A nurse suspects that the IV line infusing vincristine (Oncovin) has infiltrated. The nurse discontinued the line. Which other actions are indicated?
1. Apply local ice packs.
2. Inject hyaluronidase per protocol.
3. Place a tourniquet on the client's arm above the IV site.
4. Place warm compresses on the site.
5. Administer prednisone per protocol.
2,4
Rationale 1: Cold compresses will significantly increase the toxicity of vinca alkaloids.
Rationale 2: Hyaluronidase is used as treatment for vincristine extravasation.
Rationale 3: There is no need to place a tourniquet on the client's arm.
Rationale 4: Warm compresses are recommended as treatment.
Rationale 5: Prednisone is not given concurrently with vincristine due to increased bone marrow toxicity.
Global Rationale: Hyaluronidase is used as treatment for vincristine extravasation. Warm compresses are recommended as treatment. Cold compresses will significantly increase the toxicity of vinca alkaloids. There is no need to place a tourniquet on the client's arm. Prednisone is not given concurrently with vincristine due to increased bone marrow toxicity.
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