Forum topic

 All policies and procedure books from outside your facility can serve as examples for writing your own policies and procedures. The only time they would have the same weight legally as the INS SOP would be if a facility has a policy that book XXX is the accepted procedures for that facility. These books usually do not have polciies, although the INS book does. Most from publishers like LWW have only procedures and the facility must write there own policy. 

Photos are frequently discussed in articles about infiltration and extravasation. They are recommended by many experts as a means to protect the nurse. A written version of what a site looks like falls far short of what an expert would see in a picture. I have never seen any actual research on the use of photos though. Many are concerned about photos being used against the hospital but I think they would protect more than harm the nurse. As an expert when I am reviewing a chart and I see a check mark on an EMR that the site was WNL or benign or some other simple description, then the patient went on to develop a severe complication, my first thought is did the nurse miss something in her assessmentd. If I had a picture to see what she actually saw, then I would be more confident in my assessment of her decision. I can understand that the quality of the photo might be an issue, but I have not done any research on that. Does your RM have any research to share with you about use of photos? I would expect her to support her position with evidence the same way she is expecting that from you. Many times in a lawsuit, the available photos have been taken by the patient's family. These are many days later when they realize their is a problem. So you may be faced with photos that you have not control over. ONS states "measurement and photographs of the extravasation site per institutional plicy"

You should have some written information for all patients upon discharge about their IV site, regardless of the type of catheter. Post infusion phlebitis can occur up to 48 hours after PIV removal. Extravasation may not be known for several days. So all patients must have information about what to look for and who to contact if they have any problems. This is another huge missing piece in most legal cases. No written information, patient does not realize there is a problem that could cause severe damage to his hand, he does not seek help until it is too late, then the first person he goes to is a lawyer. There are no recommendations about return to OP at XX. ONS say periodically on follow up and is dependent upon the individual patient needs and institutional policy. So these are issues that your institution must decide. Standards and guidelines are written based on evidence. When there is no evidence about a specific issue, then the professional organization can not just make up something to include. We have moved away from the days when these documents were based on a collection of professional opinions and practices of experts. But that approach leaves many questions unanswered. Lynn

From the Oncology Nursing Society's Chemo/Bio Guidelines, 2009, pg 110:

10.  Documentation of vesicant extravasation

      g)  Measurments and photographs of the extravasation site per institutional policy.

I agree with Lynn.  A pic is worth a thousand words . . . . and yes, family may take pics when injury is at its worst.  A pic immediately after suspected extravasation event can show that the extravasation is difficult to see.  I have some pics of a 5FU extravasation 24 hrs after the event (IV had been removed) and you would have a difficult time pointing out on the arm where it happened; then a month later and there is an area of skin desquamation and discoloration that is quite visible and large.  I am always certain to obtain a photo consent prior to taking any pics. 

I think another important element about follow-up is to have a consistent person view the site and also establish a relationship (partnership) with the patient.  I have usually taken it upon myself if we have an event like this.  Give them your direct office phone number so they have A PERSON they can call.  Call them daily for the first several days to find out how the injury is doing.  How does it look?   Are they following instructions about heat/cold, elevation, keeping is out of sun?  Also, they need to come in and be seen by us so we can view the site and continue photo documentation.  (Depends on the drug how often.)  It will also help us to alter therapy for the injury if needed.  Pt feels that someone is concerned/interested in what happened to them and doesn't just send them out the door, feeling adrift and alone.