Im a nurse! Not a doctor!!!

emsboss · Sep 11, 2008

Sounds like you made the right calls... pharmacy, physician, documented that you called and that no new orders recieved. I would be able to sleep at night. If anything, the Doc might should have come in and assessed the site if it were a med known to cause tissue necrosis, but, I would not worry about it. Am not supposed to give advice, so I won't tell you to keep notes on times you called and whom you called. GOOD LUCK!

icyounurse, BSN, RN · Sep 11, 2008

I dont think there is anything else you could have done in the above situation. I too have been guilty of beating myself up about stuff, but you can only do what you can do.

mama_d, BSN, RN · Sep 11, 2008

As long as you charted all of your interventions, your butt should be covered.

We had a similar experience on our floor a few years back, now they drill us on what meds to give for what, developed a protocol for certain drugs, etc.

Unfortunately, we are often in the situation where we are expected to know better than the docs without the advantage of their training. I can honestly say that I have charted before that I did NOT do such and such a thing b/c MD or DO refused to give me orders. Like "Noted that RLE is significantly more edematous than LLE, area on calf warm to touch and swollen, pt. advised to remain on BR status until evaluated by MD. Called placed to Dr. Jones, requested stat BLE venous dopplers, request for such order denied. Dr. Jones states he will be in early AM to evaluate pt." That way I'm covered, have indicated that I used my nursing judgement to try and obtain best care for the pt, but that the MD shot it down.

Blee O'Myacin, BSN, RN · Sep 11, 2008

Root cause analysis involves asking all parties questions in order to see if something could be prevented in the future. My take on this is that you assessed, notified the proper people (MD, Pharmacy, etc.) and documented properly. I'm wondering why the patient didn't have a PICC if there were regular infusions of a vessicant.

Please try not to beat yourself up over this anymore. And most importantly, don't take the blame for this when you did exactly what you were supposed to do. If you feel that you are being scapegoated, it might be a good time to call your union rep. or whatever other resource you have if your hospital has the "shared governance system".

Blee

IVRUS, BSN, RN · Sep 11, 2008

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!

I am glad that you even knew to ask if an antidote was available...A documented lawsuit involving a dopamine extravasation reveals the danger of not knowing: An ICU nurse had a pt in which Dopamine HCL was infusing via Implanted Port. The huber needle became dislodged to the point that the dopamine was infusing into the SQ tissue. Once the RN assessed that the huber became dislodged, she deaccessed the needle and reaccessed the port with a longer huber to bypass the swelling and continued the medication. This nurse either didn't know that the medication was a vesicant ( with the possibility of causing tissue blistering. sloughing and tissue necrosis or death to the tissue ), or didn't know that their was an antidote (Regitine or Phentolamine) that should be used to infiltrate the area s/p extravasation. After reaccessing, she continued the infusion. Unfortunately the patient's skin surrounding the port sloughed and became necrotic within two weeks s/p. This resulted in a lawsuit which the RN (or hospital who employed her) couldn't defend.

The fact that you asked the pharmacy for any antidote information on the drug was a good thing... I hope you documented that.

You didn't say what the medication was that extravasated, but it's important to remember that not all vesicants listed in the nurses drug book list antidotes or care s/p extravasation. Putting cold packs over the area was a good start. This will decrease the uptake of the med by the tissues. The only time I would use warmth is for an infiltrate of an isotonic solution or an extravasation of a vinca alkaloid.

This is one reason why it is encouraged by organizations such as Oncology Nurses Society (ONS) and Infusion Nurses Society (INS) to infuse vesicants via centrally placed lines, like a PICC or an Implanted Port.

And though an implanted port usually terminates in the central venous vasculature, infusing vesicants into this central line, especially in home care, becomes a real controversial issue because of the aforementioned situation.

Thank you for your diligence in providing excellence in patient care. :saint:

Keysnurse2008 · Sep 11, 2008

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.

you did the right thing...wth did management want you to do continue to let the fluid infuse ( with meds) into the tissue without documenting it? that is crazy......you did your job.....now rm needs to get a grip and do theirs! patients move, tissue swells and iv's infiltrate.....that is a fact of life.you did exactly what you were suppost to do.

Xbox Live Addict · Sep 11, 2008

Sounds like you made the right calls... pharmacy, physician, documented that you called and that no new orders recieved. I would be able to sleep at night. If anything, the Doc might should have come in and assessed the site if it were a med known to cause tissue necrosis, but, I would not worry about it. Am not supposed to give advice, so I won't tell you to keep notes on times you called and whom you called. GOOD LUCK!

Was the drug in question a vasoconstrictive drug such as dopamine? I would think if this was the case, the doctor would be highly concerned. But it sounds like OP covered her bases as best she could and documented her interventions and the response of those she called. She did her part admirably, but I know I'd feel scared if something like that happened to a patient I took care of, and terrible that maybe I didn't do something. Sometimes these things happen because of variables we have no control over.

At one hospital I worked at, powerful vasoconstrictive drugs such as dopamine, dobutamine, and norepinephrine were only to be administered by specially trained staff, and then through a high-flow central line.

ObamaRN08 · Sep 16, 2008

The drug in question was calcium chloride. and the root analysis went well and they didn't point fingers so that was good. I made the suggestion that it no longer be an option to treat these infiltrates or not treat them. that we treat every one of them every time. everyone agreed that there needs to be a policy and procedure in place for these types of situations, and I believe they are working on one now. so at least something good came out of this and on the way out of the meeting my boss said he was proud of me. SOOOO....I guess Ill stick around a little longer...but i might update my resume! :cool:

iluvivt, BSN, RN · Sep 25, 2008

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?

Vito Andolini · Sep 28, 2008

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!

GN Dave · Nov 2, 2008

Could you be convinced to share the chart that you have made with us?:flowersfo