General Rules for Med Surg

mmm_016RN · May 9, 2016

I have never heard the rule that IVs must point "down" ie away from the heart...I don't think I have ever seen one inserted that way. I have only seen the catheter pointing toward the heart, up the arm for example.

What at about midline catheters that start in the basilic vein and end just below the axilla?

Do you know the rationale? Maybe this is one of those sacred cows of nursing...

Editorial Team / Admin · May 9, 2016

The facility's policy and procedure manuals should be resources for you. It doesn't matter what people are doing at other facilities- what matters is what your facility has determined is the way things should be done. Now, if there's a policy you think is outdated, provide the evidence to the committee responsible for it, but following written policy is wise.

blackribbon · May 10, 2016

If the IV catheter was not pointing toward the heart, then it would seem like you could really damage some venous valves. The venous system flows toward the heart and I was taught to try to "flush" a stuck IV in which means using the saline flush to gently open a valve allowing the forward motion of a partially inserted catheter. I would recheck your information on IV catheter placement. And I didn't learn how to do them in school either but was taught on the job. I don't do enough to feel confident yet. Our IV team is only available after we have two separate nurses on our floor attempt to place an IV and fail. Honestly, I do fudge when I don't believe I have at least a 50% chance of getting it in...I do not have the confidence to try some microscopic vein in a patient's thumb though I do watch the experts in hopes of some day being that good.

Also, I came out of nursing school with "only normal saline and only normal saline" is to be hung with blood products drilled into my brain...but if you follow hospital policy, it will state pretty high up on the check list that normal saline only so you will be covered if you didn't know this. So I guess my first "general rule" is to ALWAYS look up the policy (and print it) when doing a procedure you are not familiar with...that way if I am challenged by a more senior nurse, I have the justification for my actions in writing (they often do things according to old policies) and I won't do it wrong.

I mean there are other things such as never put anything in a line that is infusing TPN without a doctor's orders (that environment is ripe for infections)...it should be a dedicated line for as long as TPN is being infused. And a million other safety things that I can't even begin to list. So if in doubt, ask and look it up...which means a lot of looking up in that first year..

Always help out another nurse if you can...answer call lights, help with empty IV bags, grab an apple juice (after verifying the diet orders), etc.

One of the first lessons I learned on the floor was never leave an almost empty IV bag for the next shift...at the very least, have the new replacement bag hanging on the pole. Meet your patient's pain and nausea needs before you leave for the day so your replacement doesn't waste her first half hour handing out pain & nausea meds when she should be organizing her shift. And if your patient is using prn meds frequently but they have to be ordered from the pharmacy, order the next dose before you go.

nynursey_ · May 11, 2016

I think what you're referring to as "general rules" are really simply essential parts of knowledge of a clinical skill. For example: it best practice to flush a PEG tube with 30mL of sterile water prior to and after accessing a tube for bolus feeds or medication (unless otherwise specified by the provider).

Many policies and procedures are put together following best practices. But always check your facility.

elkpark · May 11, 2016

A) It's really hard for me to imagine a legitimate nursing school that doesn't teach students 1) how to do IV sticks, and 2) that you can only hang blood with NS. Jeez, nursing education really is going to he!! in a handbasket.

B) IVs are always inserted "pointing" toward the heart. Peripheral IVs are inserted into veins, and the venous blood flow is toward the heart. It would make no sense to insert the catheter in the opposite direction of the blood flow, and that would probably interfere with the infusion. I'd love to meet your charge nurse who considered this an "error."

NotAllWhoWandeRN, ASN, RN · May 11, 2016

A) It's really hard for me to imagine a legitimate nursing school that doesn't teach students 1) how to do IV sticks, and 2) that you can only hang blood with NS. Jeez, nursing education really is going to he!! in a handbasket.
B) IVs are always inserted "pointing" toward the heart. Peripheral IVs are inserted into veins, and the venous blood flow is toward the heart. It would make no sense to insert the catheter in the opposite direction of the blood flow, and that would probably interfere with the infusion. I'd love to meet your charge nurse who considered this an "error."

I wonder if it's different wording intended to mean the same thing - like the outside/port of the IV points "away" from the heart?

OP, as has been mentioned, the direction is due to the internal catheter's function. Imagine holding one end of a pool noodle and dunking it into a fast moving stream. If you point the loose end downstream, there is no resistance and the pool noodle will lie straight without bumping into things. If you point it upstream, it's going to get whipped around and bent and bump into things. That will happen inside a vein if you point the inner catheter "upstream", and that's before you even factor in trying to infuse anything.

My college didn't do any hands-on IV stuff unless the clinical nurse (not your instructor, the nurse who had your patient during a clinical shift) was willing to do it with you. Some mumbo jumbo about liability issues.

OP, if a procedure is new to you, start with the hospital policy. Transfusing blood is a critically important (and risky) procedure, and not one you plunge into blindly. You don't need to know everything, just where to find the information. Stop and think about what you are doing and why, before you start. When in doubt, ask someone for guidance.

guest112 · May 13, 2016

This is solid advice. If you want the right answer, always go to the policy yourself.

BeachsideRN, ASN · May 13, 2016

A) It's really hard for me to imagine a legitimate nursing school that doesn't teach students 1) how to do IV sticks, and 2) that you can only hang blood with NS. Jeez, nursing education really is going to he!! in a handbasket.
B) IVs are always inserted "pointing" toward the heart. Peripheral IVs are inserted into veins, and the venous blood flow is toward the heart. It would make no sense to insert the catheter in the opposite direction of the blood flow, and that would probably interfere with the infusion. I'd love to meet your charge nurse who considered this an "error."

I met a new grad that had never done an accu check before. Nothing surprises me. Nothing.

elkpark · May 13, 2016

I met a new grad that had never done an accu check before. Nothing surprises me. Nothing.

Sad, isn't it ...

pixierose, BSN, RN · May 13, 2016

Sad, isn't it ...

It's not sad, it's infuriating.

I'm halfway through my BSN program, at a very good school, and you have to search high and low to "gain these experiences." In regards to starting IVs, I've taken a class *outside* of school so I could learn. IV skill classes are quite popular these days with students.

Schools today? They teach to the NCLEX. Clinical settings? In my first clinical setting, my instructor was more worried about us writing care plans than developing clinical skills. Even now, we students have to be quick and observant to catch a skill being completed to be taught. Best bet? Find that nurse who's fine with having a student. That's how I've learned my skills.

elkpark · May 13, 2016

It's not sad, it's infuriating.
I'm halfway through my BSN program, at a very good school, and you have to search high and low to "gain these experiences." In regards to starting IVs, I've taken a class *outside* of school so I could learn. IV skill classes are quite popular these days with students.
Schools today? They teach to the NCLEX. Clinical settings? In my first clinical setting, my instructor was more worried about us writing care plans than developing clinical skills. Even now, we students have to be quick and observant to catch a skill being completed to be taught. Best bet? Find that nurse who's fine with having a student. That's how I've learned my skills.

This is a big piece of why so many hospitals are so reluctant to hire new grads. They resent having to spend a lot of time and money teaching new grads the basic clinical stuff they need to know to be able to get through an ordinary shift, things that the hospitals believe (rightly, IMO) people should have learned in nursing school.