Perioperative Nursing

Perioperative nursing overview

Operatives phases the perioperative period encompasses a clients total surgical experience, including the preoperative, intraoperative, and postoperative phases Perioperative nursing refers to activities performed bv the professional nurse during these phases. 1. The preoperative phase begins with the decision to perform surgery and ends with the client's transfer to the operating room (OR) table 2. The intraoperative phase begins when the client is received in (he OR and ends with his admission to the post anesthesia recovery room (PARR) or post anesthesia care unit (PACI I) 3. The postoperative phase begins when the client is admitted to PARR or PACD and extends through follow-up home or clinic evaluation.

Categories of surgery 1. Optional surgery

is done totally at (he client's discretion (eg. cosmetic surgery) 2. Elective surgery refers to procedures that are schedule at the client's convenience (e.g. cyst removal repair of scars, simple hernia, and vaginal repair) 3. Required surgery is warranted for conditions necessitating intervention within a few weeks (e.g. cataract surgery, and thyroid disorder) 4. Urgent or imperative surgery is indicated for a problem requiring, intervention within 24 to 28 hrs (e.g. some cancers, acute gallbladder infection, appendicitis, and kidney stones.) 5. Emergency surgery describes procedure (hat must be done immediately to sustain life or maintain Function (eg repair of a ruptured aortic aneurysm, gunshot, or knife wounds, extensive burns, and fractured skull)

PERIOPERATIVE TEAM The perioperative team Surgeon Anesthesiologist Nurse anesthetist OR nurse Circulating nurse Scrub nurse Surgical technician, radiographic or cardiovascular technicians PACU nurse is responsible for caring the client until the client has recovered from the effect of anesthesia, is oriented, has stable vital signs, and show no evidence of hemorrhage.

*Their roles are discussed with the client before the surgery

PREOPERATIVE PERIOD
A. Assessment
1. Identify any obvious risk factors for surgery: a Age The very young and old are at risk for increased stress from surgical experience. b. Nutritional status. Compromised nutritional status has a negative effect or recovery and wound healing c. Obesity. An obese client present certain technical problems during surgery, is at greater risk for postoperative pulmonary complication such as hypoventilalion. and hypoxia, and is more likely to have coexisting cardiac, hepatic, biliary, d. Pregnancy and any type of chronic illness or condition that may recovery from surgery 2. Asses respiratory status, including history of post operative problems, to identify risk factors for postoperative complications, such as a. Dyspnea and complaints of shortness of breaths b. Upper respiratory infection c. Cough and wheezing d. Copious mucus or expectorate c. Chest pain f. Clubbed fingers g. History of smoking h. Use of inhalants 3. Assess cardiovascular status, noting a. Blood pressure b. Pulse rate c. Electrocardiography tracings d. Presence and amplitude of peripheral pulses 4. Asses for the report evidence of fluid and electrolyte imbalance including a. Dehydration b. Hypovolemia c. Prolonged vomiting, diarrhea, or bleeding d. Abnormal serum potassium, sodium, magnesium, calcium, or pH level 5. Assess hepatic and renal function. a. History of liver disease (e.g. cirrhosis, chronic, and alcoholism) b. Complaints of dysuria, oliguria, or anuria, incontinence or urinary tract infections c. Urinalysis results

6. Examine the client's record for endocrines; or metabolic problems that could affect the client's response to surgery (e.g poorly controlled diabetes mellitus) 7. Assess immunologic and hematological function, noting a. History of allergies b. Previous reactions to blood transfusion c. Immunosuppressed status d. History of substance abuse 8. Assess neurologic function, noting a. History of seizures or other neurologic disorder (e.g. Parkinson disease, myasthenia gravis) b. Level of consciousness, mental status and orientation c. Unsteady gait d. Unequal pupil 9. Assess integumentary system, Bleeding tendencies (ecchymosis, petechiae) 10. Evaluate medication history for drugs that could increase operative risk by affecting coagulation time or interacting with anesthetics, such as a. Steroid b. Diuretics e. Phenothiazincs d. Antidepressanss e. Antibiotics f. Anticoagulants 11. Assess the client for any type prosthetic devices or mental implants (e.g. false eye, hip or knee replacements, and pacemakers) 12. Assess the client and family's knowledge base to guide the preoperative teaching program. 13. consider the psychosocial factors that could affect the client's response to surgery, including a. Anxiety and fear b. Defense mechanism (e.g. regression, denial, and intellectualization) c. Self-esteem and body image concern

B. Nursing Diagnosis 1. Anxiety 2. Knowledge deficit C. Planning and outcome identification : The major goal for client during the preoperative period may include decreased anxiety and increased knowledge of the surgical experience 1. Promote measures that help decrease anxiety for the client and family a Assess the client and family to identify concerns that can affect the surgical experience (eg fear of the unknown, fear of death, loss of work, and loss of role)

b. Encourage the client and family to verbalize feelings Listen attentively, and provide factual information that may allay concern c. Respect and protect the spiritual beliefs of the client and family and assist the client in obtaining the spiritual help that be request. d. Respect and support the cultural beliefs of the client and family and allow any activities that do not directly affect the surgical experience 2 . Discuss the surgical experience with the client and family to minimize anxiety and increase knowledge a. Provide a quiet, no threatening atmosphere when teaching the client and family b. Present information at appropriate education level of the client, include any written of visual information, and allow time for questions and answers c. Discuss exactly what happen from the time the client is being prepared the surgery (e.g. no oral intake, NPO), removing clothes, jewelry, prosthetics or dentures including when will be taken to the OR by stretchers. d. Discuss the appropriate length of time of surgery and where family members should wait for the surgeon to discuss the clients surgery. e. Reiterate that the client will be able to have pain medication and should request it before pain is severe; discuss the used of clientcontrolled analgesia (PCA) pumps if appropriate. f. Discuss the equipment the client will have after surgery (e.g. intravenous line, and Foley catheter) 3. Provide client and family: instruct the client in the following a. Deep breathing and coughing exercises b. Relaxation techniques c. Postoperative exercises for extremities d. Turning and moving techniques e Pain control techniques f. Incentive spirometry use 4. Perform preoperative skin preparation as appropriate a. Shaving the skin and in around the surgical area (most often done in the OR) b. Using an electric razor or clippers c. Having the clients take a cleansing shower with antimicrobial scrub solution 5. Provide gastrointestinal preparation as prescribed, which may include a. Restricting solid food and fluid for 8 to 10 hrs. before surgery (to reduce the risk of aspiration) b. Posting of NPO sign at the clients bedside c. Administering an enema and inserting a nasogastric tube as prescribed 6 Make sure the client or a responsible family member has provided informed consent for surgery Verify that an operative is signed and witnessed with informed consent based on an understandable explanation from the surgeon about what will be done and the risked involved. The client must be a mentally competent adult or an emancipated minor to sign the consent form If these requirements cannot be met, the responsible relatives or guardian should sign the client.

State law govern situation when a relative or guardian is not available. 7. Perform standard preoperative. A preoperative check list is completed before the clients goes to the OR. a. Take and record vital signs b. Verify any allergy identification or diabetic bands c. Validate and NPO status d. Complete and record medical preoperative orders e. Remove all jewelry, nail polish, and hair pins. f. Have the client void and don a clean hospital gown. g. Remove dentures eyeglasses, contact lenses, hearing aids, and labeled containers with the client to the OR for safe placement incase removal becomes necessary h. Administer preanesthetic medications, and instruct the clients to stay in bed i. Document any client condition inquiring OR staff attention (e.g. musculoskeletal or sensor neural problem) 8. Ensure safe transport of the clients to the surgical suite (e.g. check for a stretcher with said rails, safety strap, and warm blankets)

ANESTHESIA
Types of Anesthesia 1. General anesthesia (inhaled or intravenously) refers to drug induced depression of the central nervous system that produce analgesia, amnesia, and unconsciousness (affect whole body), stages include A. Stage I: beginning Patient starts to breath anesthetic mixture. Warm , dizziness, and feeling of detachment is experienced by the patient Patient has ringing, or buzzing in the ears although patient is conscious. Unnecessary noise and movements must be avoided. B. Stage II: excitement characterized by struggling, laughing, talking. Due to uncontrolled movement, the nursing responsibility is secure safety of the patient by restraining or putting a strap around the extremities and trunk. Patient should not be touched except for purposes of restraint. C. Stage III: surgical anesthesia Stage where patient is unconscious lying quietly on the bed. Respirations are regular, pulse rule normal. D. Stage IV: Medullary depression Danger stage. Stage where too much anesthesia is administered. Respirations are shallow, pupils dilated, cyanosis, unless prompt action is taken death will follow. 2. Regional anesthesia

is a form of local anesthesia that suspend sensation and motion in a body region or part. the client remain awake Continuous monitoring is required in the event the block is not totally effective and the client experiences pain or reaction to blacking agents (e.g. nausea, cardiovascular collapse). Regional anesthesia differs in terms of location and size of the anatomic area anesthetized and the volume and type of anesthetic agent used 3. Spinal anesthesia is a local anesthesia injected into the subarachnoid space at the lumber level to blocks nerves and suspends sensation and motion to the lower extremities, perineum, and lower abdomen 4. Conduction blocks suspend sensation and motion on various groups of nerves such as Epidural blocks (i.e. produces anesthesia of the arm). Para vertebral block (i.e. produce anesthesia of the chest, abdominal wall, and extremities) Trail sacral (caudal) block (i.e. anesthesia of the perineum).

Principle of Surgical Asepsis 1. OR personnel must practice strict Standard precautions (e.g. blood and body substance isolation) 2. All items (e.g. instruments, needles, sutures, dressings, covers and solutions) Used in the OR. must be sterile 3. All personnel must perform a surgical scrub 4. All OR personnel are required wear specific clean attire, with the goal of shedding the outside environment. Specific clothing requirement are prescribed and standardized for all ORs a. OR personnel must wear sterile gown, gloves, and special shoe covers b. Hairs must completely cover. c. Masks must be worn at all times in the OR for the purpose of minimizing airborne contamination and must be changed between operations or more often, it if necessary 5. Any personnel who harbor pathogenic organisms (e.g. those with colds or infection) must report themselves unable to be in the OR to protect the client from outside pathogens 6. Scrubbed personnel wearing sterile attire should touch only sterile items. 7. Sterile gown and sterile drapes have defined borders of sterility. Sterile surfaces or articles may touch other sterile surfaces or articles and remain sterile; contact with unsterile objects at any point renders a sterile area contaminated 8 The circulator and unsterile personnel must stay of the periphery of the sterile operating area free from contamination 9. Sterile supplies are unwrapped and delivered by the circulator following specific standard protocol so as not to cause contamination 10. The utmost caution and vigilance must be used when handling sterile fluids to prevent splashing or spillage 11. Anything that is used for client must be discarded or, in some cases, re-sterilized

INTRAOPERATIVE PERIOD 6

A. Assessment 1. Classify the client's physical status for anesthesia: a. No organic or systematic disturbance b. Mild disturbance (e.g. mild cardiac disease, mild diabetes mellitus) c. Severe systemic disturbance (eg poorly conliolled diabetes mellitus, pulmonary complication), d. Life-tin aliening systemic disease (eg severe renal or cardiac disease) e. Moribund, with little chance of survival (e.g. ruptured aortic aneurysm) 2. Assess the clients record for appropriate documentation a. Current sign consent form b, Complete history and physical assessment record c. Recent the laboratory and diagnostic reports d. Evaluation of the clients overall physiologic, emotional and psychological status 3. Specifically ask the clients about any known allergies 4. Verify client identification and that the correct surgery is scheduled 5. Assess for special surgical considerations e.g. location where an electric grounding plate can be safely placed on the client, avoiding areas where metal or prosthesis is present and precautions e.g. shielding with a lead apron if radiation is involved, if the client is pregnant 6. Assess the client's risk for accidental hypothermia or malignant hyperthenma during the anesthesia administration and surgery. Be sure that antidote supplies are readily available in an emergency. B. Nursing diagnosis 1. Risk for fluid volume deficit or excess 2. Risk for hypothermia or hyperthermia 3. Risk for infection 4. Risk for altered tissue perfusion cardiac, respiratory, and peripheral 5. Risk for inquiry Planning and outcome identification The major goals for the clients during the intraoperation period may include maintainance of fluid balance, maintainance of normothermia. Prevention or infection, adequate perfusion and absence of injury. Implementation 1. Promote measures that maintain adequate fluid and electrolyte balance A. monitor intake and output accurately, use a monitor if needed B. Assess the client for dehydration to include .skin turgor and mucous membranes C. Assess the client for circulatory overload to include breath sounds, peripheral edema and jugular electrolyte values D. Monitor pertinent electrolyte values

2. Promote measures that maintain the client's normal (25 C 26 C) a. Ensure that OR temperature is between 25 C and 26.6 C (78 F to 80 F) b. Warm all intravenous and irrigating solutions c. Monitor the client's temperature continuously d. Remove all wet gowns and drapes promptly and replace with dry to prevent heat loss. 3. Promote measures that decrease risk of infection. a. Maintain sterile procedures and techniques during surgery b. Apply sterile dressing to all wounds c. No scrubbed personnel refrain from touching or contaminating anything that is sterile. 4. Promote measures that ensure adequate tissue perfusion in the client during surgery a. Assess the client's vital sign continuously b. Assess the client's respiratory status, and assist with (he mechanical ventilation c. Assess the client's cardiovascular status d. Assess the client's peripheral vascular status 5. Ensure the client's safety in the OR. a. Set room temperature and humidity to prevent hypothemia b. Remove any potential contaminants c. Curtail unnecessary room traffic d. Keep room noise and talk at a minimum e. Recheck electrical equipment for proper operations f Make sure that necessary equipment and supplies are available g. Ensure that instrument, sutures, and dressing are ready h. Count and record sutures, needles, instruments, and sponges i. Make sure that staff call the client by name and provide individual attention. j. Assist in transferring the client to the OR table k. Cover the client with a warm blanket, and attach the safety strap 1. Remain at the client's side during anesthesia induction. m. Verity proper client positioning to protect nerves, circulation, respiration, and skin integrity. Always pad pressure area n. Ensure that newly requested items are quikly supplied to the anesthesia or scrub team by the circulating nurse 6. Perform other actions as appropriate. a. Act in the role of client advocate, providing privacy and protection from harm b Fallow establishes procedures and protocol c. Document all OR care d. Help coordinate health team activities e Promote ethical behavior (e.g. respect, and confidentially). f Monitor blood, fluid, and other drainage output. g. Maintain a quiet, relaxing atmosphere Remember, the client can hear h. Apply grounding pad

IMMEDIATE POSTOPERATIVE CARE

A. Assessment 1. Perform assessment immediately on clients's admission to the PARR or PACU to obtained baseline data. 2. Position the clients before assessment to ensure an adequate airway, most commonly, the laterals Sims position is used for unconscious client unless contraindicated. 3. Prioritized the assessment accordingly. a. Respiratory assessment, including ail way potency and skin color b. Cardiovascular assessment, including vital signs. 4. Obtain a verbal information from the OR nurse and anesthesiologist or nurse anesthetist The verbal report should describe. a. Client's age and general condition b. Any intraoperative problems encountered c. Medical diagnosis and pathology d. Fluids administered, blood loss and replacement, tubing and drains present. e. Specific individual problems or deficits, including hearing, vision, and mental status and any symptoms that may need to be immediately reported to the surgeon. B. Nursing diagnosis 1. Altered tissue perfusion cardiac, respiratory, urinary, hemoloyic, and peripheral 2. Risk for postoperative complication 3. Ineffective airway clearance. 4. Pain 5. Immobility 6. Anxiety

C. Planning and outcome identification

The major goal for the immediate postoperative period may include adequate tissue perfusion, absence of postoperative complications, maintenance of airway patency and respiratory function., relief of pain, prevention of complication of immobility, and decreased anxiety.

D. Implementation 1. Assess the client's cardiac, respiratory, urinary, neurologic, and

neurovascuiar status, and document the client's condition on the recovery room scoring guide. Seven (7) points is the minimum score required for discharge from the PACU. There is only moderate or light drainage from the operative site All essential postoperative care has been completed Urine output is usually 30 ml/hour for adult 2. Promote measures that address potential complication

1. Airway 2. Vital signs (every 5 minutes x 3. then every 15 minutes) 3. General appearance 4. Level of consciousness and reflexes 5. Movement of extremities 6. Pain level 7. Urine output 8. Intravenous or central line patency 9. Drain or cathether patency 10. Operative site and dressing for signs o( hemorrhage or abnormal drainage 11. Functioning of cardiac and oxygen monitors 12. Signs and symptoms of hypovolemic shock, a potential, postoperative complication stemming from loss of blood and plasma during surgery 3. Administer prescribed medications which may include narcotic analgesic, prophylactic antibiotics, and antiemetics 4. Maintain airway patency and optimal respiratory function. Position the client on side until she awakens, administers oxygen as necessary, and encourage the client to turn, cough, and breathe deeply every 30 minutes until fully awake 5. Provide pain relief. Assess the client's pain. rule out any complication that requires immediate intervention, medicate of intervene to decrease pain, and evaluate effectiveness of pain medication 6. Promote measures that prevent complications of immobility a. Assess the client for signs and symptoms of skin breakdown, respiratory difficulties, deep vein thrombosis (DVT), and bladder or bowel problems b. Encourage the client to turn, cough, and breathe deeply frequently. C. Encourage the client to perform passive and active range-of-motion (ROM) exercises frequently 7. Offer emotional support and reassurance, and allow the client to verbalize feelings of anxiety

INTERMIDIATE AND EXTENDED POSTOPERATIVE PERIODS

A. Assessment 1. On the client's admission to the clinical unit, perform a head-to-one physical assessment 2. Monitor overall condition and blood pressure, pulse and respirations on arrival to floor then every 15 minutes for the first 2 hours, every 30 minutes for the next 2 hours, and if stable, every 4 hours thereafter 3. Assess respiratory status, including a Airway patency

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b Rate, depth, and pattern of respiration c. Character of breath ground d. Signs of peripheral or buccal cyanosis e. Arterial blood oxygen level according to the pulse oximeter determination 4. Assess neurovascular status in extremities 5. Observe level of consciousness and responsiveness 6 Inspect surgical wounds, dressings, and drains Note signs of healing or infection, patency, and drainage characteristic 7. Assess the client's level comfort A. Note the following 1 Time of hist pain medication 2. Current pain. including its location, nature, and iiilensdy 3. Position of maximum of comfort 4. Complaints of nausea or vomiting 5. Body temperature 6. Constrictive or irritating casts, dressings, and traction B. Rule out any complications that require immediate intervention, before administering pain medication. 8. Evaluate urinary status a. Identify last voiding and amount b. Note presence of indwelling in catheter c. Monitor and assess intake and output 9. Explore psychosocial concerns related to such factors as a. The nature of the client's surgical diagnosis and prognosis b. Available support system c. The client's need for rest and quiet 10. Assess safety aspects, such as a. The need for side rails on the bed b. Correct intravenous infusion rate c. Splinting of intravenous site d. Call bell kept within easy reach e. Ambulation status and the need for assistance f. Condition of all equipment

B. Nursing diagnosis 1. Ineffective airway clearance 2. Risk for postoperative complications 3. Pain 4. Risk for fluid volume deficit or excess 5. Risk for altered nutrition status and gastrointestinal function 6. Risk for complication of wound healing 7. Knowledge deficit 8. Ineffective coping C. Planning and outcome identification The major goals for the client during the intermediate and extended postoperative periods may include maintenance of airway patency and respiratory function absence of postoperative complications

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relief of pain maintenance of fluid and nutritional intake return to normal elimination patterns prevention of wound infection and evisccration increased knowledge of postoperative care effective coping with surgical experience.

D. Implementation 1. Promote lung expansion and help prevent atelectasis and pneumonia a. Encourage coughing, deep breathing, and turning b. Use an incentive spirometer, as indicated c. Progress mobility from ROM exercises to ambulation as tolerated d. Monitor pulse oximeter as needed 2. Promote measures to address potential complications A. Monitor for signs and symptoms of postoperative complications, including 1. Hypoxemia 2. Hypovelemia 3. Hemorrhage 4. Pulmonary 5. Allergic drug reactions 6 Cardiac arrhythmias B. Encourage movement and ambulation, as indicated Have the client gradually increase exercise from lying, to sitting, to standing and then to ambulating. Provide assistance and encouragement; maintain safety precautions. C. Minimize the risk of Deep Vein Thrombosis 1. Assess for early signs (e.g. redness, edema, tenderness along vein, positive Homans signs). 2. Apply elastic hose, apply a sequential compression device, or administer low dose heparin, as prescribed 3 Teach measures to prevent vessel constrictions D. Intervene as appropriate postoperative depression, disorientation, or psychosis 1. Provide preoperative teaching and information 2. Orient the client postoperatively 3 Provide prescribed medication, close supervision, and consultation with mental health personnel as requested 3. Provide appropriate pain relief measures a. Administer prescribed analgesics and possibly PCA units, as indicated b. Implement no pharmacologic pain relief measures (e.g . relaxation, and guided imagery) 4. Promote optimal intake and output a. Encourage adequate fluid intake, and monitor electrolvte balance b. Monitor and assess fluid intake and output. Use an urometer if necessary d. Promote normal voiding patterns through such measures as

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1 Providing privacy 2. Running tap water of providing other stimuli to induce micturation 3. Increasing fluid intake 4. Relieving pain 5. Promote return to normal gastrointestinal function A. Ausculate for bowel sound to detect the return of peristalsis, (Paralytic ileus may occur after abdominal or bowel surgery B. As indicated, minimize abdominal distention resulting from decreased peristalsis (typically persisting 3 to 4 days postoperative) though exercise, amhulation Decreased narcotic dosage, or rectal tube placement C. Assess lor and report unrelieved nausea and vomiting administer antiemetic as prescribed and decrease the risk of aspirating vomitus through proper positioning 6. Promote wound healing A. Assess the dressing on wound for signs and symptoms of infections. Including redness, odor, drainage, and warmth B. Monitor the client's temperature for elevation indicating systematic infection. C. Always use sterile technique when removing irrigating, and changing surgical dressing i D. Document the surgical wound as specially us possible: the length, width, and depth of wound, any bleeding or necrotic tissue E. Reduce the risk of nosocomial infection by maintaining medical and surgical asepsis F. Classify the original surgical wound as clean, clean-contaminated, contaminated, or infected G. Observe for complications of a nonheahng wound 7. Promote wounds healing A. Assess the dressing on wound for signs and symptoms of infection including redness, odor, drainage, and warmth B. Monitor the client's temperature for elevation indicating systematic infection. C. Always use sterile technique when removing irrigating, and changing surgical dressing D. Document the surgical wound as specially us possible: the length, width, and depth of wound; and any bleeding or necrotic tissue E. Reduce the risk of nosocomial infection by maintaining medical and surgical asepsis Classify the original surgical wound as clean, noncontaminated, contaminated, or infected. Observe for complications of a nonhealing wound 8. Provide client and family teaching a. Teach the client and family members to assess for and report signs or symptoms of complications, such as 1. Deep vein thrombosis 2. Wound infection or systemic infection 3. Wound dehiscence b. Teach the client and family members about 1- Prescribed and medications 2. Treatments

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3. Diet 4. Activity level 5. Planned follow-up care c. Provide health education as detailed in client and family teaching 9. Provide client and family support, and promote coping a. Discuss postoperative depression and ineffective coping with the client and family members. Teach them about the grieving process and refer them to support groups as appropriate. b. As necessary, refer the client and family to social services to arrange for services such as Home health care Meals Transportation assistance Special equipment (wheelchair, walker, oxygen equipment) 10. Provide adequate nutrition Resume oral feeding as soon as gastric and bowels return or provide total parenteral nutrition

Nursing interventions before administering TPN 1. Ensure that solutions are refrigerated until needed then warmed to room temperature. 2. Administer TPN by performing the five rights of medication administration. Check each ingredient with the physician's order 3. Inspect TPN for paniculate matter or discoloration 4. Inspect TPN for "cracking" that may occur with total nutrient admixture, which involves layering of the solution 5. Be sure to add any medication (eg. insulin, Zantac) ordered by the physician 6. Always use a pump or controller to ensure accurate infusion rates 7. Use appropriate intravenous tubing (may use filter) Nursing interventions while serving TPN 1. Weight patient daily in hospital (two or three times each week at home) 2. Measure accurate intake and output every hrs 3. Maintain accurate caloric count of any oral nutrients 4. Monitor electrolyte and protein levels 5. Monitor serum glucose levels every 6 hrs per glucometer 6. Monitor vital signs every 6 hrs 7. Assess renal function by watching blood mea nitrogen (BUN) and creatinine levels 8. Assess liver function by monitoring liver enzymes. Bilirubin, triglycerides and cholesterol 9. Assess for signs of dehydration, hyperglycemia, and hypoglycemia 10. Change the intravenous administration tubing with every new bag, make sure all connections are scenic to avoid breaks in the integrity of the system 11. Change subclavian dressing aseptically according to hospital policy (usually two or three times weekly. 12. Label dressing and tubing with date, time, and initials of person carrying out the procedure.

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13. Monitor for signs of inflammation, infection and sepsis, the most common complication of TPN 14. If the TPN bag is not available, administer 10% dextrose solution at same rate as prescribed TPN. 15. Always taper solution when removing the patient from TPN

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