bethchpn

Well I was called in to the ED and the patient was sick with a high fever of 103. I have read some things about CV and they are now feeling it can be airborne. A lot is unknown. I am 70 yrs old and my husband is high risk. Am I being paranoid? My daughter just wants me to retire! I am not ready!

Just wondering if any PICC nurses are using N95's when they place PICC lines

Small town in Oregon, 44 yrs nursing experience, 16 yrs at this hospital. Close to top salary (one more step to go) 48.31/hr. Oncology certified so 1.50/hr more. No weekends, call and 8-5. Best job I have had in all my years of nursing. Salary isn't everything. Great coworkers, atmosphere and boss really makes the difference. Average house is 250-350K.

I agree with all the ideas Vascular nurse 1006 has. i would add two more. My favorite if a pt is awake to have them cough at the point right before it goes up the jugular. Second I have had some really tough ones that I have just waited a short time and then it slide right in. I think maybe the vein spasms after several tries and resting it works. If I have to I get warm blanket to it (I put a medium drape over everything to set the warm pack on). Sitting the patient upright is another favorite. I usually take 2 hrs from start to after X-ray and charting. After hours we have to send X-ray to another facility to read.I work in a small hospital and do them alone. We plan to get the ECG/ US soon so it will be quicker then. I have been doing them for 9 years now.

As a nurse of 44 yrs others might disagree but I have different advise. I feel the best action would be to let your supervisor know that you have learned a lot from the experience and will be able to give better care for patients in the future. You are really not saying it was your fault but it will maybe defuse the situation. If you fight it they will fight back. Maybe not in this instance but they will find other things to use against you. If it truly is their practice that caused the accident then quietly look for a better place to work. It can really backfire when you take it "up the chain " so to speak. Life is to short to let this get to you. Stress is what kills us. You will come across lots of issues in your nursing practice that can cause lots of stress. Let it go!!

It took me a long time to learn one simple fact.... If you make a bad choice you can always make a different choice. I have been a nurse for 42 years and it probably took me 30 years to learn this. I was raised that once you made a decision you had to stick with it. Probation is a period where they can let you go anytime and you can tell them it isn't working for you either. I don't think it will reflect bad on you.

Been a nurse for 40 years and my only advice is to learn quickly that the only thing we can change is ourselves. The sooner you learn it the better. You in general will always want, nurses,patients, loved ones etc to change but it is fruitless. Concentrate only on what you can do to change.

We are a small hospital that has about 100-120 PICCs a year. We are trying to get updated equipment that uses ECG guidance but at this time we can't afford it or it is being decided somewhere in the financial planning for next year. We use US and Sherlock but our sherlock is old and can't be replaced now because it is obsolete. It works some of the time but is not totally reliable. So my question is If one is pulling back or advancing a catheter to be at the CAJ is there a protocol somewhere that states when a second X-ray has to be taken. I have heard that if it is advanced 3cm or pulled back more than 5cm it must be re X-rayed. I would like to see this somewhere in writing. I have been doing PICCs for 8 yrs now and I had to pull back 6cm and the tip was easily viewed. It was a pt where getting the x-ray was difficult due to his pain and positioning, not to mention his agitation. I did have them get another x-ray and it was perfect but I really didn't want to put the pt through another x-ray. Please advice me. Is this a suggestion or more than that. Would love to see article or INS standards on this. I tried to find it but couldn't.

Thanks for all the feedback. One question. This particular pt is an outpatient that infuses 12 hrs a day. Do you all instruct pt to pull back for blood? I have read some instructions say to just have pt saline flush and not check for blood return and the RN's will check when huber needle is changed. I think the theory is they won't flush out the blood thoroughly. Also for occlusions do any of you have the protocol for ethanol (70%) or sodium hydroxide (0.1 mmol/ml).6

I wonder if any of you have used Ports for long term use of TPN. How do you keep it from getting a sluggish blood return. Do you TPA. It seems like it is more from the TPN that from a fibrin sheath. Like to have some feedback here. Thanks

When this happens I pull back from the jugular and then have the patient cough and it usually drops down.

Totally agree with iluvivt. Don't let them put you out on your own after 3 PICCs. It is a cost saving technique for the hospital but you will be much happier if you get more experience if you do more with an experienced RN. In our hospital now we have to watch 5 and do 10 with someone watching but I don't even know if that is enough.

The angle of insertion is related to how deep the vessel is. More shallow less angle, deeper more angel. Will come with experience.

Iluvivt could you send me a copy of you protocol and procedure also. I have been placing PICCs for 8 yrs and did my precasting at OHSU in Portland Or but they do not do that now so I have to train them. What is required for someone to be PICC certified. How many PICCs per year do you need to have to be competent. I work in a small hospital that only does about 100 a year. They want me to train 4 RN's but I am not sure they will be able to feel confident with that few. Please advise. [email protected]

I have been a nurse for 38 yrs. I have maybe seen 5 court cases but usually it was against the hospital or MD and the nurse just needed to testify. I went to a conference probably 25 years ago on malpractice and one thing the presenter said has always stuck in my mind. He said besides using good nursing judgement the number one thing you can do to prevent personal lawsuits is to be really, really nice to patients Not only will it help but it will make you a better nurse. Lots of people don't want to sue "that really nice nurse" Of course this is not to substitute good nursing!

Thanks for the reply. Very helpful. I do agree that Rad all disagree. Do you have or know of a good picture with landmarks on it. I received a book when I was trained but the chest x-rays and photo of the heart/landmarks was photocopied and hard to see. I have been looking a previous CXR's and that does help a lot.

I also lost a brother to alcohol and drugs and would love to give you an e-hug!!! What helped me so much was going to an al-anon meeting. Look it up in the phone book and they will lead you to an appropriate meeting. What ever you think it is not your fault.

I have been placing PICC's by ultrasound and with Sherlock for 10 months. I only place 1-4 a month as I work in a small hospital. I have had good success but my measurements are deep a lot and I have to pull back 2-4 cm often. I measure from insertion site to mid clavicle down to third intercostal space. Do any of you that use Sherlock feel like the sound change helps to see where it is at? I do realize that everyones anatomy is different. Is this to be expected or will I get better? What is the expected ratio of perfect to off by 2-4? If we pull back 2-4 we don't usually re-xray as they will still be distal SVC. The radiologist reads them in right atrium or CAJ a lot.

I have several hobbies that help me but I think yoga helps me with my work the most. I have done oncology for 5 yrs and hospice the 5 yrs before that. I have done yoga for 3 yrs and am so happy I found it. It helps me both physically and emotionally. I also feel better because I usually dedicate my yoga practice to a different patient every time I do it. When I did hospice I went to memorial services off and on and I cried a lot. I know it was usually a cumulative grieving but it worked for me. I feel chemo is nice because we do see people survive to finish more of their life business. We are helping in many ways. Dying isnt always so bad. Our job is to get them ready for it. We all will die some day and I hope someone helps me just as I do others.

Chemo certification is a two day class. To become oncology certified you need to have 1000 hrs experience and take a difficult test that takes many hours of study. If you look on the ONS site it will be more clear. After you are oncology certified you are able to put the initials OCN after your RN behind your name. Chemo certification must be obtained just to start to hang chemo in our institution.

That sounds not too bad. I think it would pay for itself. We do order bard and I think we have been thinking of getting the basic kit with microintroducer and then put our own extra stuff in a kit to go with it. I cant wait to start putting them in. We are getting all our supplies and will take over doing PICC's in our out pt treatment center.

Good info. Thanks for the response. Do you know about how much they cost. We were planning to get one but now with the economy falling apart we are not so sure.

I went and trained at a university hospital and used it for 12 PICC placements. I really liked it and the nurses there really liked it. It sometimes does get some interference but in general it worked very well. you really tell when it went up to the jugular. We used the battery pack one that was not connected to the US machine but it was fine. I guess it is even better when you get the sonisite it can be attached to. Does anyone know how much the battery pack one costs?

I too am grateful you are out of this situation. However dont feel that all oncology is bad. We have wonderful patients and it is a very rewarding field to work in. That is, if it is a safe situation.

Thanks so much for the reply. We also use Micromedix but feel it is not to up to date because it says it is not tested for LV and Irinotecan and they are run together all the time. We confirmed with the doc that yes indeed he did want the 5FU at one hour during the infusion of IRIN LV. We stopped it at one hr and gave the bolus thru the primary saline and then continued the pump with the rest. I just cant find any reasoning for the anywhere. Do you know why you would do this?