Question

Best Practice Issues

A new graduate nurse is being oriented to your medical-surgical nursing unit.  Today he is assigned to care for three patients.  One patient is an older adult on NS at 50cc per hour with an infiltrated peripheral IV in her forearm. The second patient has a PICC line for antibx therapy and the third patient has an implanted port for chemotherapy.  As his preceptor, you are responsible for teaching him how to assess patients with these devices and prevent and/or monitor for complications.

1.Which patient would be the priority assessment on and what interventions would need to be done?

2.You observe the new nurse as he prepares to restart the IV for the older adult patient. He chooses a vein in the dorsum of the hand.  What is your best response about his IV site selection and why?

3.What best clinical practices will you teach the new nurse about how to care for patients who have a PICC line?

4.For what life-threatening complication is the patient with an implanted port most at risk for?  How will you assess for this complication and what nursing measures/interventions can be used to help prevent this problem?

Clinical Judgement Issues

Mrs. Smith is a  63 year old obese, diabetic woman who is transferred from the hospital to the skilled nursing facility (SNF) where you work as a charge nurse.  Mrs. Smith is being managed with IV vancomycin 1 gm IV piggyback (IVPB) every 12 hours for osteomyelitis resulting from an arterial foot ulcer.  On review of her admission orders, you note that she has a newly inserted intermittent saline lock in her right forearm and is prescribed to receive the antibx for 4 more weeks.

5.The schedule for the administration of the IV drug is 2 am and 2 pm.  Would you schedule her antibiotic at these times? Why or why not?

6.Two days later as you are planning to end your shift, the resident reports that her IV site seems red and swollen.  What action will you take at this time? What will you document on the resident’s electronic health record?

7.What do you think about putting in a new IV on this patient?

8.What access device would you suggest and why?

9.With whom will you need to collaborate with to make this decision?

10.What does the evidence say about VAD’s for this resident and their needs?

11.Using the SBAR technique, what will you report to the oncoming nurse about the resident’s IV complications?

12.Based on the medication ordered, what particular monitoring interventions need to be done for this patient?

Answer 1

1. The priority patient out of the three patients is the older patient with infiltration of IV cannula . The cannula has to be changed because the fluid is leaking out from the veins into surrounding tissue . Patient is getting NS 50ml per hour as hydration therapy .

Intervention - removal of the dislogded cannula and placement of new one to continue the hydration therapy.

2. When the new nurse selects the site for new cannula placement ,firstly ensure that the new cannula is placed above the previous one because if you place the cannula below infiltrated tissue it will lead to leaking out of fluids from the veins at the same site and no use of placement of new cannula will be there. Secondly, make sure that the cannula is not placed at joints as it causes discomfort for the patients and easy removal of cannula.

3.PICC line is a line which is placed into the vein in upper arm and is advanced to and positioned in the vein opening into heart .

Care of patients with PICC line are :-

- Picc line has to be kept dry ,check for any leakage .

- The dressing of picc line must be done every 5-7days until it's visibly soiled .

- flush the line with 2-5ml NS before and after injection is given and at last heparin flush with 3ml syringe as final flush

- while changing the dressing assess the site for redness , inflammation ,any discharge ,pain etc (signs of infection) .

- teach the patient how to do the motion and use of PICC line inserted hand to avoid contractures.

- use of sterile technique while handling the PICC line during administration of medications and IV fluids and during dressing changes to avoid infections.

- advice the patient to cover the site during bath to avoid wetting of the PICC line .

-advise the patient to inform the nurse or other respected people if she feels any unusual pain , sensation , burning etc at the insertion site.

4. The most life threatening complications of implanted chemotherapy port is embolism /thrombosis which will further progress to pulmonary embolism, stroke and DVT.

Signs and symptoms of thrombosis are :-

- restlessness

- shortness of breath

- tachycardia

- tachypnea

- lightheadedness

- dizziness

- altered mental status

- seizure

- coma

- air hunger

- cardiac dysarthymias

To prevent this complications we should use anti coagulant therapy along with the application of implant to prevent the formation of emboli due to sluggish flow of blood . Anti -coagulants are given subcutaneously to prevent formation of clots and air emboli.