starting IV on same arm as a mastectomy

[coletanner123]

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.

[MunoRN, RN]

There's no reason not put a PIV on the side of a previous mastectomy. A very long time ago it used to be common to also perform lymph node removal when a mastectomy was done, although that's not common practice anymore. Even where there as been lymph node removal, there is not sufficient evidence to clearly say the patient can never have PIVs on that arm.

[EllaBella1, BSN]

To be honest I'm a little more concerned about the fact that you weren't aware that your patient had a mastectomy in the first place. It should have been passed on to you in report, but you also should have done a thorough enough assessment to notice something like that.

[KatieMI, BSN, MSN, RN]

EllaBella1 said:

To be honest I'm a little more concerned about the fact that you weren't aware that your patient had a mastectomy in the first place. It should have been passed on to you in report, but you also should have done a thorough enough assessment to notice something like that.

Nowadays even radical mastectomy with full dissection is not considered to be contraindication for breast reconstruction. Some of them even preserve nipples, and the results has to be seen and felt to be believed. Plus, more and more women undergo breast augmentation, lumpectomy with limited dissection, simple mastectomy with following plastics (the "Angelina Jolie procedure") and all kinds of other surgeries with their breasts. The results can look incredibly "natural", and, unless you really palpate tissue and ask the patient, you might never even suspect that what you see was her belly fat one day.

Being honest, how frequently an average RN conducts careful visual inspection of breasts and their palpation as part of her routine assessment?

[OrganizedChaos, LVN]

What about a power glide? Do they have those at your hospital?

[applewhitern, BSN, RN]

KatieMI said:

There is no scientific evidence that placing peripheral IV on the same side as mastectomy (radical or otherwise) after 20 years can cause lymphedema or any other complication if these complications did not develop within first 5 years after surgery. For the first 5 years, data is mixed.

"Never place an IV on mastectomy side, doesn't matter what because it is unsafe" is one of old wives' tales which are still taught in nursing schools despite of being disproved for decades. Relax.

We have doctors that tell us not to even take blood pressures on the affected side; even the surgeons who performed the mastectomy tell us not to use that arm.

[Ambersmom, BSN, RN]

KatieMI said:

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?

I agree PICC line is more invasive and with more risks, but with a patient with very poor access who requires IV abx, this is exactly the reason I would advocate FOR it, it will save the patient having multiple attempts when the IV needs to be changed, as well as allowing for blood draws, etc. Risk vs. benefit, the benefit of a picc in this case far outweighs the risk, unless the patient is able to take po abx and in that case wouldnt need a picc at all.

[Ambersmom, BSN, RN]

applewhitern said:

We have doctors that tell us not to even take blood pressures on the affected side; even the surgeons who performed the mastectomy tell us not to use that arm.

yup, all our mastectomy patients are bp on affected side.

[dudette10, MSN, RN]

There's a lot more that goes into it, the least of which is a mastectomy on that arm. Were lymph nodes removed? How many? Did the patient have radiation on that side?

Lymph node removal, number of lymph nodes removed (more than a sentinel node biopsy), and radiation on the affected arm should be more of a concern.

I've had a double mastectomy with SNL on the right only (two nodes) and no radiation. I don't give a crap which side I'm poked or BP'd on.

[applewhitern, BSN, RN]

KatieMI said:

There is no scientific evidence that placing peripheral IV on the same side as mastectomy (radical or otherwise) after 20 years can cause lymphedema or any other complication if these complications did not develop within first 5 years after surgery. For the first 5 years, data is mixed.

"Never place an IV on mastectomy side, doesn't matter what because it is unsafe" is one of old wives' tales which are still taught in nursing schools despite of being disproved for decades. Relax.

I have been unable to find any literature that claims this is an old wive's tale, or that it is OK to use the affected arm. The only articles I have been able to find state that the results of studies have been inconclusive, and that the possibility of lymphedema exists. I have not found one source claiming it is OK to make venipunctures or use constricting devices after a mastectomy. Could you please provide your sources? Not being argumentative, just would really like to read it.