Central Line Case study free essay sample

The patient is a 45 year old man who had GI surgery 4 days ago. He is NPO, has a nasogastric tube, and IV fluids of D51/2saline at 100 mL/hr. The nursing physical assessment includes the following: alert and oriented; fine crackles; capillary refill within normal limits; moving all extremities, complaining of abdominal pain, muscle aches, and cottony mouth; dry mucous membranes, bowel sounds hypoactive, last BM four days ago; skin turgor is poor; 200 mL of dark green substance has drained from NG tube in last 3 hours. Voiding dark amber urine without difficulty. Intake for last 24 hours is 2500mL. Output is 2000mL including urine and NG drainage. Febrile and diaphoretic; BP 130/80; pulse 88; urine specific gravity 1. 035; serum potassium 3. 0 mEq/l; serum sodium 140mEq/l, CL 92mEq/l, Mg 1. 4 mg/dL. 1. ) Analyze the data in the case study. Do the findings indicate a fluid deficit or fluid excess problem? Support your answer with data from this patient. We will write a custom essay sample on Central Line Case study or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page I would guess a fluid volume deficit. Dark amber urine, dry mucus membranes, poor skin turgor, and labs all point in that direction. Although the patient’s output seems to be adequate, everything else points towards dehydration. It also seems like the patient has a fluid/electrolyte imbalance which may be putting the water in the wrong departments, or an infection (as reflected in pt. vital signs). So even though he is receiving IV fluids, it’s not reflecting on his physical assessment and labs. 2. ) What factors could be contributing to this problem? Part of the problem may be that most of the patient’s fluids are being received via IV (2400ml in 24 hours) and has only drunk 100ml PO in the past 24 hours. Low GI motility because of recent GI surgery may have something to do with it, or a f/e imbalance, or an infection could be a contributing issue. Lastly fever and diaphoresis can cause high amounts of insensible fluid loss. 3. ) Evaluate the patients electrolyte values and give a rationale for the answer. Urine specific gravity of 1. 035 is high; this means the patient’s urine is concentrated. K+ of 3. 0 is low and is common with a patient with an NG tube on suction. Pt. ’s with NG tubes loose potassium through suctioning. Sodium of 140 is normal but on the higher end which is indicative of dehydration. Chloride of 92 is a little low which is interesting because the sodium is normal-high and usually chloride follows sodium. Mag of 1. 4 is low maybe because of low calcium. 4. ) The physician is planning to place a percutaneous central line to infuse TPN. Which site is recommend and why? A percutaneous central line is entered into the patient’s subclavian vein. Because TPN solution is concentrated it is better to have CVC access in the subclavian vein so the solution has less distance to travel to its destination. This reduces the risk of the line clotting or damaging the vein. What are the nurses responsibilities for placement of the central line? The nurse is responsible for positioning the patient and should assess the patient throughout to see how well he is tolerating it. If the patient is on a heart monitor, the nurse should monitor vital signs and heart rate as the catheter is being put in for any fluctuations. Afterword’s, the nurse should assess for complications or adverse reactions like pneumothorax. Make the patient comfortable and listen to bilateral breath sounds. Obtain a stat XRAY to verify correct placement. The assessment includes: Date and time of procedure, name of provider, site of insertion, type of fluid infusing in each lumen, blood return from each lumen, chest X-ray ordered, completed and verified, and patient tolerance of procedure 5. ) The patient asks Why cant you just use this IV in my hand? It is a 22G started in the OR four days ago. What is the nurses answer? A central line is placed to end in the superior vena cava. This is a large vessel with a large amount of blood flow, so it can handle caustic fluids being infused into it. A peripheral line is much smaller and has a lot less volume flowing through at any given time, so when certain fluids are infused, it can be very damaging to the vessel wall and can cause a lot of complications. TPN contains a lot of packed particles, such as glucose and several minerals + electrolytes which can damage the smaller veins in the arms and hands. The osmolarity of TPN solution is too high for a small vein to handle. 6. ) The patients wife asks Why dont you put one of those tunneled catheters in? My sister had one. Her doctor said it had a lower infection risk. What is the nurses response? Tunneled catheters have a lower risk of infection because they have a cuff that prevents microorganism migration into the catheter tract. However tunneled lines are inserted in the OR and are an expensive and invasive procedure. They are for patients who will be on long term TPN therapy or dialysis; for patients with chronic issues. For your husband, the issue with nutrition is more acute and a long term tunneled catheter is not appropriate at this time.