Fonte: Madeline Lassche, MSNEd, RN e Katie Baraki, MSN, RN, College of Nursing, Università dello Utah, UT
Dopo l’avvio dell’accesso endovenoso periferico (IV), è importante valutare e mantenere il catetere IV in base alle politiche istituzionali e agli standard di pratica infermieristica. La valutazione regolare del sito di inserimento e delle aree circostanti per i segni di complicanze è necessaria per prevenire le complicanze del catetere IV, tra cui infiltrazione, flebite, infezione, stravaso o spostamento del catetere. La manutenzione ordinaria per via endovenosa è altrettanto importante per preservare la pervietà della linea e per ridurre il rischio di occlusione, trombosi e tromboflebite. Secondo il CDC, i cateteri periferici IV (PIV) possono essere mantenuti in posizione fino a 96 ore, con cura e manutenzione adeguate. Inoltre, secondo l’Infusion Nurses Society (INS), un catetere IV per paziente pediatrico può essere mantenuto in posizione fino a quando la linea IV non è più brevettata o dimostra complicazioni. La rotazione di routine ogni 96 ore non è indicata nella popolazione pediatrica a causa dell’aumento dell’ansia causata dalle punture di ago.
Questo video mostra la valutazione e il mantenimento delle linee IV periferiche, comprese le considerazioni generali prima di iniziare la procedura, la valutazione del sito di iniezione per le complicanze associate e il mantenimento della pervietà del catetere lavandolo con la normale soluzione salina.
Routine assessment and line maintenance will ensure that IV therapy can continue. It also prevents avoidable complications and patient injury. If complications are noted when assessing the injection site, it is important to stop the IV fluid infusion, contact the primary care provider, and take measures to prevent further injury. If phlebitis or infiltration is suspected, the peripheral IV catheter should be promptly removed, and this should be documented in the patient's electronic health record. If the site is infiltrated, the patient's limb should be elevated; ice or heat should be applied, depending upon the type of fluid being infused and according to physician and/or pharmacy instructions. In some cases, an additional subcutaneous neutralizing medication should be administered around the insertion site. Lastly, the circulation, pulse and capillary refill should be assessed periodically to ensure that perfusion is maintained. If phlebitis is suspected, a warm pack should be applied to the site. Lastly, if extravasation or thrombophlebitis is suspected, stop the IV fluid infusion and follow institutional policy. Do not remove the IV catheter until instructed to do so, because the catheter may be necessary to deliver an antidote, if available, in some chemotherapeutic extravasations.
The assessment, maintenance, and flushing of peripheral intravenous lines-in accordance with institutional policies and nursing standards of practice-is crucial once IV access has been initiated. With proper care and maintenance, PIV catheters may be kept in place for up to 96 hours in adults, and longer in children, as long as the lines remain patent and show no signs of complications. Regular assessment can prevent complications, such as infiltration, phlebitis, infection, extravasation, or catheter dislodgement. In addition, IV maintenance and flushing helps preserve line patency and reduces the risk of occlusion and thrombosis.
This video will demonstrate the steps included in the proper assessment, maintenance, and flushing of PIV lines and discuss the management of IV complications.
First, as always upon entering the patient’s room, wash your hands thoroughly with soap and water or use hand sanitizers with vigorous friction if your hands are not visibly soiled.
Then, at the bedside computer, review the patient’s medical history, confirming the need for continued IV access, and review the IV fluid orders in the Medication Administration Record, or MAR. If the patient is receiving maintenance IV fluids, confirm that this is still necessary by reviewing the patient’s intake and output and assessing their vital signs, skin turgor, and mucous membrane and by reviewing their serum laboratory results.
Next, exit the patient’s room, wash your hands as previously described, and obtain a 10-mL normal saline flush syringe and alcohol wipes from the medication preparation area. Then return to the patient’s room, place the supplies on the counter, and wash your hands again.
The first step in assessing the IV catheter site is to inspect for redness or swelling, which can be a sign of irritation, inflammation, infection, or thrombus formation. Also look for bruising, which might indicate a hematoma that can damage surrounding tissues. In addition, assess the condition of the transparent catheter dressing, which should be clean and dry and securely adhered to the skin around the insertion site. Change the dressing using aseptic technique if it is loose, wet, or soiled. Next, assess for tenderness by palpating the area around the insertion site and ask the patient if it is painful. Pain or tenderness may indicate inflammation or infection.
Subsequently, gently palpate the insertion site with one hand, while palpating the same area of the opposite arm with your other hand, assessing for temperature, skin texture, and presence of swelling. Increased temperature and swelling might indicate inflammation or infection, while decreased temperature and bogginess might indication infiltration. These conditions indicate that the catheter should be discontinued.
Before proceeding with preparing the saline flush, wash your hands again, as previously described. Next, open the package of the saline flush syringe. Then, while holding the syringe in your dominant hand, remove the syringe cap with your non-dominant hand and place the cap upright on the counter carefully, so as to not contaminate the end of the cap. At this point, turn the plunger of the syringe to break the seal. Then, while holding the syringe upright, push the plunger gently to expel the air. Subsequently, pick up the cap with your dominant hand-taking care to maintain its sterility-and screw the cap back onto the syringe. Then place the syringe on the counter.
The next step is to cleanse the PIV needleless injection site. First open an alcohol wipe pack and hold it in your dominant hand. Then, hold the PIV needleless injection site with your non-dominant hand and wrap the alcohol wipe around it, scrubbing the site with friction and intent-as if you are juicing an orange-for 15 seconds. Continue to hold the needleless injection site without contaminating it while it dries. You are now ready to flush the catheter.
Pick up the saline syringe with your dominant hand and unscrew the cap of the syringe using your non-dominant ring and middle fingers. Next, attach the syringe to the needleless port by pushing gently to insert the tip of the syringe into the center portion of the needleless injection site and then turning it clockwise. Also open the PIV clamp. Hold the saline syringe between the dominant index and middle fingers and use the thumb to gently push the plunger, flushing the PIV line.
While pushing the plunger, assess the PIV insertion site for leaking or swelling and ask the patient if they are experiencing pain. If any of these conditions occur, or if it is difficult to inject the fluid, then the IV site is no longer appropriate for use. After the flushing is complete, continue to hold the needleless injection site with the non-dominant thumb and index finger and unscrew the syringe from the port using your dominant hand. Finally, dispose of the syringe and alcohol wipe.
The final step is to document the procedure in the patient’s EHR, recording the date, time, location, and findings of the PIV assessment. If the site is free from complications, record the absence of redness, swelling, and irritation; that the dressing is clean, dry, and intact; and that the line is patent and flushes easily. If there are any complications, record them and notify the primary care provider. Finally, wash your hands again and leave the patient’s room.
“Routine PIV assessment and flushing are important steps in ensuring that IV therapy can continue without complications. If any issues are noted during this assessment, the infusions should be discontinued and the patient’s physician should be notified.”
You’ve just watched a JoVE Nursing Skills Video on the assessment and flushing of a peripheral intravenous catheter. You should understand the supplies used and the technique for performing the procedure. You should also have a grasp of how to identify and deal with possible complications. As always, thanks for watching!
