of the Right side of after each e change the heart or e cessive intravascular C- *eigh volume - Pressure M Hcm H2O P7 can correctK o "ntravascular volume deficit( drug Hyper;alemia induced e cessive vasodialation Hypo &#P measurements must !e interpreted on Hypernatremia their o*n: !ut vie*ed along side the patients8s Hypo full clinical picture .eta!olic acidosis - $everal measurements are required to identify Hypercalcemia a trend Hyperuricemia 7eterminants: - cardiac competence o M ventricular function raises &#P - )lood volume o L venous return raises &#P - "ntra Aortic 4 "ntra Peritoneal Pressure o L &#P - $ystemic vascular resistance o L &#P

C"#t!al V"# us P!"ssu!" $CVP% - !lood from the systemic veins flo*s into the right atrium - pressure in the right atrium is the &#P - A catheter is passed viaD o $u!clavian vein or +ugular vein ",%O I o $uperior vena cavaD - to determine the venous return in the intravascular volume of the right atrium - ,ormal value: o H-@3 cm H2o Purpose: - to serve as a guide of fluid !alance in critically ill patients - to estimate the circulating !lood volume - to determine the function of the right side of the heart - to assist in monitoring circulatory failure - none of these varia!les are measured directlyD they must !e interpreted