Registered Nurses' Association of Ontario

Nursing Best Practice Guidelines

Practice Recommendations
Practice Recommendation Level of Evidence
Site Selection: Peripheral 1.0  Nurses will select a peripheral insertion site appropriate for the required therapy and with the least risk of complication.

Alert: Clients receiving vascular access therapy longer than six days should be assessed for intermediate to long-term dwelling devices. Refer to the RNAO (2004) best practice guideline Assessment and Device Selection for Vascular Access.

IV
Site and Catheter Care Safety/Infection Prevention Control 2.0  Nurses will prevent the spread of infection by following routine practices and using additional precautions.

Alert: Hand hygiene is the single most important infection prevention and control practice.

Alert: Reusable medical equipment will be cleaned, disinfected or sterilized between client use in adherence to national and provincial regulations and requirements (e.g., Health Canada or Provincial Ministries of Health). Any single use item (e.g., tourniquets, vacutainers) will remain with the client (PHAC, 1998).

IV
Skin Antisepsis 3.0  Nurses will consider the following factors when performing catheter site care using aseptic technique:
  • Catheter material (composition);
  • Antiseptic solution; and
  • Client’s tolerance (skin integrity, allergies, pain, sensitivity and skin reaction)
IV

 

IV

Tip Placement 4.0  Nurses will not use the central venous access device (CVAD) until tip placement has been confirmed.

Alert: Anatomical tip location must be documented by a radiologist/attending physician following insertion, and this documentation must be accessible to all the client’s health care providers throughout the continuum of care.

 
Dressings 5.0  Nurses will consider the following factors when selecting and changing VAD dressings:
  • Type of dressing;
  • Frequency of dressing changes; and
  • Client’s choice, tolerance and lifestyle.

Alert: The use of sterile versus non-sterile clean gloves during dressing changes remains an unsolved issue (CDC, 2002; Pearson, 1996a, 1996b). Therefore, either type can be used with performing catheter site care (O’Grady et al., 2002).

IV
Securement 6.0  Nurses must stabilize the VAD in order to:
  • Promote assessment and monitoring of the vascular access site;
  • Facilitate delivery of prescribed therapy; and
  • Prevent dislodgement, migration, or catheter damage.

Alert: Do not use pins of any kind to secure a device as this can damage the device and subsequently interfere with therapeutic outcomes for the client.

Alert: Securement devices must be changed at least every seven days (CDC, 2002).

III
Patency/Flushing/Locking 7.0  Nurses will maintain catheter patency using flushing and locking techniques.

Alert: Excessive flushing pressure can cause clots to be dislodged, catheter separation and/or catheter rupture. In order to reduce the potential of excessive pressure, it is generally recommended that a 10 mL (or larger) syringe be used for flushing (RCN 2003). Larger syringes create less pressure when flushing and more pressure when withdrawing or aspirating. Smaller syringes on the other hand produce more pressure when flushing and less pressure when withdrawing.

When using the turbulent flush technique, it is important to assess device function as high pressures could be generated in devices that have occlusion complications (e.g., fibrin buildup) or are constricted in any way (e.g., kinked or clamped). Appendix F contains information for assessment of blood withdrawal and management of withdrawal occlusion.

Critical Thinking: Remember to heparinize the device not the client. Some clients that require a significant volume or concentration of Heparin locking solutions may experience complications. Consider withdrawal of the heparin lock prior to flushing to reduce the amount of heparin a client receives. While this is practiced in some settings, there is no scientific evidence to support this recommendation. The panel offers this as an option that could be considered based on the risks and benefits for some clients at high risk of device occlusion.

8.0  Nurses will know what client factors, device characteristics and infusate factors can contribute to catheter occlusion in order to ensure catheter patency for the duration of the therapy.

IV

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
IV

Occlusion 9.0  Nurses will assess and evaluate vascular access devices for occlusion in order to facilitate treatment and improve client outcomes. IV
Blood Withdrawal 10.0  Nurses will minimize accessing the central venous access device (CVAD) in order to reduce the risk of infection and nosocomial blood loss. IV
Add-Ons 11.0  Nurses will change all add-on devices a minimum of every 72 hours IV
Documentation 12.0  Nurses will document the condition of vascular access devices including:
  • The insertion process;
  • Site assessment; and
  • Functionality.
III
Client Education 13.0  Nurses will help clients to attain the highest level of independence through client education. IV