starting IV on same arm as a mastectomy

Nurses General Nursing

Updated:   Published

Hey guys, I have been lurking on this page for awhile, but never join. Today I want some input on this topic. I'm just really worried now.

The patient is a DNR patient on peritoneal dialysis. Patient also has active pneumonia. Infectious disease physician has order IV antibiotics on patient for the previous 2 days. Patient is a hardstick. None of the previous nurses or supervisors was able to start an IV on patient. Got report from previous shift nurse that patient has IV antibiotics ordered, but no one was able to start an IV. Well I managed to start an IV on her left forearm with her daughter at bedside. Her daughter didn't say anything, just told me I did a great job and was able to start an IV where other nurses wasn't able to. In morning report from oncoming supervisors. The morning supervisor suddenly told me the patient has a history of left mastectomy! I was so angry and horrified at the same time. No one told me patient has a history of left mastectomy. It was my first day with the patient. She only had a DNR bracelet. No limb alert bracelet.

Then the supervisor told me that patient's daughter told him that she had the mastectomy over 20 years ago, and she said it was OK to start IV on that arm, but he wasn't able to. I'm thinking why the hell he didn't tell me that in the first place. I went to the patient's room and clarify it with the patient's daughter. She did say her mom had it over 20 years ago, and that it was OK to start the IV there.

What I learn in nursing school is that it is not ideal to start IV on same side as a mastectomy. However, this patient needs the medicine. I'm just overly worry guys.

totally agree, PICC seems like a reasonable choice.

1 Votes

Time frames are important - 2 vs 5 vs 20 years makes a difference. More importantly, there's a big distinction between taking the sentinel node and a full axillary lymph node dissection. This all hinges on old studies with poor data that are continually passed down in nursing education. It's unfortunate.

2 Votes
Specializes in Emergency, Tele, Med Surg, DOU, ICU.

20 years = should be ok with that arm.

Did anyone try starting on both lower extremities. 2 days no abx is not good.

1 Votes
Specializes in Pediatric Critical Care.
coletanner123 said:
The thing I was just so mad was that there was no report not to start IV on left arm, no limb alert. Supervisor didn't tell me anything. Another supervisor told me that patient daughter usually tell nurses and phlebotomist to use the other arm. The daughter didn't tell me anything. Then after I found out, I clarify with the daughter. SHe said it was OK since her mom had it over 20 years ago. If I would of known... I'm just scared now.

But the supervisor also said that it was okay to put an IV in that limb and that they just weren't able to get one. So why would there be a limb alert bracelet if it was okay to use that limb?

1 Votes
Specializes in icu,prime care,mri,ct, cardiology, pacu,.

Notice patient is DNR. For comfort I'd use the mastectomy arm rather than a picc line. But ultimately if the patient can't tell you, it's up to the family. Do the providers know what a tough stick the patient is?

Communication between shifts is one area where lots of information can get missed. Our emr had a page with diagnosises listed. That's helpful.

1 Votes
Specializes in Critical care.
winniewoman9060 said:
Notice patient is DNR. For comfort I'd use the mastectomy arm rather than a picc line. But ultimately if the patient can't tell you, it's up to the family. Do the providers know what a tough stick the patient is?

Communication between shifts is one area where lots of information can get missed. Our emr had a page with diagnosises listed. That's helpful.

DNR is not do not treat or comfort measures only. There was a recent discussion on this.

I do think using the mastectomy arm is fine in this case if someone could get a PIV in (which the OP was able to). A PIV is always preferable for infection control purposes (granted the med can be safely given through a PIV).

I do not think somebody's code status being DNR should play any type of role in deciding whether or not they get a PICC (or any other central line required for IV medications, especially antibiotics). Obviously a comfort care only patient should not have any type of line unless it's being used for a PCA (or something similar) to keep them comfortable.

1 Votes

something else...depending on GFR may also preclude getting a PICC (PD patient)

1 Votes
Specializes in Critical care.
Twinmom06 said:
something else...depending on GFR may also preclude getting a PICC (PD patient)

They would probably get a tunneled catheter in the subclavian area if there is concern about limb restriction for potential hemodialysis access.

1 Votes

Please dont lose sleep over this. Very common mistake. Ive seen nurses do this a million times and the patients were ok - this happened frequently when a patent came up from ER and had recieved a 2.5 liter saline bolus through an IV on a mastectomy arm. Its an old mastectomy; not saying this is not important; patient safety is always a main priority; i could be wrong but, but my thinking would be shes on dialysis, so even if some fluid build up happened, the dialysis will soak up the extra built up fluid. Carry on! And go be an awesome RN!

Additionally, for hard stick's, maybe an UltraSound tech can help you inserting an IV. US machines and techs are great for this (check if you need an MD order though). Additionally, if that doesn't work, you can always suggest a midline insertion, or if the family allows it, you can get an MD order for a PICC line for long term IV access especially for an infectious PNA. Check the DNR status though.

I would like to add also that these are just suggestions,- always check with your hospital's policy regarding IV access and central line insertion and never practice outside your RN scope of practice

1 Votes
Specializes in ICU, LTACH, Internal Medicine.
gmprojects93 said:
Please dont lose sleep over this. Very common mistake. I've seen nurses do this a million times and the patients were OK - this happened frequently when a patent came up from ER and had recieved a 2.5 liter saline bolus through an IV on a mastectomy arm. It's an old mastectomy; not saying this is not important; patient safety is always a main priority; I could be wrong but, but my thinking would be shes on dialysis, so even if some fluid build up happened, the dialysis will soak up the extra built up fluid. Carry on! And go be an awesome RN!

Additionally, for hard stick's, maybe an UltraSound tech can help you inserting an IV. US machines and techs are great for this (check if you need an MD order though). Additionally, if that doesn't work, you can always suggest a midline insertion, or if the family allows it, you can get an MD order for a PICC line for long term IV access especially for an infectious PNA. Check the DNR status though.

I would like to add also that these are just suggestions,- always check with your hospital's policy regarding IV access and central line insertion and never practice outside your RN scope of practice

First, the author did not make any mistake. See above why.

Second, and this is a common mistake indeed, dialysis won't "soak up" fluid from extravascular space. It works only for intravascular volume, and has nothing to do with extravascular, intracellular or any other volume. Furthermore, HD can be performed in different regiments to remove more or less water and more or less solutes, depending on patient's fluid and lytes status. The decrease of edema or pleural transsudates happens AFTER HD because of induced fluid shifts, NOT because HD somehow "sucks out water". But no HD in the world can remove water from lymph system by any means at all. It just doesn't work this way.

Should it be different, then lymphedema wouldn't be such a devilishly difficult to manage condition. But it is. These patients can be critically dehydrated with 15+% volume loss, and their edema will be still there and not bulge for a millimeter.

Third, "DNR" doesn't mean "do not treat". Patients with DNR status receive the same treatment as everyone else, including line placements, abx, chemo (curative and palliative), vents, etc. "DNR" status implies as not mandatory only actions performed under code protocol and nothing at all outside it unless patient/family requests otherwise and the care team agrees with it.

And the fourth, the described case is precisely the one when a good nurse might need to fight the policy for the benefits of common sense. Placement of midline or PICC is more invasive and carries more risks than PIV, leaving alone EJ, TLC or other types of central lines. Why would you like to subject the patient to these risks just for the sake of some silly piece of paper written by someone who still remembers the nonsenses nurses were taught decades ago?

1 Votes
brownbook said:
A surgeon in our same day ambulatory surgery center, her area of expertise is mastectomies, breast cancer, etc., said the same arm is OK.

Even if lymph nodes were removed but there was no other reasonably easy alternative. A clean "sterile" IV insertion is not going to an issue.

A "dirty" cut, scratch, wound, in the affected arm is the bigger concern.

Lightbulb! That makes a lot of sense. Thank-you.

1 Votes
Specializes in Critical Care.
Quote
DNR is not do not treat or comfort measures only.

I do know of a fairly large healthcare organization where "DNR" is defined as comfort measures only, not saying I agree with it, just saying that definition does unfortunately exist.

1 Votes
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