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Complications of Peripheral I.V. Therapy: Part 2

clock February 9, 2015 03:46 by author Lisa Bonsall, MSN, RN, CRNP

If you are administering I.V. fluids or medications to a patient through a peripheral I.V. site, be alert for signs and symptoms of complications, institute preventive measures, and know how to intervene when complications do occur. Please review Complications of Peripheral I.V. Therapy: Part 1 for information on infiltration and extravasation.

Phlebitis

 

Phlebitis is inflammation of a vein. It is usually associated with acidic or alkaline solutions or solutions that have a high osmolarity. Phlebitis can also occur as a result of vein trauma during insertion, use of an inappropriate I.V. catheter size for the vein, or prolonged use of the same I.V. site.

 

 

Signs and symptoms

  • Redness or tenderness at the site of the tip of the catheter or along the path of the vein
  • Puffy area over the vein
  • Warmth around the insertion site

Prevention

  • Use proper venipuncture technique.
  • Use a trusted drug reference or consult with the pharmacist for instructions on drug dilution, when necessary.
  • Monitor administration rates and inspect the I.V. site frequently.
  • Change the infusion site according to your facility's policy.

Management

  • Stop the infusion at the first sign of redness or pain.
  • Apply warm, moist compresses to the area.
  • Document your patient's condition and interventions.
  • If indicated, insert a new catheter at a different site, preferably on the opposite arm, using a larger vein or a smaller device and restart the infusion.

Hypersensitivity

An immediate, severe hypersensitivity reaction can be life-threatening, so prompt recognition and treatment are imperative.

Signs and Symptoms

  • Sudden fever
  • Joint swelling
  • Rash and urticaria
  • Bronchospasm
  • Wheezing 

Prevention

  • Ask the patent about personal and family history of allergies.
  • For infants younger than 3 months, ask the mother about her allergy history because maternal antibodies may still be present.
  • Stay with the patient for five to 10 minutes to detect early signs and symptoms of hypersensitivity.
  • If the patient is receiving the drug for the first or second time, check him every five to 10 minutes or according to your facility's policy. 

Management

  • Discontinue the infusion and notify the prescriber immediately.
  • Administer medications as ordered.
  • Monitor the patient's vital signs and provide emotional support.

Infection

Local or systemic infection is another potential complication of I.V. therapy. 

Signs and symptoms

  • Redness and discharge at the I.V. site
  • Elevated temperature

Prevention

  • Perform hand hygiene, don gloves, and use aseptic technique during I.V. insertion. 
  • Clean the site with approved skin antiseptic before inserting I.V. catheter.
  • Ensure careful hand hygiene before any contact with the infusion system or the patient. 
  • Clean injection ports before each use.
  • Follow your institution’s policy for dressing changes and changing of the solution and administration set. 

Management

  • Stop the infusion and notify the prescriber.
  • Remove the device, and culture the site and catheter as ordered. 
  • Administer medications as prescribed.
  • Monitor the patient's vital signs.

With careful attention and skill, you’ll be able to recognize, prevent, and manage these complications of peripheral I.V. therapy.

References
(2008). I.V. Essentials: Complications of Peripheral I.V. Therapy. Nursing Made Incredibly Easy!, 6 (1). 
Smeltzer, S. (2010). Brunner and Suddarth's Textbook of Medical Surgical Nursing, 12e. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Spencer, S. & Gilliam, P. (2015). Teaching patients about their short peripheral I.V. catheters.  Nursing2015, 45 (2).



Complications of Peripheral I.V. Therapy: Part 1

clock February 4, 2015 05:24 by author Lisa Bonsall, MSN, RN, CRNP

If you are administering I.V. fluids or medications to a patient through a peripheral I.V. site, be alert for signs and symptoms of complications, institute preventive measures, and know how to intervene when complications do occur. 

Infiltration

 

Infiltration occurs when I.V. fluid or medications leak into the surrounding tissue. Infiltration can be caused by improper placement or dislodgment of the catheter. Patient movement can cause the catheter to slip out or through the blood vessel lumen. 

 

 

 

Signs and symptoms

  • Swelling, discomfort, burning, and/or tightness 
  • Cool skin and blanching
  • Decreased or stopped flow rate

Prevention

  • Select an appropriate I.V. site, avoiding areas of flexion. 
  • Use proper venipuncture technique.
  • Follow your facility policy for securing the I.V. catheter.
  • Observe the I.V. site frequently.
  • Advise the patient to report any swelling or tenderness at the I.V. site.

Management

  • Stop the infusion and remove the device.
  • Elevate the limb to increase patient comfort; a warm compress may be applied.
  • Check the patient's pulse and capillary refill time.
  • Perform venipuncture in a different location and restart the infusion, as ordered.
  • Check the site frequently.
  • Document your findings and interventions performed.

Extravasation

Extravasation is the leaking of vesicant drugs into surrounding tissue. Extravasation can cause severe local tissue damage, possibly leading to delayed healing, infection, tissue necrosis, disfigurement, loss of function, and even amputation.

Signs and symptoms

  • Blanching, burning, or discomfort at the I.V. site
  • Cool skin around the I.V. site
  • Swelling at or above the I.V. site
  • Blistering and/or skin sloughing

Prevention 

  • Avoid veins that are small and/or fragile, veins in areas of flexion, veins in extremities with preexisting edema, or veins in areas with known neurologic impairment.
  • Be aware of vesicant medications, such as certain antineoplastic drugs (doxorubicin, vinblastine, and vincristine), and hydroxyzine, promethazine, digoxin, and dopamine.
  • Follow your facility policy regarding vesicant administration via a peripheral I.V.; some institutions require that vesicants are administered via a central venous access device only. 
  • Give vesicants last when multiple drugs are ordered.
  • Strictly adhere to proper administration techniques.

Management

  • Stop the I.V. flow and remove the I.V. line, unless the catheter should remain in place to administer the antidote.
  • Estimate the amount of extravasated solution and notify the prescriber.
  • Administer the appropriate antidote according to your facility's protocol.
  • Elevate the extremity.
  • Perform frequent assessments of sensation, motor function, and circulation of the affected extremity. 
  • Record the extravasation site, your patient's symptoms, the estimated amount of extravasated solution, and the treatment.
  • Follow the manufacturer's recommendations to apply either cold or warm compresses to the affected area.

With careful attention and skill, you’ll be able to recognize, prevent, and manage these complications of peripheral I.V. therapy. In Complications of Peripheral I.V. Therapy: Part 2, we'll review the complications of hypersensitivity, phlebitis, and infection.

References
(2008). I.V. Essentials: Complications of Peripheral I.V. Therapy. Nursing Made Incredibly Easy!, 6 (1).
Smeltzer, S. (2010). Brunner and Suddarth's Textbook of Medical Surgical Nursing, 12e. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Spencer, S. & Gilliam, P. (2015). Teaching patients about their short peripheral I.V. catheters.  Nursing2015, 45 (2).
Vacca, V. (2013). TIME CRITICAL: Vesicant extravasation. Nursing2013, 43(9). 



Measles Update

clock February 2, 2015 16:34 by author Lisa Bonsall, MSN, RN, CRNP

The current outbreak of measles, which has been linked to a California amusement park, continues to make headlines in the United States. The Centers for Disease Control and Prevention (CDC) is tracking data on the states affected and the number of cases. I encourage you to stay informed so you’ll be able to best educate your patients and answer their questions.

Before I get to the purpose of this post – to review transmission, signs and symptoms, and treatment of measles – I’d like to briefly address why we are seeing this resurgence in cases. In 1998, a study was published in the Lancet which suggested a link between the measles, mumps, and rubella (MMR) vaccine and autism. As a result, increased numbers of parents opted to refuse the MMR vaccine for their children. The researchers later retracted their study, and current evidence concludes that there is no association between vaccines and autism.

As nurses, we have a responsibility to educate patients about the importance of vaccinations and the implications when vaccine-preventable diseases reemerge. Measles is extremely contagious and can have serious complications, especially for certain high risk groups. Please stay informed about the current outbreak and recommendations for vaccinations. 

What is measles?

Measles is an acute viral illness, transmitted by direct contact with infectious droplets or by airborne spread. After exposure (the incubation period can range from seven to 21 days), a prodromal syndrome of high fever, cough, runny nose, and conjunctivitis is characteristic. Koplik spots (white or bluish-white spots on the buccal mucosa) may occur and then the development of the characteristic maculopapular rash, which typically spreads from the head to the trunk to the lower extremities, follows. 


Complications of measles

Common:

  • Otitis media
  • Bronchopneumonia
  • Laryngotracheobronchitis
  • Diarrhea

Severe:

  • Encephalitis
  • Respiratory complications
  • Neurologic complications
  • Subacute sclerosing panencephalitis (SSPE)

Who’s at risk for severe complications?

  • Infants and children younger than five years; adults over 20
  • Pregnant women
  • Immunocompromised patients

Need-to-know information for nurses

  • After appearance of the rash, infected patients should be isolated for four days in a single-patient airborne infection isolation room (AIIR).
  • Measles is a reportable disease and local health departments should be notified within 24 hours of suspected measles cases. 
  • Routine childhood immunization for MMR vaccine starts with the first dose at 12-15 months of age, and the second dose at 4-6 years of age or at least 28 days after the first dose. (More vaccine schedules and information, including contraindications to vaccination, can be found here.)

References
Finerty, E. (2008). Did you say measles? American Journal of Nursing, 108(12). 
Skehan, J. & Muller, L. (2014). Vaccinations: Eliminating Preventable Illness. Professional Case Management, 19 (6).
Wade, G. (2014). Nurses as Primary Advocates for Immunization Adherence. The American Journal of Maternal/Child Nursing, 39 (6). 
Centers for Disease Control and Prevention. (2015, January 30). Measles (Rubeola): For Healthcare Professionals.



Who are “The Ebola Fighters?”

clock December 10, 2014 07:19 by author Lisa Bonsall, MSN, RN, CRNP

They are nurses. They are physicians. They are caregivers. They are scientists.

And as Time’s Person of the Year 2014, “The Ebola Fighters” are “The ones who answered the call.” These are the people who answer the call every day, putting themselves at risk without always knowing what those risks are. These are the people who feel it is an honor and a privilege to care for others during times of crisis and uncertainty. These are the people who thrive on answering tough questions and making tough decisions. 

It is wonderful to see this group recognized for their work. I am hopeful that this recognition will inspire The Ebola Fighters to continue this battle and will motivate others to join as well. We must all stay informed and follow recommendations to keep ourselves, our patients, and the public safe.

Congratulations to The Ebola Fighters – true heroes, deserving of our utmost respect and gratitude. 



Enterovirus-D68

clock September 8, 2014 08:34 by author Lisa Bonsall, MSN, RN, CRNP

In the Midwest,  an enterovirus, known as EV-D68, is causing concern. While not a new virus, EV-D68 has recently caused severe respiratory symptoms in affected children in Missouri, and several other states have contacted the CDC for assistance with a possible regional outbreak as well. These are Colorado, North Carolina, Georgia, Ohio, Iowa, Illinois, Missouri, Kansas, Oklahoma, and Kentucky. Symptoms of a common cold are typical at the onset of EV-D68, however the development of fever, rash, or dyspnea – particularly in children with asthma – is occurring and necessitating hospitalization, and in some instances, ICU admission. 

While details continue to be released, please remember your role in patient education and infection control. Tell parents and caregivers about these symptoms of EV-D68 and advise them to seek care for their child if fever, rash, or breathing difficulties develop. Also, share these basics of infection control:

  • avoiding close contact with people who have respiratory symptoms, such as coughing or sneezing
  • staying home when sick
  • washing hands often with soap and water for 15 to 20 seconds or using alcohol-based hand cleansers 
  • not touching eyes, nose, or mouth 
  • keeping surfaces and objects (especially tables, counters, doorknobs, and toys) that can be exposed to a virus clean
  • practicing other good health habits, including getting plenty of sleep, staying active, drinking plenty of fluids, and eating healthy foods

As more details are released, we’ll be sure to keep you informed! 

Update 9/16/14 - More states have reported EV-D68 infections. Please visit our page on this topic for more information and resources!

Reference:

Bonsall, L. (2009). Be prepared for H1N1 flu. Nursing Made Incredibly Easy!, 7(6).




The ‘Threat’ of NPs: An NCNP 2014 Wrap-Up

clock May 5, 2014 07:19 by author Lisa Bonsall, MSN, RN, CRNP

It’s been a little over a week since the National Conference for Nurse Practitioners in Chicago, and I am reviewing my notes and reminded of the learning and networking that took place during the conference. On my very first page, from the Welcome and Opening Remarks of Conference Chairperson, Margaret A. Fitzgerald, DNP, FNP-BC, NP-C, FAANP, SCP, FAAN, DCC, I had written the following: 

I remember this point vividly, as Dr. Fitzgerald had commented that years ago, when our numbers were much smaller, not too many people had an issue with nurse practitioners practicing to the full extent of our education and training. Now however, as there are over 180,000 nurse practitioners, the power of our numbers is threatening to many, even despite recent research demonstrating our value in patient outcomes and satisfaction. This point is incredibly evident in this recent Op Ed piece from The New York Times, Nurses are not Doctors, where the author cites a study from 1999 to support his opinion, which is clearly not the most up-to-date, best available evidence. Have you read it? I encourage you to do so when you are sitting down, because it did bring out a bit of my temper. Rest assured that some leaders in nursing did reply with some Letters to the Editor and you can read them here

And now back to some take-aways from NCNP…

*The states with the least restrictive NP regulations see twice as many patients as those in other states.
Carol L. Thompson, PhD, DNP, ACNP, FNP, FCCM, FAANP
Keynote Address: Awesome Practiced Daily

*Don’t use an ARB and ACE inhibitor concomitantly to treat hypertension.
Joyce L. Ross, MSN, CRNP, CLS, FNLA, FPCNA
JNC-Late: A Focus and Update on the Long-Awaited Hypertension Guidelines

*Not all infected patients are febrile and not all febrile patients are infected.
Lynn A. Kelso, RN, ACNP-BC, FCCM, FAANP
Acute: Fever of Unknown Origin in Adults

*If a patient has an inappropriate tachycardia related to his elevated temperature, consider pulmonary embolism as the cause.
Lynn A. Kelso, RN, ACNP-BC, FCCM, FAANP
Acute: Fever of Unknown Origin in Adults

*Sepsis doesn’t kill patients; multisystem organ failure resulting from sepsis does.
Sophia Chu Rodgers, ACNP, FNP, FAANP, FCCM
Acute: Understanding the Latest Sepsis Guidelines

*If a patient has kidney injury, used unfractionated heparin for DVT prophylaxis.
Sophia Chu Rodgers, ACNP, FNP, FAANP, FCCM
Acute: Understanding the Latest Sepsis Guidelines

*Our patients give us very important information, if we listen!
Christine Kessler, RN, MN, CNS, ANP, BC-ADM
Common Sense Assessment Tips Every NP Should Know

*If a patient has loss of the hair that makes up the outer eyebrows, think hypothyroidism. 
Christine Kessler, RN, MN, CNS, ANP, BC-ADM
Common Sense Assessment Tips Every NP Should Know

*The presence of pulsus paradoxus is a sign of cardiac tamponade, but can also be seen in severe asthma.
Christine Kessler, RN, MN, CNS, ANP, BC-ADM
Common Sense Assessment Tips Every NP Should Know

*To assess judgment in patients with traumatic brain injury, ask “What would you do if there was a fire in your kitchen?”
Tracey Andersen, MSN, CNRN, FNP-BC, ACNP-BC
Neuro Assessment and Diagnostic Work-up for Advanced Practitioners

Thanks for reading this wrap-up! Want to see photos from the event? Here’s our album – enjoy! 



Flu Panic

clock January 20, 2013 03:11 by author Lisa Bonsall, MSN, RN, CRNP

I’m a bit ashamed to be admitting this to a group of nurses, but I figure that if I shame myself enough maybe I won’t let this happen again. Ok, here it is…I didn’t get a flu shot. There, I said it. No reason, really, I just got busy and it kept getting pushed to the bottom of my to-do list. My husband got his at work, I took the kids for theirs, but mine – I just never got around to it. I am embarrassed and yes, more than a little nervous about getting sick. 

I’ve been reading a ton about this year’s influenza viruses "taking the U.S. by storm." I get emails from the CDC with the latest numbers and maps showing flu activity around the country. Our Nursing News page has links to updates and articles about this year’s virus. Our twitter timeline and facebook newsfeed also contain quite a bit of flu-related news, opinions, and personal stories these days. 

Not only am I “virtually” surrounded by the virus, but my kids come home from school each day with a report of who was absent, or more concerning, who was sick at school. My husband returns from his work as a respiratory therapist with a flu update from the hospital floors. And of course, I’m aware of every sniffle and sneeze around me when I’m out. 

My plan, which has been working well so far, consists of the usual recommended practices: frequent handwashing, not touching my face, getting enough rest and eating well, and doing my best to avoid those who are sick. However, while I’ve dodged illness thus far this flu season, I will surely be calling my nurse practitioner this week to schedule my vaccination! 

Any other advice? 



Pneumococcal pneumonia in the house

clock January 12, 2012 08:15 by author Lisa Bonsall, MSN, RN, CRNP

The holidays were not without incident at our house this year. Illness reared its head as it usually does when excitement builds and holiday events and preparations keep us too busy to get adequate rest and eat right. This year, however, it was my husband who was down-and-out, not one of our kids.

He had a cough for about a week and was fatigued, but, despite my clinical judgment that he should rest, I “encouraged” him to help out with all that still needed to be done before Christmas. On Christmas day, he really wasn’t looking so well – high fever, chills, productive cough that seemed constant. He spent the evening in bed taking ibuprofen around the clock to help alleviate his symptoms.

By late morning the next day, we called our primary care office and found that they were closed for the holiday. We ended up heading over to the emergency department (ED) at our local hospital. In triage, he was found to be febrile, tachycardic, and hypoxic. He got a stat dose of albuterol and was quickly taken back to a room in the ED. As we went through his medical and surgical history with the ED nurse, we both paused and looked at each other when he told her that he had a splenectomy when he was younger. 

Oops – did we forget the implications of being without a spleen and the need to seek care quickly when he gets sick? And hadn’t I just read something about the risks associated with splenectomy?

Shortly after, labs came back and his white blood cell count was 43,000. So, he spent 4 days in the hospital on I.V. antibiotics. His diagnosis? Pneumococcal pneumonia.

Yes, I had read “something” recently and even put in on our recommended reading list a few weeks prior. Needless to say, I did go back and read this one again: A close up view of Pneumococcal disease.

“Risk factors for acquisition of the disease are alcohol abuse, splenectomy, immunocompromised status, smoking, and asthma.”

 

All is well now. And next time, I’ll ease up on my “encouragement” and do a better job with my assessment!



Patient safety, handwashing, and hierarchy

clock March 15, 2010 06:14 by author Lisa Bonsall, MSN, RN, CRNP

During Patient Safety Awareness Week last week, the following interview from the New York Times caught my attention. In Doctor Leads Quest for Safer Ways to Care for Patients, Dr. Peter J. Pronovost, medical director of the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore, describes his quest for patient safety after the misdiagnosis of his father and the death of a child from a catheter-associated infection.

At one point in the interview, Dr. Pronovost talks about improving physician handwashing practices. Part of the solution was for the nursing staff to make sure the doctors wash their hands and if the doctors didn’t wash, the nurse could stop the procedure. The following excerpt from the interview demonstrates how both the nurses and doctors responded:

Q. HOW DID THAT FLY?
A. You would have thought I started World War III! The nurses said it wasn’t their  job to monitor doctors; the doctors said no nurse was going to stop takeoff. I said: “Doctors, we know we’re not perfect, and we can forget important safety measures.  And nurses, how could you permit a doctor to start if they haven’t washed their hands?” I told the nurses they could page me day or night, and I’d support them.  Well, in four years’ time, we’ve gotten infection rates down to almost zero in the  I.C.U.

Wonderful outcome, right? Yes, but the strategy was not well-accepted initially. Later in the interview, Dr. Pronovost discusses the benefits of empowering nurses and avoiding the hierarchical structure seen in so many settings. As nurses, we spend the most time with patients, we are aware of subtle changes in their condition, and we have a duty to speak up when patient safety is at risk. Along the same lines, we also have the right to be heard. In short, to have a successful team, mutual respect and effective communication are critical.

How comfortable are you with your team? What approach would you take in reminding a colleague (nurse, physician, or anyone else) to wash his or her hands?



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