I have been a member of this organization for more than half of the 40 years and very honored to have served as the President in 2008-2009 (check this out).  My commitment to INS continues as I  serve in numerous committees and contribute to setting the standards for infusion care.

The celebration continues at the 2013 INS Annual Convention and Industrial Exhibition in Charlotte, NC May 18-23.  This year, I am proud to be one of the faculty presenting on Monday May 20, 2013 on BIOLOGICS TRACK: Challenges Associated with the Administration of Biologics in the Nonhospital Setting 4-5pm.

Whether you at the meeting or unable to attend this year, INS has “LIVE FROM INS2013” page where you can view updates, photos, and other information so you can stay in touch.  I hope to see you there and stop by to say hello!

Grow old with me!  The best is yet to be.  ~Robert Browning

Congratulations to INS!!!

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Source: 40th year logo from INS Website – www.ins1.org

A: While verification of a blood return on a short peripheral IV is the common way to check for patency, sometimes, it is difficult to obtain a blood return in dwelling PIVs, particularly in small gauge catheters such as a 22g or a 24g. In addition, fibrin may also begin to form and build up on the tip of the catheter contributing to the inability to obtain blood return.

Having said that, the presence of a blood return does not always provide absolute verification of placement/patency. If the tip of the PIV catheter punctures the posterior wall of the vein with the majority of the catheter tip still in the vein, a blood return may be obtained and at the same time, the fluid infusing could be infiltrating into the tissue.

It is always best not only to assess for blood return, but also for redness, tenderness, swelling, drainage, and/or the presence of paresthesia, numbness, or tingling by visualization and palpation of the PIV site as well as subjective information from the patient.

Is it unsafe to proceed? Your question did not mention what kind of IV solution you will be administering via the PIV. The Infusion Nurses Society Standards of Practice states

“therapies not appropriate for short peripheral catheters, include continuous vesicant therapy, parenteral nutrition, infusates with pH less than 5 or greater than 9, and infusates with an osmolality greater than 600mOsmol/L.”

For more information, look up the references I always use:

1. Infusion Nurses Society. Infusion nursing standards of practice. J Infus Nurs. 2011;34(1S). click here.

2. INS Position Paper: Recommendations for Frequency of Assessment of the Short Peripheral Catheter Site.  Click here 

1. National Nurses Day is May 6 ,a day to honor the 3.1 million registered nurses in the United States. This year’s theme is:

Happy Nurses Day to my nursing colleagues!

 
2.National Nurses Week, the celebration begins on May 6 and ends on May 12, Florence Nightingale’s birthday. What a remarkable woman who had, in those days, such foresight and  somewhat radical views on nursing, and medical practice. It is amazing that today, most of her notes still applies.  

For more information on celebrating National Nurses Day/Week - click here

3. Oncology Nurses Month, celebrate the accomplishments of oncology RNs who’ve made a difference in the lives of people with cancer and their families. For more information, click here

4. May 12 is Mother’s Day – don’t forget….“Every successful child is the product of an enthusiastic mother.”Let’s celebrate the special woman in our lives who had the vision, love, enthusiasm, perseverance and patience to get us to where we are now.

5. Schools of Nursing  Commencement - graduation begins this month for many colleges / universities/ schools of nursing. Congratulations and welcome to our new nursing colleagues! 

Q: Tell me do you insert a needle up or down?

A: I am assuming the question you are asking pertains to the bevel of a peripheral IV catheter during insertion.  I have been asked this question several times in the past, so here’s my answer.

Bevel down vs. bevel up when inserting IV catheters. I have always inserted peripheral IV catheters bevel up because entering with the bevel up allows the sharp tip to pierce the skin first, paving the way for the rest of the needle. I noticed that entering the vein with the bevel down causes painful tearing of the skin. I work with adult patients and have only inserted IVs in a few peds patients mostly school age kids, and use bevel up. However, when accessing a dialysis fistula, I use bevel down as it causes less damage and less bleeding.

Back in 2010, I posted a poll to see what nurses are doing. If you are interested in the results, check this post.  “POLL RESULTS: BEVEL UP OR BEVEL DOWN”

Peripheral IV

Q: It boggles my mind, how someone highly trained, a nurse, can use a single use syringe  over and over and sometimes on multiple patients. Why?

A:  I got very concerned when I read this question and while I believe no nurse will “deliberately” harm a patient, unfortunately, there are nurses who should know better but fall into this poor practice for one reason or another. I  have witnessed some nurses “unknowingly” re-use a syringe and become embarrassed once the poor practice is brought to their attention.  Some nurses say they are told to do so by management  to be “cost-effective”. This is absolutely unacceptable and the nurses should know better and put patient safety first. There is an increasing number of lawsuits related to syringe re-use involving nurses.

There is no excuse. Nurses should know but have to be reminded that “single use” is really “single use”. The CDC has launched a campaign called “One and Only” to raise awareness among patients and healthcare providers about safe injection practices. The campaign aims to eradicate outbreaks resulting from unsafe injection practices.  For more information on this campaign, go to their website  - http://www.oneandonlycampaign.org.

Here’s a video on Safe Injection Practices (from the oneandonlycampaign) , I think all nurses should view, regardless of how long we have been practicing.

There are some benefits to using manual flow regulators:

• May provide a more consistent flow than the built in roller clamps on IV tubings
• Accuracy is about the same as the roller clamps +/-10% but easier to regulate
• May provide protection against crimped tubing, and drifting of roller clamp
• May prevent accidental free flow of solutions

There are some issues as well:

• Accuracy of predetermined settings on the regulators vs. actual delivered rate. 
• Reliance that the device will deliver the set rate without confirmation. 
• Prevailing thoughts that manual flow regulators function like an infusion pump eliminating the need for counting drops.
• Misconception that variables that affect ”gravity” drips doesn’t affect rate delivered by manual flow regulators.

The decision to use these IV manual flow regulators should take into account factors such as:

• Age and mobility of patients
• Severity of illness
• Type of therapy
• Healthcare/clinical setting
• Organization’s policies, procedures, and/or practice guidelines
• Knowledge/competency of the nurses using the device

When used, these devices should be monitored during the administration of infusion therapy to ensure accurate delivery of the prescribed infusion rate.  These devices should be considered an enhancement to patient care and doesn’t replace the nurse’s responsibility to monitor the infusion of the prescribed therapy.

So now you know….IV manual flow regulators = you still need to count the drops to match the set rate on the dial.

References:

1. Infusion Nursing Standards of Practice 2011

2. Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing An Evidence Based Approach. St Louis, MO: Saunders Elsevier; 2010.

• Prescribed therapy/type of solution
• Duration of treatment
• Peripheral vein availability/vein integrity
• Diagnosis /Age
• Known complications of the device

The Infusion Nurses Society standards of practice states “the smallest gauge and length with the fewest number of lumens and shall be the least invasive device needed to accommodate and manage the prescribed therapy.”  A small gauge catheter results in less trauma to the vein, promotes proper hemodilution of the solution, and allows adequate blood flow around the catheter wall. All these factors promote increased catheter dwell time and improve patient outcomes.

The recommendation for catheter selection from the textbook “Infusion Nursing: An Evidence based Approach” include the following:

Catheter Size (Gauge) /Clinical Applications

24g – Fragile veins; for intermittent and continuous infusions

22g – Children/Older adults; intermittent general infusions

20g – Adults/continuous infusions

14g, 16g, 18g –  Trauma and surgery

It is important to note that for transfusions of blood or blood products, 14-24g can be used for adults and 22g-24g for pediatrics and neonates.

In an emergency situation where rapid infusion of large amounts of fluids are necessary, a larger gauge catheter may be used. Catheters inserted in emergency situations should be removed and replaced as soon as the patient is stabilized, but within 24 hours of the emergency as one cannot ensure that the site was adequately prepped or that aseptic technique was maintained.

So now you know….size matters but bigger isn’t always better!!

There is hope in the future. It is so inspiring and encouraging for a nurse who treat cancer patients to see a young one like him take interest in a disease that affects so many lives, families and costly to treat. Early detection is the best prevention.

Don’t forget this kid’s name…Jack Andraka….he may be the next Einstein!

Today is a day to recognize board certified nurses  in many nursing specialties.  In infusion nursing, the certification is CRNI (Certified Registered Nurse in Infusion) awarded by the Infusion Nurses Certification Corporation (INCC). In vascular access, the certification is VA-BC (Vascular Access Board Certified) awarded by the Vascular Access Certification Corporation (VACC).

Congratulations to all my certified nurse colleagues!!

For more information on Certified Nurses Day, go to http://www.certifiednursesday.org

1.  Another RN in the office routinely mixes IV medication for the infusion nurses to administer.
2. The IV medication is mixed a day ahead of the patient’s infusion appointment.

The nurse felt the practices were against everything learned in nursing school and experienced in nursing practice.

After reading this, first thing I remembered was what I learned in Fundamentals in Nursing /Medication Administration:

Administer only those medications that you have prepared yourself personally or received from the pharmacy . The RN is liable for all medications he or she administers. Carefully examine all drugs and unit dose preparations prior to administration. Do not prepare medications in advance of the prescribed time of administration.

The working environment in physician based infusion areas vary greatly than any other infusion center models – ie hospital based outpatient infusion centers. In physician’s offices, often the RNs carry a lot of responsibilities related to preparation, mixing, and administration of IV medications, among others. If this is the  scenario, the RNs must be trained  in the proper reconstitution technique and follow the organization’s policies and procedures,  state, federal and professional guidelines such as the American Society of Health-system Pharmacists and USP <797>.  Occasionally, for the sake of efficiency and to maximize productivity, one RN is designated as the “mixer” for the day and the other infusion nurses are expected to administer the”prepared” medications.  No, not ideal but yes, it is reality! A double check system during preparation of the drug and at administration is standard practice in this case (eg oncology).  In many well organized physician office based infusion centers, there are provisions for the RN to safely and properly mix both chemo/non-chemo IV medications. Some of them do hire a pharmacist/pharmacy technician who is responsible for the preparation and mixing.  Unfortunately, the latter is an expensive option so there are other practices where  RNs are faced with no training, no policies and procedures and expected to  prepare, mix and administer IV medications as well as everything else infusion related.  Not ideal but REAL! 

Now on to the second point above: RN mixing IV medications a day ahead of the patient’s infusion appointment. I  know you are hearing  ”alarms” go off as you read this. For medications that are prepared, labeled, and stored according to recommended guidelines and have a suitable expiration/stability data, perhaps this  might not be an issue. Again, follow the organization’s, state, federal and professional guidelines mentioned above. If done otherwise, as might be the case in some physician office based infusions, I would not recommend this practice. Sometimes for the sake of “efficiency”, many have resorted to “preparing” ahead of time without even thinking of “safety” and perhaps not exactly cost effective.

Physician office based infusion centers are one of the common sites of care utilized by patients. They are great places for any infusion nurse/RN to work:  Mondays – Fridays, no holidays, occasional weekends/evenings. However, not all of them have the same practices/policies/procedures (ie non-chemo) as those that are hospital based/owned and there are no national standards specific for these practices  to follow (none yet). This becomes a challenge to the infusion nurse or any RN new to this setting and should not be used as an excuse for poor practice/judgement. Just remember, protect yourselves and the patients – the basic principles of medication preparation and administration, infection control and infusion therapy will always apply regardless of where you practice.