For my Leadership and Transition course our final project is a mock trial. The case I have to argue involves a nurse being sued after the catheter became dislodged during a Mytomycin infusion. The nurse was found not liable as she followed policy and protocol during the infusion and after the suspected extravasation.
My question is that the nurse started the IV in the patient's hand, and most of the research I've done states the forearm should be used instead. I have to argue on behalf of the nurse. Does anyone know the reasoning behind starting in the hand? The reasoning I came up with is that the patient was 40 with no significant PMH (we really don't get a lot of info to go off of), so fragile veins may not be a concern. Additionally, if there was a problem with the infusion starting distal lot offers more options to move the IV.
Apr 5, '13
Extravasation might be caught faster in a hand site, but would cause more damage whereas the forearm might have less damage from the extravasation. The veins of the hand are often too small to properly dilute the vesicant, you'd want to use larger veins.
Apr 8, '13
Were there previous IV attempts in her forearm that failed? Did the nurse not see any veins that were useable in her forearm? Are her veins poor from previous chemo, thus decreasing the availability of other sites? Did she have previous extravasations? Did she refuse an IV in her forearm? Those are all viable reasons I can think of for being forced to use a IV site in a hand.
I know you said she followed policy, but specifically, Was the medication infused with a flush and was blood return checked per policy? What does the policy say specifically about IV locations for chemo?
Apr 14, '13
It's not always possible to find a vein in the forearm. Personally, I have never given chemotherapy through a peripheral IV but it can be done if policy is followed. Policy when I worked at the hospital was that chemo had to be given through a NEW peripheral IV (with + blood return verified prior to infusing) or a central line.
Apr 15, '13
The rational NOT to use the hand is that because there is not a lot of tissue there if an infiltration or extravasation should occur there is greater potential for tissue,nerve and tendon damage. The patients can end up with some pretty devastating injuries if policies are not followed.
The general rational for using more distal sites is that it preserves the more proximal sites for future use. So you work your way up the arm. If the nurse in this fictitious scenario documented that she could not find any other suitable veins and took reasonable actions that a prudent nurse should follow you can argue that she is not liable. They would also look at the hospital policies making sure they are consistent with the current standard of care and ONS and INS guidelines.
In reality though if the patient sustains injury the nurse would usually be found liable for poor site selection.not advocating for a central line or getting a more experienced person to start the PIV and perhaps more depending upon all the facts.