Category Archives: Nursing blogs

Q&A: BP cuff for vein distention

Q: I am a new RN and was always told that I can use a BP cuff to distend the veins for IV starts instead of a tourniquet. Can you tell me how high should I pump the cuff?

A:  BP cuff is one method that can be used for vein distention while assessing veins for venipuncture and during the actual venipuncture. There are various views on what the inflation pressure is best for this purpose  and the consensus opinion appears to indicate  just below diastolic pressure.  Here’s what the following infusion nursing/infusion therapy textbooks indicate:

1. Alexander et al:  Infusion nursing an evidence based approach 3rd edition 2009 states: You can inflate the cuff and release to just below the diastolic pressure.

2. Philips & Gorski Manual of IV Therapeutics 6th edition 2014:  You can apply the BP cuff on the patient’s arm, then slightly pump the cuff to about 30mmHg  The authors added this nursing fast fact: when using a blood pressure cuff, care must be exercised not to start the IV too close to the cuff, which causes excessive back pressure.

3.  Weinstein & Hagle Plumer’s Principles and Practice of Infusion Therapy 9th edition 2014. The patient’s blood pressure cuff may be used to distend the vein; inflate the cuff and then release it until the pressure drops to just below the diastolic pressure.

As an infusion nurse, I’ve only used a BP cuff in lieu of a tourniquet a few times when starting an IV.  I’ve found that inflating and releasing to about 30-40mm Hg provided sufficient distention without increased discomfort to the patient.

Good luck and thank you for your question.

hand-held-aneroid-sphygmomanometers-67891-133555

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Happy 4th of July!

Always proud and grateful to live in this country! Have a safe and wonderful 4th of July!!

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Why do nurses use the same alcohol swab over and over?

I know, this may come as a surprise to all of you, but the truth is, I have seen many nurses (even those highly trained and specialized) both in hospitals and outpatient settings, use the same alcohol swab over and over.

Imagine this scenario where a nurse is ready to withdraw medication from several vials. The nurse rips open a swab, then removes the swab from the package using the thumb and forefinger, literally touching the entire surface and both sides of the swab, then proceeds to disinfect the top of one vial. Then using the same swab, the nurse proceeds to disinfect the top of the next vial, and repeats the same until all vials are disinfected, still using the same swab. The swab is then laid on the work surface, and if additional disinfection of the vial is required, the nurse picks up the same swab and proceeds to use it again. The same observation is true when disinfecting Y-sites, connection hubs or needleless connectors attached to vascular access devices. Rip open an alcohol swab, pick up with thumb/forefinger, disinfect hub, then either lay swab on surface or disinfect another hub with same swab. Why do nurses re-use alcohol swabs?

When brought to their attention and nurses are asked – why are you re-using the alcohol swab? Often, I get a blank stare or I get this..“what do you mean”look, and I don’t get an answer. Sometimes I get this answer, “its alcohol, dummy!” or “it’s still wet”. I think back to my nursing school training and I tried to recall what my Fundamentals instructor told us about how to use alcohol swabs. I honestly don’t remember what we were told, whether or not to reuse, or use till dry…..maybe I skipped school that day.

I can’t find evidence based research about re-using alcohol swabs. The fact is that an alcohol swab (aka alcohol prep pad) contains 70% Isopropyl Alcohol and is sterile while in the package. When removed, we need to take great care not to contaminate it with our fingers before we even use it for disinfection. Discard after one use, even if the alcohol swab is still dripping wet. When disinfecting several vials, use one alcohol swab per vial; don’t share alcohol swabs between the vials. I am aware that there are non-sterile alcohol prep pads available in the market, often used by diabetic patients for insulin injections. If selected to be used for disinfection, discard after use. Alcohol swabs are inexpensive and always available. Let’s put this in perspective, if you are the patient, do you want your nurse re-using alcohol swabs on you?

So next time you are getting ready to open an alcohol swab, will you remember hold the swab properly and not to re-use?

alcohol2

 

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INS Exhibit Hall 2014 – Part 2 New PIV Technology

Don’t you just hate it when you stick a perfectly good vein  and end up going through the vein? Can you tell when the tip of the needle and the tip of the catheter have entered the vein to know when to advance the catheter into the vein?

As I always do, here’s my disclaimer – there were many different products represented there and as the owner of this blog, I reserve the right to point out the ones that caught my attention. For disclosure purposes, I was not paid to write this post and have no relationship whatsoever with these companies, nor am I endorsing the products. This is my blog, my opinions and not of the Infusion Nurses Society and is just FYI.

At the INS Exhibit Hall, there were two products that I thought were great in potentially increasing PIV insertion on the first attempt.

1. AccuCath Intravenous Catheter from Vascular Pathways:

The AccuCath™ Intravenous Catheter is a REVOLUTION in peripheral catheter technology. Its AccuTip™ nitinol guidewire creates a pathway within the vessel that deploys the catheter atraumatically. The AccuCath™ device is expected to lower complication rates and increase dwell times while enhancing patient satisfaction and healthcare worker safety.

  • Designed to increase first attempt success
  • Atraumatic delivery designed to reduce complication rates
  • Expected to extend average catheter dwell times
  • Greater patient and clinician satisfaction

1-how-it-works-tip 5-how-it-works-guidewire

You know how nurses like to test out new widgets, right? I’m no exception.  I saw the product demonstration video and was VERY disappointed I was not able to actually use the product in a simulation insertion. Why? They were not offering anyone to try their product!!!!!

I viewed their eposter entitled: Randomized Controlled Comparison of Accucath vs Conventioanl Peripheral IV authored by Bette K. Idemoto, PhD, RN, ACNS-BC, CCRN and James R. Rowbottome, MD. This poster demonstrated the effectiveness of this new IV catheter showing first successful attempt at 89% vs 43% with conventional PIV. The study randomized 248 patients.

For more information, visit their website - http://vascularpathways.com/accucath-iv-catheter

 

2. SurFlash® Safety I.V. Catheter by Terumo / CareFusion

As the only safety IV catheter with a double-flash feature that verifies both needle and catheter placement, SurFlash® improves first-stick success. SurFlash® catheters reduce needlestick injuries, blood exposure, and cost (because of fewer wasted catheters). With its new pressure rating, proprietary safety valve and bevel-up indicator, SurFlash® has it all!

Surflash

It was a great experience learning about this product and you know what the best part is? I got to try this product in a dummy IV arm!!! It doesnt feel any different than inserting a conventional PIV but it offers the first stick success, smooth skin insertion and protection from blood exposure after the venipuncture.

They also had an eposter entitled: Peripheral IV Cannulation: Technology and Technique Driving Best Practices by Mark Hunter RN, CRNI, VA-BC and Nancy Trick RN, CRNI. It described the use of evidence based technique and technologies designed to reduce infusion related risks of peripheral IV therapy.

Here’s a video from their website:  Surflash Video

For more information, visit their website – Click here

 

 

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Exhibit Hall Experience INS 2014

At every INS Annual Meeting, the exhibit hall is the one of the highlights of the week.  I am very grateful to all the vendors who were there whether they had something new to show or not because their products contribute greatly to patient care and safety. Their willingness to educate nurses is always appreciated.

As I always do, here’s my disclaimer -  there were many different products represented there and  as the owner of this blog, I reserve the right to point out the ones that caught my attention. For disclosure purposes, I was not paid to write this post  and have no relationship whatsoever with these companies, nor am I endorsing the products. This is my blog, my opinions and not of the Infusion Nurses Society and is just FYI.

 For this post, I would like to feature one of those products that was “born out of necessity” and caught my attention:

Kevin’s Cover, an adjustable PICC/IV shower sleeve designed by Kevin’s mom after Kevin’s PICC line caught on a doorknob and had to be replaced in the emergency room. It is a breatheable, waterproof version available in 7 sizes for kids and adults and features a hook and loop closure that allows for a gentle, adjustable fit. The neoprene wrap at each end ensures a watertight seal so patients have full use of their hands.

Another great idea to protect PICC lines and here’s an interesting review from an infection control perspective. Click here

Check out their You Tube Video

INS2014exhbithall3

Photo taken by @infusionnurse

This is Kevin who needed a PICC line and as a result his mother designed Kevin’s covers out of necessity to protect his PICC line. For more information, you can contact  them at hamptonhousemedical@gmail.com. Although they have a website, http://www.kevinscovers.com, I was unable to connect to that web address during this post.

Stay tuned for more featured products next few blog posts.

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Happy Mother’s Day

“Every successful child is the product of an enthusiastic mother”

Let’s celebrate the special women in our lives who had the vision, love, enthusiasm, perseverance and patience to get us to where we are now. 

Happy-Mothers-Day-2014-Wallpaper

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ICYMI: Check out these ASHP Guidelines

1. The ASHP Guidelines on Home Infusion Pharmacy Services – defines the role of the pharmacist in providing home infusion care to patients and to outline minimum requirements (indicated by use of the word “shall”) and best practices for the operation  and management of services provided by pharmacies in the home or alternate-site setting.  Home infusion services are provided by a variety of organizations, including hospitals, community pharmacies, home health agencies, hospices, and specialized infusion companies. Patients receive care in non-inpatient settings, such as their homes and ambulatory infusion centers, or in alternate-site settings, such as skilled-nursing facilities. Home infusion pharmacies may provide one or more of several service lines:

  •  Infusion therapies (e.g., intravenous, subcutaneous, intrathecal, epidural);
  • Specialty pharmacy services;
  • Ambulatory infusion center services;
  • Home health nursing;
  • Private duty nursing;
  • Respiratory equipment and clinical respiratory services;
  • Hospice services;
  • Home medical equipment and supplies (with or without oxygen service); or
  • Enteral products and supplies.

 

2. The ASHP Guidelines on Compounding Sterile Preparations -  these guidelines are intended to help compounding personnel prepare compounded sterile preparations( CSPs) of high quality and reduce the potential for harm to patients and consequences for compounding personnel. These guidelines are a revision of the 2000 ASHP Guidelines on Quality Assurance of Pharmacy Prepared Sterile Products,14 with the goals of providing more current recommendations and harmonizing the ASHP guidelines with United States Pharmacopeia (USP) chapter 797, Pharmaceutical Compounding–Sterile Preparations. These guidelines are generally applicable to all personnel who prepare CSPs and all facilities in which CSPs are prepared, pharmacists and other health care professionals responsible for the preparation, selection, and use of CSPs are urged to use professional judgment in interpreting and applying these guidelines to their specific circumstances. Users of these guidelines are cautioned that the information provided is current as of publication and are urged to consult current editions of original sources (e.g., laws, regulations, and applicable standards, including USP compendial standards) to ensure patient safety as well as legal and regulatory compliance.

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Click on title link for details of each of the guidelines.

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Reference:

American Society of Health-Systems Pharmacists (ASHP) – http://www.ashp.org

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What do you think…

Q:  We have a 24/7  vascular access team, yet we find that an ultrasound machine  in a medical floor is used for PIV insertion by untrained nurses and residents. The machine is there for other purposes but is being used for hard IV sticks.

A:  There is increasing evidence to show the use of ultrasound or vein finding technology increase success rates particularly in patients with difficult veins to access. The INS standards recommend the nurse to consider using visualization technologies that aid in vein identification and selection (S33). The use of  ultrasound allow the identification of peripheral vessels and guide the insertion procedure.  There are reports that ultrasound guided peripheral IV cannulation is successful more than 90% of cases. In addition, it improves patient satisfaction and safety with fewer sticks.

I think anyone who reads this post will agree that healthcare providers using these technology must be properly trained and/or competency checked off. Just because there is an ultrasound machine available on a medical unit doesn’t entitle anyone to use it without proper training. The operator should be very familiar with the ultrasound machine, the type of transducers used, how to improve ultrasound gain and how to control its outcome. The operator should be especially knowledgeable of the sonographic artefacts that can mislead him/her.

In addition, your facility/institution/organization should have policies and procedures related to the training. competencies and use of ultrasound technology. Check out what your policy is and hope you have one. In some, the use of utlrasound for PIV insertion is limited to vascular access teams and the ED. In your case, with a 24/7 vascular access team, the medical floor should take advantage of your service and expertise.

Thanks for your question. I wish you the best.

References:

  1. Infusion Nurses Society 2011 Standards of Practice.
  2.  Abu-Zidan Fikri M Point-of-care ultrasound in critically ill patients: Where do we stand?J Emerg Trauma Shock. 2012 Jan-Mar; 5(1): 70–71.
  3. Elia F, Ferrari G, et al Standard-length catheters vs long catheters inultrasound-guided peripheral vein cannulation. American Journal of Emergency Medicine (2012) 30, 712–716

 

 

 

 

 

 

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Large Volume IV Solution Shortages

It just doesn’t seem right that the national crisis with “drug shortages” would include  large volume (1000mL) IV solutions we commonly administer to our patients:

  • 0.9% Sodium Chloride Injection
  • 0.45% Sodium Chloride Injection
  • Lactated Ringer’s Injection
  • 5% Dextrose Injection

 

IV

But the reality is there is a shortage, IV saline solution, in particular is on the list of national drug shortages and the shortage is not expected to resolve until May or June this year. Not having IV Saline solution available  is like not have bread and milk at the grocery stores.

So what can be done?  The American Society of Health-System Pharmacists (ASHP) released a list of conservation strategies that organizations might consider to manage the shortage.  Click here to view details of the document.

 

What can clinicians do to conserve?

  • Use oral hydration whenever possible.
  • Review the suggested clinical approaches and product conservation strategies in collaboration with the organization’s stakeholders and the Pharmacy and Therapeutics (P&T) Committee or other organization-wide medication policy group for applicability to the organization.
  • Implement an organization-specific action plan to conserve IV fluids where possible. Allow flexibility as the shortage status of specific products may change frequently. For example, Lactated Ringer’s
  • Injection may be more available than 0.9% Sodium Chloride Injection and vice-versa depending product availability and allocation schedules.
  • Develop medical staff-approved policies for substitution of IV solutions based on product availability within the organization. Example: an organization might allow substitution of Lactated Ringer’s Injection for 0.9% Sodium Chloride Injection or vice-versa depending on what is in stock. Table 1 provides a comparison of common intravenous fluid components.

 

Please feel free to share what you /your organization are doing to cope with this IV Solution Shortage.

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Vesicants and Extravasation

These two terms defined by the Infusion Nurses Society means:

Vesicant – an agent capable of causing blistering, tissue sloughing or necrosis when it escapes from the intended vascular pathway into surrounding tissue.

Extravasation – the inadvertent infiltration of vesicant solution or medication into surrounding tissue.

There are several chemotherapeutic agents with vesicant properties, and when inadvertently infused into the surrounding tissue from an infiltrated IV, these agents may have the potential to cause blisters, severe tissue injury or necrosis, known as extravasation. The damage to the tissue can occur from direct contact with the vesicant medication, from compression of surrounding tissues by a large volume of fluid or from severe vasoconstriction.

But chemo agents are not the only vesicants that cause extravasation injuries. There are non-chemo medications and solutions that have vesicant properties as well and can cause extravasation. Listed below are a few non-chemo agents:

  • Vancomycin
  • Nafcillin
  • Calcium Chloride
  • Potassium Chloride
  • Sodium Chloride
  • Calcium Gluconate
  • Dobutamine
  • Diazepam
  • Dopamine
  • Norepinephrine (Levophed)
  • Phenytoin (Dilantin)
  • Promethazine (Phernergan)
  • Propofol
  • Vasopressin
  • Radiologic contrast agents

As nurses, it is our responsibility to take preventive measures, monitor, identify signs/symptoms and institute prompt treatment per policy or as ordered. If you administer any of these agents, prevention is key and consider the following:

1. Location, location, location:  When selecting an IV site, avoid areas of flexion  – this includes the wrist, hand, and antecubital fossa.  Be mindful of any punctures to veins above the area you are about to stick. If patient had a recent blood draw from the antecubital fossa, use the opposite arm to find a suitable site.  Oh, btw, extravasation can also happen in patients with central venous access.

2. Bigger is not better: Use the smallest gauge IV catheter to administer the prescribed therapy.  Good flow rates are possible even with a small gauge catheter. Using an IV catheter too large for the vein will obstruct blood flow and might cause thrombosis distal to the IV site.

3. Know your medications: Were you surprised to see a medication listed above as a vesicant?  Medications and solutions with an osmolarity greater than 600 mosmol/L  and pH lower than 5 or higher than 9 should not be infused via a peripheral IV. Know the adverse events, if any for each medication. If in doubt, always ask our friendly pharmacists!!

4. Secure your IV device: Use a stabilization device to anchor and avoid movement of the catheter. When using a dressing, avoid obscuring the IV site to allow you to observe the site.

5. Check  IV patency and assess site: Key to early recognition of complications. Refer to your organization’s policy on frequency of IV site checks.  Infusion pumps will not tell you if an IV site in infiltrating. Always aspirate for positive blood return prior to use, but remember, checking for blood return or back flow of blood is good for patency but not a reliable method for assessing infiltration at IV site. If infusion continues to run when you apply digital pressure 3 inches above peripheral IV site in front of catheter tip – suspect infiltration

6. Policy/procedure for extravasation: Do you know if your organization has one for non-chemo agents? Have you even read it? What are you expected to do when extravasation happens?  Is there a rating scale to document the severity of the problem? Are you expected to complete an “incident report”? Can you photograph the site?

7. Hot or cold: Which do you use? What does your policy state about compress? Do you need an doctor’s order for this?

8. Antidote: Is there one for the medication you administered? Obtain physician’s orders for the appropriate antidote. How is it given?

9. Document, document, document!! I know, you’ve heard this before….if it’s not documented, you didn’t do it! Keep this in mind, you will not remember what happened in the past, so hopefully, your documentation can defend you.

10. Don’t forget the patient/family: Keep them informed and provide information regarding treatment and management.

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