IV Flushing & clots
- 0Feb 21, '12 by SN22RNHello,
I was wondering how often or common is it to dislodge a clot from flushing IPIDs? I'm a nursing student and I've had a couple of patient's that I've had a hard time flushing their ipids. I would let my instructors know and they would come in and just push harder and flush the IV. What I think in my head is (OMG, what about dislodging a clot!). I had another instructor tell me to push on the flush (and I pushed some but I didn't push THAT hard) so I told her I can't push anything through. So, she told me to pull back on the syringe a little and then try flushing. So, I pulled back on the syringe a little bit then was able to flush the ipid. What's everyone else's experience with flushing? Do you push harder on ones that seem "stuck." It scares me to do that, but my instructors don't seem as concerned as I do?!
If someone were to dislodge a clot from flushing a peripheral IV site, how quickly can someone die after dislodging the clot?
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- 0Feb 21, '12 by cayenne06I have no idea, but I remember the first time I saw an air bubble go into a patient's IV site.... pt was fine but I just about died from fear! I really thought they were going to keel over and die. And this was in a clinic setting, so there wasn't even a code team near by to ease my mind.
I am curious about this as well.
- 1Feb 21, '12 by SN22RNQuote from cayenne06Have you ever had the experience of having a hard time flushing a peripheral IV site on a pt? If so, what did you/your instructor do about it?I have no idea, but I remember the first time I saw an air bubble go into a patient's IV site.... pt was fine but I just about died from fear! I really thought they were going to keel over and die. And this was in a clinic setting, so there wasn't even a code team near by to ease my mind.
I am curious about this as well.
- 5Feb 21, '12 by KelRN215A peripheral IV catheter is SMALL. A clot that forms at the end of it would be microscopic. You are not going to cause an embolus by flushing a difficult to flush PIV. If a patient had any kind of a significant clot at the IV site, you would expect that they'd have symptoms from it- swelling distal to the site, cool extremities, decreased pulses. There are a lot of tricks to flushing a difficult to flush PIV and it's not always because of a clot that they're difficult to flush. Sometimes we'll put a little (like 0.5 mL of 10u/mL) heparin in them if we can't get the saline to flush. If the IV really won't flush, it should be removed.
- 2Feb 21, '12 by MrzAmazingRNTo add to what KelRN said! Think back to A&P and how the vascular system works. Our veins have valves in them that help keep the blood moving back toward the heart. These valves will close shut instantly if harm to the vein is detected. The introduction of the peripheral IV catheter is an insult/injury detected by the vein's valves. When fluids are running, the valves are open allowing blood and fluids to continue to circulate. If fluids haven't been running for a while, then the valves will close. So, when flushing it takes alittle pressure to open the valves back up. This is why saline locks have orders yo flush them when fluids are not running. As far as air goes, remember we breathe air and oxygen and CO2 are carried in the blood to the lungs and exchanged by the alveoli. If you flush air bubbles into a patient it will not hurt them! It would take a lot of air to cause harm to the patient. However, the air bubbles do freak patients out so they should be minimized, but don't waist medication trying to get all the air bubbles out. Lastly, a piece of personal advice! Try to learn hands on as much as you can during clinicals. If your going to mess something up, chances are its a minor mistake that any veteran nurse could make. Try to overcome the fear of making a mistake and be confident. You are smarter then you think, or you wouldn't be in nursing school!
- 0Feb 22, '12 by SN22RNThank you all so much! Makes sense why my instructors are not concerned with pushing the PIV harder...But why do they teach us in school not to push on a difficult PIV because it will cause a blood clot to dislodge and it will kill your patient! Nursing school is so stressful!! Everytime I leave clinical I think I killed my patient...... It's not a good feeling.
- 1Feb 22, '12 by psu_213Quote from SN22RNBecause nursing school always teaches about the worse case senario (these senarios are rare, but they make them seem like common place)....like an air bubble in a flush will cause death by air embolism. Or, every case of pulmonary edema causes the pt to spew pink, frothy sputum and the can't breath. While its important to know about these (the latter would be flash pulmonary edema, which is an emergency), teaching just these senarios cause students to be more afraid and have less confidence in 'normal' situations.Thank you all so much! Makes sense why my instructors are not concerned with pushing the PIV harder...But why do they teach us in school not to push on a difficult PIV because it will cause a blood clot to dislodge and it will kill your patient! Nursing school is so stressful!! Everytime I leave clinical I think I killed my patient...... It's not a good feeling.
- 9Feb 22, '12 by GrnTeaas a clarification, flushing iv locks has nothing to do with valves, and valves in veins do not somehow sense no iv running or venous injury and close. venous valves have no control mechanism at all, other than backpressure from the blood that has gone past them. all they do is passively prevent backwards flow. periodic flushes on locks don't have anything at all to do anything with venous valves. we do them to be sure the caths aren't occluded.
imagine what your legs would look like if there were no valves in the ascending veins -- the vein walls at the bottom of that huge column of blood would be bulging and leaking serum...which is, of course, what varicose veins do. they are caused by a failure of a valve above, so the valve below carries a double load, and it fails, and the one below that carries a triple load... and so on.
as to clots, your body shoots little clots all the time. these little emboli are strained out by the pulmonary capillary bed and dissolve there. really big emboli that can block off a sizable piece of pulmonary circulation are bad news, but the small ones from the ends of peripheral venous caths are harmless, with very rare exceptions. remember normal blood flow:
body > veins > vena cava > right atrium > tricuspid valve > right ventricle > pulmonic valve > pulmonary artery > lungs >pulmonary vein > left atrium > mitral valve > left ventricle > aortic valve > arteries > body
the only way a venous dvt can get to the cerebral arterial circulation is if there is a direct connection between the venous side and the arterial side in the heart and the venous pressure is higher than the arterial pressure.
anyone with an atrial or ventricular septal defect and a right-to-left shunt would be at risk for arterial embolus of venous origin, and this would be bad. however, since in most people, the left heart pressures are significantly higher than right heart pressures (by a factor of five to ten, more or less), any air or clot in the right heart keeps going right on out the pulmonary artery to the capillary bed. unsuspected asds are a known cause of stroke in younger people who lack other risk factors-- think of the much-beloved erstwhile heart and soul of the patriots' line, tedy bruschi, whose stroke fortunately resolved and whose asd was repaired endoscopically; he went back to football for the rest of that season and the next one (although he has since retired). as a matter of fact, most asds are found by accident or on post for unrelated issues, since the left-to-right shunt doesn't do much harm unless it's so huge that you get bad pulmonary hypertension and capillary bed damage (seen in single ventricle, for example).
- 3Feb 22, '12 by psu_213Quote from MrzAmazingRNThat would be nice, but unfortuntely veins aren't that "smart".These valves will close shut instantly if harm to the vein is detected.
What does happen is the end of the cateter can end up lodged against a valve. In that case, to facilitate flushing, just pull back a little bit on the hub--not enough to pull any of the catheter from the vein, just enough to pull the end of the cath off the valve.