justdeda

Keeping in mind the potential hazards involved in a slow flushing PICC, I considered asking the doc to prescribe cathflo when my 6-month plus, weekly dressing change patient presented with a stiff flush on the Vaxcel PASV. Then I asked for a trial of Heparin 300u, post NS flushes first, with the intent of moving on to cathflo if it was unsuccessful. To my immense surprise (as well as relief- I see the patient in her office in my town, but she lives 2 hours away, and the time-consuming cathflo treatment would be very inconvenient for her), this was successful. I taught the patient to pulse-flush, and followed her by telephone after one and then three days, when she reported that her balloon-pump infusion duration had gone down from 40-60 minutes, to 30 minutes, as ordered. After two consecutive weeks of Heparin flushes TID, the patient had a strong blood return, as well as increasingly less stiff flushes during dressing changes. I'm sharing this as an addendum to and confirmation of ILUVIVT's always-on-target, educated reply. As a postscript, the pharmacy representative was adamant that the PASV does not take Heparin-- hopefully this episode has re-educated her.

Never seen it before or since, but then...now that I've seen it, I will know it next time (-: Thanks

Hi- I just started working outpatient oncology infusion, rotating between three sites. In all three, the nurses just use gloves to take down chemo infusions. In one, a pharmacy assistant prepares all chemos under the hood with full PPE. In the other two, the nurse prepares all chemos using standard gloves alone. When I asked for special gloves, mask, gown and goggles, they couldn't find any. justdeda

dear diva, i think the best thing you can do is hit the books! read, read, and re-read anatomy charts, phlebotomy websites, hints, tips, war stories and anything and everything you can get your hands on that will give you more information on what to do, with whom, and when. dont feel stupid or inadequate when you have to call in the iv team. your facility wouldnt have an iv team if every nurse on the floor could put in a line every time. take the time to ask the rescue nurse to explain to you how she has analyzed the problem, and what is her plan of action for solution. practice on your mother, daughter, cousin or uncle. look at veins on friends and family. close your eyes and feel them, especially the older ones. if you open yourself up to active and aggressive learning, you will find active and aggressive teachers! good luck :) justdeda:nurse: home iv nurse

thanks for the response :) pt asymptomatic of any systemic or even localized infection. the pharmacy to which i was subcontracted declined to permit me to do a TPA at home, but never contacted the MD to have it done in hospital, and recommended i simply stop using that port:rolleyes:. ill remember your words next time it happens! what i found in the occluded lumen upon withdrawal was a flesh-colored piece with a sang-tinged tip. im just grateful the pt phoned me right away, and didnt try to push the flush!!! regarding the odd sediment on the cath...my first thought was indeed fibrin buildup, especially since there was no odor, and the stuff was very regular in consistency (odd clumps) all along the area covered with it. it just didnt really look organic, somehow! i have been wondering if there are piccs that have some kind of coating that helps to block off the vein, that might have deteriorated into little, irregular clumps over the course of treatment. i was thinking this might explain both why the site didnt bleed, and why it was so stuck to the catheter that it required real persistence to wipe the cath clean, and even then, not completely clean. have read your note and replied, and thanks for your input. justdeda

As noted by earlier respondents, experience will bring easy competence, and delving into written and visual aids prepared by experienced "stickers" will bring you the tools and the confidence to accumulate that experience. One of the things that I found extremely helpful was watching carefully when experienced IV nurses were looking for veins, and asking them to say aloud the things they were thinking as they accessed the vein and established the line, to better understand the process, and also what the stumbling blocks were, and what the different means to overcome those blocks were. When I have a bad couple of days, I return to reading what the experts have written, studying anatomy charts, and concentrating on getting alot of sleep and a good breakfast, before going back to work. :wink2: Best of Luck! justdeda:nurse: Home IV Nurse

Hello, all Tonight, I removed a dual-lumen PICC in the upper brachial that was in place for just over 5 weeks. (I never received the info on the PICC, nothing visible on the cath, do not know the manufacturer, but it was not one of the newer Power or PasV types). It came out very easily, but had stuff stuck to it-- a kind of cheesy-looking, pale, tan residue starting at about 5cm proximal to the insertion level, and continuing to about 40cm proximally. The final 10cm were smooth, the end was intact. There was a plug in one of the lumens, tho I had realized that back around week 3, when I was unable to flush it at all. Since the removal was done in the home, I had no way of sending a piece off to any labs. Actually, I have never seen anything like this, and I wondered if anyone had this experience. The stuff looked like it could easily be wiped off, but when I attempted to clean the cath, it stuck tight, coming off with difficulty, and only when I held the cath tightly with gauze to wipe it. There was no particular odor. The insertion site itself was completely dry, no bleeding whatsoever. Was this possibly some kind of venous fat? The patient is a very physically fit 56yo male, trim and athletic, who could easily be mistaken for 40-45yo. He had some localized allergic reaction to the PICC line: itching, very mild distal edema, patchy pink areas here and there near the ins. site treated with oral Benadryl. This was his second line: the first was removed within a week of insertion due to localized erythema and severe itching at the site and about 5cm diameter around it, and took 2 weeks to heal properly after removal. Would appreciate anything relevant that anyone might have experienced! Thanks, justdeda:nurse: Home IV Nurse

The first time I saw this practice on a busy med-surg floor, I thought someone had forgotten to bring a cap with them, and used this odd connection mode for an emergency. After a while, at this and other hospitals I worked in the metro NY area, I saw that certain nurses used the "looping", as you call it, and certain nurses didn't. Then I saw looping when no nurse had been near the area. It was the Nurse Assistants who were looping, since they had seen, just as I had, this cute little no-hassle answer to what to do when you have to change someone for the 4th time in the shift and there's no nurse around to unhook the pump-driven IV, or when your patient is halfway out of bed and the thing is stretched to the limit-- and no nurse around. No alcohol, and not always a glove change, never mind handwashing. Then I saw looping when no nurse and no CNA was around-- the c.diff patient who is embarrassed to call the nurse yet again, when he wants to run to the toilet every 15 minutes, so he detaches and loops himself, and re-attaches himself when he gets back, usually to the correct tubing...

This is a very interesting question, and there are some very interesting, conflicting and non-conflicting responses! Using the 10ml syringe with 0.1ml of medication and nothing else, to prevent fluid overload, may result in undermedicating the patient. Using the smaller bore syringe, which is more practical, may go against manufacturer's recs. Some of the experienced/expert IV nurses feel that it's the flush that needs to be done with the larger bore; some feel it's any fluid injection that requires this method. Attempting to reduce the pressure of a tiny bore syringe is beyond human control-- but the amount of fluid that is being introduced into the catheter is too small to create a hazard to the line, and is followed with a flush with the proper bore... Here's another spanner that I'd like to throw in to the mix: I requested numerous times of the pharmacy providing medication and supplies to my home PICC patient that they once again supply me with the 10ml prefilled NS syringes they had stopped sending. Eventually, I got a phone call from their main supply house. They claimed that the 5ml prefilled NS syringes that they were sending, the kind where the plunger shaft ends up totally flat against the syringe body when the fluid has been injected, is especially designed to provide the same pressure as a 10ml syringe. Does anyone know is this was true, or a brush-off? Thanks, justdeda

dear jailrn, regarding how long you can go between flushes, it depends on the type of picc. certain types can go several days without flushing. really, really basic cleaning of the site and the extension per the most picky aseptic protocol you can find (i use the web for this), may prevent an infection that would like to start up. a ltc facility i recently worked at that had a high population of "former" drug abusers, worried more about shooting up into the picc than about the patient pulling it out. depending on your inmate's mental and emotional stability, i would think he should be under some kind of visual frequently, like q 15 min, in addition to the infection-prevention q shift. if it's true that you're going to be seeing lots more like this-- good luck with creating policy and protocol-- a terrific challenge

hi, all. just wanted to drop a note -- haven't posted in a couple of years! my last post concerned a temporary fill-in position as supervisor at a ltc facility, where the last night but one had me feeling such chilly hostility from licensed, unlicensed and managerial personnel, that, in spite of my ethic of always finishing a commitment once it was accepted, i called out for my last night's work. as it happens, i was offered a part-time position with benefits at an out-of-state facility on my very last night. this led to the world of ltc/rehab management (education, infection control, supervision) and administrative nursing (interim dns) for the next 2+ years. i have recently returned to the happier world of agency nursing, but this time i'm a bit wiser, having seen the other side of the coin. i now do ivig therapy for home patients, with the occasional side-trip into multiple-day camp nursing, occupational health fill-in, that old standby, seasonal flu shots, and some supervisory visits. the ivig home care route seems to work for me. the patients love and trust their nurse. there is one patient every day for a week once a month, several hours a day. there is challenge in anticipating and preventing allergic response, fluid overload, kidney involvement, and so forth. the patients are diverse, grateful, generous, and the family interaction is very different from the long-term home care patient scenario. im able to do this work in spite of a work-related cervical disc hernia which reduces my push-pull-stretch capability. altho bennies is once again an issue, i can shop among and between local pharmacies to find those that pay best for the service rendered; and there is apparently no conflict with my regular agency agreement! i have developed relationships with pharmacists, specialty nurses, and pharmacy assistants, all super for the professional ego. in short, there is alot of ivig out there, with more and more neurologists, pulmonologists, rheumatologists and oncologists prescribing. if you are willing to do the (brief, free) training, and to learn on the job (which agency nurses do as a matter of survival), there is money and satisfaction in this arena. just my two cents! justdeda

It's true. If you work as an agency nurse long enough, a job you can bear will happen. Through a night supervision stint at a local nursing home, I got noticed and recruited to part-time night supervisor in a nearby state. Soon after, the Staff Development/Infection Control position opened, and I slipped into something that seemed to be made for my particular mix of training, experience, and interest. I'm new at this game; the game of daytime nursing from an office, the game of running after staff hoping to catch them and teach them some mandatories and some fun stuff...and still keeping up the infection control side of the job, including employee health and resident logs, and filling in when nursing runs short! Here on your Nursing Educators forum, I'm finding educators teaching students, not staff. I'd love to hear from some Nursing Home Staff educators, if any of you are out there? Please send me a private message. Thanks! deda

it seems i forget the lessons ive learned from the years of working agency: staffing, visiting nurse, private duty, school nurse, office nurse, flu clinic shooter, etc... after a while, i find myself double checking, double thinking, wondering if im doing the right thing, wondering if i shouldnt have become a lawyer, a teacher, an architect... thats the time that i usually change agencies, or types of nursing im available for, or, if its been a really bad burn, sit at home and not work, until the bills knock at the door, and i go out there again, to smile and be exactly what the job needs, the poster-nurse for whatever agency im with-- until the next burn. something new for me, i dont know if anyone else has had this experience, but here it is. at a ltc facility ive been doing night supervision for for the past 9 months or so, the staff has suddenly become aggressively uncooperative, actively defiant, and a chilly, chilly atmosphere prevails. no clue as to why this started. after two nights of this, with one date still committed, ive decided to come down with the flu, and let someone else handle the burden. for some reason, leaving before my time is up is as much of a downer as deciding not to return after the commitment is completed, or being asked not to come back after being accused of something i havent done, even tho theres no comfortable way i can face the current staff for even one more horrible night. the hostile atmosphere mattsmom describes is so prevalent in some units, and so totally absent in others, it makes me wonder what the heck the hospital or facility is doing to their staff to make them the way they are, good or bad. i sure understand your decision not to return, mom, and i sure hope you find something that gives you satisfaction and brings in a paycheck, that doesnt involve the kind of vulnerability that our job seems to require! hugs justdeda