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Caution: Nerve Injuries During Venipuncture

Sunday May 1, 2005
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Permanent damage can result
when a needle point makes
contact with a nerve.

"Nurse, I feel an electric shock going down my arm." Would this patient complaint mean anything to you when you insert an IV catheter or draw blood? This feeling of shock is a classic symptom when a needle point makes contact with a nerve. It could result in permanent nerve injury - and malpractice litigation involving the nurse performing the procedure is not uncommon.
The two nerves most often injured during a venipuncture procedure are the radial and median nerves. The radial nerve passes along the thumb side of the arm, from the shoulder down into the wrist area, and is in close proximity to the cephalic vein. In a venipuncture procedure, the cephalic vein is often the vein of choice for many clinicians. The distal three inches of the radial nerve, just above the thumb, is the area most often injured during the insertion of peripheral IV devices.
The median nerve is the largest nerve in the arm. It runs inside the antecubital fossa and passes through the forearm into the palm of the hand. When nurses are drawing blood from the antecubital fossa or inserting peripheral IV devices, they could contact and injure this nerve. Insertion of IV catheters into the superficial veins of the inner aspect of the wrist above the palm of the hand can result in serious injury to the median nerve and carpal tunnel syndrome.
If a patient complains of an electric shock-type sensation radiating down into his or her hand as the needle is being inserted, the appropriate intervention is to remove the needle immediately. The outcome will be minimal nerve damage without permanent injury; however, if the nurse continues to advance the needle farther into the nerve, a permanent, progressive, and painful disability resulting in reflex sympathetic dystrophy (RSD) or
complex regional pain syndrome (CRPS) can result. Patient symptoms can include a mottled and cold hand and forearm, hypersensitivity to temperature changes, excessive nail and hair growth, and the inability to lift heavy objects. CRPS is diagnosed by patient history and nerve conduction studies. Treatment options include long-term pain control with narcotics, multiple nerve blocks, and even implanted morphine pumps, as well as splints, casts, and TENS (transcutaneous electrical nerve stimulation) units.
Best practice mandates nurses avoid areas of high-risk nerve injury by using landmarking techniques. The three-inch area above the thumb and the three-inch area on the inner aspect of the wrist should always be avoided since the radial and median nerves can be superficial in these areas. The risk of permanent nerve injury outweighs the benefit of IV insertion in these areas.
Standards of Practice
The Infusion Nursing Standards of Practice can be used in court to determine whether a nurse delivered appropriate infusion care to a patient. The standards state "site selection should avoid areas of joint
flexion."1 The wrist and antecubital fossa are areas of joint flexion. Insertion of peripheral IV catheters into these areas for delivery of infusion therapies can be determined to be deviations from the standard of
practice. These deviations, with documented injury
to the patient, can be contributing factors in a
malpractice verdict against a nurse. When necessary, the physician should be notified that an alternative vascular access device will be required to safely administer the IV medications.
Nerve compression injuries are also related to infusion therapy. These occur when a patient sustains an
infiltration of a large amount of IV solution into the
tissues. The IV fluid in the tissue increases the pressure within the tissues, resulting in compartment syndrome; and the duration of the high tissue pressure determines the amount of permanent nerve damage. Nerve compression is indicated when a patient's arm is infiltrated and he or she complains of numbness and tingling within the swollen area. The appropriate nursing intervention is to stop the infusion and notify the physician immediately. An emergent fasciotomy, which consists of two surgical incisions along the entire length of the arm, is required to relieve the increased tissue pressure. The incisions are left open; and, in some cases, penrose drains are used to aid in fluid drainage. A second surgical procedure is required to close the wound, and the patient will have extensive scarring of the forearm and hand.
Permanent nerve injuries are preventable by avoiding high-risk superficial nerve areas for venipuncture and by frequently documenting IV site assessments. Nerve injury related to venipuncture is one of the most common areas of nursing malpractice in which the nurse is
identified as the primary defendant. Remember - listen to the patient. Remove the IV device immediately if
the patient has symptoms of nerve contact during venipuncture, and avoid high-risk nerve injury areas.