The number of malpractice or negligence cases which involve damages from an intravenous needle or infusion seem to be on the increase. In general, the nerves run very close to the veins and arteries. The arm is no exception. Nerves can be damaged by the actual needle stick or by compression caused by infiltrated fluid. Veins can be damaged by the needle, a clot, or irritation of the vein caused by the injection of irritants. Symptoms of these injuries can resemble those of Reflex Sympathetic Dystrophy which include swelling, pain, color and temperature changes. There has been very little literature concerning needle related injuries. The medical records reflecting the whole area of IV therapy is usually very scant. IV teams in hospitals were once common and the nurses in those departments were truly experts at initiating and maintaining IV therapy. At this time, those departments are being deleted and more staff nurses are performing venipunctures. They are generally not as experienced and not as focused on the appropriate documentation. Documentation concerning venipuncture will most likely be very general, not indicating a specific site nor number of attempts made. There is no way to determine technique from a medical record. When evaluating these cases, one needs hospital policies and procedures concerning the insertion of an intravenous needle, monitoring of the site and appropriate documentation of that monitoring, and protocols involving rotation of sites, and changing of the IV tubing and containers. There should also be policies concerning administration of IV medication, the procedure to follow in case of infiltration or phlebitis, and education records of the staff. Policies about the insertion of an IV needle should include who may do it, how many attempts each person should make, and what should be done if unsuccessful. Monitoring of the IV site should be done frequently and documentation should be done at least every shift. Routinely, IV sites are rotated and tubing is changed every three days and IV fluid containers are changed every 24 hours. Policies concerning administration of IV medications should include proper dilution and rate of infusion. Many drugs must be diluted and given slowly to prevent phlebitis or irritation of the vein.
Phenergan is one of the drugs that seems to be implicated in many cases of IV complications. According to the literature, it should be diluted in 9 cc of sodium chloride and given slowly.
Amputation of an extremity is traumatic in itself, but the problems are not only immediate. After the amputation, a person must relearn many of the activities of daily living. These include personal hygiene measures, feeding oneself if the amputation is of an upper extremity and ambulating if a lower extremity is amputated. If a lower extremity is amputated, the individual must spend hours in rehabilitation strengthening and conditioning the upper body for crutch walking and gait training and the lower body for use of a prosthesis. If a lower extremity is amputated, there is a shift in the center of mass, and therefore the balance of the person. Safety is always an issue since the body is poorly balanced. There is an increase in metabolism and therefore an increase in oxygen consumption. There are problems that occur related to the stump, including wound infection, dehiscence or opening of the wound, necrosis or death of tissue, edema or swelling, and weight loss. These all affect the way a prosthesis fits and a poor fitting prosthesis may be to blame for these problems. There is always a possibility that a revision of a stump may occur in the future. Pain control is a problem that may last for a long time. There may be phantom pain that is relieved for a time and returns when triggered by some irritation or psychological factors.
The first response to loss of a body part is grief with stages of denial, anger, depression, and finally acceptance. If the amputation is due to a medical condition and the decision is made over time, the individual has the opportunity to work through some of his feelings and prepare himself for this loss. Alteration in body image is the nursing diagnosis most used in the case of any amputation. It is difficult to see one's body with such a drastic change. There may be problems with social acceptance, life style changes, depression, and employment. Mobility and independence are important to deal with these problems.
Damages may continue over an extended period of time. Once the person is "adjusted" to the amputation, he or she may still face problems, both emotional and physical such as back pain from alteration in ambulation, skin problems and nerve damage surrounding the prosthesis.
