I'm hoping to get some insight from other centers regarding hypotensive reactions with IV iron infusions.

Have any of you developed a screening tool or set of criteria to help identify patients at higher risk for hypotension?

Also, for patients who meet certain risk factors, do you ever use pre-hydration protocols or other preventative measures to reduce the likelihood of a blood pressure drop?

Any shared workflows, tools, or best practices would be greatly appreciated.

Thanks so much!

I just would like to share my experience with everyone especially to those who are considering to take the exam in the future. I used the VACC Study Guide and CRNI textbooks for my study materials. Google was also very helpful .

My appointment at Prometric was at 2:30pm but I arrived 1.5 hrs early. The receptionist asked me if I would like to take the exam earlier so I said yes. She then told me to place my belongings in the locker and bring my ID card. By the way, as of this writing, only 1 form of identification is required for the exam so I showed her my state ID. I was scanned, given instructions then asked to sign in the logbook. I was then handed a pencil and a scratch paper (which I never used). She guided me to my cubicle placing the ID card and locker key on the desk. FYI there is no break in between the test, you are actually allowed to leave but your test time will continue to run (I never went for a break myself).

The exam was for 2.5 hrs (total of 150 questions but only 125 will be scored) and it took me almost 2 hrs to finish after throughly reviewing my answers. No worries, a tutorial will be shown first and will allow you plenty of time to practice. Time only begins once you're ready to end your tutorial.

I knew the result right away after I pressed END. The word Congratulations in boldface was the first thing I saw (Phew!).

I left the room then the receptionist told me that I passed and handed me a printed copy of the result. I'll be expecting to receive my certificate and wallet card within four to six weeks.

So overall, it was a great experience . I was just happy that I passed the exam.

Best of luck to you!

we are working to move to an ehr and have gotten stuck on a picc line issue. within the program is wants us to document the picc line ports as distal proximal etc. is a picc actually setup like this? I know tlcs are but I thought picc are cut to length thus cutting a tip or other port? do meds given through different ports on a picc go through two catheters within the picc or do they mix? all meds come out the very tip of the picc, correct? any help would be great, thanks.

jason,

BSN, mha, RN-bc, emt-p, ccrn, cen

Any help is appreciated. They only test twice a year, the next one being in June...and in trying to see if that will even be enough time. 
thank you!!

I am studying in CRNI exam. I do not know what class I need to take? What Text book can I use? what practice questions? How to study on it? 

Thanks

wei

The company I'm looking at pay mileage to and from a visit but not drive time. The clock starts at the beginning of the visit. 
 

This is a PRN position. 
 

I work regular home health also (PRN), and I get paid per hour for drive time. 

I just found the straight angiocath so "loose", like the catheter was so loose on the needle that I had no control and things were moving around too much.  Both times I got in the vein and my technique was off and it blew.  Once I got in the vein I was having a hard time slipping the catheter off the needle.  On my second try the catheter was definitely filling with blood, but I think I continued to advance the needle with the catheter and something went wrong, when I clicked back the needle the blood wouldn't advaance anymore and it was blown when I flushed.

Its hard to beleive that the system I used to love so much for how "easy" it was to flush the catheter forward now has become so slippery, loose, and sloppy for me, especially how hard the nextiva was at first for me to get the hang of it.  Hopefully someone can please help me where I might be going wrong.  Thank you!

Smith Medical's Jelco IV Catheters are one of the most affordable options at $0.35 per catheter regardless of gauge. This product is described as being multi-use for its ability to achieve both atrial lines and intravenous access. It uses FEP technology for the catheter itself, thereby allowing for higher flow rates with a smaller gauge and ease of use with insertion. Some caveats exist using this catheter. For example, it does not have the technology to prevent blood exposure. Clinicians will need training on venous compression while supplies are attached with a free hand. This could be an attachment of products such as a saline lock, bolus tubing, etc. There also is training required that reminds the clinician that the needle must be manually retracted in its entirety to be safe versus other models that have a "quick" retract. Given the estimation of needle stick injuries being between 600,000 to 800,000 in the United States alone (2005)¹, the emphasis on this training cannot be excluded. Time is valuable to clinicians, so having products that have features for safety and speed of insertion can be more cost-effective. However, when arming the same clinicians with training emphasizing safety, the Jelco is a perfectly safe and effective product that can be a simple way to reduce overhead costs of a unit.

BD Becton Dickinson provides a similar style catheter to the Jelco with updated safety features at an average cost of $2.67 per catheter, depending on the gauge. This catheter is called the BD Insyte Autoguard. Per BD's website, this particular type of catheter reduces needle sticks by 95% when compared to its competitors. This is in part due to the button push retraction, which immediately encapsulates the needle in a plastic tube away from the patient and clinician. Additionally, once the needle is removed from the catheter, there is blood-stop technology. This prevents the release of blood into the field until additional tubing or supplies have been attached. Having a safe and clean field allows clinicians to release the area of insertion, allowing two hands to be free for securing the catheter and other supplies. In this instance, an ounce of prevention is worth a pound of cure. Due to the safety features on this item, hospitals can assume decreased costs in liability from less frequent adverse events, I.e., blood exposure and needle stick injuries, as mentioned above.

Both BD and Smith Medical provides an all-in-one catheter. These styles are known as the BD Nexiva closed peripheral IV catheter system and DeltaVen closed system catheter.  The Nexiva comes at an average price of $7.00, while the Deltaven can be found for as much as $11.00, depending on the vendor as well as the gauge of the needle. Before the "sticker shock" sets in, it is important to note that other IV models do not include IV extension sets which are necessary items to create a saline lock. They also include needleless injection ports, another safety option that can be sold separately. Both products certainly pack a punch with all the safety options available. The drawbacks can include clinician discomfort and uncertainty. Adjustments in technique need to be made for those inserting the IV due to the bulk and weight of the item that is not found with other models of catheters. If there has been extended use of the previously mentioned catheters on a floor, there may be refusal to change products due to clinician comfort in accessing a vein on the first attempt. From a patient vantage point, preference for a single lV attempt is optimal, especially in cases where an analgesic is not used. Whether or not the item reduces shrink to hospital stock is yet to be determined but it also is a contributing factor in cost.

Ultimately, between the options available, it would behoove a hospital to explore all three options of intravenous catheters. Different specialty units have an array of requirements and patient needs. Including staff in any decisions made (since they will be the end users) is imperative, and they will be the ones to keep patients safe.

References

• Warm Compresses ( skin warmers-warm towel-leave on for about 10 minutes)
• Double tourniquet ( don't leave on for more than 1 minute)
• Accuvein vein locator ( easy to learn how to use-works when you can't even feel a vein)
•  Using an ultrasound for access - this is more difficult to learn how to do, and a qualified provider is not always available
• Take your time and pick the best vein you can find (bouncy on palpation-no roughness from internal scaring-not too hard-preferably anchored well in the tissue)
• Don't be afraid to try at least once-your skills will improve  with practice

Was recently discussing with my peers about USGPIV success rates in our department and we were wondering if anyone had some information about any national USGPIV success rates? Or does anyone have any success rate information for their own vascular department they would be willing to share? Our department was interested to see what other teams are considering a standard for USGPIV success rates and when should a department start implementing interventions or education to increase success rates.

Appreciate your input!

Dohboy, BSN RN

What is the proper way to draw blood cultures from PICC line?

If the PICC line draws blood ok, is it best to draw blood into the cultures without first flushing and wasting blood?

Or is it best to first flush the PICC line and waste blood before drawing the blood cultures? Wouldnt this method flush the bactieria out of the PICC and reduce the chance of a successful culture.

I found an article on the internet that the first 3 inches of the inside of the wrist should not be used because there is a risk of hitting a nerve and causing permanent nerve damage. Dose any one know if this is true?

I am trying to gain some insight before I interview for a position as to what I need to know as I am new to this side of nursing.  I have been a nurse for almost 20 years and have not done this before.

Are there courses I can take online?  What questions should I ask at the interview?  What skill set is good to highlight since I haven't done infusions before?

Should I be worried if they are willing to hire me without experience with infusions? 

But until such a time as I can convince the hospital to make this major practice change (and there may be significant financial outlay involved, I have no idea), what do you think I should do? Is it better for the nurses to continue not flushing the IVs anyway, or is it better to encourage them to flush with the sterile water until the day NS might be available?

A couple of times a year we have visiting medical teams from first-world countries come to do some advanced surgeries. I asked the pharmacist what those teams use for flushes (he'd said to me yesterday, when I asked for NS to flush a central line, "oh... I think we have some left from the last American team") and he claimed they use lots of things, NS that they bring, sterile water, even LR (?). That may just have been defensiveness, but if these American and Australian ICU nurses are really using sterile water to flush, I'm alarmed! Maybe they just haven't heard of it so assume it's okay.

Is this acceptable by any stretch of the imagination?    I say hell to the no.  

 

Who has taken the CRNI exam? 

It is very hard? how long study for the exam? What books use? what prepare class helpful? what contents on Exam?

Thanks in advance

Wei

We are taught to backprime at my hospital. So, you have NS running primary and need to hang one ABX secondary. Couple hours later need to hang another ABX secondary. I get use same line, backflush. What is really annoying me though and I am hearing conflicting things about (and can't really understand the research that has been done) is:

If a medication is COMPATIBLE with the primary fluid running and does NOT require a dedicated line, it is OK to backflush even if the new ABX ready to hang is NOT compatible with the last ABX hung. ???????

I was trying to discuss this with a coworker, telling her I had seen research saying that regardless whether those two secondaries are compatible, you can backflush and hang with same tubing unless the med is not compatible with the primary fluid flush. She looked at me like I was totally crazy and stupid. I mean, if you are backflushing with NS all the way through the line and inverting the old secondary to squeeze any remaining old ABX back in the old bag before you disconnect and hang the new incompatible ABX, there really is no incompatible medication left, right? Especially when you consider dilution?

She pulled policy and it seems like the hospital wants new secondary tubing attached if new piggyback is NOT compatible. Then when you need to hand another med, you need to detach that tubing and attach another. When this practice ensues, don't you now have to change the IV tubing more frequently because you are opening the line?

Sorry, I'm a new grad and this is driving me crazy because I want to know best practice. I will follow my hospital policy but can you point me to any evidence based info on this? I only found one thing that said no one really knows with incompatible med backpriming but that backpriming compatible meds is preferred over disconnecting and connecting new secondary tubings.

HELP! Thanks!

I've been a nurse for about two years and just started working as an IV infusion nurse. In the past, I've had experience with blood draws and have started IVs a handful of times.

I'm really excited about this position and I've been successful with most of my sticks in the AC/ bicep area and have been successful with placement in the hand a few times. I'm struggling with IV placement in the back of the hand. I usually get flashback and lower my angle but then the catheter won't thread or I go to stick them and the vein completely rolls. I anchor it, but find my hand placement gets in the way of my sticking hand if that makes sense.

What angle is recommended?

I've started to go more flush to the skin but have even been missing when adjusting my angle. Getting very frustrated with this and I have to admit it psyches me out everytime I know I have to place an IV in the hand.

How do you guys keep your cool when you've had a few bad sticks in a row? Also, is there anyway to tell where valves are besides for seeing them? I've hit valves on pretty good veins that made it difficult to thread it in.

Any help is appreciated!

We're measuring exposed length and arm circumference daily. Aspirate for blood or not?

I thought they discontinued the routine use of heparin with peripheral IV flushes a loooonnnggg time ago but have ran across something given to me by a colleague (PowerPoint) recommending its use.

Has something changed? Or are they still typically only using: saline flush, med, saline flush?

Thanks in Advance!!