I'm a newer nurse (less than 2 years) and have been on my onc/surg floor for about 18 months. Part of that time I was in an RN residency program with a preceptor, which was very helpful for learning.
Our unit is technically a med/surg unit, but we take all varieties of patients, ie trach pts, cardiac drips that aren't titrated, hospice, and any overflow. We also take all general surgical cases and cardiac/ortho-neuro overflow.
My point in saying that is to highlight the fact that we see EVERYTHING on our floor and as a new nurse this has been great learning but also overwhelming. There is SO MUCH to master with so many kinds of patients and such fast-paced work. And honestly, for being an oncology unit (in name) I've had very little experience working with ports in terms of accessing and de-accessing them.
I have accidentally sent home a patient with a port accessed (the patient got dressed before discharge with coat and hat on and demanded to leave!) and recently forgot to heparinize a port before deaccessing. I did a saline flush, but I felt terrible knowing that i didn't follow our protocol. I let my day and night charges know the next morning and as the patient was visiting our infusion center for labs in a few days, they stated that the patient's port should be fine and would be heparinized then. I'm still having a hard time with it, though. I want my nursing practice to be correct and I want to know when I've made an error what I can do to correct it.
Even though I'm technically on an oncology floor, I've only accessed and deaccesed ports a handful of times. and most of the times were with another RN, and I was signed off as competent. Upon reflection I don't believe this was enough training though, and I believe our unit practice for decanulating ports is not best practice.
When we decanculate it is up to the nurse to override the correct heparin dose (and there are lots of options in the pyxis.....you better know which one is right by memory) and it is not an ordered drug so it does not appear on the MAR until it is pulled. This means it doesn't get verified by and MD or a pharmacist. (The patient on whom I forgot the heparin flush was a colon ca patient with a significant gi bleed. The wrong heparin preparation flushed through the port could be disastrous. It seems prudent to me that a medication like heparin should go through several tiers of approval before reaching the patient.)There is nowhere in the flow sheet to document that the port was heparinized, either, when its decannulated.
I think that there is a risk for error for new nurses on our unit like myself to pull the wrong heparin dose on override or forget altogether because of the lack of opportunity to practice the skill and the lack of a proper med order in the chart. I am considering approaching management about changing this. My nursing buddy at work suggested that I propose a change in this to our practice council as it doesn't appear to be a best practice.
Can anyone recommend appropriate resources to help me investigate best practice in this situation, or any other helpful information? I would greatly appreciate feedback on this topic. Thanks!
PS- As a brand new RN I once encountered a subQ heparin dose ordered incorrectly by an MD and approved by the pharmacy. The MD ordered the heparin drip bolus preparation instead of the subQ preparation. I recognized that the vial was different than I was used to and brought it to the attention of my superior and the mistake was corrected. Obviously MDs and PharmD's are not fool-proof, but if a doctor and a pharmacist can make a heparin mistake, then how much more likely an in-experienced RN who's pulling the med without an order?
Specializes in Medical-Surgical/Float Pool/Stepdown.
If I'm reading you correctly you are pushing Heparin into a port that is being kept accessed? Why? The only time you need to use Heparin is before you de-access the port and send the patient home. While the port is accessed only NS is needed to lock it between uses.
I think it's a difference in facility protocols. Ours specifically states to heparinize after blood draws, IVP meds when hep-locked, and when deaccessing. But we are suppose to draw the heparin out each time prior to flushing with saline...but our protocol doesn't say that specifically unfortunately.
Specializes in Medical-Surgical/Float Pool/Stepdown.
We had a lot of patients who were getting numerous pushes (like one every hour or two) so that seems like an excessive amount of heparin being pushed into their system?
Just food for thought and funzies. Think about how the half-life of heparin and the total dosage of heparinizing a port with hopefully drawing each flush back out before flushing with saline and compare it to say a heparin gtt or even subq heparin doses q 8. This is how I had it presented to me reinforced with the understanding to respect heparin as a high risk drug and to always be very mindful and careful in its use...just like all of the crazy cool meds we get to give as nurses ;-)!
I think it's a difference in facility protocols. Ours specifically states to heparinize after blood draws, IVP meds when hep-locked, and when deaccessing. But we are suppose to draw the heparin out each time prior to flushing with saline...but our protocol doesn't say that specifically unfortunately.
All that wasted blood adds up in our patients which is why our practice changed. Not sure using Heparin in a port that is to remain accessed falls under EBP. Not blaming you of course. Policy is policy but I'm kind of surprised. Sounds like a clinical ladder project.
AJJKRN
1,224 Posts
I think it's a difference in facility protocols. Ours specifically states to heparinize after blood draws, IVP meds when hep-locked, and when deaccessing. But we are suppose to draw the heparin out each time prior to flushing with saline...but our protocol doesn't say that specifically unfortunately.