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Zorluk: OrtaPharmacological and Parenteral Therapies

A nurse is assessing a client who is receiving a continuous intravenous (IV) infusion of norepinephrine for the treatment of septic shock. The nurse observes that the tissue surrounding the peripheral IV insertion site is pale, swollen, and cool to the touch. Which action should the nurse take first?

  1. Stop the infusion immediately and leave the intravenous catheter in place.Cevap
  2. B
    Remove the intravenous catheter and elevate the affected extremity on a pillow.
  3. C
    Decrease the infusion rate to a keep-vein-open rate and notify the healthcare provider.
  4. D
    Instruct the unlicensed assistive personnel to obtain vital signs while preparing a new IV insertion kit.

Cevap

Stop the infusion immediately and leave the intravenous catheter in place.
The client is experiencing extravasation of norepinephrine, a potent vesicant that causes severe tissue ischemia and necrosis. The absolute priority action is to immediately stop the infusion to prevent further tissue damage. Crucially, the catheter must be left in place initially so that the nurse can attempt to aspirate the residual medication from the tubing and administer the prescribed antidote (such as phentolamine) directly into the affected tissue via the existing line.

Adım Adım Çözüm

1
Identify the complication occurring at the IV site.
The pallor, swelling, and coolness indicate extravasation of a vesicant (norepinephrine).
Vesicants cause severe tissue necrosis if they leak into surrounding subcutaneous tissues.
2
Determine the priority nursing intervention.
The immediate priority is to halt the administration of the offending agent.
Stopping the infusion prevents further accumulation of the toxic medication in the tissue.
3
Establish the correct procedure for managing vesicant extravasation.
The catheter must remain in place initially rather than being immediately removed.
Keeping the catheter intact allows the nurse to aspirate residual medication and administer a specific antidote (such as phentolamine) directly to the affected area.

Anahtar Kavram

Management of Vesicant Extravasation
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Konular

Pharmacological and Parenteral Therapies

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