Tidbit: IV Dilantin

Administering IV Dilantin is one of those things you probably won't encounter very often (unless you work in the ER), but when you do, there are a few important things to remember.

• Dilantin is a caustic vesicant and can cause extensive tissue damage if it extravasates.  It should not be refrigerated or diluted for long periods because it crystallizes rapidly in solution. Doses of 500mg or more can be diluted in 50 cc NSS or 0.45% saline if administered over 30 minutes.
• NEVER give it with IV potassium because an instant precipitate will form in the IV catheter.
• Make sure you have a patent, wide-bore IV site.  If you can't get a blood return or if there's any question as to whether the line is venous or arterial, don't take chances, start a new venous line.  See picture below.  Purple Glove Syndrome is catastrophic tissue damage caused by Dilantin extravasation.
• DO NOT ADMINISTER through a PICC line as it is more likely a precipitate will form and occlude the line.
• If you're running fluids other than normal or half-normal saline, flush the line with at least 10cc of saline before administering Dilantin.  Dilantin is compatible with normal saline or .45% saline only.  It is NOT COMPATIBLE with dextrose solutions.
• Administer slowly -- no more than 50mg per minute (25mg per minute in elderly patients or those with cardiac disease). It will probably still burn.  Rapid administration can result in cardiovascular collapse, CNS and respiratory depression, and severe hypotension.  Loading doses of 500mg or more should be administered on a pump.
• Be sure to flush the line thoroughly with saline when you have finished administering the dose to prevent irritation to the vein and to wash the IV catheter clean before connecting other fluids.
• Patients receiving IV Dilantin should be placed on telemetry monitors because of the risk of depressed cardiac conduction, ventricular fibrillation and heart block.

Purple Glove Syndrome related to Dilantin extravasation.

Do You Have Ice and Water Here?

As this blog is getting started, I have dozens of topics in mind jostling to be next.  But something happened a few days ago that I want to share because it illustrates just why we need to take the time to focus on what it is we do, or what we are SUPPOSED to do -- care for our patients.

An elderly woman was admitted on day shift, around 1000.  The shift was hectic and staffing was somewhat tight, although not ridiculously so.  I won't go into the patient's diagnosis or history because there is only one detail relevant to this story -- the patient was NOT NPO.

Around 2000, the night shift nurse greeted the patient on her first round.  This little old lady, an alert and oriented octogenarian, had a distressing question for her new nurse.  "Do you have any ice and water here?"

Naturally, it was all the nurse could do to hide her awe and disgust that this little grandma had sat in that room for ten hours without a water pitcher.  She may have been placed on an air mattress to prevent skin breakdown.  She probably had all of her labs drawn.  She may have even been assisted to the bathroom once or twice.  But no one had taken the time or given thought to providing her most basic human need.

In the immortal words of Forrest Gump, "That's all I have to say about that."

Time Management

Nursing is a demanding and stressful profession.  It is important to be organized, but you have to remain flexible.  It would be nice if every shift flowed smoothly, allowing you to visit each patient in order, completing your assessments, documentation and med pass, but that is not a realistic expectation.  You have to expect the unexpected to happen at the worst possible moment and critical thinking and time management skills will help you shift gears and focus on those events without losing your stride.

Here are the most important tips to remember:

1. Arrive early and scope out your assignment.  Get your ducks in a row before you take the helm.  Expect that the nurse you are relieving did everything she was supposed to do and, if she didn't, ask her why.  Don't enable people to leave things for you.  You have enough to do.
2. Get report quickly and have a positive attitude.  Pay attention to the facts you need to know and don't let it turn into a negetivity-laced anti-pep-rally.  Getting a late start will put you behind for the entire shift and listening to complaints will affect the attitude you carry with you on your first round.
3. Give report to your tech.  A good tech can make or break your shift.  By the time you hit the floor, your tech should have been able to make a round.  This way, you will not walk in to empty water pitchers, snack requests or emergent bathroom needs.  Delegate when necessary and pitch in when able.  No one should be sitting around while someone else is in the weeds.
4. Prioritize your To-Do List.  Start with your sickest patient or your least desirable task.  That way you will not be filled with dread as you see your other patients.  Delegate when you need to.  If you are in the middle of an assessment or patient education and your tech asks you to help with a bath or linen change, ask them to get another tech to help.  It's okay.  Don't delegate learning experiences.  If you've never dropped an NG tube or pulled a central line, don't ask someone to do it for you, make time to do it yourself.  These are skills you need.
5. Chart as you go.  Take a minute to document as you complete tasks so you won't forget critical information.  Use your flowsheet to the best capacity and don't write a book of narrative charting in your notes.  Don't save all of your charting and think you're going to have hours to sit and complete it.  That is invariably when a patient will "crump out" or you will get a new admission.  Charting as you go allows you to remain flexible to step up when a patient needs you.
6. Make that final round.  After a busy shift, you may have to force yourself, but making that final sweep in the last half-hour of your shift will make shift-change that much smoother.  Tell your tech you expect her to do it as well.  Without a final round, it can be 2-3 hours between times patients see staff members.  It is no wonder they have a laundry list of requests or complaints when someone finally does show up.

Remember, this is the life we have chosen for ourselves.  It isn't always pretty, but time management and critical thinking are a nurse's best tools to help her stay sane and take the best care of her patients.

Humor

Welcome Nurses!

So many times, as we're rushing around trying to give our patients the best possible care, we come across interesting details or important points that all good nurses should know.  Sometimes our response is, "What?  Are you sure?  I've never heard of such a thing," and sometimes it's "I think I remember something about that from nursing school."  Nevertheless, we make a mental note to remember it for next time and maybe even to share our new-found knowledge with a co-worker.  Sadly, these good intentions are often obliterated by frequent interruptions, short staffing, high acuity and a host of other daily deterrents.

This blog is dedicated to those moments.  I invite you to visit daily and take a minute to absorb some helpful hints and important medical trivia.  It's easier to digest and retain information in your leisure time than in the heat of the moment, when you've got six or seven patients vying for your attention.  Use these posts to make yourself a better nurse and pass it on.  It will benefit your patients, but it will help you as well.  After all, we all feel better when we know what we're doing.  Right?

You will also find "Comfort Measures" -- posts designed to just make us feel better about what we do.  Validation is important.  We've all been a new nurse or an overwhelmed nurse.  You'll find no sugarcoating here -- just communication, appreciation and validation of who we are and what we sacrifice to do what it is that we do.  We're all in this together.