administration and care of parenteral nutrition in adults

Administration and Care of Parenteral Nutrition in Adults

Procedure Manual

Trust reference: B21/2010

Approved By: Policy & Guideline Committee

Date Approved: 28 May 2010 (Chair’s approval after the meeting)

Version: V1

Supersedes: (previously known as PN Policy B21/2003)

Author / Originator(s): Kate Pickering – Lead Nutrition Nurse

Name of Responsible Committee / Individual:

Kate Pickering – Lead Nutrition Nurse

Review Date: May 2013

CONTENTS

Section Page

uction

pe of Procedure Manual

esponsibilities (in addition to the Vascular Access Policy)

addition to the Vascular Access Policy)

mpliance

d Consultation Process

ss

irst review: May 2010

1. Introd 3

2. Aims and Sco 3

3. Definitions 4

4. Roles and R 5

5. Education and Training 5

6. Procedure Statements (in 6

7. Legal Liability Statement 7

8. Process for Monitoring Co 7

9. Evidence Base 8

10. Development an 10

11. Dissemination and Implementation Proce 10

12. Document Control, Archiving and Review 10

F

w and re-write of the previous UHL PN Policy which was Trust

rrent guidance from NMC, EPIC 2 as referenced

This document is a reviereference Number B21/2003

All changes are in line with cu

Procedure manual for Parenteral Nutrition of 10 Final Version, approved by Policy and Guideline Committee on 28th May 2010 Trust Reference B21/2010 Review Date: May 2013

1 INTRODUCTION

1.1 This document sets out all the procedures for the safe and effective administration and care of patients requiring Parenteral Nutrition within the University Hospitals of Leicester (UHL) NHS Trust.

1.2 Parenteral Nutrition (PN) is the intravenous administration of a solution containing amino acids, glucose, fat, electrolytes, trace elements and vitamins as treatment for acute or chronic intestinal failure. Intestinal failure is characterised by reduced intestinal absorption to that macronutrient and / or water and electrolytes are needed to maintain health and / or growth (Nightingale, 2001). It is used when it proves impossible to provide adequate nutrition by the gastrointestinal route. Occasionally PN may be given in conjunction with Enteral Nutrition (EN) or oral diet to meet a patient's nutritional requirements.

1.3 If the gut works - use it! Enteral feeding should always be the first route of choice as it is safer in terms of mechanical, septic and metabolic complications. PN refers to the administration of nutrients by the intravenous route. It is usually administered via a dedicated central or peripheral placed line and is generally used where there is:

a) Failure of gut function (e.g. with obstruction, ileus, dysmotility, fistulae, surgical resection or severe malabsorption) to a degree that definitely prevents adequate gastrointestinal absorption of nutrients

And

b) The consequent intestinal failure has either persisted for several days (e.g. >5) or is likely to persist for many days (e.g. 5 days or longer) before significant improvement.

2 AIM AND SCOPE OF THIS PROCEDURE MANUAL

2.1 This Procedure Manual and its associated supplements details the care provided to patients with PN with the aim of:

a) Standardising practices within UHL to ensure a consistent approach to care

b) Ensuring care is provided in line with the latest national and local guidance such as NICE and Infection, Prevention and Control Standards

c) Providing clear guidance and signposting to staff in the administration and care of PN

2.2 This procedure manual applies to all healthcare professionals who care for patients with PN in Adults.

2.3 This procedure manual must be used in conjunction with the UHL Venous Access in Adults and Children Policy (Trust Reference B13/2010) It may also be downloaded as a stand alone item.

2.4 This Procedure Manual does not cover the insertion of the lines – please refer to the UHL Venous Access in Adults and Children Policy (Trust Reference B13/2010)

2.5 This Procedure Manual does not cover PN in Children – please refer to the Childrens Hospital specific guidelines


3 DEFINITIONS

3.1 The diagram below shows (in red) the entry and exit sites for CVP and cuffed central lines.

Multi Lumen Insertion Site

Hickman Line Insertion Site

Hickman Line Exit Site

3.2. The diagram below shows the constituent parts of cuffed central lines

Hub

Dacron Cuff

Tip

Clamp

Double thickness line for clamping


3.3 The diagram below shows the constituent parts of non-tunnelled central venous multi lumen lines

Tip

Suture plate

Proximal lumen – used for TPN

Medial lumen

Distal lumen

4 ROLES AND RESPONSIBILITIES (IN ADDITION TO THE VASCULAR ACCESS POLICY)

In addition to the roles and responsibilities for all staff detailed in UHL Venous Access in Adults and Children Policy (Trust Reference B13/2010) staff who undertake the administration and care of PN must be appropriately trained and:

• Attend training booked via the CSDU website as detailed in section 5

• Be competent in administration of intravenous medications. (It is recognised that much of the theoretical and practical knowledge associated with the administration of intravenous medications also pertains to PN administration and will have been covered in their intravenous medication administration training).

5 EDUCATION AND TRAINING

5.1 Education and training comprises of;

• PN Training Day ( for initial competence assessment)

• PN Refresher day (recommended 3 yearly update or when practice changes)

5.2 The PN Training day has an emphasis on full aseptic no touch technique (ANTT) in line with EPIC 2 guidelines which is vital in the management of reducing catheter related sepsis and includes:

• Caring for the catheter site.

• Changing the infusion daily as directed.

• Monitoring, reporting and managing complications following line insertion, line maintenance and infusion of PN.


• Assessing the physical and psychological needs of the patient and their family in relation to PN.

• Liaison between patient and the multi-disciplinary team.

6 PROCEDURE STATEMENTS (IN ADDITION TO THE VASCULAR ACCESS POLICY)

6.1 Consent for the procedure must be sought under the guidance of the Trust Consent Policy. Verbal consent must be recorded in the patient case notes at the time of any procedures, which are undertaken.

6.2 No additions will be made to any PN bag either on the ward or in pharmacy.

6.3 PN will be prescribed on the regular part of the medication chart, this is the legal prescription.

6.4 The constituents of the feed will be ordered daily using the blue PN form. The healthcare professional administering the feed must record details of hanging date and time and bag batch number onto this form.

6.5 PN bags should be changed at 14.00 or there about to ensure if there are issues with the medication the Nutrition Team and Pharmacy are still on site.

6.6 PN connection (hub) will be covered with a gauze flag to reduce the likelihood of inadvertent manipulation of the line.

6.7 The PN bags and giving sets are changed every 24 hours.

6.8 Unless local policy dictates otherwise (ie for Renal patients / patients on ECMO) there is no need to withdraw Heparin lock in the PN line before connecting PN. PN and Heparin are stable mixed and PN acts as the flush.

6.9 Blood for chemical analysis must be uncontaminated therefore the first 10ml blood from the feeding lines must be discarded. All other IV infusions through the line should have been suspended for 2-3 minutes prior to blood being taken (if possible) and then re-started once all samples have been collected.

6.10 Blood for culture aims to capture to maximum bacterial load therefore the first 10ml blood from the feeding lines must NOT be discarded. All blood and PN withdrawn at the first aspiration should be used in the culture bottles.

6.11 Concerns regarding line sepsis will be actioned on immediately and escalated in accordance with supplement 9 of this Procedure Manual.

6.12 Supplements to this procedure manual are as follows:

Supplement One: Pre and post insertion care of skin-tunnelled catheters

Supplement Two: Daily inspection of the catheter insertion and exit site.

Supplement Three: Cleaning and re-dressing the PN catheter insertion and exit site.

Supplement Four: PN bag change


Supplement Five: Heparinising the PN Catheter.

Supplement Six: Removing air from the PN Giving Set

Supplement Seven: Taking blood cultures from the PN Catheter

Supplement Eight: Taking blood for analysis from PN Catheter

Supplement Nine: Sepsis protocol for PN Catheters

Supplement Ten: Blood monitoring of PN patients.

Supplement Eleven: Complications of PN.

Supplement Twelve: Nursing Monitoring of Patients receiving PN.

Supplement Thirteen: Patient Referral and Preparation Information for PN - Background Information

Supplement Fourteen: Care of PN lines in the community

Supplement Fifteen: The Administration of PN – competency and certificate (Provided on the Training day)

Supplement Sixteen: Management of patients post central line insertion

Supplement Seventeen: Antibiotic locking of PN lines

Supplement Eighteen: PN care plan

7 LEGAL LIABILITY STATEMENT

Guidelines issued and approved by the Trust are considered to represent best practice. Staff may only exceptionally depart from any relevant Trust guidelines providing always that such departure is confined to the specific needs of individual circumstances. In healthcare delivery such departure shall only be undertaken where, in the judgement of the responsible healthcare professional’ it is fully appropriate and justifiable - such decision to be fully recorded in the patient’s notes

8 PROCESS FOR MONITORING COMPLIANCE WITH THE POLICY

8.1 Key performance indicators / audit standards

A retrospective audit is undertaken annually on PN. Measurable outcomes for annual audit include line sepsis percentage, type of line, client group, line and patient morbidity and mortality and are recorded in the UHL PN audit database.

This is reported to the Nutrition Support Forum and then up to UHL Infection Control Committee for review and to recommend future actions as appropriate


9. EVIDENCE BASE

Andis, D A & Krzywda, EA (1997) Central Venous Access – clinical Practice Issues Nursing clinics of North America

Blunt J (2001) Wound cleansing: ritualistic or researched-based practice? Nursing Standard. 16 (1) 33-36

BNF (2009) British National Formulary

Colagiovanni L (1997) Parenteral Nutrition Nursing Standard. 12 (9) 39-45.

Danks L.A (2006) Infection Control. Central venous catheters: a review of skin cleansing and dressings. British journal Of Nursing15 (12) 650-654

Department of Health (2007) Saving Lives: reducing infection, delivering clean safe care. High Impact Intervention No 1. DoH. London.

Department of Health (2005) Mental Capacity Act DoH. London.

Department of Health (2004) The NHS Knowledge and Skills Framework (NHS KSF) and the Development Review Process, DoH, London

Department of Health (2003) Winning ways : working together to reduce healthcare associated infection in England. DoH. London.

Harrison M (1997) Central venous catheters: a review of the literature. Nursing Standard. 11 (27) pp 43-45.

Kennedy JF etal (2002) Nurse training is the key factor in reducing catheter-related sepsis rates in patients receiving parenteral nutrition. Clinical Nutrition. 21 (suppl. 1), 73.

Kidney, D D., Nguyen, D T & Stuart-Deutsch,L (1998) Radiologic Evaluation and Management of Malfunctioning Long-Term Central Vein Catheters AJR 171, Nov

Merrer J etal (2001) French Catheter Study Group in Intensive Care. Complications of femoral and subclavian venous catheterization in critically ill patients: a randomized controlled trial Journal of the American Medical Association. 286(6):700-7, 2001 Aug 8.

MDA alert (2008) Needle-free intravascular connectors MDA Ref:MDA/2008/016 18 March

NICE (2006) Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition. NICE. London

Nightingale JMD (2001) Intestinal failure. London. Greenwich Medical Media

O’Grady NP etal (2002) Guidelines for the prevention of intravascular catheter-related infections. Infection Control and Hospital Epidemiology. 23(12):759-69,Dec.

Pickering KAD et al (2002) Shorter feed times before CRS in multi-lumen lines. Clinical Nutrition. 21 (suppl. 1), 85.

Pratt, R.J, Pellowe, C.M, Wilson, JA, Loveday, H.P, Harper, P.J, Jones, S.R.L.J, McDougall, C, Wilcox, M.H (2007) epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England Journal of Hospital Infection 65S S1-S64

Robson, D & Daniels, R (2008) The Sepsis Six: helping patients to survive sepsis. British Journal of Nursing, Vol 17, No 1


RCN (2005) Standards for infusion therapy Royal College of Nursing, London

Rowley, J.S (2001) Aseptic-non-touch-technique Nursing Times 97(7) (Infection control supplement) V1-V1111

Rowley, J.S & Sinclair, S (2004) working towards an NHS standard for aseptic non-touch technique Nurs Times 100 (8) 50-52

Timsit JF etal (1999) use of Tunnelled femeral catheters To prevent Catheter-Related Infection. Annals of Internal Medicine: Vol130. Iss 9. Pg 729-735.

POLICY DOCUMENTS

UHL NHS Trust; Blood Cultures; Clinical Microbiology 2008)

UHL NHS Trust Caring at its best; Our Promise to Our Patients; Care Standards for Staff (2007)

UHL NHS Trust Vascular Access Policy (2010) (Trust Reference xxxxx)

UHL NHS Trust Waste management Policy (UHL Guidelines) (DMS 12213 )

UHL NHS Trust Guideline for use of personal protective equipment (UHL Guidelines) (DMS 10756)

UHL NHS Trust Guideline for hand hygiene (UHL Guidelines) (DMS 23813)

UHL NHS Trust MCA Capacity Assessment Form (DMS 52574)

UHL NHS Trust MCA Easy Read Summary (DMS 37287)

UHL NHS Trust Preparation and administration of intravenous drugs (DMS 11819)

UHL NHS Trust Policy for consent to examination and treatment (DMS 11772)

UHL NHS Trust Procedure manual for the care and management of Skin-tunnelled catheters in the Adult Patient (DMS 46468)

UHL Policy for the safety and sedation of adult patient’s undergoing diagnostic and therapeutic procedures (DMS 18852)

UHL NHS Trust venous blood sampling policy (DMS 48628 )

Health & Safety at Work Act (1974)

PROFESSIONAL DOCUMENTS

NMC Code of Professional Conduct, London, NMC

NMC Guidelines for Records and Record keeping, London, NMC

NMC Standards for medicines management, London, NMC

NMC Prep handbook, London, NMC


10. DEVELOPMENT AND CONSULTATION PROCESS

10.1 This document has been produced by the UHL Nutrition Nurses.

10.2 This policy has been consulted with and endorsed by the UHL Infection Control Committee and the Clinical Policy and Guideline Advisory Group.

11. DISSEMINATION, IMPLEMENTATION AND ACCESS TO THE DOCUMENT

The policy will be disseminated to all Divisions once approved via email and will also be available on INsite.

12. REVIEW OF THE DOCUMENT

The document will be reviewed no less than every three years, or sooner should national guidance from the Department of Health be issued.


Procedure Manual for Parenteral Nutrition Page 1 of 3 Final Version, approved by Policy and Guideline Committee on 28th May 2010 Trust Reference B21/2010 Review Date: May 2013

Pre and Post Insertion Care of Skin-Tunnelled Catheters Supplement 1 of Procedure Manual

for Parenteral Nutrition In AdultsNutrition Nurse Specialists

1.1 This supplement applies to all healthcare professionals who care for patients with PN. 1.2 It is the responsibility of the patient’s medical team to ensure that the medical preparation

and investigation of the patient happens as outlined in this document. 1.3 It is the responsibly of the nurses caring for the patient to ensure all nursing monitoring,

observations and preparations are undertaken as outlined. 1.4 Adapted from the UHL Procedure manual for the care and management of skin-tunnelled

catheters in the adult patient 2009

No. Patient Preparation Pre-procedure Rationale & Evidence 1 A skin-tunnelled line care pathway produced by

radiology should be used where available (LRI site only at present time) to document the assessment and preparation of the patient.

To ensure patient is prepared appropriately for the procedure.

2 Risk factors for insertion should be assessed • Previous neck, chest or breast surgery, including

implants • Previous central venous catheter • placement • Body mass index <20 or >30 • Cervical or mediastinal adenopathy • Previous fractured clavicle • Medication – anticoagulation therapy • Known venous anomalies • Previous thrombosis • Abnormal platelet count (high or low) • Known or suspected bleeding disorder • Pre existing infection • Patients with cardio-respiratory disease may be

unable to lie flat.

To ensure the practitioner inserting the line is aware of potential difficulties.(Andis & Krzywda 1997)

3 Ensure patients and carers receive full information about: (including written information) • The insertion procedure • Reason for insertion • Potential complications • Risks, benefits and alternatives

To ensure the patient understands the procedure and is able to give valid informed consent.(UHL Consent Policy)

4 Obtain written consent from patient. To maintain a record that consent was given. (UHL Consent Policy, DoH 2005)

5 Ensure blood has been taken for full blood count and clotting screen and results are available prior to the procedure. Results must be checked for abnormalities prior to the procedure.

To identify any abnormalities that may cause complications e.g. bleeding.


No. Patient Preparation Pre-procedure Rationale & Evidence 6 Record patient’s blood pressure, pulse,

oxygen saturation and temperature pre procedure.

To establish a baseline and to check for underlying infection which may contra indicate the insertion of a long term catheter.

7 If patient is taking anticoagulation therapy • Take bloods 2-3 days pre- insertion of line (as long

as patient is haematologically stable) o INR parameters pre line insertion o INR < 1.5 no problem with line insertion o INR 1.5-2 line insertion at discretion of

practitioner inserting line o INR > 2 Increased risk of haemorrhage, may

not be suitable for line insertion • Platelet count parameters pre line insertion

o Platelets > 50 satisfactory o Platelets 20-50 will require platelet

transfusion pre line insertion o Platelets <20 line insertion only if absolutely

necessary and after discussion at senior medical level

• Adjustments of anticoagulants should be under medical advice on an individual patient basis.

• Some anti-coagulated patients may be considered to be a higher thrombotic risk than others and may need some prophylactic anticoagulation.

• Patient will require daily INR and FBC post line insertion until re-stabilised on anticoagulation therapy.

To prevent bleeding / thrombosis.

8 Patient should shower prior to procedure and wear a disposable gown and identity bracelet.

To ensure skin is clean and patient is correctly identified. (DoH 2003, Elliott et all 1994, RCN 2005)

9 Patients notes, care pathway, blood results and only relevant x-rays should go with the patient to the inserting dept.

To ensure all relevant details are available to staff inserting the lines.

10 Patient should fast prior to insertion diet 4 hours, fluids 1 hour.

To reduce risk of vomiting if sedation is required.

11 Post Insertion Care Patient must be collected from the department by a registered nurse. The ward nurse must receive a hand-over from the department staff.

12 If sedation used the patient must be closely monitored until fully recovered. Observations of pulse, blood pressure and oxygen saturations should be taken as directed in the care pathway.

To maintain patient’s safety until fully recovered from the sedation. (UHL 2005)

13 The wound dressing should be checked for leakage at regular intervals and the dressing to remain in place for the first 24-48 hours unless excessive leakage.

To ensure there is no excess bleeding from insertion site.


No. Patient Preparation Pre-procedure Rationale & Evidence 14 Fluids and diet can be re-commenced on return to the

ward or on full recovery from sedation / anaesthetic.

15 A chest x-ray must be taken 3-4 hours post insertion and BEFORE COMMENCEMENT OF PN and it’s suitability for use should be recorded in the medical notes stating –“please commence feeding” If the line has been placed under radiological fluoscopy guidance and position is confirmed in the medical notes the PN can commence as soon as the patient returns to the ward.

To establish line position and exclude post procedure complications e.g. pneumothorax (Elliott et al 1994, Kidney et al 1998, RCN 2005)

16 On discharge from hospital with a tunnelled central line but not on home treatment; Ensure patient is given advice on how to care for their line and when to contact the hospital for advice using the ‘Care of PN lines in the community’ Supplement14 of the Procedure Manual for Parenteral Nutrition in Adults

17 Provide the patient with • 4 weeks supply of equipment needed to care for the

line. A copy of the Guidelines for care of the nutrition feeding central lines in the community.

• Community nurse letter which includes prescription for 0.9% Sodium Chloride and Heparin Sodium.


Guideline for daily inspection of the Parenteral Nutrition (PN) line

insertion and exit site. Supplement 2 of Procedure Manual


This procedure is for observation and replacement of the dressing and applies to nursing staff caring for PN patients.

ACTION RATIONALE EVIDENCE 1 The insertion and exit site of the PN line should

be inspected daily – see definitions in procedure manual.

To identify any exit site infections and assess if the wound requires cleaning.

EPIC 2 (2006)

2 Wash and dry hands, put on clean gloves and apron.

To prevent cross-infection. EPIC 2 (2006)

3 Gauze based dressing (Ward Hickman) should be used: • If there is moisture and exudate • If a moist semi-permeable transparent

dressing has been removed. • If staff feel it is indicated • At patients request These are changed daily as indicated in ‘Guidelines for cleaning and re-dressing the catheter entry site’ – supplement 3 of the procedure manual for PN. Otherwise a semi-permeable transparent dressing is to be used Semi-permeable transparent dressings (ITU/CVC) should be changed every 7 days on a Monday or when moist as indicated in ‘Guidelines for cleaning and re-dressing the catheter entry site’ – supplement 3 of the procedure manual for PN.

EPIC 2 (2006)

4 Visually inspect line insertion or exit site. Note any exudate, swelling, and redness. Ask patient, (if possible), if there is any pain at the insertion / exit site or if they are experiencing any loss of function in arm.

To assess line insertion or entry site for signs of localised infection, thrombosis or extravasation.

EPIC 2 (2006)

5 If exudate, swelling, and redness noted; • Stop PN immediately. • Refer to the medical team and Nutrition

Nurses. • Swab the site following the ‘Guidelines for

cleaning and re-dressing the catheter entry site’ – supplement 3 of the procedure manual for PN.

To assess infection status and allow early investigation and treatment.

Procedure manual for Parenteral Nutrition Page 1 of 2 Final version, approved by Policy and Guideline Committee on 28th May 2010 Trust Reference B21/2010 Review Date: May 2013

Cleaning and Redressing the PN Catheter Insertion and Exit Sites

Supplement 3 of Procedure Manual for Parenteral Nutrition In Adults

Nutrition Nurse Specialists This procedure is used to clean the line insertion / exit site, swab the site and change the dressing. This applied to the nursing staff caring for a patient with PN.

Equipment Dressing trolley Chlor-clean (to clean the trolley) Methylated Spirits Disposable apron Clean gloves Basic sterile dressing pack including sterile towel Alcohol hand rub Sterile gloves (if not already in dressing pack) 2% Chlorhexidine gluconate in 70% isopropyl applicator or wipe x 1 Semi-permeable transparent or gauze dressing (large enough to allow line to be looped underneath) Microbiology wound swab if required. (If site dry, include sterile water to moisten swab)

ACTION RATIONALE EVIDENCE 1 Explain the procedure to the patient, ensuring privacy and

comfort. To reduce anxiety and gain informed consent

UHL Caring at it’s Best (2007)

2 Clean the trolley with Chlor-clean, dry and then clean working surfaces of the trolley with Methylated spirit.

To remove dust and clean surface.

EPIC 2 (2006) Infection control (2008)

3 Assemble equipment tidily, as above and place on bottom shelf of trolley / bedside ‘work-surface’.

ROWLEY (2001a)

4 Wash and dry hands. Put on clean gloves and apron. To clean and prevent cross infection.

EPIC 2 (2006)

5 Remove old dressing without touching the line or insertion / exit site. Inspect site for sign of redness, tenderness, swelling or exudate. Observe the external lumen of the catheter for kinks or damage. Ask patient, (if possible), if there is any pain at the insertion / exit site or if they are experiencing any loss of function in their arm.

To monitor for any signs of infection and allow for all effective treatment. To monitor for any signs of line damage. To monitor for any signs of nerve or vascular damage.

EPIC 2 (2006)

6 Check that the Dacron cuff on a Hickman line is not visible.

Inform Nutrition Nurse Specialist and medical staff immediately if the cuff can be seen.

To ensure that the line is placed correctly. If dacron cuff is seen, line is at higher risk of infection and displacement. Cuffs which have slipped often look like fuzzy scabs sticking out of the exit sites.

7 Wash and dry hands. To clean and prevent cross infection.

EPIC 2 (2006)

Procedure manual for Parenteral Nutrition Page 2 of 2 Final version, approved by Policy and Guideline Committee on 28th May 2010 Trust Reference B21/2010 Review Date: May 2013

ACTION RATIONALE EVIDENCE 8 Open dressing pack onto work surface, touching only

outside and corners. This is now your aseptic field. Open all other sterile items onto aseptic field using a non-touch technique.

To maintain sterile field. UHL Infection Control (2008)

9 Wash and dry hands and put on gloves. To clean and prevent cross infection.

EPIC 2 (2006)

10 Swab catheter exit site (if necessary) with culture swab before cleaning.

To identify any infection requiring antibiotic treatment.

11

Decontaminate the exit site with a single use application of 2% Chlorhexidine gluconate in 70% isopropyl applicators or wipe working away from the entry point. Allow to dry.

To avoid contamination of the catheter line and to disinfect the skin.

EPIC 2 (2006)

12 Suture removal • If the patient has a tunnelled PN line the sutures at the

incision site may be removed after 7 – 10 days • The suture at the exit site may be removed at 21 days

at the earliest providing the cuff is not at risk of slipping out when these are removed (it is common to allow these to grow out to avoid unnecessary tension on the cuff).

Patient comfort and to remove a possible source of sepsis. To prevent wound dehissence.

13 Apply sterile dressing of choice with loop of PN line underneath to negate the need for further taping using an aseptic non-touch technique.

To prevent pulling, trauma, inadvertent catheter removal and extrinsic contamination of the catheter entry site.

EPIC 2 (2006)

14 Remove gloves and dispose of used materials in to a clinical waste bag. Discard clinical waste bag per Trust Policy.

To maintain safety. EPIC 2 (2006)

15 Clean the trolley with Chlor-clean. Clean working surfaces of the trolley with Methylated spirit. Return to storage.




EPIC 2 (2006)

17 Note the date of the dressing change. All dressing changes should be recorded in the patient’s nursing notes with a proposed date for renewal.

To maintain communication and documentation of procedure.

NMC 2003

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Procedure Manual for Parenteral Nutrition Page 1 of 3 Final version, approved by Policy and Guideline Committee on 28th May 2010 Trust Reference B21/2010 Review Date: May 2013

Parenteral Nutrition (PN) Bag Change


Nutrition Nurse Specialists

1 Introduction and scope 1.1 This procedure is used to change the PN feed bag. This applies to the nursing staff caring

for a patient with PN. 1.2 Administration PN bags via a dedicated central venous line can only be changed by staff

who have undertaken PN assessment (see sections 4 and 5 of the Procedure Manual for Parenteral Nutrition in Adults).

1.3 Education and training comprises of;

• PN Competency Assessed Training Day ( for initial competence assessment) • PN Refresher day (recommended 3 yearly update or when practice changes)

Equipment Dressing Trolley Chlor-clean (to clean the trolley) Methylated spirits Disposable apron Alcohol hand rub Basic sterile dressing pack including sterile towel Mepore tape Sterile gloves x2 pairs (if not in pack) 2% Chlorhexidine gluconate in 70% isopropyl wipe x3 Alcohol hand rub Gauze dressing if required (large enough to allow line to be looped underneath) PN order form Medication prescription chart signed by a Doctor. PN bag (must be checked against prescription and order form) Giving set Sharps bin Cleaned volumetric infusion pump (at bed side)

ACTION RATIONALE EVIDENCE

1 Wash and dry hands. Put on apron. To clean and prevent cross infection.

EPIC 2 (2006)

2 Clean the trolley with Chlor-clean, dry and then clean working surfaces of the trolley with Methylated spirit




ROWLEY (2001a)

4 Explain the procedure to the patient, ensuring privacy and comfort.

To reduce anxiety and gain informed consent


5 Two trained nurses must check the PN bag details against the order form and prescription at the patients bedside.

To ensure that the correct PN is administered to the correct patient.

NMC (2008) UHL IV drugs Policy


ACTION RATIONALE EVIDENCE 6 If previous bag still hanging, switch off pump and

close roller clamp on giving set and remove from pump.

To prevent leakage and maintain a positive lock.

7 Hang PN bag (with light protection cover) on drip stand. Roll back light protective cover and expose bag connections. Snap off port cover.

8

Scrub the port for 30 seconds with 2% Chlorhexidine gluconate in 70% isopropyl wipe using different parts of the wipe.

To decontamination of the port before cannulation.


9 Wash and dry hands. To reduce the risk of cross infection.

EPIC 2 (2006)

10 Open dressing pack onto top of dressing trolley, touching only the corners. If a sterile waste bag is included in the pack, this may be pulled over one hand and used as a sterile glove to set out the contents of the tray. When the aseptic field is set the waste bag should be attached half way down the trolley for the clinical waste. Open all sterile equipment onto aseptic field using aseptic no-touch technique (ANTT).

Allows preparation of equipment prior to procedure without contamination. Adhering to ANTT principles.

11

Between finger and thumb carefully remove sterile field from pack and place near to patient’s line.

12

Expose end of the patient’s feeding line and close clamp on double thickness part of line, remove gauze flag and discard.

To prevent the clamp cutting through the line. To prevent air leaking in or blood leaking out of venous system.

13

Scrub the hub and needless port of the PN line for 30 seconds with 2% Chlorhexidine gluconate in 70% isopropyl wipe using different parts of the wipe, using a second wipe at the same time to clean the Hickman line and clip and PN line using different parts of the wipe. (if attached).

ROWLEY (2001a)

14

Without placing the line down, manoeuvre the sterile field under the line.

To reduce the risk of cross infection and crate an aseptic working field.

Infection control (2008)

15 Open x2 pairs of sterile gloves on a dry clean surface nearby – this should not be the aseptic field.

To reduce contamination of the sterile field.

16 Wash and dry hands and apply alcohol hand rub put on one pair of sterile gloves without touching outside of them.

To reduce the risk of cross infection To maintain asepsis.

17 Pick up the new giving set on the aseptic field and close roller clamp space.

18 Wearing sterile gloves pick up giving set chamber leaving most of the line on the aseptic field and insert giving set to the bag using ANTT principles.

EPIC 2 (2006)


ACTION RATIONALE EVIDENCE 19 Prime the line. (N.B. If bubbles present, ping giving

set as taught and run fluid through to expel all air). To avoid central venous air embolism. To reduce air alarming out of hours.

20 Remove first set of contaminated gloves and discard. Put on second set of sterile gloves.

To ensure asepsis.

21 Loosen the patient’s connection to ensure it is not stuck but do not disconnect.

22 While holding clean giving set securely in your hand, disconnect existing line from patient and discard.

To dispense with used line. To connect new line in an aseptic manner.

23 Connect to the feeding line needle-less port (firmly but not tightly).

To connect the patient to the system aseptically and allow feeding to commence.


24 Wrap single layer of gauze around hub connection and secure with hypoallergenic tape with ends folded over.

Fold ends of tape to ease tape removal. This prevents scissors being used near lines.

Harrison (1997)

25 Observe and change dressing as indicated in ‘Guidelines for cleaning and re-dressing the catheter entry site’.

To assess if the wound requires cleaning. To reduce exposure to microorganisms.

EPIC 2 (2006)

26 Insert the giving set into volumetric pump and close door. Set volume and rate of infusion as prescribed Open roller clamp and the clamp on the feeding line.

To ensure an accurate flow rate.

As per manufacturers instructions.

27 Discard Clinical waste into yellow bag. Discard syringe and ampoule into sharps bin. Drain PN bag down sluice before discarding into yellow bag. Discard giving set intact into sharps bin.

To minimise risk of cross infection and needle stick injury.

EPIC 2 (2006)





EPIC 2 (2006)

30 Document bag change on prescription / order form and record procedure in nursing notes and on fluid chart.

To maintain legal documentation and promote communication.

NMC (2007) Harrison (1997)

Procedure manual for Parenteral Nutrition Page 1 of 3 Final Version, approved by Policy and Guideline Committee on 28th May 2010 Trust Reference B21/2010 Review Date: May 2013

Heparinising the Parenteral Nutrition (PN) Catheter Supplement 5 of Procedure Manual


This procedure is used to heparin lock the PN line. This applies to all health care professionals caring for a patient with PN. Equipment. Dressing trolley Chlor-clean (to clean the trolley) Methylated spirits Disposable apron Alcohol hand rub Basic sterile dressing pack including sterile towel Mepore tape Sterile gloves (if not in pack) 2% Chlorhexidine gluconate in 70% isopropyl wipe x3 2x 10ml leur-lock syringes 1x 20ml leur-lock syringe Orange needle or filter needle for heparin ampoule. Needle-less port for weekly change on a Monday Medication prescription chart signed by a prescriber.

• Hickman / PICC – 50 units in 5ml Heparin Sodium solution with 10 ml 0.9% Sodium Chloride to flush line before heprinisation

• Multi-lumen CVC – 10 ml 0.9% Sodium Chloride Alcohol rub Sharps bin Clinical waste bag

ACTION RATIONALE EVIDENCE 1 Wash and dry hands. Put on apron. To clean and prevent cross

infection. EPIC 2 (2006)





ROWLEY (2001a)




5 Clamp feeding line. If old bag still hanging, switch off pump and clamp giving set (roller clamp)

To prevent leakage and maintain a positive lock

6 Wash and dry hands and apply alcohol hand rub.

To reduce the risk of cross infection

EPIC 2 (SP6/SP8) (2006)


ACTION RATIONALE EVIDENCE 7 Open dressing pack onto top of dressing trolley,

touching only the corners. If a sterile waste bag is included in the pack, this may be pulled over one hand and used as a sterile glove to set out the contents of the tray. When the aseptic field is set the waste bag should be attached half way down the trolley for the clinical waste. Open all sterile equipment onto aseptic field using aseptic no-touch technique (ANTT).


8

Check 0.9% Sodium Chloride against prescription with another qualified nurse then squeeze in to container on aseptic field.

9

If required check Heparin against prescription with another qualified nurse then scrub Heparin ampoules for 30 seconds with 2% chlorhexidine gluconate in 70% isopropyl wipe using different parts of the wipe and place on aseptic field.

To disinfect ampoule however printed expiry date will be removed by the wipe therefore ampoule should be checked prior to cleaning.

10


11



12

Scrub the hub and needless port of the PN line for 30 seconds with 2% Chlorhexidine gluconate in 70% isopropyl wipe using different parts of the wipe, using a second wipe at the same time to clean the Hickman line and clip and PN line (if attached).

ROWLEY (2001a)

13






EPIC 2 (SP6) (2006)

15 Wash and dry hands and apply alcohol hand rub put on sterile gloves without touching outside of them.


ROWLEY (2001)

16 Filter needles are required if using glass ampoules - pick up and connect Heparin syringe to filter needle. Once done, replace on the aseptic field.

To reduce likelihood of glass fragments entering the central venous system

17 Pick up ampoule and open. Use gauze to hold ampoule top when breaking. Discard top and gauze into container for later disposal into sharps bin.

To prevent glass fragments piercing sterile gloves and to protect fingers


ACTION RATIONALE EVIDENCE 18 Holding the ampoule and if required, draw up 2

ml of Heparin Sodium 50 units per 5 ml into 10 ml syringe using filter needle. Draw up 10 ml 0.9% Sodium Chloride into 10 ml syringe

19 Remove air bubbles from syringes. Replace syringes on to sterile field in their order of use.

To reduce the likelihood of air bubbles entering the central venous system

20 Check Hickman line / CVC clamp is closed, disconnect old line from needleless port at the end of feeding line.


21 Connect 10 ml 0.9% Sodium Chloride to central line hub and flush. If required connect 2ml Heparin Sodium to central line and instil if required.


Fold ends of tape to ease tape removal. This discourages inappropriate access of device and prevents scissors being used near the line.

Harrison(1997)

23 Discard ‘paper’ waste into yellow bag. Discard filter needle, green needles, syringes and ampoules into sharps bin.

To minimise risk of cross infection and sharps injury

EPIC 2 (H&S ) (2006)





EPIC 2 (2006)

26 Document medication administration on prescription and record procedure in nursing notes.



PN lines not in use will require the following regimen;

• Hickman lines o Flush every 3-4 days with 10ml Saline and lock with 10iu / ml Heparin

Sodium. Apply gauze flag. o This should be prescribed on the regular part of the medication chart.

• CVC o Flush every 3-4 days with 10ml Saline. Apply gauze flag. o This should be prescribed on the regular part of the medication chart.

• The needle-less access device should be changed once a week on a Monday

regardless of which day it was inserted.


Removing Air from PN Giving Set Supplement 6 of Procedure Manual for Parenteral Nutrition In Adults

Nutrition Nurse Specialists 1 Introduction and scope 1.1 This procedure is used to remove air from the giving set. This applied to the nursing staff

caring for a patient with PN. 1.2 Air in the giving set should not occur if the giving set is run through thoroughly

before connection on the bag change. Equipment Dressing Trolley Chlor-clean (to clean the trolley) Methylated spirits Disposable apron Alcohol hand rub Basic sterile dressing pack including sterile towel Mepore tape Sterile gloves x2 pairs (if not in pack) 2% Chlorhexidine gluconate in 70% isopropyl wipe x3 Alcohol hand rub Sharps bin

ACTION

RATIONALE EVIDENCE


EPIC 2 (2006)





ROWLEY (2001a)




5 Switch off pump and close roller clamp on giving set and remove from pump

To prevent leakage and maintain a positive lock



7



8



9

Scrub the hub and needless port of the PN line for 30 seconds with 2% Chlorhexidine gluconate in 70% isopropyl wipe using different parts of the wipe, using a second wipe at the same time to clean the Hickman line and clip and PN line (if attached).

ROWLEY (2001a)

10








EPIC 2 (SP6/SP8) (2006)

13 Disconnect hub and leaving needle-less port on lay into receiver on aseptic field.

14 Prime the line. If bubbles present, manipulate giving set as taught run fluid through to expel all air.

To allow the feed to run through the line slowly. Reducing the risk of air into the line

As per Manufacturers instructions.


EPIC 2 (SP6/SP8) (2006)

16 Pick up giving set from aseptic field and connect to feeding line (firmly but not tightly).

To connect the patient to the system and allow feeding to commence.


Fold ends of tape to ease tape removal. This prevent scissors being used near lines

Harrison(1997)

18 Insert the giving set into volumetric pump and close door. Set volume and rate of infusion as indicated. Open roller clamp and the clamp on the feeding line if closed

To ensure an accurate flow rate




EPIC 2 (H&S ) (2006)





EPIC 2 (2006)

22 Document procedure in nursing notes. To maintain legal documentation and promote communication.



Taking Blood Cultures from Parenteral Nutrition (PN) Catheter Supplement 7 of Procedure Manual


This procedure is used to remove blood for culture. This applies to all health care professionals caring for a patient with PN. Equipment Dressing Trolley Chlor-clean (to clean the trolley) Methylated spirits Disposable apron Alcohol hand rub Basic sterile dressing pack including sterile towel Mepore tape Sterile gloves (if not in pack) 2% Chlorhexidine gluconate in 70% isopropyl wipe x5 2x 10 ml luer-lock syringe. 1x 20 ml luer-lock syringe 1x orange needle or filter straw 2x green needles Medication prescription chart signed by a prescriber.

• Hickman / PICC – 50 units in 5ml Heparin Sodium solution with 10 ml 0.9% Sodium Chloride to flush line before heprinisation

• Multi-lumen CVC – 10 ml 0.9% Sodium Chloride Blood culture bottle x2 (Aerobic and Anaerobic) Sharps bin Cleaned volumetric infusion pump (at bed side) ACTION RATIONALE EVIDENCE


EPIC 2 (2006)





ROWLEY (2001a)




5 Switch off pump and close roller clamp on giving set and remove from pump.





7 Remove tops from blood culture bottles and scrub with 2% Chlorhexidine gluconate in 70% isopropyl wipe (one wipe per bottle) for 30 seconds using different parts of the wipe. Leave bottles next to sterile field.

8


9

If required check Heparin against prescription with another qualified nurse then scrub Heparin ampoules for 30 seconds with 2% chlorhexidine gluconate in 70% isopropyl wipe using different parts of the wipe and place on aseptic field.

To disinfect ampoule however printed expiry date will be removed by the wipe therefore ampoule should be checked prior to cleaning.

10


11



12


ROWLEY (2001a)

13




14 Open x1 pairs of sterile gloves on a dry clean surface nearby – this should not be the sterile field.




16 Pick up each ampoule and open. If opening a glass ampoules use gauze to hold ampoule top when breaking. Discard tops and gauze into container for later disposal into sharps bin.

To prevent glass fragments piercing sterile gloves and to protect fingers.

17 Holding each ampoule draw up fluids using an orange or filter needle if glass ampoules are used. Replace syringes on sterile field in order of usage.

To prevent glass particles from entering the patients venous system.


18 Disconnect feeding line and withdraw 10 - 20 ml blood which may include TPN solution through needle-less port - do not discard. May be helped by • if patient is sitting upright • chin down • breathes in • arm over head

This will be the blood sent for culture and sensitivity. Lay 20 ml blood sample on aseptic field.

Microbes are found in the TPN and blood so all are suitable for analysis.

To enable drawing of blood from the central venous system.

Each blood culture bottle should receive 10ml of blood however if only gaining a small sample split this between the two culture bottles.

19 If feed to be continued – Flush with 0.9% Sodium Chloride. Reconnect feed. If feed is to be discontinued – Flush with 0.9% Sodium Chloride then inject Heparin 10 units / ml / 2 ml.

To ensure line is clear of blood which can accumulate to block line See Supplement 5 - Heprinisation of PN line.

20 Inject 10 ml blood into each bottle using a clean green needle for each.

To prevent cross infection from culture bottle bungs into the culture medium.

UHL 2008


Fold ends of tape to ease tape removal. This prevent scissors being used near lines.

Harrison(1997)

22 Label bottles and microbiology form as "CVC / Hickman, Right/Left, feeding-line blood cultures". A peripheral blood culture specimen should be taken at the same time as the central cultures. Request form informs the laboratory that ‘patient on TPN’. When requesting MC&S consider requesting yeast and fungi this can take some weeks but can be useful.

To prevent confusion with specimens from peripheral culture. To cross check focus of infection. To ensure line is free from colonisation from yeast and fungi.



EPIC 2 (H&S ) (2006)





EPIC 2 (2006)




Taking Blood for Analysis from PN Parenteral Nutrition (PN) Catheter Supplement 8 of Procedure Manual


This procedure is used to remove blood for chemical analysis therefore the first 10ml blood should be discarded. This applies to all health care professionals caring for a patient with PN. Equipment Dressing Trolley Chlor-clean (to clean the trolley) Methylated spirits Disposable apron Alcohol hand rub Basic sterile dressing pack including sterile towel Mepore tape Sterile gloves (if not in pack) 2% Chlorhexidine gluconate in 70% isopropyl wipe x5 Medication prescription chart signed by a prescriber – 10mls 0.9% Sodium Chloride 2x 10 ml luer-lock syringe. 1x 20 ml luer-lock syringe Blood bottles as appropriate Sharps bin

ACTION RATIONALE EVIDENCE


EPIC 2 (2006)





ROWLEY (2001a)




5 Switch off pump and close roller clamp on giving set and remove from pump.

To prevent leakage and maintain a positive lock. To ensure sample is not contaminated with PN solution




ACTION RATIONALE EVIDENCE 7


8


9



10


ROWLEY (2001a)

11








EPIC 2 (2006)

14 Draw up 0.9% Sodium Chloride. Replace syringes on aseptic field in order of usage.

15 Disconnect feeding line, withdraw 10ml blood in 10ml syringe and discard. Withdraw further 20ml in 20ml syringe and lay on work surface. May be helped by • if patient is sitting upright • chin down • breathes in • arm over head

This will be the blood sent for chemical analysis, Haematology etc...

To enable drawing of blood from the central venous system. Appropriate blood bottle should be prepared in advance with a needle-less adaptor to connect blood bottle to syringe of blood.

16 Flush with 10ml 0.9% Sodium Chloride. Ensure needle-less port is free from blood and reconnect feed.

To ensure line is clear of blood which can accumulate to block line.

17 Place in appropriate labelled bottles for chemical analysis. Dispatch to lab with request forms in transparent bag. *HIGH RISK specimens should be dealt with as per UHL Protocol.

To ensure correct form and specimen for correct patient arrive at the lab. Tip blood to prevent it from clotting.


ACTION RATIONALE EVIDENCE 18 Wrap single layer of gauze around hub

connection and secure with hypoallergenic tape with ends folded over.


Harrison(1997)



EPIC 2 (H&S ) (2006)





EPIC 2 (2006)




Sepsis Protocol for PN Catheter 2010



Notify PN team / medical staff

Clinically assess the patient

Turn off the PN and document on TPR chart with the time

Commence half hourly Temperature and pulse observations and ensure medical review

YES Turn off Insulin pump

until Dextrose Saline is commenced

Sliding scale insulin (as per insulin prescription chart)

NO

Undertake septic screen Feeding Catheter blood cultures

(See Supplement 7; Taking blood cultures from feeding line) Peripheral blood cultures Wound swabs MSU / CSU Sputum Other losses

Heparin lock or flush PN line

Nursing and medical reassessment of patient temperature and clinical condition 30 min after feed stopped

If temperature drops immediately that PN was stopped

If temperature remains raised • Look for other foci of infection

• Consider Antibiotics

• Consider restarting PN feed

Pyrexia 38’ or greater

Sepsis Six – actions to minimise the risk of escalating severe sepsis; • Oxygen • Blood cultures • Antibiotics • Fluids • Lactate and haemoglobin • Insert catheter and monitor urine output Wayne P Robson, Ron Daniels 2008 BJN

This established pathway is used to aid diagnosis of PN line sepsis. This applies to all Nursing and Medical staff responsible for caring for the patient receiving Parenteral Nutrition.

Procedure manual for Parenteral Nutrition Page 1 of 1 Final Version, approved by Policy and Guideline Committee on 28th May 2010 Trust Reference B21/2010 Review Date May 2013

Blood / Fluid Monitoring of

inpatient Parenteral Nutrition (PN) Supplement 10 of Procedure Manual for Parenteral Nutrition In Adults

Nutrition Nurse Specialists This monitoring is used to detect signs of metabolic abnormality. This applies to the nurses and medical team responsible for caring for the patient receiving PN. In order to optimise parenteral nutritional support, the following biochemical measures are necessary. Blood samples must be delivered to Chemical Pathology promptly on the day of request to enable the next day’s feeding to be planned. Before starting PN Blood U&E’s

Liver function tests Bone Glucose Mg FBC INR & Clotting Screen Vitamin B12 & Folate Zinc & Copper

Daily dropping to three times a week if stable Blood U&E’s

LFT’s Bone Glucose Mg FBC

Weekly Blood INR

Fortnightly Blood

BB12 & Folate Zinc & Copper

As necessary Urine Random Urine Sodium

Blood B1,B2, B6 and selenium available from Chem Path

Blood Glucose: If blood glucose consistently above 12 mmols refer to Doctor for Sliding scale insulin prescription.


Complications of Parenteral Nutrition



1 Introduction This chart should be used in conjunction with; 1.1 the BNF ( British national Formulary) 1.2 Leicestershire Prescribing Guide. 1.3 Supplement 9 of the Procedure Manual for Parenteral Nutrition in Adults. Complication Signs and symptoms Action Pneumothorax The nurse must observe the patient for

signs of respiratory distress, e.g. chest pain and/or breathlessness.

If severe may need chest aspiration or chest drain insertion.

Haemorrhage The catheter entry site must be observed for signs of bleeding following insertion of catheter and blood pressure monitored at regular intervals.

Pressure dressing over insertion site for 10 -15 min.

Infection Monitor TPR. See Sepsis Protocol (supplement 9 of the PN Procedure Manual)

The following infection screen is recommended:- Peripheral blood cultures. Central line blood cultures. Sputum specimen. MSU / CSU. Output from fistulae / stomas / wounds.

Venous thrombosis

Patients face or arm becomes swollen. May occur because: • catheter tip is situated high in the vena

cava or in the subclavian vein. • solution infused has a very high

osmolality. • there is a catheter-related sepsis. • patient is dehydrated

Diagnosis should be confirmed by venogram. Streptokinase or Alteplase may be given and/or the line may be removed.

Catheter occlusion

These can occur from debris, fibrin or lipids. The volume of fluid usually held by the catheter is 2 mls. Solutions should be drawn up using a filter straw.

Try changing position of patient or elevate the arm, attempt a gentle flush with 5 ml of normal saline or heparin solution which may remove debris.

Fibrin If line is sluggish or occluded. Urokinase may be given however this will not remove the fibrin sheath but will break down any clots within the lumen.


Complication Signs and symptoms Action Lipids If line is sluggish or occluded. 70% ethyl alcohol solution may be

given as a flush. This should not be instilled as this may cause the line to deteriorate.

Air embolism This can occur if the line becomes disconnected or breaks. If the patient becomes confused, restless and hypotensive then an air embolism should be considered.

In these circumstances the feed should be stopped, the line clamped, the patient lain on their left side, and the foot of the bed elevated. The doctor should then be contacted urgently.

Bubbles in the line

This may occur if the line is not primed sufficiently leaving air bubbles in the line.

Elevated liver enzymes. Fatty infiltration. Jaundice. Intra-hepatic Cholestasis.

Liver disease is less common if parenteral feeding is used with out excess glucose calories and with MCT/LCT lipid.

Increase of LFT’s may reduce when PN is stopped. Always give MCT/ LCT lipid source. Consider imaging to investigate biliary tree.

Miscellaneous Haemothorax Hydrothorax Chylothorax Haemo-/hydropericardium and tamponade Arrhythmias Tracheal puncture Malposition of sub-clavian catheter in internal jugular vein Major venous thrombosis: Superior vena cava obstruction Axillary vein thrombosis Pulmonary embolus Right atrial thrombi Arterial puncture (carotid) Haematoma Nerve injury Hyperglycaemia Rebound hypo-glycaemia Deficiencies of �lectrolyte and trace elements.

Seek specialist advice as appropriate.


Nurse Monitoring of Patients receiving PN. Supplement 12 of Procedure Manual


Rationale Frequency Action Fluid balance

To monitor hydration. Constantly. Measure daily input / output. Observe for thirst, lethargy, low urine output, ankle oedema / postural hypotension or breathlessness.

Weight To monitor hydration

state and effects of feeding.

Twice weekly.

Weigh twice weekly in MUST Tool (in similar clothing, at same time of day, on same scales). Record weight.

Blood Sugar To ensure patient

tolerates glucose load of feed.

4 hourly for first 72 hours then twice daily if STABLE.

BM Stix 4 hourly for first 72 hours. If patient stable, reduce frequency. (Consider) sliding scale insulin if BM>12 mmols consistently.

Temperature, pulse and respiration

To detect signs of infection / line malposition. (Tachyarrythmia may show line malposition).

4 hourly. Monitor 4 hourly whilst on PN

Line entry and dressing sites

To detect signs of localised infection. (warmth, redness, tenderness, exudate and swelling).

Observe catheter entry / exit site daily.

Observe site/s daily for discharge. Review as part of full clinical condition review.

Biochemical

To monitor fluid and electrolyte balance, clinical condition and nutritional state.

As detailed in supplement 10 of the PN Procedure Manual

U&E’s, LFT’s, Bone, Glucose, Mg, FBC, trace elements, and random urine as required.

Procedure manual for Parenteral Nutrition Page 1 of 4 Final Version approved by Policy and Guideline Committee on 28th May 2010 Trust Reference B21/2010 Review Date: May 2013

Patient Referral and Preparation Information for Parenteral

Nutrition (PN) Background Information


Nutrition Nurse Specialists This Information is for all health care professionals caring for a patient with PN. It is the responsibility of the medical team caring for the patient to refer to the Nutrition Team and to undertake the booking of the insertion of a suitable central line with the appropriate inserter after liaising with the Nutrition Team.

1 Aims and Objectives of Nutrition Team 1. Aims • To enable the provision of high quality service, to treat patients suffering from, or at risk of,

disease related malnutrition. • To continue a co-ordinated, multi-disciplinary approach to nutritional support within UHL. • To act as an ‘expert’ source of information and advice on the management of nutritional

support within UHL. 2. Objectives • To fulfil the patient’s expectation to receive care from the Nutrition team and to have all aspects

of their parenteral nutrition management explained, discussed and agreed with them. • To provide the patient with direct, immediate access to professional advice via the team. • To provide clear understandable explanation of the patient’s parenteral nutrition management

to the patient, family, and ward or departmental staff. • To promote a system which results in an effective referral pathway. • To liaise with the patients primary Consultant and team in an advisory capacity on clinical issues

impacting on the patient’s nutritional management. • To promote enteral nutrition when the gut is accessible or functioning. • To monitor the patient’s condition and need for continued nutritional support, managing changes

appropriate to the patient’s condition and the aims of their clinical management. • To provide an effective advisory and education service both to hospital staff and at district level. • To set high standards of nutritional practice by developing research based guidelines and

policies. • To actively promote research and audit. • To act as a support for other nutritional groups within the Trust.


3. Referral and Assessment of Patients for PN 3.1 See intranet http://insite.xuhl-tr.nhs.uk/index.asp?pgid=29872 A member of medical staff must refer potential PN patients to the nutrition team. The Nutrition team will assess the patient for suitability for PN, which will include full discussion and explanation with the patient. The Nutrition Team may recommend that the enteral route be used before / instead of / as well as parenteral nutrition if appropriate. (Kennedy 2002) Please inform the Nutrition Team if Parenteral Nutrition is discontinued thus preventing wastage. On referral it is helpful and time saving if the following are available: - • INR • Height & Weight • Pulse & temperature • Biochemistry - U+E's, Liver Function Tests, Bone, Magnesium, FBC • Previous completed fluid balance chart • Current fluid balance and food intake

The Nutrition team may feel that PN is not appropriate for a particular patient. In this situation alternative methods of feeding will be discussed with the patient’s medical team. 4. Nutritional Assessment In order to assess whether or not a patient requires PN the team will address the following questions: • Is the GI tract functional? • What is the patient’s current nutritional status? • What is the patient’s current clinical condition? • Is the patient’s nutritional status likely to be affected by any proposed treatment or

investigation? • Does the patient give informed consent to the administration of parenteral nutrition? (UHL DMS

11772) Assessment will include review of recent laboratory results, dietary history and weight change. 5. Venous Access for Parenteral Nutrition 5.1 Patient will usually have been referred to the Nutrition team via their consultant team. The

current INR and FBC should be available in order for the PN line insertion to take place. Administration of parenteral nutrition requires an easily placed, well-tolerated delivery system that is capable of remaining in place for long periods of time.

5.2 Types of dedicated lines appropriate for PN delivery • Central Venous Catheters (CVC) -

- Short to medium term line – either sub-clavian, un-cuffed, percutaneous inserted CVC’s or Tunnelled cuffed Hickman lines dependent on hospital site.

- Long-term line – tunnelled Hickman line with Dacron cuff ideally inserted to the sub-clavian or cephalic vein.

5.3 Catheters are ideally tunnelled through the subcutaneous tissue onto a flat area of skin away

from the vein entry site. This aids dressing changes and may impact on the risk of infection

http://insite.xuhl-tr.nhs.uk/index.asp?pgid=29872


may be reduced. (Timsit et al 1999). 5.4 Multi-lumen lines can be used to feed if dedicated ports are preserved as sepsis within this

group has a similar incidence to that found in dedicated single lumen lines. However, dedicated single lumen lines have demonstrated longer feeding episodes than multi-lumen lines and are therefore considered to be the line of choice in UHL. (Pickering 2002).

5.5 PICC lines can be used but have proven problematic due to the type of dressing and routing

the PN giving set down arm effectively trapping male patients in their pyjamas. They are also not ideal for all patients and have a tendency to occlude / leak if placed at ACF. Due to lack of training in care of PICC lines across the Trust these are not considered to be appropriate CVC’s for PN administration however usage may be negotiated with the Nutrition Team if no other options are available.

5.6 Femoral catheters can be used if venous access is not available via the cubital fossa or the

subclavian route although practitioners should be aware that use of femoral access increases the risk of catheter-related infection and thrombosis. (Merrer 2001,Timsit et al 1999). All types must be inserted aseptically, using full barrier precaution (O’Grady 2002). Short term, uncuffed feeding lines may be safely inserted by the patient’s bedside, assuming that full barrier precautions are adhered to. Hickman lines are usually inserted in the operating theatre or in the radiology department and the position of the line verified by radiology.

5.7 Physiological risk factors to be considered: • Previous neck, chest or breast surgery. • BMI <20 or >30. • Cervical mediastinal adenopathy. • Medication – clotting problems. • Previous Central Venous Catheter (CVC) placement. • Previous fractured clavicle. • Known venous anomalies. • Known venous congestion / blockage of existing venous feed sites. Other considerations: • Pre-existing infection. • Mobility of patient, with regard to site of insertion, type and duration of catheterisation. • Can the patient be laid flat? 5.8 Ensure patients receive full information about: • Procedure of inserting CVC. • Reason for inserting CVC. • Potential complications. 5.9 Ensure a consent form 1 has been completed and if required for elective patients a Mental

Capacity Assessment and subsequent Best Interests meeting should be completed and documented before a Consent form 4 is signed. (UHL 2009)

5.10The patient will have been seen by the professional inserting the line, information / counselling

are given and consent will be gained. Most central lines for PN are placed under local anaesthetic within a suitably assessed environment.

5.11The patient does not usually require fasting for this procedure and can eat and drink but this

should be confirmed with the clinician inserting the line. The patient should wear a theatre


gown and a pre-operative checklist will be completed. The line position should be checked after insertion by chest radiography however if inserted in Radiology these checks should be documented in the medical notes as completed. The tip should be at the junction of the superior vena cava and right atrium (Colagiovanni, 1997). It is essential the medical notes are checked post-operatively and that tip position of catheter is documented. The administration of PN may not commence through the line until the position of the tip is verified as being in the correct position and this fact is documented.

5.12 A feeding line must (exceptions to be discussed with the Nutrition Team) be used only for

intravenous feeding and no other substances or drugs may be put down the line. In rare circumstances, the potential benefit of inserting a dedicated feeding line is outweighed by potential risk to the patient of line insertion and they may, therefore, use their existing central venous access for the administration of PN, after consultation with the patient’s lead clinician and the Nutrition Team. Blood should not be taken from the line except for blood cultures if catheter-related sepsis is suspect unless no other option is available and then this should be undertaken by a PN assessed member of staff.

6. Altering the Rate of Infusion Any alteration to the prescribed rate of PN infusion is to be discussed with the Nutrition Team or Medical Staff. A patient may be unable to tolerate an increased rate in volume or contents. If an alteration is made to the infusion rate of the PN, medical staff must sanction the change by altering the patient’s prescription accordingly. If the Nutrition Team is available, this should be discussed with them first. If the Nutrition Team is not available, they should be informed at the earliest opportunity. 7. Important Notes 5.1 Inform the Pharmacist of any problems in relation to the feeding bag, this may include:

-Damaged, leaking bags -Suspected infection -A non-homogenous appearance to the bag (if seen)

5.2 Inform the Pharmacist/Dietitian if the feed is discontinued for any reason. Feeds are extremely expensive and wastage should be kept to a minimum.

5.3 Feeding pumps - The pump of choice is a volumetric pump to ensure a constant accurate low

pressure infusion. Drip counters are not recommended, as they are inaccurate in the measurement of parenteral nutrition fluid.

5.4 The feed rate must be calculated and set by a trained nurse. The rate must not be increased in

order to "catch up" if a feed is running behind rota, as this can increase the risk of hyperglycaemia and phlebitis. Parenteral nutrition should be discontinued gradually over one hour to prevent severe rebound hypoglycaemia.

5.5 The patient should be introduced to an oral or enteral diet gradually. Parenteral nutrition should

be maintained until the patient is achieving an oral or enteral daily intake that is 50% - 75% of their nutritional requirements as assessed by a Dietitian (usually about 1000kcal).

5.6 If the patient is to undergo any dental, urological or other procedure, they should be given

prophylactic antibiotics as if they had a prosthetic heart valve. 5.7 It is advised that the above Nutrition team be involved with any adult patient for whom Total

Parenteral Nutrition (PN) is contemplated. Early gut evaluation and suitability for PN or other methods of nutritional support is beneficial for each individual patient.

Procedure manual for Parenteral Nutrition Page 1 of 4 Final Version, approved by Policy and Guideline Committee on 28th May 2010 Trust Reference 10 Review Date May 2013

Care of PN Lines in the Community


Nutrition Nurse Specialists Nutrition Team skin tunnelled catheters (Hickman lines) or Peripherally Inserted Central Catheters (PICC) lines are central venous catheters whose tip lies in the Superior Vena Cava. Strict asepsis must be employed when dealing with these lines. The following guidelines have been provided to facilitate care of the UHL Nutrition Team lines within the community setting. In the event of any unusual occurrence or query please do not hesitate to contact the Nutrition Nurses below; Nutrition Nurse Specialist – contact via switchboard or direct dial below; Leicester General Hospital 0116 258-4713 Leicester Royal Infirmary 0116 258-6988 Glenfield Hospital 0116 258-3752 Discharge of Nutrition Team patients from hospital with a Nutrition skin-tunnelled catheter or PICC

• All patients discharged from hospital with a skin tunnelled catheter or PICC used or in use for Parenteral Nutrition will be referred to a community nurse.

• All patients discharged from hospital with a skin tunnelled catheter or PICC used or in use for Parenteral Nutrition will have a discharge form for skin tunnelled central venous lines and two copies of this guideline sent home with them one for the District Nurses and one for the patient.

• A Nutrition skin tunnelled catheter discharge form will be completed • The form will be faxed to the appropriate community nursing service • The community nursing service should be contacted to ensure a community nurse

able to care for a patient with a skin tunnelled catheter is available • Four weeks supply of all equipment should be sent home with the patient • The prescriber should prescribe the Heparin and Saline flushes. • Two copies of this guideline be given to the patient on discharge as above.

Please ensure that the Community Discharge form attached is completed by the medical team prior to the patient’s discharge into the community. The patient needs to be discharged with four weeks supply of these items; Patient’s being discharged on Home PN will not require these supplies Dressing Pack 2% Chlorhexidine gluconate in 70% isopropyl wipe X3 Needleless ports (not available in the community) Sodium Chloride 0.9%

B21/20

Procedure manual for Parenteral Nutrition Page 2 of 4 Final Version, approved by Policy and Guideline Committee on 28th May 2010 Trust Reference 10 Review Date May 2013 B21/20

Heparin 10 units/ml/5ml 10 ml syringe x2 Orange needle or filter needle Alcohol hand rub Micropore tape Sharps bin

1. Wash hands with soap and dry thoroughly. 2. Clean surface. 3. Prepare tape with ends folded over (to ensure ease of opening, thus preventing

scissors near the line). 4. Clean hands with alcohol rub. 5. Aseptically open dressing pack using the yellow bag like a glove to handle the

contents. 6. Scrub Heparin ampoule with 2% Chlorhexidine gluconate in 70% isopropyl wipe for

30 seconds and place in the corner of the sterile field. 7. Aseptically syringes, orange needle, and squeeze 10 ml Sodium Chloride into the

tray provided. 8. Between finger and thumb carefully remove sterile field from pack and place near to

patient’s line. 9. Expose end of the patient’s feeding line and close clamp on double thickness

part of line, remove gauze flag and discard. 10. Scrub the hub and needle-less port of the PN line for 30 seconds with 2%

Chlorhexidine gluconate in 70% isopropyl wipe, using a second wipe at the same time to clean the Hickman line and clip.

11. Without placing the line down, manoeuvre the sterile field under the line. 12. Open x1 pairs of sterile gloves on a dry clean surface nearby – this should not be

the sterile field. 13. Wash and dry hands and apply alcohol hand rub put on sterile gloves without

touching outside of them. 14. Filter needles are required if using glass ampoules - pick up and connect Heparin

syringe to filter needle. Once done, replace on the sterile field. 15. Draw up Saline and Heparin 16. Ensure clamp is on (clamp on double piece of tubing to protect line). 17. (Discard old bung if appropriate), connect Saline syringe to the needle-less port,

unclamp line and flush line, re-clamp line. 18. Connect Heparin syringe, unclamp line, inject Heparin, and re-clamp line using

positive lock. 19. Wrap needle-less port in gauze flag. 20. Exit site wound should be inspected daily.

Heparinisation Nutrition skin tunnelled catheters should be heparinised in line with the UHL Procedure manual for the care and management Of Skin-tunnelled catheters in the Adult Patient June 2008. These Hickman lines are used for feeding and remain the responsibility of the consultant at the patient’s hospital. They have been left in place because the patient may be required to recommence Parenteral Nutrition if they are reviewed at outpatients having further symptoms and weight loss, or if they are readmitted to hospital for further tests / operations.


Dressings The Nutrition Hickman line exit site should be observed daily for redness, exudate, or Hickman line malposition. The gauze dressing will be removed for this purpose and changed daily. In the event of any abnormalities the patient should be referred back to the Hospital. The Nutrition PICC line dressings should be observed daily for redness, exudate, or PICC line malposition and the dressing changed in line with UHL Procedure manual for the care and management Of Skin-tunnelled catheters in the Adult Patient June 2008. n the event of any abnormalities the patient should be referred back to the Hospital. Temperature The patients’ temperature should be checked daily, temperature suggests the possibility of Central Venous Catheter infection -in the event of pyrexia, rigors, or sweats the patient should be referred back to the Hospital as quickly as possible. Equipment The patient will have been discharged with enough equipment for four weeks treatment. If you find it impossible to order certain items on the community please contact the discharging ward in UHL order to get extra supplies. Swimming There is no research evidence to suggest swimming in a pool or the sea increases the risk of infection. However water will dislodge the PICC line dressings which secure the PICC lines in place therefore patients with PICC lines should not swim. It is recommended that patients with Hickman lines discuss potential risks with medical staff before swimming. The site should be covered in a transparent dressing during swimming and dressing changed immediately thereafter. Immuno-compromised patients should not undertake this activity. Practical Backup Practical teaching is available from the Nutrition Nurse Specialist if required. Nutrition Hickman lines can often be difficult to insert and access can be reduced each time a line needs to be sited, if you are in any doubt as to how to Heparinise or have any queries please do not hesitate to contact the Nutrition Nurse Specialist caring for the patient. In the event of accidents; • Line malposition - refer the patient back to their discharging ward. • Fracture of Line hub - refer the patient back to their discharging ward as urgent. • Hub breaking off - Fold the line to occlude it if the clamp is missing and call an

ambulance to get the patient to A&E. • Bleeding / or haematoma formation - refer the patient back to their discharging ward.


NUTRITION COMMUNITY DISCHARGE FORM - For NUTRITION Skin Tunneled Central Venous Lines

Hospital & Ward: Ward Tel: Fax no. Referral made by: GP:

Telephone number: Patient’s sticker Patient’s address: Date of Birth:

Next of kin:

GP address:

ALLERGIES: Diagnosis: Date of insertion: Type of line: No. of lumens: Size of line: Manufacturers life span of line: 4 weeks equipment :

Treatment required:

DRUG AUTHORISATION Drug regime MUST be authorised by a DOCTOR. This is essential for administration

DRUG: 0.9% Sodium Chloride DOSE: 10 ml FREQUENCY: DR’s SIGNATURE: PRINT NAME: DATE:

DRUG: Heparin Sodium (10u/ml) DOSE: 50u/5 ml FREQUENCY: DR’s SIGNATURE: PRINT NAME: DATE:

Pharmacy Authorization: Any other details:

Follow up arrangement:

Procedure manual for Parenteral Nutrition Page 1 of 1Final Version approved by Policy and Guideline Committee on 28th May 2010Trust Reference B21/2010 Review Date May 2013 UHL NUTRITION NURSES / Dr Gross 08.09 V4

Management of PN Patients Post Central Line Insertion SUPPLEMENT 16 of Procedure Manual for

Parenteral Nutrition in AdultsNutrition Nurse Specialists

If possible contact individual responsible for line insertion asdocumented in the medical notes (or a member of their team)

Patient becomes unwell i.e.• Tachycardia • Pale • Clammy • Short of breath• Back, neck or chest pain• Swellings or lumps in upper body

1. STOP PN OR IV INFUSION2. SALINE LOCK LINE WITH 10ML 0.9% SALINE

• Fit a reservoir oxygen mask on 15 L• Undertake observations:

• SaO2 • BP• TPR• 12 lead ECG

Request urgent FY2 surgical/ medical review from patients team including CXR

Complete Datix FormNB: if anaesthetic insertion inform Dr Janette Gross, Consultant Anaesthetist by email of issues with the patient

If haemo-pnemothorax suspected escalate to Registrar review and involve duty anaesthetist

This plan of action has been devised to prevent Pneumo/PN thorax from becoming established in newly inserted central lines

This is for action by the Nursing and Medical staff responsible for caring for the patient receiving Parenteral Nutrition

Procedure Manual for Parenteral Nutrition Page 1 of 4 Final Version approved by Policy and Guideline Committee on 28th May 2010 Trust Reference B21/2010 Review Date: May 2013

Antibiotic Locking of infected Parenteral Nutrition (PN) lines



1 Introduction and scope 1.1 This procedure is used to attempt to cleanse confirmed or suspected infective feeding lines. 1.2 This applies to all health care professionals caring for a patient with PN. 1.3 Antibiotic treatment or line locking of PN lines should only occur when there is no option to

remove a suspected contaminated central line. 1.4 All antibiotic locks should be discussed with Microbiology and a code issued if appropriate Equipment Dressing Trolley Chlor-clean (to clean the trolley) Methylated spirits Disposable apron Alcohol hand rub Basic sterile dressing pack including sterile towel Mepore tape Sterile gloves x2 pairs (if not in pack) 2% Chlorhexidine gluconate in 70% isopropyl wipe x3 Alcohol hand rub 10ml saline flush 10ml Luer-lock syringe Medication prescription chart signed by a Doctor. 0.9% Sodium Chloride Prepared antibiotic in I.V. bag Giving set Sharps bin Cleaned volumetric infusion pump (at bed side)

ACTION RATIONALE EVIDENCE 1 Wash and dry hands. Put on apron. To clean and prevent

cross infection. EPIC 2 (2006)





ROWLEY (2001a)




5 Two trained nurses must check the antibiotic bag details against the prescription. Nurse must also check if patient has any allergies and verify against the prescription chart

To ensure that the correct medication is administered to the correct patient.

NMC (2008) UHL IV drugs Policy


ACTION RATIONALE EVIDENCE 6 If previous bag still hanging, switch off pump and

close roller clamp on giving set and remove from pump.


7 Hang antibiotic bag on drip stand. Snap off port cover.

8

Scrub the port for 30 seconds with 2% Chlorhexidine gluconate in 70% isopropyl wipe using different parts of the wipe.

To decontamination of the port before cannulation.


9 Wash and dry hands. To reduce the risk of cross infection.

EPIC 2 (2006)



11


12



13


ROWLEY (2001a)

14




15 Open x2 pairs of sterile gloves on a dry clean surface nearby – this should not be the sterile field.




17 Draw up 10 ml 0.9% Sodium Chloride into 10 ml syringe

18 Remove air bubbles from syringes. Replace syringe on to aseptic field.


19 Pick up the new giving set on the sterile field and close roller clamp space.


ACTION RATIONALE EVIDENCE 20 Wearing sterile gloves pick up giving set chamber

leaving most of the line on the aseptic field and insert giving set to the bag using ANTT principles.

EPIC 2 (2006)

21 Prime the line. (N.B. If bubbles present, ping giving set as taught and run through as little fluid as possible to expel all air).

To avoid central venous air embolism. To reduce air alarming out of hours.


To ensure asepsis.

23 Loosen the patient’s connection to ensure it is not stuck but do not disconnect.

24 While holding clean giving set securely in your hand, disconnect existing line from patient and discard.

To dispense with used line. To connect new line in an aseptic manner.

25 Connect to the feeding line needle-less port (firmly but not tightly).

To connect the patient to the system aseptically and allow feeding to commence.




Harrison (1997)

27 Insert the giving set into volumetric pump and close door. Set volume and rate of infusion as prescribed Open roller clamp and the clamp on the feeding line.

To ensure an accurate flow rate.




EPIC 2 (H&S ) (2006)





EPIC 2 (2006)




30 When the antibiotic infusion has finished the antibiotic should be left in the line for 24 hours or until the next antibiotic infusion is prescribed. DO NOT FLUSH OR HEPARIN LOCK the PN line.

31 Prepare the patient as above 32 Undo and discard antibiotic administration set. 33 Wrap end in sterile gauze and apply tape with end

folded over to create tab. Leave antibiotics instilled for 24 hours before flushing and connecting TPN.

Fold ends of tape to ease tape removal. This discourages inappropriate access of device and prevents

Harrison(1997)


ACTION RATIONALE EVIDENCE scissors being used near the line.



EPIC 2 (H&S ) (2006)





EPIC 2 (2006)





Final Version Approved by Policy and Guideline Committee on 28th May 2010 , Trust Reference B21/2010 Review Date May 2013 Page 1 of 2

Parenteral Nutrition Care Plan

Daily care plan to • ensure the appropriate patient monitoring to detect abnormalities whilst the patient is on PN. • ensure prompt action and intervention as per the PN policy if the patient’s monitoring deviates out of identified range.

Monitoring Date

Date Date Date Date Date Date Date Date Date Date

Please initial boxes











TPR checked (If >38 follow sepsis flow chart) Blood sugar (if >12 mmol contact medical staff for sliding scale)

Strict fluid balance – accurately charted Weight (twice weekly / daily)

Rate of infusion checked and correct Incision and exit wounds checked (Inform CNS/Dr’s of redness, exudate or inflammation)

Dressing changed; • Meapore daily • Opsite as required

Monitoring Date

Date Date Date Date Date Date Date Date Date Date












TPR checked (If >38 follow sepsis flow chart) Blood sugar (if >12 mmol contact medical staff for sliding scale)

Strict fluid balance

Weight (twice weekly / daily)

Rate of infusion checked and correct Incision and exit wounds checked (Inform CNS/Dr’s of redness, exudate or inflammation)

Dressing changed; • Meapore daily • Opsite as required


Final Version Approved by Policy and Guideline Committee on 28th May 2010 , Trust Reference B21/2010 Review Date May 2013 Page 2 of 2

Please note any abnormalities or comments on rear side of this sheet Parenteral Nutrition Care Plan Comments Date Comments Signature

administration and care of parenteral nutrition in adults

Documents

parenteral nutrition

care of parenteral nutrition

adequate nutrition

parenteral nutrition

previous uhl pn policy

care of patients

enteral nutrition en

care b