Saturday, March 1, 2014

The Nightly TPN Set Up System

I'm conflicted with having a line and TPN dependency.

I do love the fact that for the first time in months, my labs (minus the sodium) are stabilizing. I love that I have normal(ish) energy (I move and talk almost maniacally. Except on sick days. Then I move like a slug. There is no such thing as in between) and that I can keep up with making sure my home does not get disorganized and, of course, forget about sterile technique.

I do not love the unwavering fact that I've already met sepsis three times including septic shock, that if you screw up TPN or IV anything set up you have just risked your life, and let's just be honest, this is not the good kind of stress (euestress) that keeps one motivated.

Or maybe it is, and I am just masochistic?

That was sarcasm.

So I'm just going to outline how my drawers are organized and how I set everything up, every night, to set up my TPN just to give an idea of how one person found a system works for her. You may not like this one, so I encourage you to find one that works for you as well. I do want to stress that it's best to find a single system so as not to skip anything. But do not just settle into complacency while doing this, lest you break sterile technique.

First, the drawers. I'll explain a few key items and their use.

Drawer one: getting the prep station ready, and keeping connection points sterile:

Gloves: Many uses, but mainly for any time I'm messing with my line. Every time. Meds, clothing changes, everything. But also for use with

Sani-Cloth: Don't be stupid like me and try to sanitize surfaces with your bare hands. On the label is says NOT A SKIN WIPE for a reason: it will eat away at your hands. It's taken a week to repair them, ample Eucerin Auquaphore, and much cringing  since so much hand washing and sanitizing stings when your skin is peeling off. Gross, I know. Do remember that these wipes are really strong, but it does take two minutes -- not two seconds -- to kill any unfriendly invisible critter that may be living there. There is a huge difference between this and, say, Lysol. Lysol kills 99.9% of "bacteria", which is pretty ambiguous. The problem is you don't need to worry about only bacteria. This is not just anti-bacterial, it is bactericidal, tuberculocidal, and virucidal. BIG DIFFERENCE. It also kills the following that can grow on lines causing sepsis: Campylobacter jejuni, E. coli O157:H7 (the kind that is deadly), Klebsiella, pseudomonas, Staphylococcus aureus (what is colonized in my blood) including Methicillin Resistant strain (MRSA), VRE, and Candida albicans. It also kills all strains of Influenza A (H1N1) including 2009 Pandemic "Bird Flu" and Hong Kong. Very, very important and highy recommended.

Alcohol Wipes: DO NOT ATTEMPT TO USE SANI-CLOTH ON LUMENS OR IV CONNECTIONS. USE AN ALCOHOL WIPE. An alcohol wipe should be sufficient if your hands and skin are cleaned, you are wearing gloves, and not breathing on what you are cleaning. Use friction because that is what kills germs. Leave it alone for a bit before connecting to anything.

Protective Masks: I don't use these every single time I need at disconnect and reconnect. I only use it for TPN set up, lab draws (my nurse does this, she loves that I have them here), and dressing changes (which are included in my dressing change trays). 

Drawer Two: Pump set needs and line care

Really crappy picture. sorry about that

Pump set needs: 9V battery (WASTEFUL, CADD) and pump sets, including the key to lock it in place (not pictured)

Saline flushes: You only see two but I have them stored all over the place, I can have as many from my infusion company as I need.

Alcohol "swab cap": These screw on top of the lumen to protect it when not in use. I have three lumes since we use three lumens in hospital, at home usually one or two. This keeps the surface protected and packs alcohol into the hub.

Glad brand "Press n Sea"l cling wrap: Wrap around  PICC line during bathing (legs don't work = shower bench). Even though there is a dressing, you don't want the dressing getting soiled or wet.

Drawer Three: Stuff for my nurse and other items


Dressing change kit needs: Includes my dressing change trays which are paneled Tegederm, chlorhexadine and alcohol swab sticks for cleaning the site, and Stat-Lock stabilization device. I also have BioPatches, which my nurse puts on the insertion site.

Purple and red top blood sample tubes: Twice weekly labs, lucky me! There are also extra needles. Those tops are for CBC, CMP, BMP, Triglycerides, and other labs to monitor counts. If something is off IV medications and TPN are altered.

Thermometer: It reads in F or C. I read in C, since the metric system is used in health care. This is to make sure I don't have an elevated temp. elevated temp could mean line infection. I use it twice daily.

There are other items that aren't related to line care as well.

When it's time to set the TPN bag out to warm, I clean the counter top and these baking sheets with Sani-Cloth. These sheets I bought new, they were not ever used to bake with. I use the sheets to organize what items go where. The sheets I clean at a different location than the counter top, since it does take two minutes to kill germs. When all surfaces are safe, I set the TPN out.

Keep your counter top clutter free for safety reasons.

I set the TPN to warm for three hours as directed. Your instructions may be difference. Always go by what your doctor's orders say.

When it's time to set up everything else to begin the TPN set up, I set it all out at once.

Be sure to keep your hands and wrists clean. Preferably antibacterial soap and warm water, and thoroughly dried. In between, if you are not sure, use a hand sanitizer.

I like some variety...

Here's how my set-up looks:

Largest tray: TPN, Infu-Vite (multi vitamin and trace minerals), IV Protonix (Proton Pump Inhibitor for reflux), which I administer inside the TPN bag itself with a syringe and needle

Tray at the front: All alcohol pads I need to connect sterile to sterile. Pre-opened, you don't want to touch any paper wrapping or other surfaces while doing this. Grab the corner of the wipe and shake off into the sink. Clean up immediately after finishing.

Tray to the back: Saline flushes and syringe and needle, again, pre-opened.

If it looks involved, it is. If it looks overwhelming, once you get going, it isn't.

And once you get going...just keep going. If you followed sterile technique, you have done your part to ensure the safety of the TPN and line. Can things still happen? Yes. But lots of things can happen. Try not to dwell on it, it will only serve you drive you crazy.

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