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lapizius lapizius (New Member) New Member

Forbidden Extremity Sign and VTE in Arm

Safety   (4,966 Views 9 Comments)
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I'm a new grad nurse and in my first week of being on my own. Long story short, I had a patient admitted on my unit with a clot in her arm. She is young but she has had an injury in which she can't walk for a while. When I was assessing her, my aide was about to check her BP in the arm that has the clot (she was previously given 1 lovenox shot before coming up to my floor). The pt stopped her and reminded her that she couldn't do that with the arm that has the clot...so I ordered a 'forbidden extremity' alert band and a sign that warned not to use that arm for BPs...

I felt like I was doing the right thing for the safety of my pt at that time, but I tend to self-doubt a lot and now I'm wondering if that was the 'right thing' to do? The nurse for the next shift didn't say anything when I pointed it out during hand off, so I guess it was okay that I ordered the alert band?

I guess I'm just not sure, but I felt that it's better safe than sorry when it comes to clots..

Edited by lapizius

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You did the right thing. In this type of situation, ask yourself what potential harm may come if you do NOT take action (not placing the alert band and sign, resulting in BP taken in that arm that could dislodge clot) vs. potential harm of the action (placing band/sign, no potential for harm).

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Appropriate, especially the sign. Aides are not always properly trained to look at arm bands, even though they should be!

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Appropriate, especially the sign. Aides are not always properly trained to look at arm bands, even though they should be!
Well I am. We put armbands on and even a sign up in the room. I teach every CNA I train to do the same things. Common sense. You did the right thing OP.

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You did the right thing. In this type of situation, ask yourself what potential harm may come if you do NOT take action (not placing the alert band and sign, resulting in BP taken in that arm that could dislodge clot) vs. potential harm of the action (placing band/sign, no potential for harm).

I was going to say this exact thing! What reason would you have NOT to take the nursing actions that you did?

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First off, for the record, you did the right thing.

Totally out of curiosity, what makes you think it was possibly not the right thing to do?

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If you're worried about HIPAA, don't be. As the other posters have said, the risk to the patient from NOT posting that information in her room is so much higher than the risk of someone inadvertently knowing anything about her personal health information because of it.

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