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Zorluk: OrtaPharmacological and Parenteral Therapies

While performing an hourly clinical assessment, a critical care nurse evaluates the peripheral intravenous site of a client receiving a continuous norepinephrine infusion. The surrounding skin appears blanched, edematous, and cool to the touch. The client reports intense burning in the arm. Which intervention is the most appropriate initial action?

  1. Halt the infusion immediately while leaving the intravenous catheter intact in the vein.Cevap
  2. B
    Extract the peripheral intravenous catheter immediately and elevate the affected extremity.
  3. C
    Reduce the pump rate to a keep-vein-open setting while notifying the healthcare provider.
  4. D
    Administer a prescribed as-needed systemic analgesic to manage the acute burning pain.

Cevap

The most appropriate initial action is to halt the infusion immediately while leaving the intravenous catheter intact in the vein.
The client is experiencing extravasation of a vesicant (norepinephrine), which causes profound vasoconstriction and tissue necrosis. The immediate priority is to stop the flow of the harmful medication. The catheter must remain in place to allow for the aspiration of residual drug and the local administration of an antidote, such as phentolamine, directly into the infiltrated tissue.

Adım Adım Çözüm

1
Assess the clinical signs at the peripheral intravenous site.
The blanching, edema, coolness, and severe pain indicate extravasation of a vesicant medication.
Norepinephrine is a potent vasoconstrictor and vesicant; its leakage into surrounding tissue causes severe ischemia and necrosis.
2
Determine the highest priority nursing intervention.
The infusion must be stopped immediately.
Halting the infusion prevents further vesicant from entering the subcutaneous tissue, mitigating the extent of the injury.
3
Maintain the intravenous access.
The catheter is left in place.
Retaining the catheter allows the nurse to aspirate residual medication from the line and provides a route to instill an antidote (e.g., phentolamine) directly into the affected area.

Anahtar Kavram

Management of Vesicant Extravasation
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Konular

Pharmacological and Parenteral Therapies

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