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ebaxter6
mastectomy/lymph node dissection
Our hospital policy states to avoid using an arm for a peripheral iv on the affected side of mastectomy/lymph node dissection.  However, looking at the INS Standards of Practice S37 site selection and device placement it states (j. A physician should be consulted and an order obtained prior to cannulation of an arm of a patient who has undergone breast surgery requiring axillary node dissection, who may have existing fistulated access and other contraindications.) Does this mean if we obtain an order from a physician it is okay to place a piv in the affected arm?  Are we going to be covered in a court of law if this patient presents with lymphadema after a nurse places an iv because the physician has written an order?
lynncrni
It would always be best to

It would always be best to avoid cannulation in the post mastectomy arm, however there could be times when this is unavoidable (bilateral mastectomy for instance). The risk of lymphedema is related to the lymph nodes that were dissected. The physician should make the decision about whether this arm should be used for infusion. I would be the first to tell you that the presence of a physician's order will not provide total legal protection in a lawsuit. The nurse must use critical thinking skills and protect the patient. This standard is saying that a physicians order is needed to use these arms, but there will never be any guarantee that a serious negative outcome would not lead to a lawsuit. The outcome of the lawsuit would depend upon the agreements between the attorneys and whether it went to a jury trial. No one should ever try to guess what a jury will decide.

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

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Heather Nichols
    I disagree Lynn.  I

    I disagree Lynn.  I do not think there are times when this is unavoidable.  A bilateral mastectomy patient has other options that should be utilized.  EJ, IJ, port placement, tunneled line/PICC, and more.  I think of my patients as I do myself and/or my family.  If I would not want it done to me, than I do my darndest not to do it to anyone else. After a bilateral mastectomy, and everything that goes with it,  I would think the last thing the patient needs is lymphadema.

   And as far as a doctors order goes......  I will be the first to tell you that it don't mean squat!  The hospital either.  Neither one will protect you in court, and most likely will not even try, so if you need to ask a question like that, I think the first thing you need to ask yourself is, should you even be doing it?  Maybe you had your answer to begin with.

lynncrni
I understand what you mean

I understand what you mean about other sites and other catheters when the infusion need is for several more days, etc. But I know there will be times when a physician will say a peripheral venipuncture is acceptable because there were no lymph nodes dissected and the risk of those other sites and catheters outweigh the use of the arm. It all involves a thorough vascular access assessment by a knowledgeable, skillful infusion specialist. 

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

www.hadawayassociates.com

Lynn Hadaway, M.Ed., NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257

Website http://www.hadawayassociates.com

Office Phone 770-358-7861

Heather Nichols
   And one that realizes
   And one that realizes physicians are not God and it is ok to say NO! if it is not in the best interest of your patient.
Donna Fritz
I think that one needs to
I think that one needs to address the element of risk of lymphedema when determining vascular access best for the patient.  For lumpectomy or mastectomy, there are risks that generally relate to how many lymph nodes were resected, although breast surgery in and of itself may also be a risk.  We used to get fairly deep into the axilla.  With our new techniques of sentinel lymph node biopsy rather than axillary dissection, lymphededema risk is less.   Also consider the other therapies--radiation can add more risk of lymphedema.   So I think looking specifically at the lymph node surgery and subsequent treatments will help you to determine how much at risk the patient is for lymphedema.
Mats Stromberg
Hi, anyone that places or

Hi,

anyone that places or would consider placing a PICC line in the same side as breast cancer surgery was performed? If so, for which patient and under which criteria? If not, why not, today with the sentinel node teqnique beeing so widespread? Is a patient having gone through bilateral mastecomy disqualified when it comes to a PICC?

Thanks

Mats in Stockholm

PS. For those who read my postings earlier on  access choice for myeloma (which I have got), I ended up with an untunneled CVC. I am not happy with that, but I could not convice my haematologist. Got high dose melphalan yesterday through it, went OK. Today stem cell reinfusion - should be OK. DS.

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