So I am a new PICC nurse. I have been inserting PICCs now for 5 whole weeks. I have an experienced PRN who is never with me when I have a difficult insertion. I have had 4 misses on one particular MD's pts. 2 were in for chemo, 1 PNA, 1 outpt infusion.
1st pt - lt basilic, good blood flow, visibly flinched with guidewire x 2, aborted & sent to IR.
2nd pt - Lt basilic, good blood flow, good purchase with guidewire, around shoulder then couldn't advance. Sent to IR.
3rd pt - anxious, rt basilic, good blood flow, visibly flinch with guidewire. rt cephalic (morbid obese), pt started yelling with lidocaine. Aborted, sent to IR.
4th pt - anxious, rt basilic, center of vein, good blood flow, no purchase with guidewire, then flinched. Chit chat x 15 min, rt basilic again upstream, good flow, good purchase, pt went through the roof with introducer/dilator, aborted, going to IR for Mod Sed.
I have also had two misses where IR MD came in, we went to fluoro and MD showed me stenosed areas I couldn't have seen. I guess because I am so new, and these 4 misses have been for the same doc, I am losing some confidence for his pts. All are oncology, and it has been so similar. Is there something else I should be trying? The flinching with guidewire advancement is getting me - what is this telling me?
Thanks!
~K
I think you are dealing with learning curve issues and it happens to everyone learning to place PICCs. I am not sure I totally understand what you mean by "flinching with the guidewire advancement". If you are referring to the paitent feeling the wire move up the arm, this would indicate that the wire is in contact with the vein wall, meaning it is destroying endothelial cells lining the vein wall, setting the patient up for thrombus. The wire should easily advance without the patient feeling anything. This endothelial layer does not have nerve endings, so if the patient is feeling any discomfort, then the wire is in contact with the tunica media, the middle layer of the vein. Maybe this is not what you meant though. 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
Thank you both. Lynn, the guidewire feels like it is floating freely but I see the patient can feel it. It just seems strange. Mark - yes, the good ones have been good ones. I just think its because these 4 have been with the same MD. I've had my preceptors come back, and my technique is consistent so far. I am just going to continue stopping when something doesn't seem right. Thank you both! I feel lucky to have good IR support with a MD who is happy to teach.
Lets re-focus...take a deep breath! Tell me about your good insertions in your 5 weeks. I have been doing Vascular Access for more years than I want to put into print but we all have our days. The positives..you stoped to gather more information and seeked assistance. Give yourself time and focus on the new skills you have learned during these 4 difficult experiences. And remember you tell your patients to take a deep breath...do it yourself!
and Kudos for knowing when to stop. Hang in there, you'll be a pro in no time.
I feel your pain, but things will get better! You'll learn something new with each insertion, especially with the difficult ones. I've learned the hard way to assess anxiety and pain levels when first meeting pt, so we can get a benzo or narcotic on board if needed. Oncology pts in particular seem prone to anxiety and hypersensitivity, likely because their world has been shaken. An ativan and time provided for it to start working can make a big difference. Having a partner with you to distract and comfort the pt and help you decide what to do next is a huge help, but it sounds like that is not always available for you. I also use lidocaine pretty freely; 1ml for the venipuncture, another ml before the introducer. Learning how much pressure to use with the introducer and how much discomfort to expect is hard! Brands of introducers make a difference--we have a 'rough' one in our picc kit, and a smoother one in our separate introducer pkg.
Patti Dickinson CRNI VA-BC
Lawrence Memorial Hospital
Lawrence, KS
Don't get frustrated or discouraged. I remember kicking myself with every miss I had. It wasn't until much later-- when I was teaching another person-- that I suddenly realized that we shouldn't be so hard on ourselves while we are acquiring our skill.
It's funny... we can teach the steps on how to insert rather easily... but the "feel" is what takes time to learn. You will get it.
Be confident when talking with your patients. You can ease their anxiety by being confident and calm yourself.
Good luck. :)
Janette Whitley, RN, VA-BC
PICC Program Coordinator
Janette Whitley, RN, VA-BC, Vascular Access Specialist