NursingCenter.com

NursingCenter’s In the Round

A dialog by nurses, for nurses
NursingCenter.com

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. 



Suicide assessment – an important nursing responsibility

clock August 20, 2014 09:09 by author Lisa Bonsall, MSN, RN, CRNP

As we continue to mourn the loss of Robin Williams, an iconic entertainer and comedian, it’s important for us to take a step toward learning from his death. As nurses, our responsibilities to our patients are numerous, but we know that safety is a number one priority. Even if we don’t routinely care for patients with mental illness, patients that we encounter may have a mental illness of which we are unaware. Some patients may have an undiagnosed or newly diagnosed disorder that may increase their suicide risk, whether due to its pathophysiology or its impact on quality of life. In nursing school, we learned about suicidal ideation and how to do a suicide assessment. I’d like to share some resources from our journals with you to revisit this important topic.

 

Assessing patients for suicide risk
Nursing2010 

Suicide Prevention in Neurology Patients: Evidence to Guide Practice
Journal of Neuroscience Nursing

All along the watchtower: Suicide risk screening, a pilot study 
Nursing Management

As If the Cancer Wasn't Enough... A Case Study of Depression in Terminal Illness
Journal of Hospice and Palliative Nursing

Additional Resources
American Foundation for Suicide Prevention
National Alliance on Mental Illness
U.S. Department of Health and Human Services – Directory of support groups



Directing nurses back to patient care

clock July 25, 2014 03:09 by author Cara Gavin, Digital Editor

What made you decide to become a nurse? Was it the thrill of directly impacting a patient’s life? Or, was it because you really love tracking down medications and filling out paperwork? I’m going to guess it wasn’t the latter, and the people at the Institute for Healthcare Improvement agree.

In a recent article this week in the Wall Street Journal, Laura Landro explored the institute’s new partnership with the Robert Wood Johnson Foundation to develop Transforming Care at the Bedside, a program “to help hospitals increase to 70% the amount of time nurses spend in direct patient care while improving the work environment for nurses.”

This initiative attempts to answer the increasing need to streamline the work nurses are doing, while improving nurses’ delegation practices, “shifting more routine tasks to certified nurse assistants and other less high skilled staffers.” In an interview between Landro and Patricia Rutherford, a nurse and vice president at the institute, Rutherford explained, “We shouldn’t be using expensive professional nursing time doing unnecessary and inefficient things when that time could be reinvested in direct patient care.”

The institute isn’t the first to notice the lack of time nurses are spending with patients. In 2008, the American Journal of Nursing published a series of studies that found direct patient care “accounts for less than 50% of working hours.”

NursingCenter’s own clinical editor, Lisa Bonsall, MSN, RN, CRNP, remembers her frustrations at the bedside. “Patient care is what nursing is all about. I can remember clearly being pulled away from the bedside searching for supplies or medications, or even fixing or calibrating equipment. One time, I was caring for a patient admitted with DKA (diabetic ketoacidosis), who needed finger stick blood glucose checks every hour for titration of his insulin drip. We had two machines on our unit and one was broken. At about my third hour of the shift, the machine that was working needed to be calibrated…[which] took quite some time. This event not only took me away from the bedside, but put him at risk as I was unable to check his blood sugar for about two hours. Fortunately, no untoward events occurred, but I remember thinking at the time, ‘There’s got to be a better way!’”

Studies show the more time a nurse is at the bedside, the better the outcomes. Bonsall explains, “The relationship between patient safety and nursing care is documented in the research, including direct impacts on healthcare-associated infection, readmission rates, and mortality. We are the ones noticing the subtle changes in a patient’s status. If we are repeatedly pulled away from the bedside, those changes can go unnoticed.”

In a 2010 internal audit conducted by Presbyterian Medical Center, it was discovered that “nurses were involved in direct patient care at the bedside for only 2.5 hours every 12-hour shift.” Nurses were spending too much time searching for missing test results and supplies and not enough time monitoring their patients. After implementing the Transforming Care at the Bedside program, the center was hitting “6.5 hours per shift at the end of 2013 with a goal to hit 8.5 hours by the end of 2015.”

Time will tell if the center is able to hit their goal. But, as more hospitals begin to take a robust approach at managing their nurses’ time and delegation strategies, the hope is to return nurses back to why they began their work in the first place – to care for the patients.



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! 



The American Nurse Project

clock April 25, 2014 01:25 by author Lisa Bonsall, MSN, RN, CRNP

During a discussion with several nurses last night, we acknowledged the importance of nurses having a passion for the profession, and how this passion makes a difference in patient care. When I view the trailer for The American Nurse: Healing America, I feel the passion in the voices of those nurses featured. I can only imagine the impact that viewing this entire feature documentary will have. It premieres during National Nurses Week and I am really looking forward to seeing it! 

In 2012, Carolyn Jones, a photographer and filmmaker, traveled across the United States documenting the work of nurses. Her book, The American Nurse, was published that year and includes portraits, interviews, and biographies of nurses she encountered on her journey. An interview with Jones reveals her passion for this project, despite not being a nurse herself. She states, “Nursing is real. I'm fascinated by how a nurse can help all different people, even people that have committed terrible crimes, with the same compassion that they can treat a friend.” She learned a lot during her conversations with nurses and her journey is bringing our important work into the eyes of the public. For that, I am grateful. 

I will leave you with this powerful quote from the mission of The American Nurse Project: 

“At some point in our life each of us will encounter a nurse, whether it be as a patient or as a loved one. And that one encounter can mean the difference between suffering and peace; between chaos and order. Nurses matter.

I hope that many of you will get the opportunity to see this film. You can find a list of theaters here. I look forward to hearing what you think! 



3 days left!

clock February 25, 2014 05:03 by author Lisa Bonsall, MSN, RN, CRNP

Two of our most popular CE collections will be expiring on Friday, February 28, 2014. If you haven’t already taken advantage of these specially-priced collections, you should check them out ASAP!

Anticoagulant Medications
7.3 contact hours - $19.99
Expiration Date:  2/28/2014
When patients are on anticoagulant medications, significant safety concerns exist, especially the risk of excessive anticoagulation and hemorrhage. It is important to understand these risks yourself, as a healthcare provider, and to educate the patients in your care on how to minimize their risk and be alert for complications. 

NP: Pharmocology Hours
10.4 contact hours/10.4 advanced pharmacology hours - $44.95
Expiration Date:  2/28/2014
Depending on the state where you work as a nurse practitioner or your area of practice, it may be necessary for you to maintain a certain number of advanced pharmacology hours for your license or certification. 

Need more CE? See our complete list of topical CE collections and our special collections on ‘never events.’ Please be aware that the CE tests for each article must be taken before they expire.



AACN Choosing Wisely®

clock February 8, 2014 00:19 by author Lisa Bonsall, MSN, RN, CRNP

The Choosing Wisely® campaign was launched in 2012 by the American Board of Internal Medicine as a way to spark conversations to improve care and minimize unnecessary testing. The goals of the campaign are to ensure that care is supported by evidence; not duplicative of other tests or procedures already received; free from harm; and truly necessary (ABIM Foundation, 2014). Many organizations have released recommendations in support of the campaign – a full list is available here.

Last week, the American Association of Critical-Care Nurses (AACN) became the first nursing organization to get involved in the campaign. Its Choosing Wisely® list includes the following five evidence-based recommendations (American Association of Critical Care Nurses, 2014) :

  • Don't order diagnostic tests at regular intervals (such as every day), but rather in response to specific clinical questions.
  • Don't transfuse red blood cells in hemodynamically stable, non-bleeding critically ill patients with a hemoglobin concentration greater than 7 mg/dL.
  • Don't use parenteral nutrition in adequately nourished critically ill patients within the first seven days of a stay in an intensive care unit.
  • Don't deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation.
  • Don't continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort.

As a nursing professional, I am proud to see AACN collaborate on this important initiative. I encourage you all to remain cognizant of these recommendations, share them with your peers, and stay up-to-date on the latest evidence.

For further reading, the articles below are available for free to logged in members of Lippincott’s NursingCenter.com.  Not a member?  Join now!

In the News: Rethinking Routine Blood Work in Patients with MI
American Journal of Nursing
 
Blood Management: Best-Practice Transfusion Strategies
Nursing2013
 
Parenteral Nutrition Risks, Complications, and Management
Journal of Infusion Nursing
 
Sedation Vacation: Worth the Trip
Nursing2013 Critical Care
 
Ethics in Critical Care: Twenty Years Since Cruzan and the Patient Self-Determination Act: Opportunities for Improving Care at the End of Life in Critical Care Settings
AACN Advanced Critical Care
 
Hoping for the Best, Preparing for the Worst: Strategies to Promote Honesty and Prevent Medical Futility at End-of-Life
Dimensions in Critical Care Nursing

References:

ABIM Foundation. (2014). About. Retrieved from Choosing Wisely: http://www.choosingwisely.org/

American Association of Critical Care Nurses. (2014, January 28). News: Critical Care Groups Issue 'Choosing Wisely' List. Retrieved from American Association of Critical Care Nurses: http://www.aacn.org/wd/publishing/content/pressroom/pressreleases/2014/jan/choosing-wisely-aacn-ccsc.pcms?menu=aboutus



Recent Comments

Comment RSS

About your comments

We welcome comments, discussion, curiosity, and debate. Let us know about your nursing lives and personal experiences. We reserve the right to moderate comments that are intended to sell something or that are inappropriate or hostile.

Disclaimer

Views expressed on this blog are solely those of the authors or persons quoted. They do not necessarily reflect Lippincott's NursingCenter.com's views or those of Wolters Kluwer Health/Lippincott Williams and Wilkins.

Sign in