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Mary J. Matteson
Let the experts respond !
A patient with a S/P total hip infection( MRSA) Hx. of DM. AICD in lft chest.  Hx. of bil. radical mastectomy.( + CA.with node disection) Rt. breast 2000.  Lft breast 2003.  Would a PICC be appropriate in the RT. arm?  A surgeon said  " Mastectomy is not an issue these days".What would INS say about that?  Pt to be on IV Abx. for at least 6weeks.  Would a groshong tunneled catheter in the rt. chest be a better idea? A mediport?   Help!!
lynncrni
The INS standards of

The INS standards of practice call for a physician's order when using an extremity s/p mastectomy. The issue is lymph node dissection and the risk of lymphedema. This must be addressed in your hospital policy and procedures. 

For this patient I would prefer a tunneled catheter, preferably inserted by a skilled interventional radiologist with the venipuncture into the IJ. An implanted port would not be my first choice because of the need to change the needle, issues with maintaining the port access needle, etc. Lynn 

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Mary J. Matteson
Thanks Lynn.  That's what I

Thanks Lynn.  That's what I suggested but thats not what I had to do.  The Md's insisted on a PICC in the Rt. arm and it was 3 against 1. I hate when I have to do what I know isn't right.

 

lynncrni
For anything that is
For anything that is contrary to your best professional nursing judgment, you have the right to refuse to do it. Don't ever forget that nurses are patient advocates above everything else. I have refused to do many things that a physician expected me to do, but was always supported by the chain of command. Lynn

Lynn Hadaway, M.Ed., RN, BC, CRNI

Lynn Hadaway Associates, Inc.

126 Main Street, PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Nadine Nakazawa
I would let the physicians
I would let the physicians know that the patient is at high risk for lymphedema.   I would recommend a small bore tunneled catheter to be placed by an interventional radiologist (if you have one).  It can be a Hohn catheter or even a polyurethane PICC line placed into the IJ and tunneled about 2-3 cms onto the upper chest.  Perfect for a few weeks of IV antibiotics or any prolonged IV therapy course as you use with a PICC line.  It is relatively easy to remove, especially compared to a Groshong tunneled catheter and a port is not appropriate in this situation.   And definitely not a PICC.

Nadine Nakazawa, RN, BS, OCN, CRNI, VA-BC

kokotis
half a dozen of one a dozen

half a dozen of one a dozen of another

It is a multi-disciplinary clinical decision and the Medical Physician felt the risk of thrombisis was lower than the risk of an implanted/ tunneled line.  I woudl chart that you reveiwed the clinical factors with the physician team and that a PICC line was the vascular access device selected. 

The highest risk of symptomatic thrombosis in an oncology patient if Grove is right on that one ( I think they are on the chemo drugs and history of chemo) is 10%.  As far as non-symptomatic no one knows what the true result of any location is.

Kathy Kokotis

Bard Access Systems

Heather Nichols
  I agree with Lynn 100%

 

I agree with Lynn 100% here.  I cannot understand why a nurse feels as though he/she "has to do" what a physician orders just because he/she is the physician. Did this physician have sound rational as to why he did not want to place a tunneled catheter? Did you ask him/her for documentation to back up that decision?  Was the patient given a good explanation of all of her options?  Because the documentation sure is there to give a good argument NOT to place that PICC. It is great to document when there is a need to cover yourself, but what about the patient?  Sure sounds like this patient has enough to deal with in life without the added addition of lymphadema, UE DVT, or blood stream infection. Nadines suggestion was perfect.  Stand up for your patient.  It is not 3 against one.  It is three against two. 

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