WT TO DO Wil YOUR PATIENT NEEDS IMMEDIATE I.V. nAP BUT IS AFRAID OF NEEDLES.
PAUL BLUM, 20, IS IN THE ED WITH fever, headache, neck and back stiffness, and a petechial rash. The physiclan diagnoses meningitis, pending further workup, and orders immediate I.V. antibiotics. But because of a traumatic experience as a child, Mr. Blum has an overwhelming fear of needles. Telling you he can't stand the pain of a needle stick, he refuses to let you insert an I.V. catheter. The thought of a lumbar puncture is more than he can handle. Despite your repeated attempts to reassure him, he refuses treatment.
Reviewing your options Which of the following recommendations is most appropriate?
a. Offer to give Mr. Blum an S.C. injection of lidocaine to dull the pain of I.V. cannulation.
b. Defer treatment to another nurse who might be more convincing. c. Administer EMLA cream to provide local anesthesia before the needle stick.
d. Numb the skin using iontophoresis of lidocaine before the needle stick.
Making the right choice
The best choice is d. Iontophoresis of lidocaine (Numby Stuff, Iomed) is a fast, cost-effective, noninvasive system that uses a mild electrical current to deliver local analgesics to the skin without tissue distortion. It consists of two electrodes or pads (one to deliver the medication) and a handheld device connected to the electrodes.
To use the system, place the drugdelivery electrode containing Iontocaine (2% lidocaine and epinephrine 1:100,000 topical solution) over the venipuncture site you've selected. Then place the other electrode on the patient's skin 4 to 6 inches (10 to 15 cm) away from the drug-delivery electrode and program the handheld device as directed. A low, constant electrical current introduces ions of soluble salts into the skin or mucosal surfaces, providing anesthesia to a skin depth of up to 10 mm. The analgesia takes effect in about 10 minutes. Tell Mr. Blum he might feel some mild tingling under the pads.
Iontophoresis can also be used to numb the skin before superficial dermatologic procedures (such as shave biopsies and curettage) and lumbar puncture.
Option a, an S.C. injection of lidocaine, would numb Mr. Blum's skin. But given his fear of needles, he's unlikely to consent to it.
Deferring treatment to another nurse (option b) would delay care, which could be life-threatening in this case.
Option c, applying EMLA cream to numb the skin, would be a good choice if time weren't crucial. This mixture of lidocaine and prilocaine takes up to 60 minutes to become effective-too long for Mr. Blum. In circumstances where time is less crucial, EMLA may be used for venipunctures and minor superficial procedures.
Controlling Pain is coordinated by Jane Faries, RN, OCN, MSN, clinical nurse coordinator of the acute pain service at Holston Valley Medical Center, Wellmont Health System, Kingsport, Tenn. This month's author is Georgette Love, RN, APRN, MSN, coordinator of the acute pain service at the University of Utah Hospital in Salt Lake City.
Copyright Springhouse Corporation Mar 1998
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