Phlebitis management. Was this handled correctly?

[elephantlover]

Hello,
I am a senior nursing student. I am working to develop my clinical decision-making skills by observing the nurses I work with as a CNA. I have some questions regarding a situation I witnessed at work. I have read old discussion posts on related topics, but I still haven’t found my answer. Looking for your input.

A patient developed what appeared to be grade 3 or 4 phlebitis while receiving a vancomycin infusion through a peripheral line. I notified the RN and asked if she wanted me to remove IV catheter. After assessing the site, the RN decided she was going to leave the IV catheter in because it still flushed. This patient was in a lot of pain. I thought the proper course of action would be to remove the catheter, apply heat, and monitor frequently. This patient did not look like she would be a difficult IV start.

The policies and procedures manual stated that IV site removal may be warranted for treating phlebitis. This was not the definitive answer I was looking for. What would you do? Would contacting the provider to discuss a PICC line be warranted? How do you manage IV site complications like this one?

Thanks for letting me pick your brain.

[Spadeforce]

7 hours ago, elephantlover said:

THANK YOU! This seems so straightforward in my mind. This patient's vein was being irritated by the catheter and the abx. Solution. STOP and remove. Further complications could develop. I just could not understand why my hospital's policy was so vague. We have resource nurses that will use ultrasound to start IVs as well. Takes the burden off the nurse. This seems black and white. Now I know what not to do. Thank you for walking me through the big picture.

she prob just lazy

[Wuzzie]

On 1/17/2019 at 2:03 AM, elephantlover said:

I just don't think to claim someone is a difficult poke is a valid excuse to leave an IV catheter in a patient a red, rock hard vein just because it flushes.

It isn't and you're right to think that way! If the patient is a hard stick and unstable I might leave it in long enough to get another but I would most certainly not be infusing anything into it. To do so is a violation of good nursing practice and frankly smacks of stupidity and laziness.

[elephantlover, BSN, RN]

5 hours ago, Wuzzie said:

It isn't and you're right to think that way! If the patient is a hard stick and unstable I might leave it in long enough to get another but I would most certainly not be infusing anything into it. To do so is a violation of good nursing practice and frankly smacks of stupidity and laziness.

Thanks for your feedback. I do not want to rip on this nurse. She is a new nurse figuring things out. I just wonder why the policy at my hospital is so vague about phlebitis. Perhaps a certain degree is acceptable, and simply needs to be monitored depending on the circumstances (e.g. the patient is discharging shortly etc.)?

[Wuzzie]

2 minutes ago, elephantlover said:

Thanks for your feedback. I do not want to rip on this nurse. She is a new nurse figuring things out. I just wonder why the policy at my hospital is so vague about phlebitis. Perhaps a certain degree is acceptable, and simply needs to be monitored depending on the circumstances (e.g. the patient is discharging shortly etc.)?

While I appreciate your wanting to support your nursing colleague being new is not an excuse to provide poor nursing care. As a new nurse when faced with a situation that he/she is unsure of how to proceed it is imperative that the nurse seeks out assistance from others with more experience rather than shooting from the hip. We are taught about phlebitis in nursing school and what nursing interventions to carry out in treating it. Of course there is some latitude that allows us to adjust our care according to the idiosyncrasies of the situation, which is why policies are often a bit ambiguous, but that latitude applies only if one has experience in dealing with said situation which you have implied this person did not. The mistake made was not seeking out more help in deciding what to do and making an assumption that the line was okay just because it flushed which we both know was not correct. There are several reasons people don't seek out help (ego, fear, laziness, stupidity, poor judgement, lack of education to name a few) but none of them are plausible excuses for not doing so especially in the setting of patient care. As an experienced nurse and a nurse mentor I would have provided education and support to this nurse had she come to me. In other words, we would have worked out the solution together and in the end she would have come away with the knowledge needed to handle the problem when it came up again. It's a win-win for everyone. You are actually doing the right thing by first checking your policy and then asking more experienced people how they would have handled this. Hopefully you will take away some good nursing tidbits when it comes to IV therapy.

[elephantlover, BSN, RN]

40 minutes ago, Wuzzie said:

While I appreciate your wanting to support your nursing colleague being new is not an excuse to provide poor nursing care. As a new nurse when faced with a situation that he/she is unsure of how to proceed it is imperative that the nurse seeks out assistance from others with more experience rather than shooting from the hip. We are taught about phlebitis in nursing school and what nursing interventions to carry out in treating it. Of course there is some latitude that allows us to adjust our care according to the idiosyncrasies of the situation, which is why policies are often a bit ambiguous, but that latitude applies only if one has experience in dealing with said situation which you have implied this person did not. The mistake made was not seeking out more help in deciding what to do and making an assumption that the line was okay just because it flushed which we both know was not correct. There are several reasons people don't seek out help (ego, fear, laziness, stupidity, poor judgement, lack of education to name a few) but none of them are plausible excuses for not doing so especially in the setting of patient care. As an experienced nurse and a nurse mentor I would have provided education and support to this nurse had she come to me. In other words, we would have worked out the solution together and in the end she would have come away with the knowledge needed to handle the problem when it came up again. It's a win-win for everyone. You are actually doing the right thing by first checking your policy and then asking more experienced people how they would have handled this. Hopefully you will take away some good nursing tidbits when it comes to IV therapy.

I appreciate your input. You sound like a good preceptor. I am trying to learn as much as I can about clinical decision making before I am on my own this summer. I agree there aren't excuses for incompetent care. This particular nurse was precepted by an RN who is rather flippant and short with new nurses who ask questions. Management has been made aware and this woman has improved her behavior. I have enough confidence to not care how others perceive my question. I wish all nurses would provide the support that you describe.

[Wuzzie]

2 minutes ago, elephantlover said:

I am trying to learn as much as I can about clinical decision making before I am on my own this summer. I agree there aren't excuses for incompetent care. This particular nurse was precepted by an RN who is rather flippant and short with new nurses who ask questions. Management has been made aware and this woman has improved her behavior. I have enough confidence to not care how others perceive my question. I wish all nurses would provide the support that you describe.

That is truly unfortunate but remember we, alone, are responsible for the care we provide. You sound like you have a good head on your shoulders and your priorities straight. those two things will serve you very well on your journey to being an expert nurse!?

[JKL33]

elephantlover,

Looks like you've had a good discussion here. I would only add a request for you to consider that hard rules, protocols and algorithms aren't always the answer. Many situations call for leeway as Wuzzie explained. Even if your workplace's policy was very clear in calling for the discontinuation of all IV sites with signs of phlebitis, the underlying problem is still that this nurse didn't recognize clear assessment findings for what they represented. Thinking all is well because a line like this will flush displays quite a lack of appropriate knowledge.

Protocols and policies can't make up for ignorance and lack of experience/expertise when these are combined with neglect in seeking second opinions - - but removing options will cause unnecessary problems in other scenarios. There is no substitute for building and maintaining a knowledge base and seeking others' expertise as warranted. IMVHO hospitals wish nursing was a job that anyone could do by performing series of protocolized tasks, but that hasn't proven to be true so far, and attempts to make it more likely have had numerous drawbacks - - some very serious, such as unnecessary testing, lack of thorough patient assessment, etc.

Food for thought. I'm sure this observation has been a good learning experience for you.?

[elephantlover, BSN, RN]

I appreciate your input everyone! I love learning from experienced nurses.

In my opinion, the rise of ligation in healthcare has contributed to this protocolization of tasks as you describe JKL33. The way in which reimbursement works has also. Nursing care is not so black and white though. I digress. Thank you for your time!

[MotoMonkey, BSN, RN]

Often policies are left vague because situations may not always be "black and white." This leaves room for a nurse to use their experience and judgment in the decision making process.