TOTAL PARENTERAL NUTRITION (TPN) AND CENTRAL VENOUS PRESSURE LINE

(CVP) / MECHINAL VENTILATOR

Total Parenteral Feeding (TPN)

 It is a way of supplying all the nutritional needs directly into blood stream
bypassing gastrointestinal tract.
 It is administered outside the digestive tract, intravenously.

Indications

1. When individuals cannot or should not get nutrition through eating.

2. When the intestines are obstructed, when the small intestine is not absorbing
nutrients properly or a gastrointestinal fistula (abnormal connection) is present.
3. When the bowels need to rest and not have any food passing through them.
Bowel rest may be necessary in Crohn’s disease, pancreatitis, ulcerative colitis,
and with prolonged bouts of diarrhea in young children.
4. Individuals with severe burns, multiple fractures, and in malnourished individuals
to prepare them for major surgery, chemotherapy, or radiation treatment.
5. Individuals with aids or widespread infection (sepsis).
Composition of Ingredients in Bag for IV Delivery

 Usual fluid volume is 1.5 - 2.5L over a 24 hours period for most people.
 Actual infusion depends on:
a. Site of infusion; and
b. Patient’s fluid and nutrient requirements.

Composition:

1. Carbohydrate
- Dextrose provides the carbohydrate content of PN, up to 75% of the total
energy of the solution. It provides 3.4 kcal/g.
- Glucose is the body’s main source of energy.
- Concentration is 12.5% (maximum for peripheral introduction) to 25% (total
parenteral nutrition)
- Restricted in ventilator patients because oxidation of glucose produces more
carbon dioxide than does oxidation of fat.
2. Protein
- Mixture of essential and non-essential amino acids
- Concentration 3.5 – 15%
- Quantity of amino acids depends on patients estimated requirements and
hepatic and renal function.
3. Fat
- Lipid emulsion is a soluble form of fat that allows it to be infused safely into
the blood.
- Safflower and soybean oil with egg lecithin used as an emulsifier.
- Isotonic
- Significant source of calories.
- Usual dose is 0.5 to 1 g/kg/day to supply 20- 30% of total kcal requirement.
- IV fat contraindicated for severe hepatic pathology, hyperlipidemia or severe
egg allergies.
- Used cautiously with atherosclerosis, blood coagulation disorders.
 4. Micronutrients
- Standard multi-vitamin and trace mineral preparations added to parenteral
solutions to meet micronutrient needs.
5. Electrolyte
- It is dictated by patient’s blood chemistry values and physical assessment
findings.

Ordering and Mixing PN Solutions

 The physician writes the order for the TPN prescription.

 The pharmacist mixes the TPN solution using aseptic technique.
 Prescriptions are compounded by mixing the solutions at a 1:1 dextrose-to-amino
acid ratio and placing in 1-L bags.

Intravenous Access for PN

 Intravenous lines for PN may be inserted into a number of different veins

although the tip (inner end) of the line will usually be located in the: 1. Vena cava;
or 2. Axillary veins; or 3. Subclavian veins.

PN Routes depends on:

1. Intended duration of nutrition support

2. Patient’s condition
3. Osmolality of available solution
4. Any limitations to access (such as trauma or obstruction)

2 Ways of Access:

1. Central Venous Access

- It means that the fluids are delivered to the superior vena cava or right atrium,
or less commonly the inferior vena cava (from a femorally-inserted line).
- The central position of the line tip is always confirmed chest x-ray.
2. Peripheral Venous Access
 - The tip of the line is usually in the axillary or subclavian veins.
- Intradialytic PN is another form of peripheral access.

Blood Vessels Commonly Used as PN Access Sites

Sites of Delivery

1. Central
- Superior vena cava, right atrium, or inferior vena cava
- Access:
 Percutaneous central catheter
 Hickman line
 Broviac line
 Groshong line
 PICC line
 Portacath
- Indications:
 Longer-term use
 Short-term use when peripheral solution cannot meet full nutritional
needs or if peripheral route not available
2. Peripheral
- Any other veins
- Access: ✓peripheral cannula ✓midline catheter midclavicular catheter
- Indication: ✓ short-term use (<10-14days)
3. Intra-dialytic
- Administered during hemodialysis
- Access:
 Venous port of hemodialysis tubing (into AV shunt)
- Indication:
 Malnourished hemodialysis patients who are unable to maintain weight
and oral / enteral nutrition is not possible or has failed.

Equipment
  Intravenous Access Device
 Intravenous Giving Set
 Light Protective Covering
 Administration Reservoir Containing PN Solution
 Infusion Pump
 Syringes for Additives

Initial Considerations

 TPN should start slowly so that the body has time to adapt to both glucose load
and the hyperosmolarity of the solution, and to avoid fluid overload.
 A pump controls the infusion rate of the TPN solution.

General PN Initiation Procedure:

1. Start with 1 liter of TPN solution during the first 24 hours (or use 42 cc/hr as a
typical start rate).
2. Increase volume by 1 liter each day until the desired volume is reached.
3. Monitor blood glucose and electrolytes closely.
4. Pump administer TPN at a steady rate.
5. Don’t attempt to catch up if administration gets behind.

Types of Parenteral Nutrition

1. Peripheral vein is used.

- Must be isotonic and therefore low in dextrose and amino acids to prevent
phlebitis and increased risk of thrombus formation.
- The need to maintain isotonic solutions of dextrose and amino acids while
avoiding fluid overload limits the caloric and nutritional value of PPN
- Advantages:
a. Delivers complete but limited nutrition.
b. The final concentration cannot exceed 12.5% dextrose – lower concentrations
of amino acids.
c. Vitamins and minerals are added.
 d. Lipid emulsion may be added to supplement calories depending on the
patients’ tolerance.
e. Provides temporary nutritional support.
f. Short - term: 7 – 10 days and do not require more than 2000 to 2500 kcal per
day.
g. May be used for a post surgical ileus or anastomotic leak or for patients who
require nutritional support but are unable to use TPN because of limited
accessibility to a central vein.
h. Sometimes used to supplement an oral diet or tube feeding or transition from
TPN to enteral intake. Total Parenteral Nutrition (TPN)
2. Superior vena cava is used
- Hypertonic solutions provide more dextrose and/or protein but they must be
delivered centrally in a large diameter vein so that they can be quickly diluted,
- Higher concentration is used for TPN due to more rapid dilution in superior
vena cava.
- It is used when nutritional requirements are high and anticipated need is
relatively long 3 litres of 10% dextrose provides only 1020 kcal.
- Indications:
a. Severe malnutrition
b. GI abnormalities: due to obstruction, peritonitis, severe acute pancreatitis
c. After surgery or trauma especially that involving extensive burns, sepsis
d. Need for supplementation of inadequate oral uptake in patients who are being
treated aggressively for cancer
e. Bone marrow transplantation

Choice of Nutrition Regimen

1. Continuous
- Infuses for 24 hours continuously.
- This is the most common type of regimen in the hospital setting.
- Infusion rates usually range between 40 – 150 ml/h. Choice of Nutrition
Regimen
 - Advantages:
a. Allows the lowest possible hourly infusion rate to meet nutrient requirements.
b. Better control of blood glucose levels due to continuous carbohydrate input. 3.
May result in better utilization of nutrients.
- Disadvantages:
a. Physical attachment to the pump (may affect quality of life)
b. Higher risk of biliary stasis (if no oral/enteral intake)
c. Promotes continuous high insulin levels, which may increase risk of fatty liver.
2. Cyclic / Intermittent
- It is commonly used in long-term parenteral nutrition
- The patient is fed for 12 - 18 hours during the night and fasts during the day
or given only on some days of the week. This gives the longterm TPN patient
freedom from the machinery to lead a less restricted life during the day.
- It helps prevent hepatotoxicity that can develop with long-term TPN and the
fasting period allows essential fatty acids to be released from fat stores.
- Used for home patients
- Advantages:
a. Allows greater patient mobility (may improve quality of life)
b. Mimics physiological feeding / fasting pattern, which may help to prevent
accumulation of fat in the liver and sludge in the biliary system.
- Disadvantages:
a. Compared with continuous nutrition, a higher infusion rate is required to
provide the same volume of feed. This may be less well-tolerated, with a
higher risk of problems such as:
b. Fluid overload (and frequent urination during infusion, inconvenient especially
at night)
c. Electrolyte Fluctuations
d. Unstable blood glucose levels

PN Infusion Rate
  All patients require individual assessment for determining the rate of delivery of
nutritional support, which depends on the patient’s nutritional requirements and
medical condition.
 Typical infusion rates vary between 40-150 ml/h, but cyclic infusions may be
delivered at rates as high as 300 ml/h.

Monitoring of Nutrition Support

Purposes of Monitoring:

What should be Monitored, and the Frequency of Monitoring will depend on Factors
such as:

1. Expected duration of treatment

2. Health care setting
3. Patient’s disease state
4. Presence (and severity) of any abnormal results
5. Whether the patient is stable

Areas of Monitoring:

1. Anthropometry
2. Biochemistry / Hematology
3. Liver tests
4. Iron studies
5. Lipid studies
6. Vitamins, minerals and trace elements
7. Indicators of protein status
8. Clinical assessment and monitoring:
9. Nutritional assessment
10. Dietary intake

Common Problems

1. Line problems
- Blocked intravenous line
 - Suspected line infection
2. Blood vessel problems
- Phlebitis
- Thrombosis
- Line displacement
3. Formulation problems
- Stability problems
- Drug – nutrient interactions
4. Intolerance
- Allergic reaction to parenteral nutrition infusion ❑ Nausea or vomiting ❑
Appetite problems
- Constipation
5. Metabolic Abnormalities
- Re-feeding syndrome
- Overfeeding
- Dehydration
- Fluid overload
- Abnormal biochemistry

TPN Procedures

Parenteral Nutrition Infusion utilizing the Peripheral Access

1. Verify doctor's prescription.

2. Explain the procedure to reassure patient and significant other (benefits, risks,
duration, changes in volume and flow rate, etc.).
3. Secure consent from patient or/and authorized member of the family.
4. Prepare parenteral solution and all other devices needed for the parenteral
administration, taking into consideration the mode of administration such as:
5. Peripheral access
6. Central access
7. Check the integrity and functionality of the parenteral solution and IV devices.
8. Observe 10 rights in safe drug administration.
 9. Assess patient and choose suitable vein, location and get baseline vital signs.
10. Do hand hygiene and maintain asepsis throughout the procedure.
11. Prepare Parenteral Nutrition solution (follow procedure of IVT Setting Up).
12. Insert IV catheter aseptically (large, bore0catheter. Follow procedure for IV
insertion).
13. Connect the tubing to the prepared parenteral solution and regulate flow rate as
prescribed.
14. Dress IV sites as per IV standard.
15. Label IV site and solution as per IV standard.
16. Continue to reassure patient and do pertinent health education.
17. Dispose waste materials according to Health Care Waste Management
(DOH/DENR).
18. Document procedure and observations with corresponding nursing intervention in
the patient's chart like I and O , weigh daily, etc.
19. Monitor patient periodically and report unusual findings if there are signs of
infection, hyper and hypoglycemia, change of color and consistency of solution,
etc.
20. Document observation and intervention as necessary.
21. Reassure patient.

Parenteral Nutrition Infusion utilizing Central Vascular Access

1. Follow procedure in Peripheral Access from steps 1-9.

2. Assist surgeon in Open or Closed Central Vascular Access Procedures (Maintain
asepsis throughout the procedure).
3. Connect the IV administration set to the central vascular access catheter
aseptically and regulate flow rate as prescribed.
4. Assess dressing over central vascular access for swelling, redness, pain and
foul-smelling discharges.
5. Monitor/reassure patient.
6. Document observations and circumstances as necessary.
 7. Discard waste materials according to Health Care Waste Management
(DOH/DENR).

Discontinuing Parenteral Solution Infusion

1. Verify written prescription (Discontinues upon completion of TPN requirements,

(e.g., 24 hours, 12 hours or in the occurrence of any adverse reaction).
2. Observe 10 rights.
3. Explain procedure to the patient and significant others.
4. Prepare the necessary materials to be used in discontinuing TPN utilizing
Peripheral / Central Vascular Access (Prepare sterile dressing set and stitch
scissor for Open Central Vascular Access).
5. Follow doctor's prescription, e.g. electrolyte; weight; blood laboratory monitoring.
6. Monitor patient closely and document observation and intervention.
7. Refer to MD for any unusual observations. 8. Discard waste materials according
to Health Care Waste Management (DOH/DENR).

Central Venous Pressure (CVP)

 It is acquired by threading a central venous catheter into any of several large

veins.
 It is threaded so that the tip of the catheter rests in the lower third of the superior
vena cava.

CVP Catheter

 It is an important treatment tool used to:

a. Assess right ventricular function and systemic fluid status.
 b. Allow for rapid infusion.
c. Allow for infusion of hypertonic solutions and medications that could damage
veins.
d. Allow for serial venous blood assessment

Factors that affect CVP

 Normal CVP is 2 – 6 mm hg.

 The condition of the patient and the treatment being administered determine how
often CVP measurement should take place.
 CVP is elevated by:
a. Overhydration which increases venous return
b. Heart failure or PA stenosis which limit venous outflow and lead to venous
congestion
c. Positive pressure breathing, straining.
 CVP decreases with:
a. Hypovolemic shock from hemorrhage, fluid shift, dehydration
b. Negative pressure breathing which occurs when the patient demonstrates
retractions or mechanical negative pressure which is sometimes used for high
spinal cord injuries.

Equipment

 Manometer
 Intravenous Access Device
 Transducer

Insertion Sites

1. Internal Jugular Vein

- This site is chosen frequently as there is a high rate of successful insertion
and a low incidence of complications such as pneumothorax,
 - Internal jugular veins are short, straight and relatively large allowing easy
access, however, catheter occlusion may occur as a result of head movement
and may cause irritation in conscious patients.
2. Subclavian Vein
- This site is often chosen as there are more recognizable anatomical
landmarks, making insertion of the device easier.
- Because this site is positioned beneath the clavicle there is a risk of
pneumothorax during insertion.
- A subclavian CVC is generally recommended as it is more comfortable for the
patient.
3. Femoral Vein
- This site provides rapid central access during an emergency such as a
cardiac arrest.
- As the CVC is placed in a vein near the groin there is an increased risk of
associated infection.
- In addition, femoral CVCs are reported to be uncomfortable and may
discourage the conscious patient from moving.

CVP Recording

 It is usually recorded at the mid-axillary line where the manometer arm or

transducer is level with the phlebotomid axis.
 This is where the fourth intercostal space and midaxillary line cross each other
allowing the measurement to be as close to the right atrium as possible.

Using a manometer:

Steps:

1. Explain the procedure to the patient to gain informed consent.

2. If IV fluid is not running, ensure that the CVC is patent by flushing the catheter.
3. Place the patient flat in a supine position if possible. Alternatively, measurements
can be taken with the patient in a semi-recumbent position. The position should
 remain the same for each measurement taken to ensure an accurate comparable
result.
4. Line up the manometer arm with the phlebostatic axis ensuring that the bubble is
between the two lines of the spirit level.
5. Move the manometer scale up and down to allow the bubble to be aligned with
zero on the scale. This is referred to as 'zeroing the manometer ‘.
6. Turn the three-way tap off to the patient and open to the manometer.
7. Open the IV fluid bag and slowly fill the manometer to a level higher than the
expected CVP
8. Turn off the flow from the fluid bag and open the three-way tap from the
manometer to the patient.
9. The fluid level inside the manometer should fall until gravity equals the pressure
in the central veins.
10. When the fluid stops falling the CVP measurement can be read. If the fluid
moves with the patient's breathing, read the measurement from the lower
number.
11. Turn the tap off to the manometer.
12. Document the measurement and report any changes or abnormalities.

Using a Transducer

Steps:

1. Explain the procedure to the patient to gain informed consent.

2. The CVC will be attached to intravenous fluid within a pressure bag. Ensure that
the pressure bag is inflated up to 300mmHg.
3. Place the patient flat in a supine position if possible. Alternatively, measurements
can be taken with the patient in a semi-recumbent position. The position should
remain the same for each measurement taken to ensure an accurate comparable
result.
4. Catheters differ between manufacturers; however, the white or proximal lumen is
suitable for measuring CVP.
 5. Tape the transducer to the phlebostatic axis or as near to the right atrium as
possible.
6. Turn the tap off to the patient and open to the air by removing the cap from the
three-way port opening the system to the atmosphere.
7. Press the zero button on the monitor and wait while calibration occurs.
8. When 'zeroed' is displayed on the monitor, replace the cap on the three-way tap
and turn the tap on to the patient.
9. Observe the CVP trace on the monitor. The waveform undulates as the right
atrium contracts and relaxes, emptying and filling with blood.
10. Document the measurement and report any changes or abnormalities.

Interpreting Measurements

1. The normal range for CVP is 5-10cm H2O (2- 6mmHg) when taken from the mid-
axillary line at the fourth intercostal space.
2. Many factors can affect CVP, including vessel tone, medications, heart disease
and medical treatments.
3. A CVP measurement should be viewed in conjunction with other observations
such as pulse, blood pressure and respiratory rate and the patients response to
treatment.

Potential Complications

1. Hemorrhage from the catheter site

2. Catheter occlusion
3. Infection
4. Air embolus
5. Catheter displacement

Care for Patient with Mechanical Ventilator

  Patients who can’t breathe, for any reason, need to.be attached on a mechanical
ventilator. This machine helps critically ill patients achieve the needed oxygen to
survive. The patient is then connected to the ventilator with a tube that passes
into the mouth and down to the trachea. There is some point of complexity on
this type of procedure that is why Nurses who are assigned in the intensive or
critical unit should be competent in caring for the patient with mechanical
ventilator.

Purposes of Mechanical Ventilation

 The patient does not have to work as hard to breathe – their respiratory muscles
rest
 Helps the patient get adequate oxygen and clears carbon dioxide
 Preserves a stable airway and preventing injury from aspiration
 Air is delivered in patients with compromised ventilation
 Oxygenate the different organs of the body
 Expel the carbon dioxide in the lungs
 Provide comfortable breathing pattern to patients experiencing shortness of
breath
 To breathe for patients who are seriously compromised ventilation such as in
comatose, brain damaged, or patients with spinal cord injuries (Links to an
external site.).

Indication for mechanical ventilator use:

 1. Continuous decrease in oxygenation
2. Increase arterial carbon dioxide
3. Persistent acidosis
4. Respiratory failure:
- Apnea / respiratory arrest
- Inadequate ventilation(acute vs chronic)
- Inadequate oxygenation
- Chronic respiratory insufficiency with FTT
- Compromised airway patency
5. Cardiac insufficiency
- Eliminate the work of breathing
- To reduce the oxygen consumption
6. Neurologic dysfunction
-Central hypoventilation and frequent apnea
Comatose patient with GCS < 8
Inability to protect the airway
7. ABG Results
8. If the patient is under the following conditions:
- Multiple trauma
- Shock
- Multi-organ failure
- Drug overdose
- Thoracic or abdominal surgery
- Neuromuscular disorders
- Inhalation injury
- COPD

Complications of long-term ventilation

1. Infections– A foreign object such as the endotracheal tube in the trachea makes
the patient more susceptible to bacteria entering the lungs. This is treated with
the use of antibiotics.
 2. Pneumothorax –This is the condition when the lung/s collapses. It is a
complication when the lungs are damaged because of gets over-expansion. If
this happened, a chest tube is inserted on the collapsed lung to allow it to re-
expand and seal the leak.
3. Lung damage – The air forced in the lungs can increase the risk for injury.
4. Side Effects of medications– Intubated patients are most of the time given
sedatives to allow easier ventilation of the machine. These medications keep the
patient calm and sleepy.
5. Maintenance of Life– The ventilator sometimes serves as the only reason why
the patient is alive. Organs fail because the body is dying, this includes the lungs.

Ventilator settings and controls:

1. Tidal Volume (TV) – Air that the client receives per breathing. Percentage in the
mechanical ventilator is adjusted depending on client’s needs (40-100%). The
normal value of tidal volume is ½ L or 500 ml.
2. Fraction of inspired oxygen (FiO2) – the oxygen concentration delivered to the
client. ABG is usually determined before adjusting FiO2 levels. It is adjusted from
40%-100%.
3. Peak Flow Rate (PFR) – The peak flow rate is the maximum flow delivered by
the ventilator during inspiration. Peak flow rates of 60 L per minute may be
sufficient, although higher rates are frequently necessary.
4. Back-up Rate (BUR) – for spontaneous or time mode ventilator, back-up rate is
set so that the client may receive a minimum number of breaths per minutes if
the client fail to breath. If the client’s breathing rate is slower, it will cycle inhale /
exhale pressure at the set rate. The usual setting for BUR ranges from 12-22
breaths per minute, depending on the physician’s order.
5. Pressure end-expiratory pressure (PEEP) – is exerted during the expiration
phase of ventilation, which improves oxygenation by enhancing gas exchange
and preventing atelectasis. Not all clients with mechanical ventilator is attached
to PEEP. A typical initial applied PEEP is 5 cmH2O. However, up to 20 cmH2O
 may be used in patients undergoing low tidal volume ventilation for acute
respiratory distress syndrome (ARDS)
6. Continuous positive airway pressure (CPAP) – used for spontaneously breathing
clients. Positive airway pressure is introduced during the respiratory cycle.
7. Sensitivity- used to describe the ventilator’s responsiveness to the patient’s
breathing effort. Sensitivity adjusts the level of negative pressure required to
trigger the ventilator. With assisted ventilation, the sensitivity typically is set at -1
to -2 cm H2 O.

How to troubleshoot ventilator alarms?

 Alarms are designed to warn nurses that there is something wrong either to the
patient or to the mechanical ventilator. But sometimes, alarms can give nurses
apprehensions especially if the alarm is non-stop and we don’t know how to
troubleshoot the problem.
 So as a nurse, how will you manage if there’s an alarm? First, assess the patient
if he/she is in distress. Identify the alarm whether high pressure or low pressure.
Some mechanical ventilators have their own indicators and shows the cause of
the alarm, so it’s important to check your machine as well.
1. Low Pressure alarm
- Low pressures alarm may indicate leak in the patient’s tube, disconnection of
the tube, or the patient stops to breath.
- What are your interventions for low pressure alarm?
a. Check the tube connections.
b. Reconnect patient to the ventilator.
c. Replace leaking tubes by manually ventilating the patient.
d. Auscultate patient’s lung fields for bilateral lung sounds.
e. Monitor respiratory rate and breathing patterns.
f. Evaluate cuff pressure. Reinflate if needed.
2. High Pressure alarm
 - High pressure alarm may indicate displacement of the ET tube, increased
secretions, obstruction in the tube, bronchospasms, or the patient is coughing
or biting the tube.
a. Assess your patient.
b. Auscultate lung fields for secretions. This should be done at least every 2
hours or more.
c. Suction secretions as needed. Oxygenate patient manually before suctioning.
d. If patient is biting the tube, provide bite block.
e. Sedate patient if necessary especially when patient is fighting the vent. Make
sure this is ordered by the attending physician or hospitalist on duty.
f. Monitor pulse oximeter continuously if cardiac monitor and pulse oximeter
devices are present.

What are the bundles of care to avoid Ventilator-associated Pneumonia (VAP)?

 Bundles of care for VAP should be strictly observed by the Critical Care Nurses
or nurses in any department.
- Strict hand washing. The best way to prevent cross-contamination of any
disease is hand washing.
- Oral hygiene. Nurses should always perform oral care to patient attached to
mechanical ventilator. Know your hospital policies regarding your standard
oral hygiene procedures.
- Initiate closed suction system. Change the system at least every 72 hours or
as indicated/needed.
- Avoid pressure ulcers. Turn patient to sides every 2 hours or as needed.
Apply cream or ointment to bony prominences or as indicated by the
physician.
- Elevate head of bed >30 degrees. Always observe aspiration precaution.
- Assess patient daily for extubation readiness. Early extubation can greatly
prevent VAP.
- Daily interruption of sedation.

How to perform closed system suctioning?

Equipment

1. Sterile Closed Suction Kit

2. Normal Saline Irrigation
3. Suctioning machine or device: wall or portable
4. Oxygen source
5. Personal protective equipment
6. 10 cc syringe
7. Pulse oximeter
8. Stethoscope

Procedure

1. Check the guidelines or standard procedure of your unit for closed-suctioning

system.
2. Prepare all needed equipment. Position all supplies so that they are easily
accessible. Check suction setup for correct functioning. Read instructions of the
closed-suction kit.
3. Explain the procedure to the client. Explain the benefits of closed-suctioning
system and how it can prevent infection.
4. Assess patient first. Auscultate patient’s lung fields for abnormal breath sounds.
Attach patient to continuous pulse oximeter monitoring device.
5. Wear personal protective equipment. Perform hand washing (Links to an external
site.).
6. Attach closed suction catheter system between ventilator circuit and patient
airway.
7. Ensure that wall or portable suction is turned on (no higher than 120 mmHg). Set
vacuum setting according to policy of your unit.
8. Attach suction tubing from setup to suction port of catheter.
9. Hyper-oxygenate patient to 100% 02 for 2 – 5 minutes.
10. Attach saline to irrigation port. You may use also a 10 cc syringe for introducing
saline irrigation or depending upon the set-up of your closed-suction kit.
11. Introduce catheter before instilling saline – lavage on inspiration.
 12. Introduce catheter until a restriction is met or until you can stimulate cough reflex.
13. Withdraw the catheter slowly while applying intermittent suction. Suction should
not be applied for more than 15-20 seconds.
14. Upon completion of suctioning, withdraw catheter, ensuring that tip is completely
withdrawn from airway.
15. Rinse suction catheter after each suctioning by depressing thumb control and
squeezing a new saline irrigation using the 10cc syringe or depending on the set-
up of your close suction kit.
16. Repeat suctioning process until the patient’s airway is clear.
17. Discard personal protective equipment and wash hands.
18. Evaluate patient’s condition by auscultating the lung fields and by monitoring
patient’s oxygenation using pulse oximeter.

Plan of Care for Ventilated Patients

 Promote effective breathing pattern

 Promoted adequate gas exchange
 Improve the nutritional status that the body needs
 Prevent patient from developing pulmonary infection.
 Prevent patient from developing problems related to immobility.
 Patient and/or family will demonstrate understanding of the purpose for
mechanical ventilation (Links to an external site.).

Extra Sources & Videos:

TPN: https://www.youtube.com/watch?v=IGnwzdRe7KQ

Peripheral IV Catheter Insertion: https://infusionknowledge.com/peripheral-iv-catheter-

insertion/?
fbclid=IwAR0i05WFIyMfgZbJcyfd1Mm9a81W5IbxbiHRYe4HPEtEhS549me9ype9HKg &
https://youtu.be/TIw0-HYZafM
Central Lines & TPN: https://sites.google.com/site/nurs210lpnarticulation/tpn-central-
lines/group-1?tmpl=%2Fsystem%2Fapp%2Ftemplates%2Fprint
%2F&showPrintDialog=1&fbclid=IwAR3rVIsbYpuekeJp1BtCX4xblxT9F_NtOMeP7Bpz0
YYq3HxYUUlsendgxqQ

How to Remove an IV Catheter: https://www.youtube.com/watch?v=__NZ_AICD2I

Removing a Central Line: https://www.youtube.com/watch?v=H22PVadE6xg

References

Hinkle, J.L. & Cheever, K.H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical
Nursing (14th ed.). Philadelphia: Wolters Kluwer.

Ignatavicius, D.D., Workman, M.L., & Rebar, C.R. (2018). Medical-Surgical Nursing:
Concepts for Interprofessional Collaborative Care (9th ed.). St. Louis: Elsevier.

Lewis, S.L., Dirksen, S.R., Heitkemper, M.M., Bucher, L., & Harding, M.M. (2017).
Medical-Surgical Nursing: Assessment and Management of Clinical Problems (10th
ed.). St. Louis: Elsevier.