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- by kstec Jul 15, '08I'm an LPN, so I do not know a whole lot about Picc lines, central lines, etc. I'm only familiar with you basic INT. In my state we don't even get to learn about them, much less do anything with them. Well my question is, I had a new admit at a rehab facility that I work in. He was brought there to ultimately pass due to d/c'ing his dialysis. He had a AV shunt in his left forearm that was never used, I'm assuming because of the acuity of his renal failure, it had not healed yet so they put in a IJ. Okay, I've looked this up and I'm confused. I know it's intrajugular, with a V on one lumen and a A on the other, I can figure that out. But my question is, the resident had a CVA appx 1 month ago and is completely agitated while awake. He took off his O2, attempted to pull out his one week old peg tube and grabbed his IJ port and managed to pull a stitch lose. I contacted the doctor to get an order for something for anxiety/agitation, since I really didn't want this guy pulling anything out, especially the IJ port. Well when the doctor gave me the orders, he said to give Ativan IV. Well I know I'm not allowed to due to LPN's scope of practice, but my gut told me that maybe this port was not for use of administering medications, but just for dialysis. So I apologized to the doctor of my ignorance to this type of site and asked for an order for IM or peg tube adminstration of Ativan. He agreed, but in the interim I felt like an incompetent idiot. I'm actually pretty intelligent, but I'd never been exposed to any other access for dialysis other than an AV shunt or AV fistula. So is this something I should of known, or am I an idiot? I've been researching all evening and have come up with nothing. I know you can give meds through a PICC, a CVC, a INT, but the IJ port confused me. Please be kind in your responses. I know as nurses whether it be a LPN or RN, we don't know it all, but when you have to admit it especially to a MD, you kind of feel like a moron. And we do have RN's in house all the time and they to said you couldn't use it for medication administration, but they also have worked LTC with little to no acuity since graduation, so I don't know if it's a case of it you don't use it, you lose it, or they were never subjected to this in school or at their clinicals. Any clarification would be wonderful. There are not to many times that I wish I had my RN, but knowledge is power and I felt pretty powerless the other night. I think about getting my RN to know more, but along with that comes more responsibility and I'm not sure I'm ready for that. Please be nice with your responses, I don't want to be made to feel like less of a nurse, but that its okay to not know everything and be able to admit it and to not feel like an idiot. Thanks in advance....
- Jul 15, '08 by TRAMA1RNBy no means should you feel like an idiot. I think that it showed great critical thinking on your part to ask the pysician for an IM or peg med order. ALL dialysis catheters are off limits to anything except dialysis. If you worked with me I would have been very proud of you and honored to know that you had the clarity of mind to think twice about the MD order.:clphnds::urck:
- Jul 15, '08 by jennjen512You are not dumb at all; you have just never been exposed to that particular line. In my facitily we are not to use dialysis catheters for meds unless there is a doctors order stating that it is OK to do so or it is an emergency situation (code). There is too much of a risk of clotting off one or both of the ports if they are not flushed properly and the ports are usually locked with heparin and must be pulled back so the heparin is not administered to the patient. Dialysis is much more important in most cases, especially if the drugs can be given IM or PO.
- Jul 16, '08 by ?burntoutWell first you did a wonderful job so don't feel dumb. It doesn't matter if you are a RN or LPN, we can not know everything.
In my facility, we do not use a dialysis catheter/Vas Cath unless it is an emergent situation or we have no other access and then we get an MD order to use it. Most of ours do have a pigtail port that we use like you would a central line lumen. But if we have to use the other lines, we must deaccess all that heparin and re instill it after our infusions are complete.
- Jul 16, '08 by Daytonitei was an iv therapist. those ijs for dialysis are never used for anything but dialysis, so no medications are given through them. they are heparinzed to keep them patent. the dialysis nurses would have a hissy fit if our iv team did anything with those catheters. you are correct that one port is arterial and one venous. if the patient manages to pull the cap off of the arterial port, he will spurt arterial blood just as if an artery were severed. if the cap of the venous port comes off he can pull in air by negative pressure and an air embolism can form in his heart. if he pulls the catheter out pressure needs to be held over the exit site until the bleeding stops and then a pressure dressing applied.
as far as your rns giving any iv ativan, i would advise you to defer to your facility policies. i also worked in ltc. if there is ever a question as to what you can or cannot give, check your iv and medication policies and then call your pharmacy service and consult with the pharmacist on call. that's what they are there for. some hospitals won't even let their medical staff nurses give iv ativan and it is a hospital policy.
since this patient was a dnr i would have asked for an order to d/c the ij if dialysis was no longer going to be done since it was a safety risk and i would have charted that the doctor was asked about this even if he did not give the order. he may be reticent to order the d/c and would rather that the renal doctor give the actual order for that because he is probably the one who inserted the ij. at that point, i'd contact the renal doc and explain the situation.
- Jul 16, '08 by mpccrnummm some of the above information is correct, some not so accurate. i left ICU and was a dialysis nurse for about 5 years.
First, IJ's are a central line like PICC's, subclavians or femoral lines. yes there are 2 ports marked V and A, but it's in the same vessel. The V and A are more likely indicative of the where the other end of the catheter lumen lie in the vessel itself, distal or proximal. It is used to hook the patient to the machine. 'A' being the line used to withdraw the blood from the patient to feed the machine and 'V' used for its return.
2nd: the lines are heparinized with a more concentrated heparin solution to ensure their patency. Dialysis nurses and docs are EXTREMELY territorial when it comes to their lines. we didn't want people messing with them because they were essentially the patient's lifeline and their only means of dialysis access. Nephrologists don't place lines and must rely on someone else to put them in. that's a pain in the butt and slows us down. a 4 hours treatment is really about 6 hours to the nurse doing it cuz they have to warm up the machine, test it and then disinfected it after the treatment. better no one uses our line.
3rd: a dialysis line CAN be used for med administration, provided you pull the heparin out of it, 10 cc waste is usual, and block it again with heparn when done. we'd prefer if you don't use it for routine med administration but in an emergency or no other options availabe it is a viable route. refer to #2.
4th: a fistula may or may not be accessible depending on it's blood flow and maturity. it's usual to place a line in as the fistula develops and matures. it's not uncommon to try sticking it and see what happens. sometimes it collapses, sometimes it's flow is not enough to sustain the machine, sometimes you pull from it and return to the line. using it will eventually make it stronger.
5th: your suggestion of an alternative route and opening a discussion with the doc should in no way make you feel like an idiot! i'd worry more if you tried to fake it. docs and your co-workers will appreciate your conscientiousness. it show you were thinking and your confidence in your knowledge base to ask in the first place. you were your patient's advocate. good job!
6th: nursing is an ongoing learning process. when you are unwilling to continue leaning, it's time to get out!
hope this helps. :heartbeat
- Jul 16, '08 by Fiona59I used to work dialysis and let's just say territorial is a nice way of describing the view of the lines.
In my hospital we have an acute and chronic renal unit. So if a problem arises or questions we are encouraged to call the unit. I've seen former workmates come down and re-attach dressings and cover the lines that hang.
We're line lines just dangling? We were trained to cover them with gauze and even had little bags with drawstrings to cover them up.
Kinda funny looking back. Those lines really were some of those nurses "babies"
- Jul 16, '08 by onyx77My community clinical was in dialysis, I know it has been about 6 months now since graduation, but I do remember my mentor telling me that the dialysis catheters were ONLY for dialysis and not for med administration or blood draw. But then again, I only had 28 hours in dialysis!
- Jul 16, '08 by -MNC_RN-Generally speaking, dialysis catheters are used for nothing else. There are always exceptions.
My big question would be if he was admitted to your facility and dialysis was DCd, why leave in the line? It's a route for infection and a risk if pulled (obviously). Unless there was a good chance that he or his family would change minds, it should have been taken out even before he hit your doors.
[In regards to your original post, you did the right thing.]
- Jul 16, '08 by kstecThanks for all the replies. Yes the resident was brought to us to pass. He is alert and confused and does pull at this IJ and peg tube. My question also was ,why didn't they pull the port before sending him to us. We are not an acute LTC facility. I did write a request to the house MD to either give the RN's orders to maintain the line, or to have it d/c'd due the the high risk of being pulled out. I obviously know enough to know that he would bleed out if not caught and pressure applied immediately.I realize that I'm not an idiot, but when you have to admit to a MD that you do not know, you feel kind of inadequate, especially being a LPN. I know alot but 1 year of schooling compared to 2 or four gives you a lot less time to be exposed to things. It was almost comforting to know the RN's at the facility were just as confused as me re: the IJ. I assume it's more of a specialty area. I've only been out of LPN school for 2 years, and I have said "I don't know", a lot but prior to becoming a LPN I was a pharmacy technician in a hospital for 14 years, medications are my strongest asset. I'm gaining excellent assessment skills, and I learn something new everyday, if not from a coworker, from the internet. I love to learn, but don't want to go back to school right now. Thanks again, for you information and reassurance. Unfortunately in nursing school you learn a little about everything and a lot about nothing.