In many clinical settings, it may not be important at all because of the smart pump technology. And for patient safety, it is best practice to use infusion pumps because gravity drip rates are not accurate and precise. But what happens in a situation when pumps fail and/or in an emergency situation when the IV tubing has to be removed from the pump and even in a setting where infusion pumps are not available?

• A nursing colleague recently admitted to me that she has forgotten how to count drops and struggled to remember how to calculate when she volunteered in a medical mission in Haiti. Luckily she said, it was just hydration fluids and patients were not critically ill.

• Another nurse colleague said she has never counted drops as a student nurse and now as a new RN struggled when she had to help evacuate patients out of the building during an emergency and the IV pump battery failed on a  patient  who was on TPN.

• In a small rural physician’s office,  the staff was not aware that IV tubings have different drop factors and although they knew they had to count drops, they didnt realize they were using the incorrect drop factor.

• Another nurse told me that she doesnt count drops because she uses a “dial-a-flow”.

If you are in a situation where you need to infuse by gravity drip, remember the following steps:

• Identify the drop factor of the IV administration set (tubing) you are using. You can find this information on the label of the tubing package.  Macrodrip sets are either 10, 15 or 20 drops to deliver 1 ml of fluid.

• Use this formula to calculate gravity flow rates:
  • Drops/min:        ml/hr divided by 60 min/hr x drop factor

• Examples:

A. IV fluid of 1000ml to infuse for 8 hours using tubing with drop factor of 15.

• 1000ml for 8 hours = 125ml/hr.
• 125ml/hr divided by 60 min/hr = 2.08ml/min
• 2.08ml/min X 15 drop factor = 31.2 drops/min

B. IV fluid of 1000ml to infuse for 8 hours using tubing with drop factor of 10.

• 1000ml for 8 hours = 125ml/hr.
• 125ml/hr divided by 60 min/hr = 2.08ml/min
• 2.08ml/min X 10 drop factor = 20.8 drops/min

C. IV fluid of 1000ml to infuse for 8 hours using tubing with drop factor of 20.

• 1000ml for 8 hours = 125ml/hr.
• 125ml/hr divided by 60 min/hr = 2.08ml/min
• 2.08ml/min X 20 drop factor = 41.6 drops/min

Regardless of what flow control device is used, remember that the flow control 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.

Oh, by the way, in case you have forgotten, when infusing by gravity, you do need to count the drops/minute – for a full minute and adjust the flow using the roller clamp till you have regulated to the desired rate. 

If you are enticed to use  “flow regulators” (like dial-a-flow), remember, those are still gravity drip infusions and you will need to count the drip rate even if you set the dial to the correct number to ensure accuracy.

Have fun counting drops….you’re going to make this guy happy!!! 

One!!! HAHAHA…Two!!! HAHAHA… Three!!! HAHAHA!!…

Enjoy your day!!  For more information about “Certified Nurses Day” click here!

Krystexxa (pegloticase) has been approved by the FDA  for patients with gout who either did not respond or could not tolerate conventional therapy. Gout is the result of an excess of uric acid in the body, leading to needle-like crystals forming in the joints or soft tissue, causing swelling, pain, joint stiffness, heat and redness. There are an estimated three million adults with gout in the USA. 3% of thee million is about 90,000 patients. Krystexxa is an enzyme, metabolizes the uric acid into a harmless chemical that the human body expels through urine, thus lowering uric acid blood levels. The patient receives an intravenous infusion once every two weeks. For more information about Krystexxa, including dosing and adverse events, click here.

The new lupus drug, Benlysta (Belimumab)  is the much awaited development for Lupus in 50 years. Lupus is an autoimmune disease, in which the body’s disease-fighting system attacks healthy tissue. The condition disproportionally affects women, usually aged 15 to 44. Symptoms commonly include joint pain and swelling, sensitivity to light, fever, chest pain, hair loss and fatigue.  In addition to the joints, lupus can affect the skin, kidneys, lungs, heart and brain. As many as 1.5 million people in the United States have the disease, although estimates vary widely, the FDA said. Black women have a three times higher incidence of the disease than Caucasian women. Benlysta is administered as an intravenous infusion and is the first inhibitor designed to target B-lymphocyte stimulator (BLyS) protein, which may reduce the number of abnormal B cells thought to be a problem in lupus. For more information about Benlysta, including dosing and adverse events, click here.

These new treatment options have given new hope for many patients suffering these painful chronic and debilitating conditions. It is an exciting time for infusion nurses as well. Since most of these new treatments are given intravenously, we play an important role in helping our patients understand how the new agents work, the infusion process and what to expect during their treatments. Often patients are intimidated by the term, “infusion” but one important aspect for patients to remember is that a professional will be administering these agents. Prior to infusion, they are assessed and healthcare professionals are there to monitor not only their progress but how they tolerate the procedure.

Unlike the other museums  in London, this one was very simple, small and unassuming – very much like the lady herself. The museum was a tribute not only to Florence Nightingale but to her beloved nursing profession. The self guided tour was very interesting and the exhibits showed her personal life and achievements as well as the evolution of nursing. I thought it was very clever that they provide you with a stethoscope to listen the audio portion of the  tour. Of course,you can also get your very own version of “Notes on Nursing” from the gift shop.

So if you find yourself  in London – spare a few minutes, head off to St. Thomas Hospital, and say hello to the Lady with the Lamp!

One of the two scales is the phlebitis scale from the Infusion Nurses Society that many infusion nurses have used for years.

Phlebitis Scale (from the Infusion Nursing Standards of Practice 2011 S47)
Grade 0 – No symptoms
Grade 1 – Erythema at access site with or without pain
Grade 2 – Pain at access site with erythema and/or edema
Grade 3 – Pain at access site with erythema and/or edema, streak formation, palpable venous cord.
Grade 4 – Pain at access site with erythema and/or edema, streak formation, palpable venous cord greater than 1 in in length; purulent drainage.

The other is the Visual Infusion Phlebitis (VIP) scale, developed by Andrew Jackson, Consultant Nurse Intravenous Therapy and Care, Rotherham General Hospitals, NHS Trust. This scale was evaluated in a study by Gallant and Schultz.  (Gallant P and Schultz AA (2006) Evaluation of a visual infusion phlebitis scale for determining appropriate discontinuation of peripheral intravenous catheters. Journal of Infusion Nursing. vol. 29, no. 6, p. 338-45.)

Phlebitis resulting from peripheral IV’s should be monitored and the incidence should be calculated. A consistent,  standard, and clinically feasible calculation based on point prevalence should be use to monitor phlebitis rate.

So next time you find yourselves looking at an arm with possible phlebitis,  use a phlebitis scale to assess and document the severity of your findings! No guessing required….

For more information or to purchase the 2011 Infusion Nursing Standards of Practice, click here.

Q1  Are you aware that there is a Standard of Practice for Infusion Nursing?   n=75

Yes:  82.5%                      No:  17.65%

Q2  If you are an RN, LPN or APN performing, administering, delivering IV/infusion therapy, do you think the INS Standards of Practice applies to you?  n=75

Yes: 88%                           No:  12%

Q3  Do you believe that Standards of Practice are only suggestions for practice and not mandatory? n=75

Yes: 76%                          No:  24%

Q4  If you disagree with any one of the standards, do you believe you can be excused from following the standards of practice? n=75

Yes: 18%                          No: 82%

Q5  If your organization’s infusion therapy policies and procedures are significantly different from the Infusion  Nursing Standards of Practice, which would you follow? n=75

My organization’s infusion therapy policies and procedures:  65%

Infusion nursing standards of practice:     18%

Whichever is the strictest policy and procedure:    18%

None of the above:    0

Standards of practice define nursing accountability and provide a framework for evaluating professional competency in the delivery of patient care services. This differs from standards of care, which is developed and individualized by the organization where the care is delivered.

Many thanks to everyone who took the time to participate in the survey. I greatly appreciate your input. Your  thoughts about standards of practice were very valuable.

For more information or to purchase the 2011 Infusion Nursing Standards of Practice, click here.

I understand that not all may share my enthusiasm about the Infusion Nursing Standards of Practice. Many say that it only applies to infusion nurses and the rest of the nursing world doesn’t care at all. Ouch!!!… that hurts.    The reality is, I have seen so many situations where nurses get in legal trouble related to infusion/IV therapy and they are held to the same Infusion Nursing Standards of Practice, whether they know about it or not, follow it or not. Claiming ignorance of the  standards is not an excuse and not a defense.

What do you think? Take our survey and tell us ….

In October 1980, the professional practice of infusion nursing was formally recognized when the United States House of Representatives declared January 25 as IV Nurse Day. Courtesy of the Infusion Nurses Society, click here to view the proclamation.The first IV Nurse Day celebration was January 1981, 30 years ago…

IV nurses aka infusion nurses have played a key role in patient safety, in reducing catheter related blood stream infections, and  contributing to good patient outcomes.  As we celebrate this day, I want to wish each infusion nurse… Happy IV Nurse Day. Whatever you do and wherever you are, on this special day, take the time to celebrate the numerous accomplishments that make us proud to be infusion nurses.

“What do you think about using “nitroglycerin” ointment to help find veins for IV starts?”

There are literature supporting the use of nitroglycerin ointment for dilating veins prior to venipuncture both in adults and children. Most of the literature were prior to  2000 with the latest published in 2004. This article concluded that the application of epidermal nitroglycerine , especially when combined with a topical local anesthetics, can be recommended in infants and children. Its use in neonates and premature babies appears to be associated with higher rates of side effects.

• Haas, N. (2004). Vascular access for fluid infusion in children. Critical Care, 8(6), 478-484.

I also found this statement from the “emergency nursing world” blog by Tom Trible RN, CEN

• Nitroglycerin venodilation: To dilate a small vein, apply nitroglycerin ointment to the site for one to two minutes as you make last preparations. Remove the ointment as you make your final disinfection of the site with alcohol. Used briefly, good vasodilatation occurs without significant systemic effect if fully removed, and without the hassle of using hot moist towels.

There is no statement from Infusion Nurses Society’s “Infusion Nursing Standards of Practice” on  the use of nitroglycerin ointment to promote vein dilation prior to venipuncture.

Speaking from my experience, we did not routinely use nitroglycerine ointment but have used it in the past (like many moons ago). While it did work quickly as it only stayed on the patient’s skin for a few minutes, the patient however complained of headache after the venipuncture.

As always, it is good to  check your organization’s policies and procedures regarding this. Also, keep in mind there are other techniques to help dilate veins such as use of dry heat.

” Are there other places that should be avoided for peripheral access like the ac (antecubital)?”

Yes, the Infusion Nurses Society Standards of Practice states to avoid areas of flexion – antecubital areas (you already knew that), the wrist (cephalic vein) or veins in the palm side of the wrist. The radial nerve is located is located near the vein, causing excessive pain during insertion and potentially resulting in nerve damage.

In addition, avoid affected extremity of a patient who had a CVA because of the extremity’s decreased or absent neurological sensation. Avoid catheter placement in arms of post mastectomy or axillary node removal. Avoid arms with fistulas or grafts. Avoid the vein of the lower extremities in the adult because of the increased risk of phlebitis.

“I have seen nurses use their thumbs to palpate veins, I thought you’re suppose to use the forefinger?”

It is recommended to use the index finger (also called forefinger) since it is usually the most dextrous and sensitive finger of the hand . Here’s a tip I’ve written about vein palpation.

• ” To palpate veins: Apply the tourniquet. Use your index finger to palpate the veins. Press directly on the vein with your index finger, assessing for vein softness and volume. Then release the pressure slowly without lifting your finger and feel the vein bounce back to your index finger. Repeat as often to ensure you found a suitable vein. Don’t stick without palpating the vein!”

“Should you insert the catheter at an angle or parallel to the skin?”

From a previous blog entry: Enter skin at an angle: Select the smallest gauge and shortest length catheter. Position catheter tip bevel up. Approach angle to skin at 10 –15 degree. Deeper veins need greater angle. Superficial require lesser angle. If parallel to the skin surface, will drag the skin as you puncture it. Lower angle once blood return is observed and advance the catheter.

I’m looking forward to getting more…thank you for your Q’s and hope you find my A’s helpful!!

• Standards of Care
• Standards of Practice
• Policies and Procedures
• Practice Guidelines
• Protocols

Often I hear these terms used interchangeably. To help clear up the confusion, let’s define these terms.

• Standard of Care – the consumer of care, the patient, is the focus of standards of care. These are statements of the expected patient care experience or outcome. Organizations are encouraged to develop standards of care addressing patient care throughout their organization or specific to a care unit or specialty area. An example of an infusion specific standard of care is: “Patients with PICC will remain free of hospital acquired blood stream infection”

• Standards of Practice – focus on the provider of care and clearly state the acceptable levels of practice in patient care delivery. In nursing, standards of practice define nursing accountability and provide a framework for evaluating professional competency in the delivery of patient care services. Professional nursing organizations have researched, developed, and published standards of nursing practice that reflect commitment to quality patient care. Standards of practice can be generic (applies to all nurses) such as the ANA Standards of Nursing Practice or specialty standards applicable to certain areas of practice such as the Infusion Nurses Society Standards of Practice. (2011 edition coming in January 2011)
  

• Standards of care vs. standards of practice – published standards of nursing practice define criteria relative to nursing accountability and professional competency so many healthcare organizations adopt these standards. This differs from standards of care, which is developed and individualized by the organization where the care is delivered.

• Policies and Procedures – Policies are the established rules that guide the organization in the delivery of care. Policies are not negotiable and not modified unless it undergoes an official review or revision. Procedures contain a series of precise steps that outline the recommended manner in which the  pyschomotor skills should be performed by  healthcare providers.

Example: Policy: Only registered nurses are permitted to start a peripheral IV.

Example: Procedure:  Performance of venipuncture

• Practice guidelines -  are used by organizations to help make clinical care decisions based on the current state of knowledge about a specific disease state or therapy.  Nursing practice guidelines are based on the nursing process and can assist with decision making in the delivery of nursing service.

Example: Practice Guidelines on venipuncture suggest that based on the patient’s age and condition. an intradermal local anesthetic is recommended prior to venipuncture.

• Protocols – complement procedures and practice guidelines because protocols provide a basis for clinical decision making in specific patient care issues.

Example: Protocol for intradermal local anesthetic: Lidocaine 1% 0.2mL inject intradermally

Yes, these terms may be confusing but one thing is so clear, and that is..  the nurse is responsible and accountable for the quality of nursing care given to patients. The single most important protective strategy for the nurse is to be a knowledgeable individual, to follow the standards of  nursing practice and to meet the standards of care with all patients.

Reference: Alexander M et al. (2009) Infusion Nursing: An Evidence based approach. 3rd edition; St. Louis, MO; Saunders.

In 2010, this blog turned a year old and I was very happy to have passed that milestone.  I am very thankful to all of my blog visitors, very grateful to many of you who have been regular readers, and appreciate those who have left comments.  I am truly humbled and appreciate your support.

So to close off this wonderful year, here are the top ten most read blog posts in 2010.

10. “Numbing with Bacteriostatic Normal Saline” – a blog about the use of bacteriostatic normal saline to numb the site prior to insertion. Yes, it works, read to find out how.

9.  “Should doctors follow nursing standards of practice?” – a post on when there are standards of practice for nursing ( eg infusion therapy) and none in medicine. A registered nurse inserting a peripheral IV would be expected to follow the Infusion Nursing Standards of Practice, but what about the doctor? What standards of practice would the doctor be held up to?

8. “Sterile Water for injection…not for infusion” – a post on a case  involving an RN who added a medication to a 250mL bag of Sterile Water(unintentionally) and administered by infusion via a peripheral IV  to a patient.

7. “When an infusion nurse gets an IV” – a post about my experience having an IV. It is not easy when a nurse is on the receiving end as the patient.

6. “Wearing gloves…is NOT optional” – a post about wearing gloves when starting an IV…yes, you should wear gloves!!

5. “Is there a difference? Osmolarity vs. Osmolality” – These terms have always been confusing. In infusion therapy, particularly with Fluids and Electrolytes and IV solutions, these two terms certainly have  important roles and understanding each term will be helpful to us.

4. “Nurses + Artificial Nails = Bacteria” – my blog about artificial nails and the potential danger for our patients.

3. “Infusion by Gravity Drip” - my blog on calculating IV rates for gravity drip..do you remember how?

2.“Phlebitis – the sequeal” …my blog about using the phlebitis scale to identify and document phlebitis.

1. “Just say No”…the most read post of the year – my blog about avoiding the antecubital fossa when starting IV’s.

Good bye 2010….it has been a great year!

Hello 2011… May you bring lots of luck, happiness, joy, wealth, good health, and more blog posts!!

Happy New Year….Cheers!!!

As a nurse, I have had my share of working on holidays.  Honestly, I will admit that I didn’t like going in on holidays when everyone else was celebrating so I whined and wished I was off.  I know our profession is 24/7 and it wasn’t about the work, it was just the thought of working on a holiday. But once I got to work, it wasn’t that bad at all. We partied too like we would at home. There were always lots of food, chatter, laughter, silly gifts, goofy santa hats, and festive uniforms. We had fun….with the occasional interruption of a beeping infusion pump, clotted central line, and an infiltrated IV.

Now that I am privileged to be off on the holidays, I’m not complaining at all and can appreciate those who are working today to care for sick patients, keep us safe, and protect our country. Thank you!! I hope you would be able to celebrate with your loved ones too.

I also would like to thank  everyone who have come here to read my blog, posted comments, and subscribed…I am grateful and humbled.  I hope that I have helped you in some ways appreciate our specialty. Thank you!!

So on this special day, I wish you Happy Holidays and wherever you are, be safe and have fun!!

Nurse: Please tell me your name?

Patient: “St. Nicholas” but you call me“Santa Claus“. I am also called Father Christmas, Kris Kringle, and many other different names depending on the language. “HO! HO! HO!”

Nurse: Hmm, ok, …now I will need your date of birth.

Patient: “HO! HO! HO!”…

…but according to the patient’s companion, an “elf” .. “He is over 1700 years old! He was born about 270 AD in Asia Minor (Turkey).

Nurse: Ok,…next question, where do you live?

Patient: “Why, the North Pole, my dear.” Don’t you remember writing to me when you were 4 yrs old? Ho! Ho! Ho!!

Nurse: Hmm..occupation?

Patient: “I bring presents to good boys and girls on Christmas Eve”. HO, HO, HO!!

2. I would jot down a few key observations about him…

• Overweight, jolly male in red velour suit with white trim, wearing a red hat, white gloves, and black boots.
• Full white facial beard with flushed cheeks and wears reading glasses
• Patient accompanied by many elves and his wife, Mrs. Jessica Claus
• Patient came to town in a sleigh pulled by 9 reindeers, one reindeer had a shiny nose.
• No food allergies, loves cookies and milk.
• Pets at home includes penguins and seals…
• Drinks eggnog, bourbon or scotch occasionally after work with the elves
• Patient has an annoying habit of saying “HO, HO, HO”!!!
• Patient’s wife reports ” hypertension” only between Thanksgiving and Christmas eve.

3. Don’t worry boys and girls – Santa is not ill.  Doctors have encouraged Santa to loose weight, otherwise, he has no significant illness. After Christmas eve and his incredible journey around the world, carrying those heavy bags full of toys for good boys and girls, Santa experiences “dehydration” and perhaps some electrolyte imbalance. Mrs. Claus just want to make sure he gets some IV fluids before he goes to work!!!

4. I can’t imagine starting a PIV on Santa…that would be like starting an IV on your favorite celebrity or rock star!!! I’d be so starstruck, be afraid I might miss or blow his veins and end up on the “naughty” list!!

HO! HO! HO!….Happy Holidays to all!!

“Are you a new IV nurse?”

I give them an honest reply… “I’m not new here or a new nurse”…then I tell them my IV experience, and the reason why they haven’t seen me at the infusion center before -where I’m not a full time employee. I must admit that sometimes I am very tempted to answer with a remark such as – “yes, I’ve never done this before and you are my first IV stick” or something funny.. but I didn’t want to add more to the stress they are already dealing with.

Familiarity breeds comfort. This happens to everyone. When we aren’t acquainted with a person, an image or a sound, our senses say; ‘I don’t understand, I’m nervous, I’m out of control’. We have to create a new reference in our memory bank so eventually we feel comfortable and in control. In unfamiliar situations, we have to evaluate what is going on around us then make decisions based on a variety of factors such as our beliefs, habits and past experiences. This is so true with our patients. Patients like  routines and having a familiar face caring for them brings comfort and reassurance. Patients are very perceptive, they know and can tell a lot about our experiences by just observing how we perform procedures, our demeanor and body language. They also know their rights and can certainly ask for another nurse should they wish to.

At the end of the day, my patients are very pleased and very appreciative. Then the next question they ask is…

“Are you working next time I come?”

In the United States and other countries,  “Intravenous Clinics” or centers are emerging offering complimentary medicine with intravenous services. Considering that an IV access gives straight access to the circulatory system, many take advantage of this route of administration.

“Some cultures like IV’s” -  as this article stated, in China, ” injections and intravenous treatment are liked. This is a culture that seeks intravenous treatment.” The article describes:

“One 52-year-old woman is being treated for a cold with a half litre mixture of antibiotics and glucose. Another, who has a badly bruised face from a fall after a stroke, is receiving an infusion of Gingko Biloba, the popular Chinese herb, which a nurse says is used for dissolving blood clots. Next to her, a young man with his eyes closed, wearing a blue face mask, is also being treated with intravenous antibiotics for a cold.”

The western culture has influenced many countries including this Asian country, which is known for blending Eastern traditional medicine with Western technology.

One doesn’t have to go China to find some of the “alternative” treatments given intravenously. Here in the United States, there are centers that administer some of these:

Intravenous  Hydrogen Peroxide: I am not sure why anyone would take this IV since everything I recall from using H2O2 is the foam and bubbles it creates when applied to a wound or open sore.  Ha, but what do I know? There are many articles on the Internet on this, good and bad.   This article, describes how it is given IV and the benefits of H2O2.

In IV H2O2 therapy, hydrogen peroxide is infused into the circulatory system through a vein in the arm. It drips in over a ninety-minute period. Five cc of pharmaceutical-grade, three-percent hydrogen peroxide are put in 500 cc five percent glucose in water as a carrier solution. Two grams of magnesium chloride are added along with a small amount of manganese to prevent vein sclerosis.

Then of  course, there’s the bad news - Hydrogen Peroxide Therapy Linked to Patient Death and the resulting effect on those involved, Compounding Pharmacists Sued for Death  from Intravenous Hydrogen Peroxide and those who say that Hydrogen Peroxide doesn’t kill.

Intravenous Vitamin Therapy: I get this one, it makes sense to me and as an infusion nurse, I have infused IV fluids with muli-vitamins added but mostly to patients with nutritional deficiencies. There are articles about high dose infusions of Vitamin C for patients with cancer as well as Vitamin B. Ok, so what’s the big deal? Sometimes these infusions with good purposes are often used because of its “oxidative properties” claiming a role in the anti-aging process.  You get the point here.

Intravenous  EDTA Therapy: This one, called chelation therapy has been around for a while now. The chelating agent, called EDTA, removes toxic metals, improves circulation, enhances the immune system and inhibits the creation of “free radicals”. Free Radicals are now believed by many scientists to be an important contributing cause of atherosclerosis, cancer, diabetes, alzheimer’s and other diseases of aging.

There are more…but I decided not to include those…

Perhaps there are some benefits to these “infusions” and I’m not one to judge the efficacy or safety of these therapies nor am I disregarding the value and importance of  complimentary alternative medicine.  But as infusion nurse, it is a concern that some of these infusion therapies are provided in a setting where standards of practice are not followed or loosely implemented, IV meds are perhaps used off label, whether or not the infusions are provided by a physician, or a technician, or a licensed professional nurse, and the lack of assessment and monitoring parameters for good patient outcomes. Reimbursement doesn’t seem to be an issue here as most of the patients who opt for these infusions are aware that the treatments are not covered by insurance.

Test your knowledge by taking the Infusion 101 quiz!! Have fun!

Thank you!

The poll showed, inserting bevel up is the technique used by 92.11% of the blog readers who took the poll. It is also the common practice and the common insertion method taught in many IV insertions classes and training programs. A twitter colleague  @TorontoEmerg ask: What does the literature say? The Infusion Nurses Society’s latest textbook ” Infusion Nursing: An Evidence based approach” third edition states ” with the bevel up…” (chapter 23 pg. 460).  Several other textbooks, like Nursing interventions & clinical skills by Elkins, Perry and Potter 2007 edition states bevel up.  In addition, several comments from nursing colleagues on twitter and face book have stated they use  “bevel up”.

As far as pediatric patients, a long time colleague and friend Lynn Hadaway posted this reply on Face book:

“For peds the bevel length can be designed shorter and with a slightly greater angle so make it easier to cannulate small vessels. This would be a C size bevel. Most have a B size bevel. There is huge amounts of engineering to make a bevel.”

While majority use “bevel up”, 5.26% use “bevel down”. I’d be curious to find out why that technique works for them.  One twitter reply from @portapatti stated:  “I use bevel down.when pt has high bp. I’ve had blood shoot back at me if you r alittle getting in.“  Then @podmedic commented: “I wonder what the people who chose “Neither” do? Sideways?” I agree, it would be interesting to find out what the 2.63% who use neither do?

Thanks to  everyone who participated, read and visited my blog.  Of course, this is an unscientific poll but I appreciate your participation. This was fun and hopefully it made you stop and think. As always, feel free to post your questions or comments here.

“Can you shed some light on the “bevel down” technique that some profess for peds?”

It was an interesting question, to which I replied:

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 patient 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.

I think most nurses were taught to insert bevel up. There are a few who insert bevel down and have found it very helpful resulting in a successful insertion.  What do you think? Do you insert bevel up or bevel down? If you work with peds, do you use the bevel down insertion?  Take our poll:

IV Therapy in Jails and Prisons? Yes….and No!

Guest Post by Lorry Schoenly, PhD, RN, CCHP-RN

Have you had inmates come to your hospital or infusion clinic for IV therapy and wonder about the level of care provided behind bars? Do nurses perform IV therapy in jails and prisons? The answer is yes….and also no. Let me explain.

Think of the healthcare given behind bars as an ambulatory care clinic or home care. Anything that can be provided in the home or in a clinic could potentially be provided by nurses and doctors in corrections. Some states such as Texas and New York even have accredited acute care facilities within the security perimeter. But that is more of a rarity than a regular occurrence.

When inmate patients require clinical services which would be a security concern in the cell block area, they are moved to a sub-acute ward most commonly called the infirmary. Infirmary care includes a higher level of nurse observation and physician contact than normal ambulatory care. Inmates in the infirmary may be preparing for diagnostic tests, isolation for infectious diseases such as active MRSA,  or require intermittent or continuous infusion therapy.

However, not all correctional facilities have the staffing and resources to provide every type of clinical service. Inmates may be brought to your facility for infusion therapy because the jail is too small to staff a full-time nurse to monitor IV’s or they may not have an infirmary to house an inmate needing an IV. Larger facilities such as jails with thousands of inmates will have a large and well-stocked infirmary that could even provide simple chemotherapeutic regimens.

If you care for inmate patients brought in from a nearby correctional facility, make it a point to get to know the correctional nursing staff and the therapy levels provided at their institution. Establish communication systems so that continuation of care and any side effect management can be provided when the inmate returns to his home location. By working together with correctional nursing staff, you can make a difference in the care provided across the continuum.

To learn more about correctional nursing care and the unique challenges of nursing in jails and prisons, visit CorrectionaNurse.Net. Follow Lorry on Facebook or Twitter for updates in correctional healthcare. Her  podcast Correctional Nursing Today is on BlogTalkRadio.

Fast forward to a few weeks ago when I met an RN working in an infusion clinic owned by a physician. She had been a nurse for 38 years, was an IV Team nurse for many years then retired but got bored, so now works 3 days a week giving infusions. I’m always excited to meet long time nurses because I love to hear their “nurse” stories and more excited meeting this particular one since she was an IV nurse. Older and wiser, that’s how I think of these nurses.

Then things took a nosedive when I observed this “older experienced” nurse used a syringe to reconstitute a medication for a patient, then set it aside for use on the next patient. Yes, she was using one syringe to reconstitute all the medications she will be infusing that day. Maybe it was just an oversight, so I gently asked if she meant to throw the syringe she had set aside. She replied in an irritated voice, “No, I will need that for the rest of the patients today”. I reminded her that she is “re-using” a disposable item meant for single use. She replied, “is something wrong with that?”

This scenario of “re-use” was repeated many times by this nurse during that day – with an IV catheter that was removed from its protective covering and laid on work surface; IV tubing dropped on the floor; alcohol swab used then re-used over and over till dry; cleansing an IV site with betadine and wiped off with non-sterile gauze prior to venipuncture; and many more!

We had a long and contentious conversation about all these at the end of the day. My biggest heartache was the failure of this nurse to recognize that her actions were harmful or cause potential harm to the patient. I wish I can tell you this is an isolated incident. I’m sorry to say that I have seen this many other times, in different settings, with other nurses of all ages. Yes, its not just the “older” ones but somehow I expected more from them. They are older (age/experience), they should be wiser, right? You tell me!!

BTW, take a look at the syringes at work, you will see “single use” printed on the syringe. The definition from the CDRH (Centers for Devices and Radiologic Health, a division of the FDA) of a single-use device, also referred to as a disposable device, is intended for use on one patient during a single procedure. It is not intended to be reprocessed (cleaned, disinfected/sterilized) and used on another patient. The labeling may or may not identify the device as single use or disposable and does not include instructions for reprocessing. 1

Reference:
1. Labeling Recommendations for Single-Use Devices Reprocessed by Third Parties and Hospitals; Final
Guidance for Industry and FDA (July 30, 2001), available at http://www.fda.gov/cdrh/comp/guidance/1392.html.

When I am challenged to insert a 24g peripheral IV catheter in a tiny, invisible vein of a dehydrated infant, I jump for joy as I watch anxiously for the blood return and pray that blood continues to backflow as I advance the catheter into the vein. YES!! YES!!! YES!!!

When I aspirate for blood return from central venous catheters (CVC), it gives me the feeling of victory, knowing that the CVC is properly functioning and ready to use.  Positive blood return means a free flowing blood return easily obtained on aspiration, and the color of whole blood. In other words, bloody RED, not pink-tinged.

Seeing blood gives me the feeling of success as I watch the blood tubes fill up when I am drawing blood samples from a patient’s antecubital fossa.

Oh yes, it doesn’t take much to make an infusion nurse happy.   BUT in the world of infusion therapy, bloody may also indicate a serious problem.

• Seeing blood at the peripheral IV site and/or CVC insertion/exit site can mean complications. Redness or blood at the site may indicate infiltration, phlebitis or infection.

• Seeing a patient turn RED during an infusion is not a good thing -it may a sign of an infusion reaction. Stop whatever is infusing and manage the patient accordingly.

NOT able to obtain a blood return from CVCs makes an infusion nurse unhappy -  as this indicates a problem.

• If the tip of the CVC is in the lower thirds of the superior vena cava at the junction of the SVC and RA, then you should get a blood return. If you can’t get a positive blood return, do not use and assess the cause.
• It is not an expectation for patients to do arm and shoulder movements or what most nurses refer to as “central line aerobics” while you aspirate for a blood return.
• If unable to obtain a positive blood return, then there is a problem with the central line. Consider possibly drug precipitate, fibrin sheath, thrombus formation at tip of catheter, and mechanical problems such pinch-off syndrome, malpositioning of catheter tip, or catheter dislocation.

Ok, so you’re thinking, but in practice if we call the physician and report the problem (inability to obtain blood return), we will be told to go ahead and use the CVC for infusion. It is a dilemma but don’t forget… Assessing for blood return is one of the key indications of a properly functioning CVC and  without a blood return, the use of the CVC can put the patient at risk of serious complications.

Today is Halloween and this is where my love affair with all things bloody ends. Honestly, I love Halloween but I’m a wimp. I’m  not in love with scary movies, nor care for people’s costumes with blood, guts, and gore. No offense to anyone, it’s just not for me… probably because  I’ve seen enough in real life!!

Happy Halloween!!

Class I Recall: CareFusion Corporation, Alaris PC Units (Model 8015) Reason for Recall:
Under certain wireless network conditions, a communication error can occur, which freezes the PC Unit screen. This error may result in a delay of therapy and inability to make programming changes to current infusions.

If the communication error occurs during infusion, infusion continues on all channels, as originally programmed, but cannot be modified. When this error occurs, stopping the infusion to make any modification or programming changes causes the PC unit to shut down resulting in a delay or interruption in therapy. This could lead to serious injury and/or death.

If users experience the problem, they are to remove the device from service and contact the CareFusion Recall Center immediately. The corrective action will require a hardware update to all affected units. CareFusion does not require that the devices be returned.

Class I Recall: Excelsior Medical 5 ml Fill in 6 cc Prefilled Saline Flush Syringes: Recall – Potential Loss of Sterility
Routine internal testing conducted on this product found that some of these syringes may leak and lose sterility. This recall pertains only to syringes with the following product code numbers: E0100-50, 10056-1000, 10056-240, 14056-240, 910056-1000, and S5. Exposure to syringes with a sterility issue could result in systemic infection, which may lead to serious injury and/or death.

Consumers who have 5ml fill in 6 cc saline pre-filled syringes manufactured by Excelsior Medical should immediately discontinue using these syringes and return them to the point of purchase.

Voluntary Recall: Methotrexate Injection, 50mg/2mL and 250mg/10mL Vials: Recall – Presence of Glass Particulates
Sandoz and FDA notified healthcare professionals of a recall of Methotrexate Injection, 50mg/2mL and 250mg/10mL vials, due to small glass flakes detected in a limited number of vials in four lots. The flakes are the result of delamination of the glass used to manufacture the vials of the two dosage presentations.

Parenteral injection of drug from the affected lots could lead to serious adverse events in areas where the particles lodge. Potential adverse events after intravenous administration include local damage to blood vessels in the lung, localized swelling, and granuloma formation. Intramuscular administration could result in foreign-body inflammatory response, with local pain, swelling and possible long term granuloma formation. Neurologic damage could result from intrathecal administration.

Customers and patients should immediately discontinue use of this product and patients should contact their physician or healthcare provider if they experience any problem that might be related to the use of this product. Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration.

Product lot numbers, label type, expiration dates, and recall instructions are listed here.

Voluntary Recall: Heparin Sodium (B. Braun): Recall – Trace Contaminant
B. Braun Medical Inc. and FDA notified healthcare professionals of a nationwide recall of certain lots of Heparin Sodium USP Active Pharmaceutical Ingredient (API) sold to B. Braun because testing indicated a trace amount of oversulfated chondroitin sulfate (OSCS) contaminant. These lots were manufactured in 2008 and will be expiring on October 31, 2010 and November 30, 2010.

Customers who have product from the recalled product lots in their possession should discontinue use immediately. Product lot numbers, expiration dates, and recall instructions are listed here.

For more information, visit the FDA MedWatch site, click here.

Here’s a story of a health care colleague who was looking to fill a director position for a disease management program in his organization. He received many resumes/applications from qualified RN’s and in particular, he was leaning towards one particular applicant with impressive credentials, clinical and management experience.  This applicant was exactly who he wanted to be in this position. Many interviews later, he wanted to move quickly and  hire her but she has to interview with the CEO of the organization. The interview went well until the applicant fully disclosed a past (like 10 years ago) State Board of nursing disciplinary action resulting from chemical dependency problem. She voluntarily surrendered her license, was reinstated 10 years ago to active status and has been cleared by the SBON.

So perhaps you can guess how the story ended. Her self disclosure has caused her the job. Although my colleague believed that she can do the job even with her past history and was willing to hire her, his CEO, however, wouldn’t take the chance. Self disclosure, although admirable and has many advantages, involves risk and vulnerability on the part of the person sharing the information. The risk is that the people will not respond favorably to the information. Self disclosure does not automatically lead to favorable impressions.

Employers and others in management have their reasons (and the choice)  not to hire or promote people with “past history” like hers. Having said that,  I do however believe everyone is entitled to be given an opportunity to do good and make things better. Some great leaders and presidents of this great country have made mistakes in the past, yet they have turned out to be well respective individuals with remarkable contributions to our society.  This RN was being honest by her disclosure yet the stigma of her past mistake prevented her from a career advancement in nursing. What if this RN didn’t disclose her past? Isn’t there a statute of limitations, after all it has been ten years? As saying goes, “no good deed goes unpunished”.

Do you think she got what she deserved or should they have given her a second chance?

I was clinging to my new found friends and  fellow nurse bloggers/colleagues from Twitter at the Social Health track sponsored by Johnson and Johnson and Medpage Today. I listened to many legendary bloggers such as @epatientdave (Dave deBronkart), @kevinmd (Dr. Kevin Pho) and our very own nurse blogger @emergiblog (Kim McAllister).  I had many “aha” and “duh” moments during the day and I quickly realized how physicians and patients have effectively utilized the power of social media for empowerment, for answers to their health questions, and/or to communicate effectively with patients.  I was excited and at the same time, I felt sad that there were only a handful of nurses in the room!  Where are the nurses? Weren’t we once the ones patients turned to for information when they felt intimidated or shy asking the physicians? Is it just because nurses didn’t know about the social health track at blog world? Or have we (nurses) not fully embraced social media not realizing that perhaps our patients might be more informed than we are?

I know that we all have our own reasons, and not all nurses want ( or need) to be on social networking sites ( or attend blog world). Yes, it is a choice and not a requirement. I do know many nurses are on social networking sites. I do wish however that they utilize the power of the internet and the social networks not only for personal reasons but for professional growth as well. We have to catch up with the rest of the world where information is shared at lightning speed. Like it or not, there are benefits to social media we can’t overlook.

It was a great learning experience for me and I met the most incredible people in healthcare and “celebrities” in the blogging world! I am glad I came and will plan on going again next year. Hey, why don’t you come too?

Many thanks to Johnson and Johnson Campaign for Nursing for rounding up the nurse bloggers who were at Blog World together for breakfast. Your continued support for nursing is greatly appreciated!

Nurse Bloggers Breakfast at Blog World 2010 Las Vegas. Left from front @mommystory, @emergiblog, Becky from JNJ and staff from GCI, @podmedic (head of table). Right from front @infusionnurse, @lorryschoenly, Kelly from GCI and Amy Davis. Not in picture is @jdlasica from @timefornurses

Pictures from Infusionnurse.

Ok, so I am really grateful that many are reading my blog but I am also a bit concerned that perhaps people are still on the fence about not using the antecubital fossa for an peripheral IV start.

Location, location, location… my stand is still the same as what I have posted and I would still strongly recommend to avoid using an area of flexion like the antecubital fossa and if you have to, remember to think about what you will be infusing into that vein, the possible consequences and remove as soon as possible. Remember, if an IV site in the antecubital fossa infiltrates, that will limit the use of the veins below. If extravasation occurs, there’s  potential for more serious complications.

So, continue to just say no and think location, location, location!!