greenterra

Hi BizzieRN! It sounds to me like you are a great patient advocate. Your Doc sounds like his priorities are not screwed on quite right-- a minor setback in whatever research is being done is definitely a reasonable cost to pay to avoid serious harm to the "subject", and playing around with blood sugars less than 60 for prolonged periods sounds like an accident waiting to happen. And what kind of protocol tells the subjects that they don't have the autonomy to decide to hold their insulin dose if it is less than 60 on their own? Is there any kind of chain of command in this non-hospital facility that might help give you a reasonable scope of practice? Another suggestion-- contact your state board of nursing ASAP and try to get an immediate opinion. I bet they will say that if a nurse fails to hold insulin when needed, even under a doctor's order, and the client/patient/subject is injured, that nurse can be held negligent.

Thanks for doing the research, 3rdCareerRN! Especially thank you for including citations, although they muddy the water a bit. For instance, although the first article concludes that disinfection isn't needed, in the body of the abstract it states "Of the cultures done on single-dose vial stoppers, 99% were sterile". I will try to access the full article and see what the results were on the non-sterile vial tops. My only other concern is that the study was done in 1994, and controls might not be as strict today, especially if vials are made overseas. Greg

Yes, in an ideal world nurses would be able to maintain aseptic technique in the midst of poo. As a final note, some facilities do prohibit aspiration using pre-filled flushes, though it isn't clear whether aspiration is OK if there is some injection prior to the aspiration, so the plunger is never pulled back beyond it's original "sterile manufactured" position. For example, here is an exchange from http://www.apic.org/source/Communities/viewDiscussionTopic.cfm?section=apic_communities&CmtyId=5&FrmId=36&TopicId=20259#Top Non-sterile pre-filled flush syringes Manufacturer of these syringes does not recommend using them if plunger will be pulled back (as in aspirating for blood return)before injecting as they are not packaged sterily and, therefore, the "back end" of the syringe barrel is not sterile and, thus, the contents may become contaminated upon aspirating. Argument is being given by some nursing folks that once a regular syringe is removed from packaging and handled to draw up hep/saline flush, that syringe is also not sterile. Has anyone addressed this issue in your facility, and what was the outcome? Katherine R. Stauffer, RN, CIC ICP Shandsat AGH 352.338.2121 ext. 3609 Gainesville, FL Non-sterile pre-filled flush syringes (02) We were taught in nursing school techniques so as to not touch the plunger when drawing up medications. Sue Chen Infection Control Specialist California Dept of Health Services Richmond, CA I emailed Ms. Stauffer, and she OK'd my reprint of the above, and answered my query about whether they had come to a final conclusion about aspirating with flushes. She said: Based on dialogue with the manufacturer, our decision was to use the syringes only when it is not necessary to aspirate, and definitely not to mix a med in a syringe -- i.e., when the plunger would be pulled back into the non-sterile pathway. Kay Stauffer, RN, CIC I don't know if this thread helps anyone or merely muddies the waters, but thanks so much for the information that everyone has given! Greg

Well, if you are aspirating to verify the central line is correctly placed, you are bringing the sterile saline in the syringe back over an area of the barrel interior which was just below the non-sterile plunger, and been next to the non-sterile end of the rubber stopper. Typically one would then continue to flush with the same syringe to clear the central line of blood, but this might not be advisable with a non-sterile flush, as discussed above. Is this a theoretical problem or a practical problem?

Thanks for all the information in your posts, lpnflorida! Additionally, I've looked around the internet some more. It looks like many nurses are OK with using prefilled syringes to aspirate, and (if syringed is immediately relabeled) to dilute meds, and almost no one indicates concern about non-sterility of the plunger or "dry side" of interior barrel. Although popularity doesn't equal best practice, there doesn't seem to be any documentation or evidence showing that this isn't appropriate practice by manufacturers or anyone else. I may try to repeat the post with a subject which would get the attention of infection control nurses to see if anyone has seen any research about this. Thanks again! Greg

Actually, I've been searching the manufacturer's site to get their recommendation, and I can't find anything. I couldn't even find any mention of single use NS vials on Hospira's site.

Yes, it's true we're not talking about pulling blood into the syringe. The question is whether microbes would "fall off" the plunger and contaminate the barrel when you push, and then contaminate the saline when you pull back to check blood return. Presumably this isn't an issue with non-flushes because they are completely sterile until removed from the package? Page three of this article implies this issue when diluting meds with prefilled saline syringes: www.ismp.org/newsletters/nursing/Issues/NurseAdviseERR200702.pdf

Elsewhere on allnurses.com, a poster pointed out that one of the reasons why nurses shouldn't use prefilled normal saline syringes for diluting IV medications was that, in many cases, only the saline and interior of the syringe is sterile-- if the plunger isn't sterile, when you push out saline to make room for the medication, microbes on it can contaminate the barrel, and when you pull up the med, the diluted medicine contacts the contaminated barrel. Doesn't the same thing happen when we use pre-filled syringes to check blood return on a central line? We're taught to flush the line with a couple of ml's of saline (which could theoretically contaminate the inside of the barrel), then pull back to aspirate blood and verify blood return (which brings the sterile saline into contact with the contaminated barrel) then continue to flush. BTW, our sterile syringes are packaged in plastic labeled "DO NOT PLACE SYRINGES IN STERILE FIELD", which suggests to me that after the contents are sterilized, the syringe is processed in a non-sterile environment, so the plunger shaft is non-sterile. Should I be paranoid about flushing with pre-filled syringes?

During orientation for my hospital system's, the IV nurse educator said that the single use vials of normal saline we use are manufactured with porous plastic caps, so after breaking off the plastic cap, we should swab them with alcohol. I work in an "outlying" hospital, and NONE Of the nurses I work with swabs off the rubber tops after removing the new caps, and they think I am crazy and wasting time. I have no idea if this hospital uses the same NS as the other hospital in the system that nurse educator is from. I do know that once I remove the cap, I see little "stars points" in the metal foil on the underside of the plastic cap-- it looks to me like that is how the cap was attached, and there MIGHT be gaps in the metal between these points where microbes could enter before the plastic cap is broken off. Is there any way I can tell whether I need to swab the rubber tops, or if it is indeed a waste of time? The label indicates they are single use Hospirus 0.9% normal saline vials, but there are no instructions about cleaning the tops. Thanks, Greg

Thanks so much for the help. I will definitely count to 3 after giving insulin. Regarding the lovenex, my hospital's policy is to only give it in the love handles, not in the anterior abdomen around (but away from) the umbilicus. The nursing management says that in their study of best practices, only using the love handles reduces the risk of hematomas and bruising. I don't know where they got that or if there is any conflicting evidence based practice! Thanks again, Greg

Hi all! I am in my first month of nursing. This week I was giving a subQ insulin-R shot (8 units) and when I withdrew the needle, a droplet of insulin came out with it. I wondered if I got the insulin in the wrong type of tissue (I pinched skin behind the arm and injected at a 90 degree angle). The patient is a young adult of average or slightly above weight, admitted for DKA. The same day, I gave a 70 unit lovenox shot in the "love handle" (left abdoment, lateral to umbilicus) of an older adult who is a bit on the heavy side, and I noticed the exact same thing. If the answer is using the z-track method for insulin, I shouldn't do this for lovenox, right, or I risk bruising or hematoma? I've given subq shots in school clinicals and on the job, and never noticed this before. Am I doing something wrong? I talked to my preceptor and she didn't seem concerned, but she was busy, too. Thanks, Greg

Thanks for the replies! At least some of the time I'd like to remain by the bedside. Infection control interests me, too... I need to try to collect my thoughts and determine long term goals. The one thing I know is that I miss learning, and thinking about new things (though I don't miss exams and papers!), so I think I'm headed to graduate school in another year.

Hi Guys! Congratulations on entering PhD programs! I am hoping you won't mind answering a question: do you know if a PhD can help a clinical nurse's career goals? Or is a PhD solely for nurse educators and researchers? Of course, I know about DNP programs-- but I'm not sure I want to become a nurse practitioner... I still don't know what I want to do when I grow up :wink2:. I do have a previous masters degree from before I got a BSN, so I'm tempted to go straight into a BSN to PhD program. Thanks for any replies!

Also take a look at the allnurses air_embolism_iv_therapy thread: https://allnurses.com/forums/f27/air-embolism-iv-therapy-96687.html, it has a references that explicitly talks about how much is too much air, and mechanisms of complications.

Thanks, Suzane4 and IIG . Yes, I hope that the evidence for the cause of poorer NCLEX performance after a delay is not simply because one is losing the information one has crammed. However, the concern being brought up in KY is that the pass rate has dropped substantially this year for all students. The professors seemed to think there is merit in the argument that this is because of the enforced several week delay between graduation (and therefore, test preparation) and taking the exam. Is there any evidence suggesting that NCLEX scores actually do improve, or at least stay the same, for practicing nurses? The data is very preliminary in KY since the BON just implemented this requirement in 2007-- do other states require delays, and do they affect pass rates? I certainly hope not, since the NCLEX's primary goal is to ensure safe practice (isn't it?), but if nurses' NCLEX scores don't improve from actually working, then does it really measure safe practice? If it does, are nurses really practicing safely? Or is some other factor at work here?