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Letters to the Editor – March 2009


Avoiding the dangers of I.V. phenytoin 
As an infusion nurse specialist, I’d like to add some information to and clarify some points in “Phenytoin: Keep patients in the range and out of danger” in the January 2009 issue. The author recommends giving phenytoin through a central venous catheter, a good practice, but she didn’t mention the importance of assessing for a brisk blood return before administration. Certain factors can alter the fluid pathway, causing a retrograde flow and leakage of this vesicant drug into the subcutaneous tissue. Because of this danger, a nurse should also frequently check for blood return during the infusion—even when using an infusion pump. Remember, a pump can keep pumping an extravasated drug without sounding an alarm.
For peripheral administration, many sources recommend a large catheter, such as an 18-gauge catheter. But an infusion nursing standard of practice is to always use the smallest gauge catheter capable of delivering therapy. A large catheter can alter blood flow through the vein, reducing the amount of blood available to dilute the drug. It can also cause mechanical and chemical vein irritation and increase the risk of thrombosis distal to the venipuncture site. All these factors increase the risk of extravasation injury. To avoid this complication, I would use a 22-gauge or 24-gauge catheter, frequently assess for a brisk blood return, and flush the catheter with 10 mL of normal saline solution before and after administration. As the author points out, I.V. administration of phenytoin always requires a 0.22 micron in-line filter. I would add that filters may easily clog with drug precipitate and should be replaced if occlusion occurs.
Lynn Hadaway, MEd, RN, BC, CRNI
Milner, GA

Editor’s comment: Now that generic fosphenytoin is available, the Institute for Safe Medication Practices recommends using it instead of I.V. phenytoin to avoid these complications.

Foreign nurses: A question of education
I read “Short-term solution to our shortage” in the November 2008 issue’s Letters to the Editor, and I agree that nursing education is a vital solution to the shortage. But I don’t agree with the suggestion that hiring nurses from other countries puts patients at risk.
Nurses educated outside the United States are subject to the same standards of practice as nurses educated in this country. Plus, many of these nurses undergo difficult training, earn bachelor’s degrees, and pass numerous board and proficiency exams. All nurses are worthy of the respect of the public and other nurses.
Johanna Divinagracia, BSN, RN
New York, NY

Documenting our stories
I enjoyed the thought-provoking Editorial, “Telling our story” in the January issue and would like to share some suggestions. To make our accomplishments known, we must collect and publish value-added outcome data. Our traditional missions include providing patients and family members comfort, realistic hope, and appropriate alternatives. We accomplish these missions daily, but we don’t document an increase in our patients’ comfort or hope. Nor do we document our suggestions for alternative therapies when a patient faces a difficult regimen. And we don’t document whether a patient adopted our suggestion and whether or not it worked.
Nurse administrators should track data about strategies they use to effectively orient, reward, and retain good nurses. These strategies include making staffing decisions based on patient and family needs and creating work schedules based on needs of nurses. Outcome data about such decisions, including attendance, overtime, and retention, must be published to share what works.
Data on patient and management outcomes are more likely to show positive changes if they are based on a shared theory of nursing, in which all healthcare team members are invested. To collect value-added patient data, we need to devise mechanisms for charting. When medical records show positive outcomes and they are publicized, nurses will be telling their stories effectively and credibly.
Dr. Kathy Kolcaba  PhD, RN
Chagrin Falls, OH

Correction: In the January 2009 issue, the table on page 20 called “Interpreting arterial blood gas values” has two incorrect values. The compensation value for metabolic acidosis should be Paco2 < 35 mm Hg, and the compensation value for metabolic alkalosis should be Paco2 > 45 mm Hg. Visit for a corrected PDF.

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