IV Questions from a New Nurse

[BowHunterRN]

I'm a new nurse and have some questions about using IV's. We were taught NOTHING about IV's in school, and it seems like at work everyone just assumes I know all about them. So here it is:

When a patient states that their IV is "hurting" should you not use it? I know some medications burn, like phenergan, but I don't want to use an IV that is possibly infiltrated.

Another question - My preceptor and I had a patient who had a peripheral IV and said it was hurting. It was due to be rotated the next day, so I was just going to change it. My preceptor went ahead and used it. The next week, the patient was back with cellulitis in the same place that the IV was. So, did my preceptor use an infected site?

What is the best thing to do when an IV infiltrates? Ice? Elevate? My preceptor didn't do anything on one patient. And, are you supposed to try to restart the IV in the opposite arm? This patient had an IV in their hand that infiltrated, and it was restarted on the same arm in her AC. If it's above the infiltrated site, that's ok, right?

And - This is more of a med question, but - why is it that some nurses give IV phenergan and dilaudid close together, but others wait an hour? I've looked in books to see why they should be an hour apart, but haven't found an exact answer. Just wondering about this for patient safety.

I feel like I don't know the signs that an IV should possibly be restarted, so I've been trying to read up on it. But I still had some questions, so I thought I'd come here. I hope I don't come off as a clueless nurse, I just want to know more than I do. Thank you so much!!

[BowHunterRN]

• What are we infusing through it? What is the ph of the medications (s) and osmolarity. (this will take sometime for you to learn and I can give you a list of the most irritating medications if you want me to. Any med with a ph of less than 5.5 or greater than 9 are VERY irritating to veins so your site will not last as long. A central line is always preferred in these case but is not always done. Blood osmolarity is about 290 so the farther away you get from this the greater the irritation to the vein
  

I'm very interested in the list of most irritating medications. If there's any way you could give it to me, I would really appreciate it.

[iluvivt, BSN, RN]

brittrn pm me with your private E mail and I will get a list to you....your teachers comment about IV therapy is laughable....did you know that IV therapy related (including IV medication administration) is the number one reason nurses are sued? So yes it is extremely important that you educate yourself on all aspects of IV therapy. Your teacher is ignorant!

[SunnyAndrsn]

Phenergan is a big one, as everyone else has said. The vials that we get have a reminder to dilute further, with at least 10ml of saline. I push phenergan very, very, very slowly...much to the irritation of pts. who like their "power hour" with dilaudid.

Sadly, I recently cared for a youn (just out of high school) bullimic who had managed to get some dilaudid and phenergan ordered. Very sad, as she was drug seeking. Her friend in the room asked me why I was taking so long to give the medications and my pt. commented on the fact that they 'don't work as good' when pushed slowly. I called her out and she admitted that she liked the high :-(

I'm very interested in the list of most irritating medications. If there's any way you could give it to me, I would really appreciate it.

[Eliseinalaska]

My teacher actually told us that IV's are just a "task" and have nothing to do with nursing.

Now that's just absurd. Sure, starting IVs isn't the most knowledge intensive part of being a nurse. But it's a necessary part of the job, and it takes a lot of practice to get good at the skill. I also didn't learn the skill in school. 15 years later, I finally started my first IV. I'm finally starting to get past all those years of doubt! Do what it takes takes to get that skill solid early on. You won't be sorry!

[iluvivt, BSN, RN]

Just remember not to view IV therapy just as a "task" especially the actual starting of an IV. There is so much more to it than most realize....more than I even realized when I started in this specialty. When I go in to start or re-start a PIV or when you do...look at the whole picture of what is going on with the patient. Sometimes this will be quick assessment as in an emergency situation...sometimes you will have a little more time and you can evaluate what is best for this patient. I understand that the modern nurse is very busy and at times can barely keep up and that is why I believe the IV specialist or in a nurse knowledgeable in this field is crucial to deliver safe IV care. I look at the whole picture when I go in to assess the IV needs of any patient....what is the diagnosis? or diagnoses ...what IV therapies are being delivered? What is the ph or osmolarites of the IV fluids and meds? What is the anticipated duration of the IV therapies? What is the current quality and state of the patient/s peripheral veins? Can we deliver the prescribed treatment peripherally in a safe manner? What is the most suitable access for this patient taking in all the various factors? Once I go through all of that and believe me I can do it quickly now and I rarely have to look anything up anymore...I make a plan and proceed. it is also important to view IV therapy not just as placing an IV...it includes all aspects of infusion......the drugs..the IV fluids...blood and blood product administration ...TPN and Lipid administration..IV pump technology and safety .....chemotherapy administration....treatment of all potential complications .....I could go on and on...we are involved in all of that An IV nurse is a wonderful resource for you if you happen to have them..if not ......you can start to study on your own and add to your knowledge base

[allthesmallthings]

Heat is the treatment for a phlebitis.

:yeah:

I keep being confused as to why people say to treat phlebitis with heat. Phlebitis is inflammation -- inflammation is treated with cold, yes?

Also, on the topic of IV's, I'm confused as to why I rarely get blood return when I pull back on a heplock/IV that's been in the vein for more than just a few minutes. That is to say, when I'm assessing the heplock/IV by flushing it, I rarely get blood return if I pull back (unless it's a brand-new IV that I am placing right then). Why is that? Lack of blood return happens with the majority of my IV's/heplocks, so it can't be that the cannula is outside the vein; but as long as the cannula is in the vein, why doesn't negative pressure pull back blood?

One more question, to any and all: if a non-maintenance fluid, such as an antibiotic, is running and I need to give an IV push such as a pain med, nausea med, toradol/decadron, etc., is it acceptable to pause the antibiotic with the IVAC pause button, flush the line, push my IV push med, flush the line again, and restart the antibiotic?

Also, could I do this with blood running? I know that you're not supposed to run anything other than NS with blood (why? IV meds go into blood for absorption and metabolism, by definition; and we run fluids other than NS, so what's with the rule that only NS can prime a blood tubing system? I understand hypertonic/hypotonic/isotonic, but fluid flowing into cells/out of cells doesn't hurt the Pt, although of course the MD determines which fluid to give), but as long as I kink the tubing proximal/above the Y-port so that there's no back flow and flush it well before and after pushing the med, is that okay?

,

[LilRedRN1973]

inflammation is treated with cold, yes?

Not in my experience (I have rheumatoid arthritis) I treat mine with heat!

[talaxandra]

if a non-maintenance fluid, such as an antibiotic, is running and I need to give an IV push such as a pain med, nausea med, toradol/decadron, etc., is it acceptable to pause the antibiotic with the IVAC pause button, flush the line, push my IV push med, flush the line again, and restart the antibiotic?

I certainly do, if the patient only have one IV access, provided the infusing med is compatible with N/Saline, and is running relatively quickly.

However, the rate of the infusion is essential in determining whether or not this is safe, because the pre-push flush is potentially increasing the rate of infusion of the running drug. So if the infusion's an antibiotic running at 200ml/hr then it's fine. But if the infusion was a narcotic analgesic or an inotrope, running at say 2ml/hr, flushing 4ml of tubing would give the patient a rapid bolus of two hours' worth of medication, and they would then not receive any of the medication for a subsequent two hours (as the post-push flush is being infused).

I know that you're not supposed to run anything other than NS with blood (why? IV meds go into blood for absorption and metabolism, by definition; and we run fluids other than NS, so what's with the rule that only NS can prime a blood tubing system?

In part because the blood you're infusing isn't the same as circulating blood - it's packed cells with a small amount of plasma, so it doesn't react to fluids and other drugs the same as circulating fluid. If, for example, you prime a line with 5% dextrose instead of with N/Saline a significant number of the transfusing cells with rupture, reducing the effectiveness of the transfusion (fewer RBCs), increasing the K+, and increasing the risk of organ damage secondary to the toxic effects of free haemoglobin.

[Asystole RN]

For some of you asking for a list I would say the list of what is NOT an irritant is shorter.

Here are some

• Acyclovir > 7mg/mL (Zovirax®)
  
• Aminophylline
  
• Calcium salts ( 100 mg/mL concentration)
  
• Chlorothiazide (Diuril®)
  
• Cisplatin (Platinol®)(in concentrations 0.5 mg/mL)
  
• Dactinomycin (Actinomycin-D, Cosmegen®)
  
• Daunorubicin (daunomycin, Cerubidine®)
  
• Dextrose solutions >10%
  
• Dobutamine (Dobutrex®)
  
• Dopamine (Intropin®)
  
• Doxorubicin (Adriamycin®)
  
• Epinephrine
  
• Epirubicin (Ellence™)
  
• Hydroxyzine (Vistacot™) Do NOT administer IV
  
• Idarubicin (Idamycin®)
  
• Mannitol (> 5% concentration)
  
• Mechlorethamine (nitrogen mustard, Mustargen®)
  
• Mitomycin C (Mutamycin®)
  
• Mitoxantrone (Novantrone®)
  
• Nitroglycerin
  
• Norepinephrine (Levophed®)
  
• Oxaliplatin (EloxatinTM)
  
• Phenylephrine
  
• Phenytoin (Dilantin®)
  
• Promethazine (Phenergan®)
  
• Sodium bicarbonate (>8.4% or > 1 mEq/mL)
  
• Thiopental (Pentothal®)
  
• Total parenteral nutrition (TPN)*
  
• Tromethamine (THAM®)
  
• Vasopressin (Pitressin®)
  
• Vinblastine (Velban ®)
  
• Vincristine (Oncovin ®)
  
• Vinorelbine (Navelbine ®)
  
• *TPN solutions containing amino acid solutions >5% and/or Dextrose >10% are considered
  
• Amiodarone (Cordarone®)
  
• orificenic Trioxide (Trisenox®)
  
• Bleomycin (Blenoxane®)
  
• Bortezomib (VelcadeTM)
  
• Busulfan (Busulfex®)
  
• Calcium salts (
• Conivaptan (Vaprisol®)
  
• Carboplatin (Paraplatin®)
  
• Carmustine (BiCNU®)
  
• Cisplatin (Platinol®) (
• Cladribine (Leustatin®)
  
• Dacarbazine (DTIC-Dome®)
  
• Dalfopristin/quinupristin (Synercid®)
  
• Dextrose (
• Docetaxel (Taxotere®)
  
• Erythromycin
  
• Esmolol (Brevibloc®)
  
• Etoposide (VePesid®)
  
• Etoposide phosphate (Etopophos®)
  
• Fluorouracil
  
• Gemcitabine (Gemzar®)
  
• Gentamicin
  
• Ifosfamide (Ifex®)
  
• Irinotecan (Camptosar®)
  
• Liposomal cytarabine (DepoCyt®)
  
• Liposomal daunorubicin (DaunoXome®)
  
• Liposomal doxorubicin (Doxil™)
  
• Liposomal vincristine (Marqibo™)
  
• Melphalan (Alkeran®)
  
• Nafcillin (Nallpen®)
  
• Paclitaxel (Taxol®)
  
• Paclitaxel, nanoparticle albumin-bound (Abraxane®)
  
• Plicamycin (Mithracin®)
  
• Potassium chloride
  
• Sodium chloride ( 1% or 170 mEq/L)
  
• Streptozocin (Streptozotocin, Zanosar®)
  
• Teniposide (Vumon®)
  
• Thiotepa
  
• Topotecan (HycamtinTM)
  
• Vancomycin
  

[iluvivt, BSN, RN]

good list just need to deliniate the irritants from the vesicants.....so a vesicant if extravasated can cause tissue necrosis

• Dextrose 10% or greater
  
• Calcium Chroride and Gluconate (Ca Cl worse)
  
• Diazoxide
  
• Diltiazem
  
• Dopamine
  
• Dobutamine
  
• Indomethacin
  
• Esmolo
  
• levophed
  
• Lorazepam
  
• Metronidazole
  
• Midazolam
  
• Nitroprusside
  
• Norepinephrine
  
• Phenergan
  
• Phenobarbital
  
• Phenytoin
  
• Pipercillin
  
• Potassium>40 meq
  
• Rifampin
  
• Sodium bicarbonate
  
• Sulfamethoxazole
  
• TPN
  
• Vancomycin
  
• Zosyn
  
• 3 and 5 % sodium Chloride
  
• Contrast medium (ionic worse than non-ionic)
  

The absolute worst of these are the CaCL.the 3 and 5 percent NS,the ionic contrast medium.levophed and dopamine, phenergan ,phenytoin. I have not included any of the chemptherapy agents in the list . For example, the worst vesicant of all times is Adriamycin

[BowHunterRN]

thanks for the list to both of you!

i just thought of another question if you don't mind..

is it ok to take blood from a peripheral IV? I know when first inserted that is done, but what about after a day or two? I always thought that if it wasn't brand new, or if meds have already gone through, you shouldn't take blood from it. But I've seen people try to see if they get a blood return from an IV that wasn't new, and if they did, use it for a blood draw. I just was wondering if this is ok. Thanks.

[seekingedu]

I'm a new nurse having serious questions about how to take care of patients with IV sites that are obviously infiltrated. A pt pulled her IV out of her hand because it must have been hurting her (she can't communicate very well and has alzheimer's). Her hand was bruised badly and she had a few areas that felt squishy. The pt needed her hand treated and I don't know how to do it. Gosh, any information you can give me is great! I need to learn so I can treat it on my own the next time. What do you do for bruising? Thank you so much for your help. Also, I would LOVE to have the list of meds that are caustic.