IVRUS

YES, YES, AND YES! Each time, Every time! Now, once you assess and have patency with NSS, then you don't need to assess it again if you are heparinizing the line after your saline flush, but a brisk, free-flowing blood return the color and consistency of whole blood is important.

Heparin Flush will prevent fibrin build-up. Keeping a line open with Saline only is doable, but one should be flushing at greater intervals if that is what you are using. In hospital settings, they usually use Saline only as they are manipulating and accessing their IV catheters frequently. This is NOT the case in home care, nor LTC. AND, increasing the manipulation through flushing the line, in this case, introduces the potential for bacterial introduction. So, that is discouraged.

Infusion Nurses Society (INS) reviews in its standards, that Heparin Flush, if it is to be used on Non-Valved IV catheters should be the lowest concentration available. In hospitals, most IV catheters are being used sooo frequently, that Heparin flush isn't necessarily. However, in other settings, that isn't the case, and if the IV catheter is Non-Valved, flushing with Heparin is important to prevent Fibrin build up. We use 5mLs of 10unit per mL on all non-valved catheters.

I would contact BARD. They often provide PICC "certification" classes.

A curos cap is a good idea, but if it is not your policy to use them, then scrub, scrub , scrub that needleless connector each and every time before you enter it.

This is a total NO-NO. Shaving causes microabrasions and possible staph infections. If you must, clip the hair.

So, let's say that you are giving an IVAB. Med is due at 0600. At 0555, you do all your checks on the IV catheter/drsg, you check the saline syringe, and you do a good, vigorous scrub of the needleless connector. You hook up your saline syringe, flush about two mLs, then slowly aspirate for a brisk blood return, the color and consistency of whole blood, then flush with the remaining 8 cc saline (if your policy is 10mL flush a and p) disconnect the saline syringe and scrub again vigorously with alcohol pad. Then administer the IV antibiotic over the needed time frame, stop when BAG IS EMPTY, then disconnect. Scrub connector again, then saline flush and Heparinize if needed, depending on the IV catheter. The only time to assess is blood return is at 0555. NOT at 0555, 0630, 0635 when the second saline is flushed.

That is why you are PALPATING initially with non-sterile gloves on, so that you only have to stabilize the port's body with one hand, while accessing it with the other hand. Yes, with sterile gloves on, you technically can touch the port, but I'd only stabilize the body. Why would you need to touch the septum after it was cleansed, when you already should have a good perspective of how the port lies under the skin?

Well, Your process doesn't appear problematic, but how is your tourniquet placement? If you are placing the line on a geriatric pt, you may very well have difficulty being successful if you tourniquet is too tight. Elderly patients require loose tourniquet application, or you'll BLOW the vessel. In addition, choosing a metacarpal vein isn't always the best choice for this populi as they have lost a lot of SQ in the back of the hand with age. That SQ used to support the blood vessel, and without it, the vessel appears to be a road map on the back of their hand, but actually is a very fragile vessel. And, what gauge IV catheter's are you putting in. Remember INS standards say to choose the smallest gauge for the task at hand.

Any issues/complications, real or imagined, must come under the PRN dressing change tab. If you think you are seeing redness under at the site, that is a time when you MUST perform a sterile dressing change to assess and identify the next step in patient care. Our policy delineates dressing changes with a Transparent Sterile Membrane (TSM) covering the site to be performed q 7days and PRN!!

https://multimedia.3m.com/mws/media/993615O/picc-cvc-chg-device-application-guide.pdf Maybe their website instructions can help

Kristine, What is the concentration that you are using to "lock" the PICC line? Standards, and many Policies have you locking catheters with the lowest concentration, namely 10 units/mL. With this concentration, there is no need to withdraw the heparin that was dwelling in the catheter lumen prior to flushing. Withdrawing prior to flushing is mandatory, however, on Dialysis Catheters as the concentration used is much greater.

I would try to find a Post Acute / LTC facility which takes complex patients. We have a couple in my area that take vents/trachs, and they do tons of IV therapy. Given that you are such a new RN, I seriously would discourage you from trying to branch out into IV therapy as a specialty or even radiology at this time. Get a couple years of solid experience and great venipuncture skills before pivoting to this specialty.

Were you actually ACCESSING an implanted port, or truly de-ACCESSING? Upon accessing, some ports are easier to access if the patient is sitting up; this is especially true if the pt is a large chested female.

First of all Karen, this conclusion, imo, is nonsensical. Yes, having a central line in increases the chance of large vessel thrombosis, but the benefit of having it is so much better than the inherent risk. Bloodstream infections can occur with all types of IV catheters especially if ANTT is not followed. Pneumothorax is a concern only upon catheter placement, and arterial injury??? I've seen unskilled MD's attempt vascular line placement and go intra-arterial instead of in the vein, but again, those are unskilled physicians. Also, greater than 1 out of 10 had issues... that is unacceptable. And, it says the risk may be overstated and unfounded. The osmolarity of 3% Sodium Chloride is > 1,000. Anything over 900, has a much greater probability of causing serious harm to the smaller blood vessels in the arms. Circulation/blood flow is nowhere near what it is in the central venous system. Disagree with this "study". However, as said in my earlier post, I would much rather see this infused via SPC, than a Midline, and that was really what my comment was about.

I too would have obtained an order for a "chaser" bag with this 50 ml IVAB. Not doing this, leaves too much medication in the IV administration set, whereas having it as a secondary will increase the amount of antibiotic cleared from the IV tubing.

I get that, you probably don't but I would seriously bring this up with your staff development person and DON

I would NEVER run a vesicant medication such as this via a MIDLINE. That is a huge NO-NO. Think about it: Can you see, much less palpate the blood vessels under the shoulder or right before the Axillary vein? NO... therefore, since the blood vessels are so deep , by the time you as a nurse notice s/s of issues, a huge issue is at hand. Phlebitis, Extravasation, etc.... I would much rather see it infuse via short peripheral catheter (SPC) vs. a Midline. But one would help the pt out immensely by ordering and getting a PICC or another CVAD in this pt.

Another important thing to remember is that some IV catheters are packaged and sent to you "heat sealed". Insyte Autoguard IV catheters used to be that way. Therefore, the junction of the IV catheter and the needle hub must be separated first and then put back into position. If this is NOT done, one will have a difficult time threading that catheter off of the needle and into the vein.

Feel free to PM me, and I'd be happy to speak with you on the phone...

Standard 36 specifically addresses add-ons and it states, " When indicated, preferentially use systems that minimize manipulation and reduce components, such as integrated extension sets" Therefore, it is saying, that if at all possible, don't use add-ons as they greatly contribute to bacterial introduction. And, yes, 2016 is that last one. They update standards every 5 years.

What is it about Med/Surg do you hate? If it's the fact that they have many different types of IV catheters and IV medications, then Infusion nursing is not for you. Infusion nursing is sooo much more than just being a "Good Stick" , it's about knowing where to stick, how to stick, and why you shouldn't stick. It's about knowing you IV catheters inside and out and why one deserves preferential treatment or placement over the others. It's about care and maintenance and having the knowledge base to see optimal patient outcomes given the situation that presents itself. Infusion Therapy is a specialty, and like other specialties, you should have a passion for it.

WOW!, 6 lumens.. Is the patient that much of a sick puppy??? First of all, like you, I know that the more lumens means more manipulation, and an increase in CRBSI's. But, also remember that this is an ADD-ON device. According to INS, add on devices are a no-no, as this too causes an increase in infection. Filters, manual flow control devices (Dial-a-flows) or elongated tubing should be part of an integral set, and add on devices prohibited. Secondly, I too would be worried about compatibility issues. AND, last, but not least, the catheter you said that this patient has is known to HAVE THE HIGHEST INFECTION RATES OF ALL C-LINES. All of these things bring me to the need to evaluate the situation more closely...I am so glad that you are there to advocate for this patient.

IMPLANTED PORTS are sutured into a subcutaneous pocket. If these sutures broke, the port will travel under the skin and be hard to pin down. The MD should go in and fix this problem. Now lack of blood return could mean that the IV catheter has been severed from the ports body. This given the situation, would not be uncommon. Do not use this port. It must be surgically fixed. The lack of blood return also could be from fibrin buildup, so just how recently was it placed, and is the patient hypercoagulable?

I don't know who you are, or what the issue is, but if you read the first two posts, this person seemingly was frustrated because over several days without a response to her OP, she came back. So, it needed to be pointed out that in order to get the responses she/he desired, then specifics were needed. How is that problematic? Arrogance is not the issue here. It is however, problematic when one merely imparts information and he/she gets slammed for it.. "Indeed, no good deed goes unpunished."