PICC lines are also safe for patients to take home and administer medications intravenously. Home care for PICC lines can be tricky and likely to develop complications such as infection, dislodging or blockage.

PICC line is centrally placed into the big veins of the body, specifically the subclavian vein. This make PICC line a great asset that can be used for months if maintained properly.

Here are some few tips on how to care for a PICC line at home.

1. Make sure the clear occlusive dressing is intact all the time. Covering the PICC line with occlusive dressing when taking a shower is recommended.
2. Avoid heavy using of the arm that has a PICC line to avoid complications such as dislodging and kinking.
3. PICC line dressing must be changed every 72 hours under sterile technique is no Biopatch was used and every 7 days if a biopatch was used.
4. Flush each PICC line port with 10cc normal saline without mixing the syringe. This is a good way to prevent cross contamination of PICC line ports.
5. Always use alcohol prep to clean PICC line head/ports before and after use. Alcohol prep helps to prevent introducing bacteria into your body.
6. You must flush PICC line with atleast 10cc of normal saline after administering medications. This prevents mixing of incompatible medications that may precipitate and clog the PICC line.
7. Never administer any medication on PICC line without consulting your physician.
8. PICC line ports should be changed with every dressing change, Microclave male adaptors are recommended for use as PICC line access ports.

Advantages of using microclave male adaptors on PICC lines

1. Microclave male adaptors prevent PICC line leakages
2. The minimize/eliminate use of needles, thus making them safer for patient and staff use.
3. They minimize introduction of bacteria into the blood stream
4. Makes it easy to make a connection or disconnection without compromising sterility
5. They can be changed regularly with dressing changes and as needed.

How to flush a PICC line

1. Wash your hands with soap and warm water for at least 15 seconds and dry with clean towel.
2. Wear gloves for protection incase of accidental PICC line retrograde leakage.
3. Clean the tip of the microclave port with alcohol pad and wait for it to dry.
4. Using the luer, screw in a 10cc syringe filled with normal saline. Do not use less than 5cc syringe to prevent bursting out the tip of the PICC line, which can cause ischemic conditions like stroke, pulmonary embolism or heart attack.
5. Use turbulence flush technique. In turbulence PICC line/central line flush technique, you flush intermittently with the full 10 cc of normal syringe.
6. Never leave blood showing on PICC line tube.

1. If you are planning on having a baby, be healthy before you get pregnant and take folic acid to prevent birth defects of the brain and spine.
2. Tell your doctor if you have high blood pressure, diabetes or any other illness.If you think you may be pregnant, see a medical provider immediately. Early prenatal care could prevent having the baby too soon. Learn the signs of pre-term delivery – dads, family and friends need to know too.
3. If possible, breastfeed your baby. Breastfeeding during the first year may prevent the baby from getting sick and may reduce the risk of infant death. Research has shown that breast fed babies have very few cases of sudden infant death syndrome (SIDS)
4. Make the baby’s sleep environment safe. Babies should sleep on their back. Do not use soft bedding, don’t smoke around the baby and don’t let the baby get too warm. Avoid sharing the bed with an infant as this can facilitate SIDS. The true causes of SIDS are not clearly known but heat and possible suffocation/asphyxia has been blamed for infant deaths.
5. Use a car seat that is the right size for the age and weight of the baby. Make sure it is properly installed. If unsure how to secure a car seat, your local fire department can help you learn how to do it for free.
6. Never shake a baby. Crying is a baby’s way of communicating but if the crying is too much to handle, call someone to help or place the baby in a safe place and leave the room until you are calm. Shaking the baby can break bones, cause spinal cord injuries with permanent injuries and disability. Shaking a baby is illegal in USA punishable with jail time and fine and the baby taken away by child protection services.

Recently I took care of a patient with testicular cancer and multiple metastasis to bones, lungs and the brain. This was a mid adulthood male who was admitted to the ICU with shortness of breath and pain all over the body related to pathological fractures.

The patient in his history talked about a lump he had on his testicles years ago and he described it as “itchy” lunp under the skin but didn’t hurt enough to seek medical attention. It went on for years and later he forgot about it as he got used to the mild itchy feeling in his scrotum.

On arrival to ER, the patient had been having shortness of breath with blood tinged sputum and sudden weight loss. He also complained on bones pain all over the body and on x-ray, he was found to have pathological fractures of long bones of the upper and lower legs bilaterally. He also got a chest x-ray that showed multiple masses in his lungs consistent with lung cancer.

Further, the patient was sent for CT-Scan of the whole body and was found to have brain masses sitting on the 4^th ventricle and brain stem areas. The outcome is almost certain that it was just a matter of time before bidding goodbye to this world.

Any physician at such a time when a patient has stage 4 cancer would explain things to the family and facilitate end life tough decisions. This was done and with Hispanic community, letting go of a loved one no matter how sick they are is never an option. Hispanics are known to keep their patients even when there is no possibility of survival.

Chaplain was contacted and after the family insisted that everything possible should be done to save the life of their loved one, the doctors in ER sent the patient to ICU and I was the one to take care of this patient.

Immediately on arrival, serial labs were ordered and drawn. The physicians in ICU without wasting time inserted a central line anticipating the need of good intravenous access for fluid resuscitation.

The patient shortness of breath was getting worse by the minute and the doctors decided to draw an arterial blood gas to check oxygenation status of the patient. In 15 minutes the results were called from the lab as panic with CO2 level of 78. The normal CO2 level in arterial blood gas is 35-45. The oxygen level was only 42 (normal is 78-95). This warranted immediate intubation to secure the airway and optimize oxygenation.

Anesthesia team was paged and within a matter of minutes, they arrived in the ICU and intubated the patient. Everything was explained to the family that he might never be able to breathe on his own for the rest of his life. The family insisted that they wanted everything done.

The following day, the oncology experts evaluated the patient and was started with chemotherapy. Radiation therapy was not an immediate option as cancer had spread to many parts of the body.

The first round of chemotherapy was done with every expectation explained clearly to the family. The patient was first given 4 units of blood as he had very low hemoglobin count. He also received several units of platelets that he needed the most.

24 hours after the initial chemotherapy dose, the patient was literally fighting for his life on the ventilator. His heart rate was in 160’s and poor perfusion was evident. Doctors were concerned because of the fact that the bone marrow was destroyed so bad by cancer that the patient was barely making any new blood cells. This meant that the patient had to be transfused many times with multiple blood products.

The struggle fighting for life went on and on and eventually, he coded after being in ICU for about 2 weeks. His bones were so fragile and brittle that CPR the sternum and most ribs, making it a bloody experience.

He died days later after his initial arrest, leaving behind a wife and three beautiful girls. The youngest was 6 years old and the oldest was 10 years old.

Everyone in the unit was feeling the pain just imagining the family and the loss they have incurred. No words could have been good enough for the young girls who came to bedside to view the body of their beloved dad. No tears were painful enough than those shed by the wife, a homemaker who never had a job and could barely speak a word in English. It is a life ahead full of broken dreams for the family. It was an experience painful enough even for doctors and nurses who took care of the patient until their final breath.

Moral of this story

1. Testicular exams are very necessary and every man should do it every month.
2. Never ignore anything that feels or appear abnormal to you. See a doctor immediately for evaluation.
3. Testicular cancer is curable if identified early. Lance Armstrong survived it because it was caught early before metastasis.
4. Testicular cancer can metastasize fast especially to the spine, lungs and the brain. The earlier it is diagnosed, the better the outcome.
5. Multiple organ metastasis called stage 4 cancer and has poor prognosis. Chances of surviving stage 4 cancer are very low, sometimes none.
6. When cancer is a true end stage, hospice care could be a better option that aggressive treatment which the already cancer weakened body cannot tolerate.
7. There is no age too young for cancer. Testicular cancer is commonest between 14 and 40 years. This is such a young age that a lot of people may not think they are in danger.
8. Testicular cancer is one of the most curable cancers known but it has to be identified early enough to increase chances of survival.
9. Any pain, swelling, lump, lack of sexual interest, blood in the semen, lower abdominal dull ache should be reported immediately to your physician.
10. Annual physical exams are vital in detection of testicular cancer.

• Do skin checks in the morning and the last thing at night. Look for redness, dark areas, cracks, bruises, and blisters. Note any white spots or areas. The skin may turn white before it reddens. Watch for red, tender, or swollen areas on the skin. Pay special attention to any areas that stay red after the pressure has been relieved. The goal is to find and correct problems before skin breakdown occurs.

• Feel for lumps, soft areas, or unusual warmth (use the back of the hand). Do not massage a reddened area.

• Clean when incontinent (wetting or soiling the bed) as soon as possible. Use a soft cloth or sponge to reduce injury to skin.

•  Minimize moisture from urine or stool, perspiration, or wound drainage. Use pads or briefs that absorb urine and have a quick drying surface that keeps moisture away from the skin.

• When bathing or showering, use warm (not hot) water and a mild soap.

• To prevent dry skin, use creams, ointments, or oils on the skin. Don’t use alcohol or other drying agents on the skin.

• Avoid cold or dry air.

Change positions often

• Limit pressure over bony parts by changing positions.

• If in bed, change position at least every 2 hours.

• If in a wheelchair, change position every 15 to 60 minutes.

• Be careful not to scrape sensitive areas when changing positions. Bed sheets or lifters can be used to help lift the body. A thin layer of cornstarch on the skin may help reduce damage from friction.

• Avoid lying directly on the hip bone when lying on your side. Also, choose positions that spread weight and pressure more evenly.

• Massage may help. Do not massage bony areas of the body such as knees and elbows.

• Exercise to relieve pressure, such as “push-ups” from the wheelchair or bed and shifting weight.

Use devices to relieve pressure

• Use a foam, gel, or air cushion or mattress to relieve pressure. Ask your healthcare provider which is best. Avoid donut-shape cushions because they reduce blood flow and cause tissue to swell, which can increase the risk of getting a pressure ulcer.

• The head of the bed should be raised as little and for as short a time as possible depending on the medical condition. When the head of the bed is raised more than 30[degrees], skin may slide over the bed surface, damaging skin and tiny blood vessels.

• Use pillows or wedges to keep knees or ankles from touching each other. If completely immobile, put pillows under the legs from mid-calf to ankle to keep the heels off the bed.

• Keep sheets wrinkle-free.

• Wear clothing without thick seams.

• Never put a heating pad where there is no sensation.

Eat well

• Eat a balanced diet. Protein and calories are very important. Healthy skin is less likely to be damaged.

• Drink plenty of liquids.

• If unable to eat a normal diet, talk to your healthcare provider about nutritional supplements.

• Some studies show zinc and Vitamin C help promote healing of large wounds.

• Limit stretching the areas around your wound. This will help prevent bleeding and swelling of the wound area. Try not to bump or hit your wound site on anything as this could open the wound up.

• Ask your caregiver how you should bathe or shower. You may need to cover your wound with a waterproof dressing. If you do not need to use a waterproof dressing, remove your bandage. Throw it away in the trash. Carefully wash your wound with soap and water. Pat the area dry with a clean towel. Ask your caregiver if you need to put medicine, such as an antibiotic (germ-killing) ointment, on your wound. Cover your wound with a clean, new bandage.

• Wear a binder. Conditions such as a long-term illness and weighing too much put you at a higher risk of your wound coming apart. Using steroid medicine can increase this risk. If you are at a high risk, you may need to use a binder over the area of your wound. A binder is a snug piece of clothing that you wear to help keep your wound from pulling apart.

• Manage your medical conditions. If you have certain diseases, such as diabetes (high blood sugar) or heart disease, it may take longer for your wounds to heal. Conditions where there is poor blood flow to your arms and legs can also slow healing. Take your medicines as ordered. If you have diabetes, keep your blood sugar level in the right range. Ask caregivers for help managing other medical conditions.

• If your wound is on your arm or leg, raise the wound higher than the level of your heart. Doing this may help decrease pain and swelling. You can use pillows to elevate your arm or leg while you are sitting or lying down.

• Drink enough liquids. Men 19 years old and older should drink about 13 eight- ounce cups of liquid each day. Women 19 years old and older should drink about 9 eight-ounce cups of liquid each day. Follow your caregiver’s advice if you must change the amount of liquid you drink. For most people, good liquids to drink are water, juices and milk. Limit juices to avoid too much sugar calories intake.

• Tell caregivers about all of the medicines that you use. Using certain medicines, such as steroids, cancer medicines and blood thinners may delay wound healing.

• Eat foods that are high in protein. Taking vitamins and eating healthy foods that are high in protein may help your wound heal. Poultry, meat, and dairy products such as eggs and cheese, are high in protein. Ask your caregiver if you should use vitamins, and for more information about a high-protein diet.

• Do not smoke cigars, pipes or cigarettes. Smoking may cause blood vessels on your wound site to get smaller. When this happens, your wound will not have a good supply of blood. A good blood supply is needed to carry oxygen and nutrients to your wound so that it will heal.

* Diabetic ketoacidosis is also called “DKA.” It is a serious problem in people with diabetes  mellitus. DKA happens when your blood sugar gets very high and is not treated properly.

* Much of what you eat and drink is changed into sugar (glucose). Sugar gives you energy. Insulin makes your body use this sugar and helps keep your blood sugar normal. With diabetes mellitus, your body does not make enough insulin or your body does not respond normally to insulin. Without insulin, sugar builds up in the blood.

* With diabetes, sugar stays in your blood and is not changed into energy. Your body must now use fat for energy. When this happens, chemicals called ketones are left in your blood. Your blood sugar will keep getting higher if you do not get enough insulin. Ketones build up in your blood and cause body cells to be damaged. This makes you very sick and you can even die.

Causes: DKA can come on slowly or happen very quickly. Some of the main causes are:

• * Not getting enough insulin.
• * Missing a dose of insulin.
• * Illness, such as pneumonia.
• * Infection, such as a urinary tract infection.
• * New diagnosis of diabetes.
• * Diabetes that is not being treated.
• * Stress.
• * Injury.

Signs and Symptoms:

* Early signs and symptoms of DKA:

** Fast, deep breathing.

** High blood sugar.

** Vomiting (throwing up).

** Weakness.

* Later signs and symptoms of DKA:

** Abdominal pain.

** Chest pain.

** Confusion.

** Dry mouth.

** Fruity-smelling breath.

** Fullness in abdomen (belly).

** Headache.

** Hungrier than usual.

** Nausea (upset stomach).

** Tiredness or sleepiness.

** Thirstier than usual.

** Urinating (going to the bathroom) more than usual.

** Weight loss.

** Coma (unable to be woke up from sleeping).

Care:

* DKA can be treated and controlled most of the time. But early treatment is very important. Call your caregiver when you see or feel any signs of DKA. Check your blood sugar and urine ketone levels as often as your caregiver tells you to. Check your blood sugar more often when you are sick. Ask your caregiver for the CareNotes(tm) handouts explaining how to do these tests if you don’t know.

* You may need to be put in the hospital for tests and treatment. You may need to have an EKG, blood tests, x-rays, and have an IV. The dose or type of medicine that you take for diabetes may have to be changed. Your diet may have to change, and your urine and blood checked often. Ask your caregiver for information about DKA to help you understand about the different tests and treatments.

PICC lines are my favorite access because unlike other central lines like subclavian and internal jugular central lines, PICC lines are more durable and not as delicate. Although PICC lines are more durable, they tend to clot easily and fail to give blood return easily than other central lines.

Here are some tips for taking care of a PICC line.

1. Flush each port at least twice a shift. Use different 5cc or 10 cc syringe on each port to prevent cross contamination
2. Use turbulence flushing technique. This simply means, you flush intermittently with a whole 10cc syringe. This creates good enough pressure to prevent red blood cells clumping causing clots and blocked ports.
3. Never use less than 5 cc syringes on a PICC like or any other central line. To be on the safe side, always use 10cc syringe. The smaller the syringe, the higher the pressure it exerts on the ports and this can make the tip to break off and result in more serious damage like strokes and cardiac ischemia.
4. Always verify that there is a date and an initial on the date the last dressing was done. If there is a bio-patch™, the PICC line dressing can be done every 7 days unless it is not intact or signs of infection are noticed.
5. Always check your drugs compatibility to prevent drugs crystallization in the PICC causing blockage.
6. When PICC line is not in use, always make sure one port has normal saline “to keep open” (TKO). This again is to prevent from blockage from red blood cells clumping together.
7. When drawing blood from a PICC line, use turbulence technique (pull intermittently). This will not only prevent red blood cells clumping but it will also keep red blood cells intact. If you pull continuously and the pressure is high, the red blood cells will hemolyze, making it impossible to give accurate results on labs like CMP, BMP, CBC etc
8. Incase of PICC line blockage, always notify the provider and/or PICC nurse. If not comfortable, do not try to de-clot using TPA. Some facilities does not allow use of TPA on PICC lines except by PICC line nurses or MD
9. After removing a PICC line, always verify the tip is intact. Always make sure the measurements after removing the PICC corresponds with those documented on insertion date
10. If your PICC line is not working, you have no reason keeping it. Remove it and follow your facility protocol. Most facility required culture done for the tip.

Enjoy the great convenience of a PICC LINE

Since the elderly tend to use the Foley catheters for a longer time than the rest of the groups, I will give you tips on how to take care of a Foley catheter and how to prevent developing infections like urinary tract infections (UTI)

1. A Foley catheter should always be inserted using a sterile procedure by either a registered nurse of qualified vocational nurse.
2. Foley catheter should be done at least once daily. This includes washing the penis with warm soapy water, and the vagina in females.
3. Foley catheters should be changed at least once every 28 days and where contamination is suspected, should be changed sooner.
4. Patient with Foley catheters should be given urine-acidifying foods like cranberry juice. This acidity prevents bacteria colonization causing UTI.
5. Keep elderly patient with Foley catheters well hydrated. Elderly tend to loose third drive, making them not to crave for water or other fluids. This dehydration is attractive to bacteria.
6. Urine culture is recommended atleast every 2-4 weeks on patient who are chronically on Foley Catheters.

Here are some of tips about general Foley catheter care.

1. Never put a Foley catheter on a patient suspected or already diagnosed with UTI. This could push the infection into the bladder
2. Always use a sterile technique when inserting a Foley catheter.
3. Never take the patient to operating room without a Foley catheter. You need to monitor urine output every hour during surgery.

Call the doctor immediately if an elderly patient becomes confused with falls or likelihood to fall. These are the earliest signs of UTI in elderly patient.

Here are some few good tips you can use when taking care of a patient on mechanical ventilation, commonly known as “vented patient”.

1. Always note the ventilator settings during report even before you go into the room the patient is.
2. Make sure that the physician orders for ventilator settings are correct and correspond with the settings you got in nurse-to-nurse report.
3. Never ever turn ventilator alarms off. These alarms are your patient lifesavers and without the alarms, it is hard to know an emergent ventilation problem.
4. Never ever ignore a ventilator alarm or dismiss it as a false alarm. Always make sure you review your alarms as this may give you indication of impeding event.
5. Low pressure alarm troubleshooting:
   1. Make sure your tubing connected to the ventilator are not disconnected or have air leaks.
   2. Make sure that the endotracheal balloon is inflated; hence, there is no air leak when the vent machine is delivering positive pressure.
   3. Make sure the patient has not pulled out the endotracheal tube (self extubation)
   4. Make sure the machine is functioning properly
6. High pressure alarm troubleshooting:
   1. High-pressure alarm may go off when the patient is coughing.
   2. High-pressure alarm may go off when the patient is vomiting.
   3. Make sure your vent tubings are not kinked.
   4. The patient may have sputum blockage and may need to be suctioned. To suction a patient with endotracheal tube;

                                                              i.      Auscultate breath sounds before suctioning. This gives you a starting point and a way to evaluate if your suctioning is effective.

                                                             ii.      Elevate the head of bed as tolerated. (Vented patients should always have head of bed above 30 degrees to prevent G.I system content aspiration causing ventilator associated pneumonia.

                                                           iii.      Pre-oxygenate the patient with 100% oxygen. Once you turn on 100% oxygen, wait for about 15 seconds before you begin suctioning.

                                                          iv.      Using in-line suction, advance fast but gently until you feel resistance. This resistance is the “carina” where the trachea divides into right and left bronchi

                                                            v.      Pull the catheter backwards with intermittent suction. Let the patient receive 100% oxygen for about 15-20 seconds before advancing suction catheter again.

                                                          vi.      If the heart rate start going down, quickly remove the suction catheter and give 100% oxygen. This rapid drop in heart rate is an indication of myocardial tissue oxygenation compromise and must be corrected immediately.

                                                         vii.      Auscultate breath sounds after suctioning and notice the difference with the lung sounds before suctioning.

                                                       viii.      Document the procedure stating the procedure, amount and color of sputum obtained, how the patient tolerated and the lung sounds change before and after auscultation.

1.  
   1. Pneumothorax can also cause high-pressure alarms to go off. If this is suspected, call physician immediately and emergency chest tubes may need to be inserted.
   2. If all trouble shooting have been tried and still getting high pressure alarm call the physician and put the patient on 100% oxygen while you continue looking for the cause of the problem

                                                              i.      Make sure the lung sounds are equal bilaterally. This will help catching pneumothorax.

                                                             ii.      Make sure the sternum is symmetrical. This will help you catch tension pneumothorax.

                                                           iii.      Absent lung sounds may indicate pneumothorax or complete airway blockage

1. Never change vent settings without physician orders. I like to let the respiratory therapist do the vent settings change.
2. Always have Bi-valve mask by bedside at all times connected to 100% oxygen for use incase of an emergency.
3. Never try to do it all by yourself. If your instincts tell you there could be something wrong, call for help. Obey your instincts as time passed may be the difference between life and death.
4. Never leave a vented patient un-attended. Always let another nurse know incase you decide to step out for a break or anything.

Enjoy taking care of vented patients