Banishing the Bully Among Us

It seems odd to end Nurses Week with a post about bullying – after all, when thinking about celebrating our week, why be a “downer?” Hasn’t there been enough talk and articles about this ugly side of nursing?

But like other problems, raising awareness is usually the first step towards change.  The sentinel event alert from JCAHCO in 2008 on the dangers to patients from intimidating and disruptive behaviors spurred many organizations to look seriously at the behaviors of their staff. We saw several research reports and reviews about the phenomena of bullying among nurses, nurses and physicians, nurses and ancillary staff and students. We can’t just point fingers at the clinical setting. Cynthia Clark and colleagues reported their research on faculty-to-faculty incivility in the April 2013 issue of the Journal of Nursing Education. In a study of 588 educators from 40 states, they found that faculty perceived this to be a “moderate to severe problem” and that it persisted because of “fear of retaliation, lack of administrative support, and lack of clear policies addressing the problem.”

But, maybe there are a few subtle signs that we’re starting to deal with bullying.

One piece of good news is that since it was first published in January 2009, Cheryl Dellasega’s article, Bullying Among Nurses,” always ranked among AJN’s top 20 most viewed and most emailed articles, which to me, meant it was all too relevant. I’ve heard from more than a few nurses in the clinical setting that people are getting tired of the sniping and are confronting those responsible. Articles moved from describing the problem to reporting on dealing with it, like: Organizations, too, are helping members with resources, such as the American Association of Critical Care Nurses, which developed standards for a health work environment. The ANA has a list of resources addressing bullying and incivility.

Later this year, look for an article in the American Journal of Nursing  on how one hospital successfully rallied staff to deal with bullying behavior.

Perhaps people are getting the message that we’re losing too many nurses because of the untenable work environment – the “toxic workplace” – that this can create. As I noted in a message I wrote in a 2011 editorial for Nurses Week, “Our work is too important; we can’t afford to be sidetracked by bullying and other forms of relational aggression. Use this Nurses Week as a catalyst for focusing on all that we share and accomplish as colleagues.”

Maureen Shawn Kennedy, MA, RN, FAAN
Editor in Chief, American Journal of Nursing

Posted: 5/12/2015 7:04:59 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

End-of-Life in Acute Care

In today’s society, we have seen many great advances in medicine, science, and technology that have resulted in an aging population with chronic illnesses. Often times, these issues require frequent or prolonged acute care admissions. With this in mind, choices need to be made that involve discussing end-of-life care goals with patients and their families. As nurses, we must work hard to provide high value end-of-life care for these patients in the acute care setting when death is near.
Although many patients would prefer to die at home, the truth is a majority will die in acute care settings and other healthcare institutions. Over the years, end-of-life care in acute care settings has taken great stride in the implementation of specialty practices such as palliative care.1 However, in a healthcare organization that does not benefit from such a specialty, how is end-of-life care provided?
The first step in being able to plan and provide good end-of-life care is for the patient, family, and nursing staff to accept that death is the outcome.1 Next, all active life sustaining medications should be discontinued. These medications would include but not limited to: intravenous fluids, antibiotics, insulin, steroids, and blood pressure medications, but intravenous access should be maintained in order to administer end-of-life medications. Typically, in the acute care setting before transition to hospice is made, or if the patient is awaiting a hospice bed, the standard appropriate medical procedure for transitioning a patient to end-of-life care is started. A morphine bolus and/or relaxant such as Ativan is administered. These medications are given in end-of-life cases in order to decrease anxiety that the patient may experience as well as ease any feeling of breathlessness. It is very important to remember that the administration of these medications is not to promote death, but to aid the patient with the symptoms that often accompany dying.
Next, a continuous morphine drip which should be titrated for patient comfort is initiated. Often times, medications to aid with the patient’s secretions (such as levsin) is administered. Basic nursing care such as mouth care, turning, and repositioning of the patient should also be continued.
With life, comes death. As good as a healthcare professional may be, we, as a profession have yet to keep anyone from dying. We have kept people alive longer, but everyone dies at some point. Much of this understanding should not be when, but how. As a profession, when a patient’s care transitions to end-of-life care, we are not failing them. We often times begin to fail the dying patient when the health care team does not provide what the patient needs. If the outcome of the disease process or admission is death, then as a health care system, we are failing that patient by not providing a death for them that is good. Curing everyone is simply impossible, but what we can do as a profession and as patient advocates, is to provide a death that is comfortable for the patient’s final life journey.
Bloomer, M., Moss, C., & Cross, W. (2011). End of life care in acute hospitals: an integrative literature review. Journal of Nursing and Healthcare of Chronic Illnesses, 3(3), 165-173.  

William Pezzotti, MSN, RN, CRNP, AGACNP-BC, CEN 
Acute Care NP at Penn Medicine Chester County Hospital
Adjunct faculty at Drexel University, College of Nursing and Health Sciences​

Posted: 5/11/2015 5:23:06 AM by Lisa Bonsall, MSN, RN, CRNP | with 17 comments

Categories: Patient Safety

Moral Distress

When I think about moral distress, I’d describe it as a gnawing, distraught feeling born of perceived injustice.  The underlying catalysts are highly variable and include lack of essential resources necessary to provide the standard of care to patients, interpersonal or inter-professional conflict, especially involving ethically challenging situations with patients, families, providers, or co-workers, as well as errors and disturbing treatment decisions. It encompasses a constellation of emotions that nurses have likely felt since the dawn of our profession. If left to fester without effective intervention, moral distress can lead to disillusionment, disenchantment, and even disengagement with the nursing profession. 
Over 30 plus years of practice, I’ve not only observed moral distress in colleagues, but have experienced it personally on several occasions. Until relatively recently, I didn’t have a name for it. My earliest memories of what I’d now term moral distress typically stemmed from being a party to treatment decisions that I simply couldn’t fathom -- they involved care that was either too aggressive (and seemingly abusive) for patients who simply had no hope for any type of recovery, or care that was not aggressive enough in patients who did. These were the days before evidence-based care pathways or palliative care services existed. I felt outraged that the hospital I worked for at that time didn’t seem to address these issues with the medical staff. A nurse, seasonedand hardened by her own years of enduring ethically challenging assignments, brushed off my distress as reality shock. “Just do what’s ordered; that’s our job,” she advised. But my own professional framework wouldn’t allow me to be satisfied with that advice since I felt the patients deserved so much more.  As this situation recurred repeatedly, I felt something had to change, but I didn’t know how to affect change at that point in time. Simply being mad wasn’t constructive.
Sadly, the way many nurses, especially ones in their formative years, handle this type of challenge is by jumping ship in their search for calmer seas or greener pastures. The true reality shock, in my opinion, is that no sea is always calm or pasture always greener. The secret is learning how to cope with resilience and fortitude, and at the same time, derive strategies to tackle the root causes of the situations that lead to moral distress in an effective manner. 
Mentoring and supportive relationships are essential among colleagues, nursing educators, and leaders to help individuals in the throes of moral distress to sort out their feelings, identify the causative factors, plan the resolution, and regain their own healthy emotional balance. Sometimes employee assistance programs are the best options to help nurses deal with the emotional toll in highly sensitive and confidential matters when discussions with colleagues or leaders wouldn’t be conducive to the open dialogue needed to sort out feelings and develop potential solutions.
For nurse leaders, listening and observation skills are key to identify problem situations and the impact they have on the staff. Ongoing vigilance and diligence are necessary to deal with the issues in our healthcare facilities that cause moral distress in nurses. Frankly, these issues should be very visible in the priority scheme of all healthcare leaders.  The solutions aren’t always straightforward, quick or easy, but they are essential to preserving quality and safety in patient care, as well as nursing itself as a long-term career choice.

Linda Laskowski-Jones, RN, MS, ACNS-BC, CEN, FAWM
Editor-In-Chief, Nursing2015

Posted: 5/10/2015 6:25:55 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

An Ethical Perspective on Elder Abuse

Nurses have a duty to report and to protect vulnerable populations including older adults. Yet it can be difficult for nurses to intervene successfully or to feel that they have made a difference in clients’ lives when older adults choose to stay in abusive situations. Abuse in the family and intimate partner abuse are often complicated because older adults are struggling with conflicting social, cultural, religious, or other pressures to continue living with their abusers (Finfgeld-Connett, D. 2014). In order to prevent harm to your clients at risk for abuse, nurses must carefully assess the ethical implications from the perspective of older adults, and then develop the best plan to intervene.

Social and Cultural

When deeply rooted cultural stigma about broken families exists, women may endure decades of abuse to portray an image of family unity rather than taking assistance to ensure their own personal safety (Finfgeld-Connett, D. 2014). As most abuse occurs in families, some older adults feel shame, guilt, or fear over reporting their relatives to the authorities (Olson & Hoglund, 2014).


Think about the dilemma of having a client with a lifelong religious devotion and a deep commitment to his/her marital vows when the relationship is abusive. There are reports of elders whose spiritual advisors have encouraged them to remain in abusive relationships rather than to leave (Finfgeld-Connett, D. 2014).


Low income contributes to the risk of abuse (Dong & Simon, 2014) and complexity of assisting elders who are abused. Some elders who have been abused feel trapped and unable to leave the relationship because of guilt over dependency of their spouse for shared income or fear for their own ability to provide for themselves (Finfgeld-Connett, D. 2014).

Nurses Role in Suspected Abuse

  • “provide an accurate assessment of abuse and risk factors for abuse;
  • clearly and objectively document assessment findings;
  • report suspected incidents of abuse and participate in investigation as appropriate;
  • provide support and referrals for clients experiencing potential or actual abuse; and
  • implement strategies to prevent elder abuse.” (Olson & Hoglund, 2014)
Just remember that safety comes first. If there is a situation when a client is in eminent danger or has been injured, there should be immediate action to obtain treatment and to remove weak or disabled individual to a safe location.  In non-urgent situations, nurses should take steps to help their clients to seek support from the community including counseling services, religious organizations, senior centers, or support groups to reduce their risk for being abused.
For more information, on risk factors and protective factors related to elder abuse, go to

Free Article:

Elder Abuse: Speaking Out for Justice 


Dong, X. & Simon, M.A. (2014). Vulnerability Risk Index Profile for Elder Abuse in a Community-Dwelling     Population. Journal of the American Geriatric Society, 62:10–15, doi: 10.1111/jgs.12621
Finfgeld-Connett, D. (2014). Intimate partner abuse among older women: Qualitative systematic review. Clinical Nursing Research, 23(6) 664–683.
Olson, J.M. & Hoglund, B.A. (2014). Elder Abuse: Speaking out for justice. Journal of Christian Nursing, 31(1):14-21 DOI:1097/CNJ.0000000000000028

Karen Innocent, DNP, RN, CRNP, ANP-BC, CMSRN
Executive Director, Lippincott Continuing Education
Wolters Kluwer, Health Learning Research & Practice

Posted: 5/9/2015 6:31:36 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

Informed Consent: An Ethical Way of Nursing

As nurses, we deal with informed consent a lot—on admission to a hospital/clinic or before a procedure/surgery. Nurses typically are assigned the task of obtaining and witnessing written consent for healthcare treatment. I’ll never forget admitting to our busy psychiatric unit a young mother who’d been found unresponsive after a drug overdose. She’d been taken to the emergency room to stabilize, and her young child taken into protective custody. Now on the locked psych unit, she was terrified to sign the consent form for admission and treatment, afraid for herself and her child whose whereabouts she did not know. I repeatedly explained what I knew about her child, treatment plan, and consent process, including that she did not have to sign the admission consent. However, if she did not sign, her admitting psychiatrist would request, and be granted, a “court hold” to admit her involuntarily. If she signed as a “voluntary” admission, it would suggest she was cooperating with treatment.
I knew it was in her best interest to sign, but understood it was her decision. The goal of informed consent is to assure patient autonomy. My patient didn’t have a choice of treatment alternatives, but she did have a choice to be admitted voluntarily or involuntarily. I felt ethically compelled to preserve that choice.
After almost an hour of listening, supporting, and explaining, I needed to give medications to other patients. My plan was to offer this woman a hot shower to help calm her and give time to process what was happening. Then, if she still could not sign the consent, I would explain I had to inform her psychiatrist, and we would proceed with a court hold.
When I stepped out of the room, I told my supervisor my plan. She hastily went to the patient, stuck the form and a pen in front of her, saying, you need to sign this NOW! My patient complied, tears streaming down her face.
I’ve since thought a lot about informed consent. I’ve worked in med-surg, cardiac rehab, intensive care, medical research, and psychiatry. In all settings, nurses are on the front lines of assuring patients truly are giving informed consent.

What is involved in informed consent?

Legally, this requires that the patient, or his/her surrogate, is informed of the risks, benefits, and alternatives to a treatment. A signature on the consent form provides legal documentation of consent.
Ethically, consent is about patient autonomy, meaning the patient understands and freely agrees to the treatment.
Consent may be withdrawn at any time. Healthcare providers must accept and support refusal or withdrawal of consent even if they disagree with the patient. 
The consent process can be affected by complexity of the treatment, patient condition and ability to understand information, and if treatment is emergent or elective.

What can nurses do to improve informed consent?

Think about consent as a process to assure patient understanding and agreement, not just signing a form.
Informed consent should be a collaborative activity between the physician, nurse, and patient. The physician should have obtained consent before the nurse has the patient sign a form.  
Nurses can offer what we do best—patient teaching, as we check patient understanding and obtain written consent. Where possible, use the teach-back method, asking the patient to repeat back what he/she understands. However, our teaching cannot take the place of prior physician / patient shared decision-making.
Assess for paternalism – from the physician, from yourself. We understand so much more than the patient and are trying to help, but we cannot pressure or tell a patient what to do.
Consenting to treatment is scary. As much as possible, obtain consent in a quiet and calm setting, with time to answer questions.

What about informed consent for nursing interventions?

Although we normally don’t obtain written consent for nursing interventions, such as holistic care using mind-body practices or spiritual therapeutics, we still must assure patients’ informed consent.
A critical topic we discuss frequently in Journal of Christian Nursing is spiritual care. How do we assess for spiritual needs and appropriately respond? What ethical guidelines must be followed when offering spiritual care? A comprehensive article discussing informed, ethical, and non-coercive spiritual care that could be applied to other holistic nursing interventions is, “Spiritual Care: Evangelism at the Bedside?,”by nurse researcher and spiritual care expert, Elizabeth Johnston Taylor. Take a look at this free article and discover principles for ethical nursing interventions.
This Nurses Week, remember that informed consent is a way of nursing each of us needs to live out as we offer our patients ethical practice and quality nursing care!
Barry, M. J. (2012). Shared decision making: Informing and involving patients to do the right thing in health care. Journal of Ambulatory Care Management, 35(2), 90 – 98.
Cook, W. E. (2014). “Sign here:" Nursing value and the process of informed consent  
Plastic Surgical Nursing, 34(1), 29-33.
Menendez, J. B. (2013). Informed consent: Essential legal and ethical principles for nurses. JONA's Healthcare Law, Ethics, and Regulation, 15(4), 140-144.

Kathy Schoonover-Shoffner, PhD, RN
Editor, Journal of Christian Nursing

Posted: 5/8/2015 4:56:36 AM by Lisa Bonsall, MSN, RN, CRNP | with 4 comments

Categories: Patient Safety

Ouch! Safely keeping patients pain-free

A few weeks ago my husband was in the emergency room with a broken rib, which resulted from a fall. His nurse was very attentive to his need for pain management. He had never had morphine before and after his second dose, he asked the nurse “How much of this will you give me?” Her reply was, “As much as it takes to safely control your pain.” What a great answer!

It isn’t always this easy when it comes to pain management. I’ve shared a story previously about a patient in our ICU, whose family member, who happened to be a nurse himself, wouldn’t allow us to treat his sister’s pain. It was a challenging case, and ultimately, our hospital’s ethics committee was consulted.

The position of the American Society for Pain Management Nursing (ASPMN) and the International Nurses Society on Addictions (IntNSA) is “that every patient with pain, including those with substance use disorders, has the right to be treated with dignity, respect, and high-quality pain assessment and management.” As nurses, we have a responsibility to make ethically sound decisions when it comes to pain management. But, how do we do this?

Be familiar with related ethical standards

  • Beneficence is the duty to do what's good for the patient while considering his or her wishes. Nonmaleficence is the duty not to harm patients. The challenge here is to achieve pain control while ensuring patient safety.
  • Justice refers to fair treatment for all. This can be tricky because pain can't be measured objectively and we must rely on a patient’s self-report.
  • Autonomy requires us to respect, support, and advocate for patients, even when it goes against our own beliefs.

Be aware of barriers to effective pain management

  • Sometimes patients aren’t able to communicate about their pain. Whether the patient is non-communicative, there is a language barrier, or the patient finds it difficult to describe the pain they are experiencing, use your knowledge and skills to perform a thorough history and physical assessment.
  • Time constraints can get in the way of assessing and managing a patient’s pain. Do your best to actively listen to the patient, plan, and collaborate with other team members.
  • Sometimes cost is an issue and certain modalities aren’t covered by a patient’s insurance. If this is not in your realm of knowledge, consult with a colleague who is familiar with the financial aspects of pain management.

Set goals and make a pain management plan

  1. Assess your own beliefs and think about your past experiences.
  2. Remember that every patient is unique.
  3. Tailor your patient and family education appropriately.
  4. Encourage patients to become active partners in controlling their pain. Remind them that pain control aids recovery.
  5. Actively listen to the patient’s self-report of pain.
  6. Be alert to fears related to reporting pain. For example, patients might not report pain for fear of having to undergo more procedures.
  7. Consider asking about burning, aching, tightness, discomfort, or throbbing. Research shows that to minimize their pain, elders may not use the word ‘pain.’
  8. Take cultural differences into account.
  9. Use pain scales that are appropriate for the patient.
  10. Ask the patient what level of pain would be satisfactory.
  11. Explain the difference between pain elimination and pain control; completely eliminating pain while maintaining safety is not always realistic.
  12. Work with the patient to set ‘functional goals’ – for example, being able to walk down the hall and back.
  13. Consider non-pharmacologic methods, such as lighting, positioning, distraction techniques (music, guided imagery), relaxation techniques (breathing, progressive muscle relaxation), and advanced complementary modalities (massage, biofeedback).
  14. Monitor the patient for medication adverse reactions, contraindications, and interactions.
As nurses, we are well-positioned and obligated to advocate for safe pain management. Remember to listen, collaborate, plan, and evaluate!


Diallo, B., & Kautx, D. (2014). Better Pain Management for Elders in the Intensive Care Unit. Dimensions of Critical Care Nursing, 316-319.
Oliver, J., Coggins, C., Compton, P., Hagan, S., Matteliano, D., Stanton, M., . . . Turner, H. (2012). American Society for Pain Management Nursing Position Statement: Pain Management in Patients With Substance Use Disorders. Journal of Addictions Nursing, 210-222.
Quinlan-Colwell, A. (2013). Making an Ethical Plan for Treating Patients in Pain. Nursing2013, 64-68.

Lisa Bonsall, MSN, RN, CRNP
Clinical Editor

Posted: 5/7/2015 4:40:44 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Patient Safety

A Tale of Two Patients

In 1859, Charles Dickens wrote the book, "The Tale of Two Cities," which was a comparison of life in London and Paris and compared life of the aristocracy versus life of the peasantry in those two cities. Throughout my 30 plus years of being a nurse and nurse practitioner, I have watched and participated in the ethical dilemmas nurses and other healthcare providers encounter on a day to day basis. I have spent the majority of my professional nursing career in acute and critical care. As a nurse practitioner, my role is different than when I was a nurse; however, the issues I face are the same as all nurses in regards to ensuring patients receive optimum care that improves quality of life, not necessarily extending it.  This brings me to, "The Tale of Two Patients."

A few weeks ago I took care of two patients; two patients with similar stories, both had end-stage COPD and both were admitted to the ICU for a COPD exacerbation. Both patients received similar treatment, and both patients continued to deteriorate simply because their disease had progressed beyond recovery.  As a nurse, I was always taught to focus on quality not quantity of life, and quality of life is defined by the patient, not the healthcare professionals or the family.

The first patient had an advanced directive and had obviously communicated well with her family. They were all in agreement the patient should not be intubated, and instead, be placed on hospice and made comfortable. There was great peace among the patient, her family members and the entire nursing and healthcare staff. They rejoiced in the fact the patient had lived a full life and could now go on to a better place to be with her husband who had passed two years prior. Everyone agreed -- following the patient's advanced directive and making her a do not resuscitate was the right thing to do.

The second patient did not have an advanced directive, and had never spoken to her family about her wishes. Despite numerous attempts to discuss the patient's prognosis with the patient and her family, the family insisted everything be done and the patient capitulated to their demands. The patient was intubated and placed on a ventilator. Everyone knew the patient would never come off the vent and would eventually die in the ICU. After several days, the patient went into multiorgan failure and the family finally agreed that the patient should be allowed to die in peace. The patient was placed on a morphine infusion for comfort and died with the family still fighting over her. There was great sorrow in the eyes and hearts of everyone taking care of her. Nurses are about quality care, and even though the patient eventually died comfortably, everyone knew the situation could have been avoided if the patient had discussed her wishes with her family and her primary care provider and had an advanced directive.

As nurses, we see the ethical importance of doing what our patient's want; we are their advocates and their voice even in their most desperate hour. Healthcare professionals have an obligation to speak with their patients before the patient is in a life-threatening situation. The first time a discussion occurs should not be when the patient is critically ill and facing no chance of recovery. Quality of life must be defined by the patient and no one else. In this day and age, the tale of two patients should not be a story we tell in healthcare.

Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC
Chief Nurse
Wolters Kluwer
Health, Learning & Practice
Nurse Practitioner, Critical Care Services
Penn Medicine Chester County Hospital
Adjunct Faculty
Drexel University
College of Nursing & Health Sciences

Posted: 5/6/2015 4:43:04 AM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

Ethics in Nursing – Upcoming blog series

We face ethical issues and make related decisions – or help others to do so – every day. As we focus on nursing ethics for National Nurses Week, we will be bringing you daily blog posts related to nursing ethics. We have some guest blog authors lined up to cover ethical topics important to nurses, including informed consent, advance directives, moral distress, horizontal violence, pain management, elder abuse, and end-of-life issues. We hope that you’ll join this important conversation with us. Have a great week everyone!

Posted: 5/4/2015 6:55:46 AM by Lisa Bonsall, MSN, RN, CRNP | with 1 comments

Categories: Patient Safety

Complications of Peripheral I.V. Therapy

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.PNGInfiltration 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
  • 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.
  • 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 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
  • 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.
  • 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.


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
  • 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.
  • 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.


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


Local or systemicinfection  is another potential complication of I.V. therapy. 

Signs and symptoms

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

(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).



Posted: 2/9/2015 6:59:20 PM by Lisa Bonsall, MSN, RN, CRNP | with 7 comments

Categories: Patient Safety

Suicide assessment – an important nursing responsibility

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

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

Posted: 8/20/2014 9:10:22 PM by Lisa Bonsall, MSN, RN, CRNP | with 0 comments

Categories: Patient Safety

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