IV tubing basics did it just click or was it practice?

[Kitty Hawk, ADN, RN]

I'm having a really stupid brain block here.

I'm about a week to coming off of orientation. I work in an IMC, since we can get pulled to the ICU, I'm with a preceptor for that unit now. I give you the background so you can imagine the more important info coming at me at warp speed!

Further background, I work with an awesome team. My preceptors have been great, my NM is very supportive of me. Everyone says I expect more of myself than what they are expecting and my NM even has complimented my intelligence and where I'm at so far. However she can see I'm not believing it myself (why would I, I'm new?!)

However I'm feeling like common sense is out the window with me and I've always struggled with mechanical things. I'm being told I'm thinking about things too much when it's more of a "go with it and trust instincts" type thing.

Here's what I got so far and maybe someone can help make this click. (or maybe it is just practice, practice) we have the alaris pumps for reference and they are great compared to the baxter, but I never got real experience w/those either.

I understand hanging multiple things on different channels and differrent ports on picc's (good, right ) I got the IVPB if you have some type of maintence running and you want to infuse say a run of k. I've now learned if you need to give an IV push you can go to a port closest to pt and do a push and pinch method.

I understand the y-port method if you can't stop the primary and IVPB and that's closest to pt (and other ports are taken)

I figure in another month I will be kicking myself for not getting this but right now it's driving me nuts! I thought I was okay with all of the above then yesterday I walked in and the pt had a picc with all ports already taken, plus was running a fentanyl which I now see that will also have a smaller bag of fluid to push the fentanyl through and seperate y tubing!

I had to do a run of k and since they were already running lasix, and propofol, along with the fentanyl it threw me! I ran a compatibility check (gotta love the computerized ck for that) on all and one came up questionable. So I had no idea if any of that could be paused for a IVPB or what. I think we ended up PB'ing it but I can't remember to what...yest was a whirlwind!

I can't stand that I can't go into a room with various infusions and need to add something and know what to do, it's like I go stupified or something and I don't know if it's the pressure of all the other things I'm learning or what. And it's only going to get more intense as we often get cardiac as well as heparin drips. I did have a pt on a heparin and a nitro drip but she only had those 2 things going and other than balancing out the titration...that was okay.

And I have gone to my preceptors, co-workers with this, I'm not standing there like "yeah I get it" and I'm afraid to tell them, I TELL them I am absolutely stupid on this and they smile and say "it'll come with time/practice"...Really? Did any of you struggle with basics like this?

Oh and just when I thought *maybe* I'd have enough info to muddle through because I'm figuring okay IVPB the port before the pump got it...y-porting ...the one closest to the pt....but what about the port right below the pump? Well my preceptor said she's never really used it...I said "good...good enough for me, don't need to know right now" ...then she says....well, you could hook up another compatible fluid there if you didn't have anywhere else to go! Nooooo I didn't want to hear that! I wanted her to stay with "you'll never use that port!"

Lastly, do I have it right with incompatible and picc lines you can just choose one of the compatible alternative and it's okay to run b/c the picc line port exit at different points in the SVC? I always thought if it was incompatible you couldn't run it even through a different port.

Thank you for any perspective. I now understand why they say when you're new you go home and cry and it's not necessarily from being yelled at or mistakes. It can be b/c I'm so frustrated with not getting it and wondering if they made a mistake putting a RN behind my name.

[Reno1978, BSN, RN]

You have the right idea, you just need to build your confidence with practice.

Remember that different lumens on a PICC or Central Line are separate "tubes" so to speak and they release whatever fluids/medication that are running in them at different exit points in the patient's bloodstream. So, things that are incompatible can run at the same time, but in separate lumens.

When you're checking for IV compatibility, you're not making sure all of the things running are compatible together, you're checking to make sure the things you have running in each lumen are compatible together. For example, you may have Fentanyl and Versed running in one lumen as they're compatible, then Protonix, Heparin and Lasix in another lumen since they're compatible. Yet, Protonix and Fentanyl are incompatible, but it's okay since they're running in different lumens and they will not touch each other.

Now, if you had to add a drip, you'd check it against both fentanyl and versed to see if you can add it there, or against your protonix, heparin, and lasix and see if you can put it there.

Make sense?

[brownbook]

The most experienced nurse, doctor, or pharmacist, in the world could NOT walk into a patient's room with all those lines and drips and at the snap of her finger know compatibilities, which port to use, where to hang another drip, etc. And I wouldn't trust a nurse who thought she knew everything about every port and drip and didn't double check.

A competent nurse in these situations has to stand back, stop, slowly confirm all the drips, ports, and check with a reference book or pharmacist, before hanging something new!!!!

Unfortunately there is no "click," just a lot of hard thinking, double checking, etc.

Unless it is a code blue you have time to stop and double check what drugs you are hanging.

[netglow, ASN, RN]

OY!

I feel your cluster headache, OP.

[tyvin, BSN, RN]

Just because you're new doesn't mean you can't believe in yourself.

[Kitty Hawk, ADN, RN]

You have the right idea, you just need to build your confidence with practice.

Remember that different lumens on a PICC or Central Line are separate "tubes" so to speak and they release whatever fluids/medication that are running in them at different exit points in the patient's bloodstream. So, things that are incompatible can run at the same time, but in separate lumens.

When you're checking for IV compatibility, you're not making sure all of the things running are compatible together, you're checking to make sure the things you have running in each lumen are compatible together. For example, you may have Fentanyl and Versed running in one lumen as they're compatible, then Protonix, Heparin and Lasix in another lumen since they're compatible. Yet, Protonix and Fentanyl are incompatible, but it's okay since they're running in different lumens and they will not touch each other.

Now, if you had to add a drip, you'd check it against both fentanyl and versed to see if you can add it there, or against your protonix, heparin, and lasix and see if you can put it there.

Make sense?

yes thank you! That's a good starting point to go from. At least if I have an understanding with incompatibles as long as they're not IVPB'd, y-ported or pushed with incompatible, they can be connected to a diff lumen. I thought it was that they couldn't be given in the same time frame at all, that you'd have to hold off or something.

I do get I'm not going to "know" compabilities w/o checking....I'd always check. It just seems from my observance, most nurses can just get the new orders and go in there and be able to hang and connect the stuff w/o too much trouble, these nurses all have at least 2yrs experience, some much more.

I guess I just can't believe I'm not the only one freaking out about these sorts of things. There's so, so much more with constantly assessing your pt's for subtle changes, to listening for any alarms and diciphering the monitors...that this just seems like to me, that no one else had issues with...that they just got that part of things.

I'm trying to relax and at least have some faith in my abilities. It's hard, but I've heard from everyone that panic and anxiety are part of it for a long time, some have even said they've actually gotten sick on the side of the road before coming in to work! I thought the anxiety I'm starting to feel going into work was just nuts...but overall I am enjoying it and that's the big picture I try to remember when I have days when I think what have I done and I can't do this.

[johnson.2614]

HELLO!?... no you have not made a mistake by wanting to be an rn. As a matter of fact, by showing that you are analyzing the situation, CHECKING COMPATIBILITIES (I mean, jeez that's great! Even the super experienced nurses I work with don't do that half the time.) and attempting to minimize the patient's risk your well equipped. One thing I like to do is attempt to put all my compatible drips together in one port using stop cocks as a manifold. This may even free up one or two ports (the whole not checking your drips can go both ways here by now allowing you free ports to work with). Also, don't know what the rest of the nursing world suggests but I find it acceptable to flush a line with 5-10cc saline, push/give med, flush again, and then restart the pump.

[netglow, ASN, RN]

johnson.2614,

Could ya elaborate the stopcock deal? Not sure I understand ...you are still running one of what's hooked up to your stopcock at a time, right? Then, you manually "switch" over to your other IVPB bag and line, so, you are not running concurrently, right? I could see how this saves hook up time if you are gonna get repeaters of the same med., or am I missing your intent?

[missdeevah, NP]

johnson.2614,

could ya elaborate the stopcock deal? not sure i understand ...you are still running one of what's hooked up to your stopcock at a time, right? then, you manually "switch" over to your other ivpb bag and line, so, you are not running concurrently, right? i could see how this saves hook up time if you are gonna get repeaters of the same med., or am i missing your intent?

my intepretation of the statement is that the two compatible fluids are being run in at the same time, one on each side of the stopcock

[Reno1978, BSN, RN]

If the patient has minimal drips, it's always a good idea to have one of the lumens hooked up to good old NS for running IVPB medicines. This is also your goto line for a code situation when you need to push important drugs FAST.

Clearly labeling what is running at the point in the tubing where you're connecting it to the patient and at the pump also helps.

Also, you *could* run something IVPB into a lumen that has other things running if the compatibility is okay. However, be very careful not to do this on a lumen that has vasoactive drugs running!

[felineRN]

Please don't feel bad at all! I've always felt that I over analyze things and as a consequence, I have frequent "brain farts." I like to just stop for a second and write down what drips/fluids I have and what I need to accomplish. I tend to want to internalize my thought process, but writing things down helps me deconstruct my conundrum.

[iluvivt, BSN, RN]

Of course it can be confusing...keep asking questions...better safe than sorry. First of all it will help if you understnad PICCs and CVCs better. Most short term percutaneousely placed CVCs have a multi-staggered tip design...so even though lumems ARE seperate they do exit at different points on the catheter...distal being at the tip......this is good to know for CVP reading and blood draw issues. PICCS though seperate lumens exit at the same point on the catheter...(the Groshong PICC has a slight difference) but there is substantial hemodilution in the SVC so no worries. Yes you are correct in knowing and watching for potential incompatabilities..some are physical and you will see a precipitate..some are chemical and you will not see a precipitate but the drug may not work at all or may only partially work...you want neither to happen. You will start to see the same medications and drips and drugs over and over again and you will start to remember what can go together. If you have extreme phs anticipate you are going to have a problem. Remember your secondaries have to be compatable with the primary but do not need to be compatable with each other if you back prime before you hang. best to leave drips in seperate lumen if you can..not always possible..but ideal....in an emergency you can assume nothing is compatable..check as soon as you can if you want to combine...do not forget about SAS....Saline...agent...saline...at the t -ext or closest port for incompatable meds. The other thing I would do..is make a list of all the meds you are seeing...look them all up for compatabilites and make your own little cheat sheet......I have been making my own forms and tools my entire career b/c I know best how my brain works