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Difficulty: Very hardReduction of Risk Potential

A nurse is monitoring a critically ill client who is receiving a continuous intravenous infusion of norepinephrine through a peripheral vein in the right forearm. The nurse assesses the insertion site and notes it is blanched, cold, and swollen, and the client reports severe burning pain. Arrange the following nursing interventions in the correct order of priority to mitigate tissue necrosis.

  1. 1Stop the norepinephrine infusion immediately.
  2. 2Attach a sterile syringe to the intravenous catheter and attempt to aspirate residual medication.
  3. 3Remove the intravenous catheter from the client's forearm.
  4. 4Administer prescribed phentolamine subcutaneously in a circular fashion around the blanched area.
  5. 5Elevate the client's right arm on pillows.

Answer

The correct sequence is to first stop the infusion, then aspirate residual medication, remove the catheter, administer subcutaneous phentolamine, and finally elevate the extremity.
The protocol for vesicant extravasation prioritizes limiting the exposure to the chemical agent immediately. The sequence follows a strict logic: halt the source, remove residual agent from the micro-environment, remove the delivery device, chemically neutralize the agent in the tissue, and provide mechanical support to reduce swelling.

Step-by-Step Solution

1
Stop the norepinephrine infusion immediately.
Halts the continuous flow of the vesicant into the subcutaneous tissue.
Immediate cessation of the infusion is the most critical first step to minimize the total volume of tissue-damaging medication delivered.
2
Attach a sterile syringe to the intravenous catheter and attempt to aspirate residual medication.
Removes trapped norepinephrine from the catheter lumen and the immediate venous puncture site.
Aspiration prevents the remaining medication in the tubing and catheter from being pushed or leaking into the tissue when the catheter is manipulated or removed.
3
Remove the intravenous catheter from the client's forearm.
Eliminates the source device from the compromised tissue.
The catheter must be removed prior to administering the antidote to ensure no further vesicant is accidentally flushed into the tissue and to clear the area for subcutaneous injections.
4
Administer prescribed phentolamine subcutaneously in a circular fashion around the blanched area.
Reverses the extreme localized alpha-adrenergic vasoconstriction caused by norepinephrine.
Phentolamine induces local vasodilation, restoring perfusion to the ischemic tissue and preventing necrosis. It must be administered directly into the affected tissue, not intravenously.
5
Elevate the client's right arm on pillows.
Utilizes gravity to improve venous and lymphatic drainage from the affected limb.
Elevation reduces hydrostatic pressure at the capillary level, which helps to decrease the accumulation of edema in the compromised tissue.

Key Concept

Vesicant Extravasation Management and Complication Prevention
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Topics

Reduction of Risk Potential

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