A nurse is assessing a client who is receiving a continuous peripheral intravenous (IV) infusion of a vesicant antineoplastic agent. The client suddenly reports severe burning pain at the IV insertion site. The nurse observes local swelling, erythema, and a lack of blood return upon aspiration. In what order should the nurse perform the following interventions? Arrange the actions in the correct sequence.
- 1Stop the continuous intravenous infusion immediately.
- 2Disconnect the administration set from the peripheral catheter hub.
- 3Attach a sterile syringe to the catheter and attempt to aspirate residual drug.
- 4Remove the peripheral intravenous catheter from the client's arm.
- 5Elevate the affected extremity and apply the indicated thermal compress.
Answer
The correct sequence is to first stop the infusion, disconnect the tubing, attempt to aspirate residual drug through the existing catheter, remove the catheter, and finally elevate the extremity and apply a thermal compress.
When extravasation of a vesicant occurs, the immediate priority is to stop the infusion to prevent further tissue damage. The tubing should then be disconnected from the hub. Crucially, the catheter must be left in place temporarily so the nurse can attach a syringe and aspirate any residual medication from the line and subcutaneous tissue. Only after aspiration is attempted should the catheter be removed. Finally, the extremity is elevated to reduce edema, and the appropriate thermal compress is applied based on the specific pharmacological properties of the vesicant involved.
Step-by-Step Solution
Key Concept
Extravasation Management of Vesicant Medications
Estimated Time:1m 30s