Im a nurse! Not a doctor!!!

Just want to add my two cents here. I have spent the last year working on a document that lists all the medications and IV fluids that if extravasated have the potential to cause tissue necrosis. You refer to the incident as an infiltration but in actuality it is an extravastion. An extravastion is the inadvertent administration of a drug or IVF that is known to cause necrosis into the tissues. I do not mean to burst your bubble...rather just inform you so you will be a better nurse. It does not matter whether or not the MD knew what to do or not.....you.....as the RN are responsible to provide the standard of nursing care in this situation. Let us just say,you have a Dopamine extravastion and you fail to call the MD and request a Phentolamine (Regitine) order to treat the area...you will have failed to provide the standards of care. Now in the case of the Calcium Chloride what you should have known is that first it has a huge potential to cause tissue necrosis,sloughing and cellulitis if extravasted and optimally should have been given through a central line after a verified good blood return. If no CVC available you can give it through a PIV but should be no more than 24 hours old. You could have also requested from the MD to change it to Calcium Gluconate which can still cause tissue damage but not as much as the Ca Chloride (10 x more potent). The best possible thing is to avoid the whole problem is by knowing what you are up against, After the incident you did the right thing by applying cool compress and the recommendation is just slight elevation. The site should have been immediately treated with Hyaluronidase to spread the offending agent out and decrease it concentration in one area (spread and dilute). Some Hyaluronidase brand names Amphabase,and Hydase. This is mixed in a similar manner as Regitine and given in multiple SQ injections around the extravasted area. Next you continue to monitor and document and repeat the dose within 12 hours if blistering or s/sx of worsening. If any s/sx of Compartment syndrome call MD stat and have a Plastic Surgeon consult. There have been many lawsuits aroung this issue and others like it. About 2 weeks ago we had a proximal port of a CVC that was in the chest tissue and Ca Chloride had extravasted and I gave some Amphadase with great results. Please remember that these injuries can sometimes occur weeks after the injury and sometimes are not painful. What your hospital needs is an Extravastion Policy and nurses need to be made aware of all the medications and IVF that have this potential. I have noticed this in my own workplace and thus I made myself my own chart. If you would like any more info just send me a pm I am always willing to share. Do you have an IV team to call for recommendations?

If she is expected to know everything to do and do it, is that without an MD order? Is that do it even if MD explicitly says not to? Is she supposed to get consults without orders from MD to get them?

Where does the RN's responsibility end and the MD's begin these days, since there is, apparently, no captain of the ship any more? I am going to PM you to please get a copy. Thanks!

I am so sick of my facility expecting me to be a nurse doing total care of critical patients AND expecting me to be a doctor. I did not go to medical school. I went to NURSING school. yeah sure I need to question crazy orders and get orders for crazy things that happen. I am okay with that. That is my job. I am NOT okay being held resposible for a MD's decisions. I had an IV infiltrate.. okay my job to deal with this. fine. I call pharmacy and ask if this drug needs any kind of extra attention ( an antidote or what-not) Pharmacy says well, there could be some damage but it is not likely and is not common practice to treat. I didn't go to medical school so I call the person who did and is responsibe for making these types of desicions. Pt IV infiltrated, such andsuch drug was running pharmacy said this and this, area is swollen but pt states is not painful at all , didn't even know it was infiltrated, ice pack applied per pharmacy suggstion. MD in to see pt...no new orders. will continue to monitor. 2nd Iv site infitrate area slightly swollen, pt states area is not painful ice pack applied. Md notified. No new orders.will continue to monitor. end of shift and I go home.
2 wks later.
call from upper management for root cause analysis. pt infiltrate site got necrotic and had to be debrided. then a wound vac. where do I stand here? Did I not do what I was supposed to? I notified the doc and called pharmcy about it. I caught it from assessing the site properly. but for some reason I feel responsible. Pt has now passed after a surgery on the legs, an unrelated incident I HOPE. Manager says it was not related. I stil feel responsible though. IV infiltrates happen. you can check it and maybe even the moment you leave the room the patient moves wrong and its 2 hours before you get back in there. It sucks but I am not negliegent in this as we assess patency Q2. WHY do I feel responsible. Why do I feel like the worst nurse in the world like I should somehow magically aquire the judgement skills of a medical dr in 1 year of nursing. like I shoud have insisted the MD do something differently based on some knowledge of pharmacology and pathophysiology one aquires in medical school. Yes I know that I need to know quite a bit, but come on! If I knew everything why do we even need doctors???????
Okay. Its out now and I feel better. Thanks for reading the VENT!