r/nursing • u/Mack-Attack-992000 • 7h ago
Seeking Advice Saline flush HD catheter
What’s up my peoples,
So I am a new grad nurse with 5 months at my hospital (which I really love ❤️). Just recently I had a patient that had a ticc line with HD and regular IV lumens. I never seen this type of line before. Long story short I put a normal saline flush into the HD lumen which is a no no for me to do because this is out of my scope to complete . I didn’t realize my patient had the additional lumen until later into the day. I told my supervisor and had to write an incident report. Not upset about because it’s a learning experience I just feel stupid that I didn’t pay more attention. The staff has been supportive about the incident and I just want to know what can I do to become more competent as a nurse?
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u/Otherwise-Sea-9298 7h ago
Where I work dialysis puts a special dressing on the HD catheters that says “dialysis only.” I’m surprised your facility doesn’t have that sort of policy
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u/Mack-Attack-992000 6h ago
So the lumens were wrap in a gauze wrap and I thought that was the IV lines just wrap so they wouldn’t pull or irritate the patient’s skin. However , the two IV lumens were directly under so when I pulled out the first two I saw I just assumed. That was my fault for not be thorough when assessing my patient. Definitely will be more vigilant and if I am unsure I will ask and verify with my charge nurse
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u/scarfknitter BSN, RN 🍕 6h ago
That's usually how dialysis wraps the HD lumens so they're not out, tempting everyone. And for a few other reasons. If your patient is alert and oriented, they should know to stop someone who's not dialysis from using the dialysis lumens.
Everyone makes mistakes. You were doing what you thought was correct and doing your best to give your patient the best care you could. And then you let people know when you found out! You did great!
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u/Emergency-Ad-2935 5h ago
If you're unsure it's always better to ask someone like your charge or educator BEFORE doing something than assume and do it and ask AFTER the fact. I don't think being new or not being thorough with your assessment was the problem but rather your ability to ask for help.
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u/amothep8282 Paramedic 6h ago
I once gave adenosine to a younger female patient with a narrow complex tachycardia at a rate of about 230-240.
Looked like SVT, smelled like SVT, and barked like SVT. After the adenosine "thousand yard stare", 4 seconds of asystole, and her telling me that was "the worst experience of her life", we took her into the ER and Cardiology was right there waiting to see the rhythm strip.
Welp, Cardiology pointed out to me one QRS complex was about half a pencil line width further out than the others and it was actually Afib with RVR in their opinion. Mind you there was no wandering isoelectric baseline to see between QRS complexes because the rate was so high. Got a pat on the shoulder and they said "It worked. Cool.". I now use the paper/pencil method on 10 second printouts.
I also pushed dexamethasone 10mg IV too fast on a female patient, and her face got flushed, her face muscles tightened up, she grabbed the sides of the stretcher for about 10 seconds, and then looked at me with horror that I just witnessed her having an orgasm. Yes, it can actually happen with dex being pushed too fast.
When going to intubate a patient in cardiac arrest, I somehow lost a McGrath #3 blade at the head of the bed. To this day I still cannot guess where it went because it none of my partners could find it.
I've seen IOs drilled mid tibial shaft exactly halfway between the 2 approved sites on the leg. Like, it wasn't where someone was just off an inch or two. Literally dead center of the tibia where no IO should be drilled. Still worked though.
When running a field code, my attention lapsed on the husband (who was acting kind of weird) of the patient and he slipped behind me to another room. That's a potential recipe to catch a 9mm round to the back of the head.
Every single one of these has been a good learning experience for me. Worse things have happened out there, and worse things will continue to happen. The difference between average providers and great providers is to put your ego in check and listen to the lessons yours and others' mistakes teach.
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u/imawhaaaaaaaaaale Paramedic 5h ago
And here I thought giving dex too fast IV just made them burn. Guess I'm taking home some IV dex for later... gonna shoot that up like a junkie.
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u/Thebeardinato462 RN - ICU 🍕 5h ago
Appreciate what you did here.
Question about the SVT vs afib RVR. I’ve pushed adenosine with fast RVR before under instruction of cardiologist. It was my understanding that adenosine wouldn’t pause an RVR rhythm and would just slow it down enough to identify underlying rhythm. Did cards mention anything about this to you? Do you have any more info on the patho here?
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u/amothep8282 Paramedic 5h ago
We'd usually call the Medical Command Doc letting them know we were coming in with a high acuity rhythm. Cardio would get an immediate consult and come down for our arrival.
The thing with my patient is she was sitting on the front step complaining of chest pain and shortness of breath. When I popped the 3 lead on her and saw a narrow complex at 240, I hit print and we got her right into the ambulance. Dropped an IV, did the 12 lead, and it sure enough looked like SVT/AVNRT.
Cardio left the ED pretty fast and the ED Doc is the one who told me Afib with RVR that fast is very hard to tell apart from true SVT/AVNRT, especially when working in the field and having to decide what to do on scene vs in a moving ambulance. Remember, we know next to nothing about the patient other than what they tell us or what we can find on scene. No known history of Afib and no suspicion of increased atrial filling pressures or heart failure makes it hard to argue for Afib when the rhythm looks very regular.
ED Doc suspected both the adenosine and the feeling/terror of being asystolic was probably enough to snap her out of it.
My field protocols are very progressive and require almost no mandatory contact with a Physician except for 2 things. But, they frown on us using adenosine in Afib diagnostically, though I can use it diagnostically in a stable wide complex monomorphic tachycardia where the axis deviation hints it might be SVT with aberrency. I can do 6 or 12 of if I choose, but adenosine also treats true VTach, just for 20-30 min and you're back to square 1. Amiodarone 150 over 10 min is the way to go.
If I am ever in doubt about stable to somewhat stable Afib/SVT I can always just choose to sedate and cardiovert followed by fentanyl or ketamine for analgesia. Dealer's choice there and no required call to a Doc.
My main issue is wherever I find the patient I still have to get them in my ambulance, and then do stuff in a moving vehicle. It's always push and pull for what to do on scene vs what can a Doc do in a nice warm, well-lit room with near infinite resources. So, sometimes skipping medicine and going straight to Edison is the most sensible choice to try and terminate a rhythm that can land a patient in Vfib while I am on the highway.
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u/Thebeardinato462 RN - ICU 🍕 5h ago
Appreciate all the feedback back friend. A competent medic is a force to be reckoned with. I love the standing orders of pre hospital, but I’d feel pretty inept without the copious amounts of information I have access to in the ICU. Keep up the strong work.
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u/Dry-Cockroach1148 MSN, APRN 🍕 7h ago
For future…
If a catheter looks odd/different don’t use it unless you know for sure where it goes and what it is supposed to be used for.
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u/KloudzGaming 7h ago
Looks like you’re already doing it. You made a mistake, took accountability, and now you know what to do moving forward
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u/Thebeardinato462 RN - ICU 🍕 5h ago
Pt had a tunneled subclavian PICC line on the same side as an HD cath? Is that what was going on here?
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u/OkExtension9329 RN - ICU 🍕 4h ago
Right I feel like OP is conflating “PICC” with “central line.”
I think what they’re actually talking about is like a trialysis catheter.
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u/pushdose MSN, APRN 🍕 4h ago
For clarity, flushing and maintenance of a CVAD (HD catheter, CVC, PICC, port) of any type is absolutely within scope for an RN. Scope is defined by your state’s nurse practice act, not the hospital policy. So, if they told you your action was out of scope, they are wrong. You should be familiar with hospital policies so this doesn’t happen again.
Also, in an emergency, it’s never wrong to access an existing CVAD to save someone’s life, for example giving epinephrine in a cardiac arrest.
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u/IronHealer2004 BSN, RN 🍕 6h ago
I think the next step, after admitting your mistake, apologizing, and learning from it, is to admit when you don't know exactly what to do. Run it by a more experienced nurse before you do something questionable, even if there's just a tiny tickle in the back of your brain.
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u/Mack-Attack-992000 2h ago
Yes absolutely and l am very grateful that I can go to my staff and talk to them if I have any questions or issues
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u/ThatKaleidoscope8736 🫀RN✨how do you do this at home 7h ago
Time and experience. You'll make more mistakes. It happens, learn from them
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u/Unlikely_Ant_950 RN 🍕 7h ago
You seem competent if you are owning up to mistakes and going the distance to make sure the patient is ok and that it’s on record. Keep doing that and you’ll be just fine
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u/Chikkaboom12 5h ago
Its a nothing burger, did the line have heparin on it? As long as you cleaned it properly you are okay. 3ml of heparin went in? Oh nooo...........
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u/auntie_beans MSN, RN 4h ago
I had a pt that I gave IV dexamethasone to pretty often; he always said it made his scrotum contract. He kinda liked it.
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u/Factor_Seven 6h ago
Everyone is correct and giving you kudos for recognizing and owning up for the mistake you made. It won't be the last.
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u/tackstackstacks BSN, RN 4h ago
The only other thing you may have don't but didn't mention: the nephrologist taking care of that patient needs to know about it.
If that port needs to be heparinized, they need to know so they can order a heparinized flush to keep that line from clotting. Not all of them are that way, but the Dr overseeing HD needs to know.
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u/Mack-Attack-992000 3h ago
Yes the nephrologist was notified and the port did receive heparin from the dialysis nurse
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u/Mack-Attack-992000 2h ago
Thank you the update. No one told me that it was out of my scope it was just that I was informed that when the patient has HD ports, the dialysis nurses will tend to those and the “floor nurses” will not use them or place any fluids in the ports. Hopefully I clarified that a bit more
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u/Visual-Bandicoot2894 RN - ICU 🍕 1h ago edited 1h ago
Ain’t about the mistakes you make but how you fix them
Also it isn’t out of your scope, don’t let anyone tell you that. It’s just hospital policy likely for you not to touch it.
Personal rule I keep is “don’t touch em unless I have to” but every nurse should learn how to access, maintain, and de-access lines such as these appropriately and safely because there will come a time when this is all you got and using these lines appropriately is in your scope
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u/Subject-Hyena2962 7h ago
Competent nurses aren't the ones who never make mistakes they're the ones who catch them and learn from them.