A nurse is assessing a client who is receiving a continuous peripheral intravenous (IV) infusion of norepinephrine. The nurse notes that the IV insertion site is blanched, cool to the touch, and swollen. The client reports a severe burning sensation at the site. Arrange the following nursing actions in the exact sequence they should be performed, from first to last.
- 1Stop the norepinephrine infusion immediately.
- 2Aspirate the residual medication from the intravenous catheter.
- 3Notify the healthcare provider to obtain a prescription for an antidote.
- 4Administer phentolamine through the existing intravenous catheter.
- 5Remove the intravenous catheter and elevate the extremity.
Answer
The correct sequence for managing a vasopressor extravasation is to first stop the infusion, then aspirate the residual medication, notify the healthcare provider, administer the antidote through the existing catheter, and finally remove the catheter.
When a vesicant like norepinephrine extravasates, the immediate priority is to stop the infusion to prevent further tissue damage. Crucially, the catheter must be left in place initially. This allows the nurse to attach a syringe and aspirate any residual drug from the line and the subcutaneous tissue. The provider is then notified to obtain an order for an antidote, typically phentolamine. The antidote is administered directly through the existing IV line to ensure it reaches the exact site of extravasation and reverses the vasoconstriction. Finally, once the antidote is delivered, the catheter is removed and the extremity is elevated.
Step-by-Step Solution
Key Concept
Management of Vesicant Extravasation