infusion nursing standards of practice -...

Supplement to

January/February 2011

Volume 34, Number 1S

ISSN 1533-1458

www.journalofi nfusionnursing.com

Infusion NursingStandards of Practice

Funded by an educational grant from BD Medical–Medical Surgical Systems

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INFUSION NURSING

STANDARDS OF PRACTICE

Developed by

Infusion Nurses Society

REVISED 2011

315 Norwood Park South, Norwood, MA 02062wwwwww..iinnss11..oorrgg

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Journal of

Infusion NursingInfusion Nursing

Proud Platinum Sponsor of The Journal of Infusion Nursing, the official publication of the Infusion Nurses Society (INS), seeks to promote excellence in infusionnursing by presenting new research, clinical reviews, case studies, and professional development information relevant to the prac-tice of infusion therapy. Articles selected for publication represent the broad scope of the infusion specialty and draw on the expert-ise of all healthcare providers who participate in the delivery of infusion.

EditorMary Alexander, MA, RN, CRNI®,

CAE, FAAN

Editorial OfficeINS315 Norwood Park SouthNorwood, MA 02062(781) 440-9408(781) 440-9409 (fax)www.ins1.org

INS Board of DirectorsPresidentNancy Mortlock, BSN, RN,

CRNI®, OCN®

President-ElectJeanette Adams, PhD, ACNS,BC,

CRNI®

Presidential AdvisorLynn Phillips, MSN, RN, CRNI®

Secretary/TreasurerMarvin Siegel, RN, CRNI®

Directors-at-LargeAngie Sims, RN, CRNI®, OCN®

Mary Zugcic, MS, RN, ACNS-BC,CRNI®

Public MemberDavid Schmick, RPh

INS Chief Executive OfficerMary Alexander, MA, RN, CRNI®,

CAE, FAAN

Infusion Nursing Standards ofPractice ReviewersJeanette Adams, PhD, RN,

ACNS,BC, CRNI®

Teri Aguiar, BSN

Steve Bierman, MD

Corrine Bishop, RN, CRRN, CRNI®

Paul Blackburn, MNA, RN

Beth Bonilla, BSN, MEd, RN

Cynthia Brown, RN, ARNP, GNP-

BC, CCRN, CRNI®

Heather Buxton, BSN, MSN,

CNSRN, CRNI®

Gwen Cole, RN, CRNI®

Ann Corrigan, BSN, MS, RN,

CRNI®

Ann Earhart, MSN, ACNS-BC,

CRNI®

Charles Edmiston, PhD, CIC

Seth Eisenberg, BSN, RN, OCN®

Nina Elledge, MBA, RN, CRNI®

Beth Fabian, BA, RN, CRNI®

Michelle Fox, RN

Gina Gilbert, RN

Kevin Glover, MS, MEd

Donna Gordon, MSN, RN, CRNI®

Richelle Hamblin, MSN, RN, CRNI®

Mark Hunter, RN, CRNI®

Pamela Jacobs, BSN, MHA, RN,

CRNI®, OCN®

William Jarvis, MD

Kenn Jones, BSN, RN, CRNI®,

Debra Kovasevich, MPH, RN

Sandra Kronn, BSN, RN, CRNI®

Elizabeth Krzywda, MSN, ANP

Melissa Leone, RN

Alicia Mares, BSN, RN, CRNI®

Elizabeth Martinez, RN

Mary McGoldrick, MS, RN, CRNI®

Karen McKeon, RN, CRNI®

Katherine McKrill, RN

Paula McMahon, RN, CRNI®

Nita Meaux, RN, CRNI®

Geno Merli, MD

Britt Meyer, RN, CRNI®

Jeannette Meyer, MSN, RN, CCRN,

CCNS, PCCN

Crystal Miller, BSN, MA, RN,

CRNI®

Susan Miller-Hoover, DNP, RN,

CCNS, CCRN

Libby Montoya, MSN, APN, CNS-

BC

Nancy Mortlock, BSN, RN, CRNI®,

OCN®

Robin Nelson, MEd, RN, CRNI®

Barbara Nickel, APRN-CNS, CRNI®,

CCRN

Thomas Nifong, MD

Shirley Otto, RN, CRNI®, AOCN

Roxanne Perucca, MSN, RN,

CRNI®

Lynn Phillips, MSN, RN, CRNI®

Susan Poole, BSN, MS, RN,

CRNI®, CNSN, CIC

Debbie Potts, RN, CRNI®, OCN

Kathy Puglise, MEd, RN, CRNI®

Laura Rutledge, RN, CRNI®

Pam Sabatino-Holmes, ARNP, RN,

CRNI®

Ofelia Santiago, BSN, RN, CRNI®

Marvin Siegel, RN, CRNI®

Angie Sims, RN, CRNI®

Marc Stranz, PharmD

Virginia Strootman, MSN, RN,

CRNI®

Anne Swanson, RN

Joseph Thomas, BSN, RN

Alan Tice, MD

Cora Vizcarra, MBA, RN, CRNI®

Jeffrey Wagner, BSN, RN

Timothy Weimken, MPH, CIC

Sharon Weinstein, MS, RN, CRNI®,

FACW, FAAN

Marcia Wise, RN

Mary Zugcic, MS, RN, APRN,BC,

CRNI®

*CRNI is a registered trademark of the Infusion Nurses Certification Corporation.

JANUARY/FEBRUARY 2011 Volume 34 • Number 1S

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VOLUME 34 | NUMBER 1S | JANUARY/FEBRUARY 2011

Acknowledgments S1

About the Standards of Practice Committee S2

Preface S4

Strength of the Body of Evidence S5

STANDARDS OF PRACTICE

NURSING PRACTICE1. Practice Setting S6

2. Neonatal and Pediatric Patients S6

3. Older Adult Patients S7

4. Ethics S8

5. Scope of Practice S8

6. Competence and Competency Validation S11

7. Quality Improvement S12

8. Research and Evidence-based Practice S13

9. Policies, Procedures, and/or Practice Guidelines S14

PATIENT CARE10. Orders for the Initiation

and Management of Infusion Therapy S15

11. Patient Education S16

12. Informed Consent S17

13. Plan of Care S18

DOCUMENTATION14. Documentation S20

15. Unusual Occurrence and Sentinel Event Reporting S21

16. Product Evaluation, Integrity, and Defect Reporting S22

17. Verification of Products and Medications S24

INFECTION PREVENTION ANDSAFETY COMPLIANCE18. Infection Prevention S25

19. Hand Hygiene S26

20. Compounding of Parenteral Solutions and Medications S27

21. Scissors S27

22. Safe Handling and Disposal of Sharps, Hazardous Materials, and Hazardous Waste S28

23. Disinfection of Durable Medical Equipment S29

24. Transmission-based Precautions S29

25. Latex Sensitivity or Allergy S30

INFUSION EQUIPMENT26. Add-on Devices S31

27. Needleless Connectors S32

28. Filters S33

29. Flow-Control Devices S34

30. Blood and Fluid Warmers S35

31. Tourniquets S36

VASCULAR ACCESS DEVICESELECTION AND PLACEMENT32. Vascular Access Device Selection S37

I. Short Peripheral Catheters S37

II. Midline Catheters S37

III. Central Vascular Access Devices (CVADs) (Nontunneled, PICC, Tunneled, Implanted Port) S38

IV. Arterial Catheters S38

33. Site Selection S40

I. Peripheral Venous Access via Short Peripheral Catheters S40

II. Peripheral Venous Access via Midline Catheters S41

III. Central Venous Access via Peripherally Inserted Central Catheters (PICCs) S41

IV. Central Venous Access viaNontunneled Central VascularAccess Devices (CVADs) S42

V. Central Venous Access viaTunneled Central Vascular Access Devices and Implanted Ports S42

VI. Peripheral Arterial Access S42

VII. External Jugular Vein Access S42

34. Local Anesthesia for Vascular Access Device Placement and Access S43

35. Vascular Access Site Preparation and Device Placement S44

I. General S44

II. Short Peripheral and Midline Catheters S44

III. Central Vascular Access Devices (CVADs) S45

IV. Arterial Catheters S45

36. Vascular Access DeviceStabilization S46

37. Joint Stabilization S47

38. Site Protection S48

ACCESS DEVICES39. Implanted Vascular Access

Ports S50

40. Hemodialysis Vascular Access Devices S51

41. Umbilical Catheters S52

42. Apheresis and Ultrafiltration Catheters S53

SITE CARE and MAINTENANCE43. Administration Set Change S55

I. General S55

II. Primary and SecondaryContinuous Infusions S55

III. Primary Intermittent Infusions S55

IV. Parenteral Nutrition S56

V. Intravenous Fat Emulsions (IVFE) and Other Lipid Product Infusions S56

VI. Blood and Blood Components S56

VII. Hemodynamic and ArterialPressure Monitoring S56

Journal of


ContentsNote: The “S” in page numbers denotes supplement issue and does not refer to a specific standard.

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Journal of Infusion Nursing

Journal of


44. Vascular Access Device Removal S57

I. Short Peripheral Catheters S57

II. Midline Catheters S57

III. Nontunneled Central Vascular Access Devices (CVADs) S58

IV. Surgically Placed CVADs:Tunneled/Implanted Ports S58

V. Arterial Catheters S58

45. Flushing and Locking S59

46. Vascular Access Device Site Care and Dressing Changes S63

INFUSION-RELATED COMPLICATIONS47. Phlebitis S65

48. Infiltration and Extravasation S66

49. Infection S68

50. Air Embolism S69

51. Catheter Embolism S70

52. Catheter-Associated Venous Thrombosis S71

53. Central Vascular Access DeviceMalposition S72

OTHER INFUSION-RELATEDPROCEDURES54. Vascular Access Device Repair S75

55. Central Vascular Access Device Exchange S75

56. Catheter Clearance: Occluded Central Vascular Access Devices S76

57. Phlebotomy S77

I. Phlebotomy via DirectVenipuncture S78

II. Blood Sampling via a Vascular Access Device S78

III. Therapeutic Phlebotomy S79

NONVASCULAR INFUSION DEVICES58. Intraspinal Access Devices S81

59. Intraosseous Access Devices S82

60. Continuous Subcutaneous Infusion and Access Devices S84

INFUSION THERAPIES61. Parenteral Medication and

Solution Administration S86

62. Antineoplastic Therapy S87

63. Biologic Therapy S89

64. Patient-Controlled Analgesia S89

65. Parenteral Nutrition S91

66. Transfusion Therapy S93

67. Moderate Sedation/AnalgesiaUsing Intravenous Infusion S95

68. Administration of ParenteralInvestigational Drugs S96

Illustrations S97

Glossary S101

Index S109

ContentsNote: The “S” in page numbers denotes supplement issue and does not refer to a specific standard.

Journal of Infusion Nursing (ISSN: #1533-1458) is published bimonthly for the Infusion Nurses Society by Lippincott Williams &Wilkins, Inc., at 16522 Hunters Green Parkway, Hagerstown, MD 21740-2116. Business and production offices are located at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103. Periodicals postage paid at Hagerstown, MD, and at additionalmailing offices. © Copyright 2011 by Infusion Nurses Society. Address for Subscription Information, Orders, or Change of Address (except Japan, India, Bangladesh, Sri Lanka, Nepal andPakistan): 16522 Hunters Green Parkway, Hagerstown, MD 21740-2116; phone 1-800-638-3030; fax 301-223-2400; in Maryland, call collect 301-223-2300. In Japan, contact LWW Igaku-Shoin Ltd., 3-23-14 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; phone: 81-3-5689-5400; fax: 81-3-5689-5402. In India, Bangladesh, Sri Lanka, Nepal and Pakistan, contact Globe Publication Pvt. Ltd. B-13,3rd FL, A Block, Shopping Complex, Naraina Vihar, Ring Road, New Delhi 110028, India; phone: 91-11-25770411; fax: 91-11-25778876.Annual Subscription Rates Worldwide: Individuals – US: $119.99; Canada: $131.43; UK, Australia: $151.11; Rest of World:$235.22. Institutions – US: $341.00; Canada: $390.52; UK, Australia: $420.99; Rest of World: $465.22. (The Canadian GST tax of 7%will be added to the subscription price of all orders shipped to Canada. Lippincott Williams & Wilkins, Inc.’s, GST IdentificationNumber is 895524239. The Canadian Publications Mail [CPM] Agreement Number is 40052291.) Subscriptions outside the UnitedStates must be prepaid. Single copies are $25.00. A $5.49 shipping and handling fee has been added to all subscriptions.Subscriptions outside North America must add $8.73 for air freight delivery. Prices are subject to change without notice. Copies willbe replaced without charge if the publisher receives a request within 90 days of the mailing date, both in the U.S. and worldwide.For commercial reprints and all quantities of 500 or more, e-mail [email protected]. For quantities of 500 orunder, e-mail [email protected] or call 1-866-903-6951. Visit us on the web at www.lww.com.Postmaster: Send address changes to Journal of Infusion Nursing, P.O. Box 1550, Hagerstown, MD 21740.

Text printed on acid-free paper.

The Infusion Nursing Standards ofPractice is intended to reflectcurrent knowledge and practicesof the clinical nursing specialty ofinfusion therapy. Because clinicalpractice continually evolves basedon ongoing research, users shouldmake an independent assessmentof the appropriateness andapplicability of a standard in anyspecific instance, and should alsoconsider the applicable federal andstate laws and regulations, as wellas the standard of care in aparticular jurisdiction, as thesemay take precedence. INS is notresponsible for injury to personsor property, or other harm, arisingfrom the use of the Standards.

8

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VOLUME 34 | NUMBER 1S | JANUARY/FEBRUARY 2011 S1

INS recognizes the significance that the Infusion Nursing Standards of Practicehas to clinical practice. Not only have the Standards been reviewed, revised,and updated, but this edition ranks the strength of the body of evidence to sup-port each standard.

First, I want to recognize the Standards of Practice Committee: Lisa Gorski, chair,Julie Eddins, Lynn Hadaway, Mary Hagle, Marcia Orr, Deb Richardson, and PennyWilliams. Without their knowledge and expertise, plus countless hours of researchand writing, this document would not have been completed. Their commitment tothis project is unsurpassed.

Thanks go to the reviewers of the Standards. From INS members and committeemembers, physicians, pharmacists, legal advisors, health care clinicians, and indus-try partners, their thoughtful reviews and diverse perceptions added a unique perspective.

I want to thank the INS Board of Directors for supporting the efforts of theStandards of Practice Committee during the entire revision process. I am also grate-ful to the INS staff for the assistance and coordination they offered in ensuring thatthis publication was completed.

I also want to recognize BD Medical–Medical Surgical Systems for their contin-uous support over the years of the Standards of Practice revisions. INS thanks themfor the educational grant that helped to fund this project.

Lastly, I want to thank our INS members. It is your passion and commitment toproviding quality patient care that motivates us to continue to provide products andservices that support your practice.

Mary Alexander, MA, RN, CRNI®, CAE, FAANEditor

Journal of


A C K N O W L E D G M E N T S

The Art and Science of Infusion NursingThe Art and Science of Infusion Nursing

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S2 Journal of Infusion Nursing

Copyright © 2011 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited.

Lisa A. Gorski, MS, HHCNS,BC, CRNI®, FAAN – ChairClinical Nurse Specialist, Wheaton Franciscan Home Health & Hospice,Milwaukee, WI

Ms Gorski has over 25 years of experience in home care and home infusion thera-py, including patient care, nursing education, implementation of evidence-basedpractice in home care, research, and consultation. She is widely published and is theauthor of 3 textbooks specific to home infusion therapy. Ms Gorski also served asINS president from 2007 to 2008.

Julie Eddins, MSN, RN, CRNI®

Staff Nurse, Barnes Jewish Hospital, St Louis, MO

A critical care RN with 35 years in nursing, Ms Eddins has worked as a direct clin-ical provider of infusion therapy to general and intensive care patients, most recent-ly to bone marrow transplant patients. She has presented programs both nationallyand internationally designed to educate professionals in the clinical application ofvascular access devices. She has been a contributing author for several nursing andinfusion therapy publications.

Lynn Hadaway, MEd, RN,BC, CRNI®

President, Lynn Hadaway Associates, Inc, Atlanta, GA

With more than 35 years of experience in infusion therapy, Ms Hadaway broughtclinical experience as well as staff development, consulting, and regulatory expert-ise to this committee. Her areas of expertise include all aspects of vascular accessdevice management, complication prevention and management, and legal and regu-latory issues. She holds national certifications in infusion nursing and professionalstaff development.

Mary E. Hagle, PhD, RN, WCC Nurse Researcher, Clement J. Zablocki VA Medical Center and the University ofWisconsin-Milwaukee College of Nursing, Milwaukee, WI

With 10 years’ experience as a nurse researcher and over 20 years as a clinical nursespecialist in academic and community medical centers, Dr Hagle has worked withpatients and nurses in acute care, ambulatory, and long-term care settings. Her clin-ical and evidence-based practice (EBP) focus has been on vascular access device andpain management with prevention of adverse events in medical/surgical and oncol-ogy practice. She has contributed to several textbooks on infusion nursing and evi-dence-based practice, as well as national guidelines on vascular access devices.

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A B O U T T H E S T A N D A R D S O FP R A C T I C E C O M M I T T E E


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Marsha Orr, MS, RNDistance Education Faculty Liaison, California State University, Fullerton, School of Nursing(CSUF), Fullerton, CA

Ms Orr is an entrepreneur and consultant in the area of home infusion nursing, home medicalequipment, and medical gases, and is a home accreditation surveyor in these areas. Her specialtypractice areas include infusion therapy, vascular access, and nutrition support. She is currently afull-time faculty member in distance education at CSUF, a member of the technology staff, and apast board member of the American Society for Parenteral and Enteral Nutrition.

Deb Richardson, MS, RN, CNSPresident, Deb Richardson & Associates, Houston, TX

Ms Richardson has over 30 years of experience in the field of vascular access and infusion therapy,including research, education, and evidence-based practices. She is an active member of several pro-fessional organizations; a frequent national and international speaker on vascular access; andauthor of multiple publications related to vascular access.

Penelope A. Williams, MS, RN, CRNI®

Clinical Consultant; Adjunct Faculty for College of Lake County, IL

Ms Williams has over 30 years of experience in infusion therapy, clinical research, education, prod-uct development, management, and consulting in hospital practice, home care, academic, andindustry settings. She is a published author in her special interest of patient advocacy and is anactive member of several professional organizations.

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The Infusion Nurses Society (INS) is recognized as the global authority ininfusion nursing, dedicated to exceeding the public’s expectations ofexcellence by setting the standard for infusion care. One pillar of INS’mission is developing and disseminating standards of practice.

As the science and research of infusion nursing expands and technologyadvances, it is imperative that the Infusion Nursing Standards of Practice be currentand relevant. It provides the framework that guides our clinical practice. Therefore,it is important to integrate the best evidence and research available into each stan-dard.

Each standard provides criteria for nursing action and accountability, while thepractice criteria provide guidance for implementation of the standard. TheStandards are written to be applicable in all patient settings and address all patientpopulations. They are actions that must be followed in order to provide safe patientcare. Clinicians should be advised that the Standards is a legally recognized docu-ment.

In this edition of the Standards, not only are the practice criteria supported bythe latest available research, but the strength of the body of evidence is also ranked.A ranking system was developed to identify the level of evidence and research thatsupports each of the practice criteria. The rankings range from Level I, whichincludes meta-analyses, systematic literature reviews, and guidelines based on ran-domized controlled trials, to Level V, which includes clinical articles, consensusreports, and generally accepted practices. Also, the practice criteria allow for moredetailed explanations for specific patient populations and practice settings.

As nurses strive to meet the infusion needs of their patients in a complex healthcare environment, the Infusion Nursing Standards of Practice will be invaluable toguide decision making and for developing patient-centered plans of care.

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P R E F A C E


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Evidence that is research based is preferred; however, it may come from avariety of sources as needed. The strength of evidence in this documentreflects the body of evidence available and retrievable at the time ofreview, and thus is titled Strength of the Body of Evidence. The strengthof the body of evidence is only as robust as the highest level of a single

item of evidence. Studies and other evidence comprise similar patient populationsunless otherwise noted. Regulatory evidence is kept separate since these criteria maychange based on changes in technology or body of research available.

Journal of


S T R E N G T H O F T H E B O D Y O F E V I D E N C E


Strength ofthe Body ofEvidence

Evidence Description*

I Meta-analysis, systematic literature review, guideline based on randomized controlledtrials (RCTs), or at least 3 well-designed RCTs.

I A/P Includes evidence from anatomy, physiology, and pathophysiology as understood atthe time of writing.

II Two well-designed RCTs, 2 or more multicenter, well-designed clinical trials withoutrandomization, or systematic literature review of varied prospective study designs.

III

One well-designed RCT, several well-designed clinical trials without randomization, orseveral studies with quasi-experimental designs focused on the same question.

Includes 2 or more well-designed laboratory studies.

IV

Well-designed quasi-experimental study, case control study, cohort study, correlation-al study, time series study, systematic literature review of descriptive and qualitativestudies, or narrative literature review, psychometric study.

Includes 1 well-designed laboratory study.

V

Clinical article, clinical/professional book, consensus report, case report, guidelinebased on consensus, descriptive study, well-designed quality improvement project,theoretical basis, recommendations by accrediting bodies and professional organiza-tions, or manufacturer recommendations for products or services.

Includes standard of practice that is generally accepted but does not have a researchbasis (for example, patient identification).

RegulatoryRegulations and other criteria set by agencies with the ability to impose conse-quences, such as the AABB, Centers for Medicare & Medicaid Services (CMS),Occupational Safety and Health Administration (OSHA), and state Boards of Nursing.

*Sufficient sample size is needed with preference for power analysis adding to the strength of evidence.

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1. Anatomic characteristics and their effect onphysical assessment, vascular and nonvascularaccess device site selection, insertion procedures,site rotation, and use of specialized infusion-related equipment, including care and mainte-nance practices during infusion therapy.3-5 (V)

2. Physiologic characteristics and their effect on drugand nutrient selection; administration set selection(eg, free of Di[2-ethylhexyl] phthalate); dosage andvolume limitations with reference to age, height,weight, or body surface area; pharmacologicactions, interactions, and side effects; monitoringparameters; and response to infusion therapy.3-11 (V)

3. Growth and developmental stages, includingimplications related to promoting comfort andreducing pain and fears associated with infu-sion therapy procedures.3,4,9,12-14 (V)

4. Interaction with parents, other family members,or legally authorized representative as membersof the patient’s health care team, includingpatient education that is provided with attentionto age, developmental level, health literacy, cul-ture, and language preferences (see Standard 11,Patient Education).2,4,15 (V)

5. Safe and appropriate setting (eg, acute care,ambulatory, school, or home care) for patientsreceiving infusion therapy.2,16 (V)

6. Obtaining assent from the school-age or adoles-cent patient as appropriate (see Standard 12,Informed Consent).2,17-19 (V)

REFERENCES

1. American Nurses Association. Neonatal Nursing: Scope and Standardsof Practice. Silver Spring, MD: ANA; 2004.

2. American Nurses Association. Pediatric Nursing: Scope and Standardsof Practice. Silver Spring, MD: ANA; 2008.

3. Frey AM, Pettit J. Infusion therapy in children. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:550-570.

1. PRACTICE SETTING

Standard

1.1 The Infusion Nursing Standards of Practice shall beapplied and met in all practice settings where infusiontherapy is administered.1.2 Administration of infusion therapy shall be estab-lished in organizational policies, procedures, and/orpractice guidelines.1.3 Administration of infusion therapy shall be in accor-dance with rules and regulations promulgated by thestate’s Board of Nursing and federal and state regulatoryand accrediting agencies in all practice settings.

2. NEONATAL AND PEDIATRICPATIENTS

Standard

2.1 The nurse providing infusion therapy for neonataland pediatric patients shall have clinical knowledge andtechnical expertise with respect to this population.2.2 Clinical management of neonatal and pediatricpatients shall be established in organizational policies,procedures, and/or practice guidelines and in accor-dance with applicable standards of practice.2.3 The nurse shall verify that informed consent fortreatment for neonatal and pediatric patients, as well asthose patients who are deemed emancipated minors ormature minors, is documented.

Practice Criteria

A. The nurse should provide care to neonatal andpediatric patients that is individualized, collabo-rative, and age appropriate.1-4 (V)

B. The nurse providing infusion therapy to neonataland pediatric patients should have knowledge anddemonstrated skill competency in the areas of:

Nursing Practice


Standards of Practice

NAN200132.qxd 12/24/10 9:35 PM Page 6

4. Pediatric intravenous therapy. In: Weinstein S, ed. Plumer’s Principles& Practice of Intravenous Therapy. 8th ed. Philadelphia, PA:Lippincott Williams & Wilkins; 2007:613-685.

5. De Jonge R, Polderman K, Gemke R. Central venous catheter usein the pediatric patient: mechanical and infectious complications.Pediatr Crit Care Med. 2005;6(3):329-339.

6. Hughes RG, Edgerton EA. Reducing pediatric mediation errors:children are especially at risk for medication errors. Am J Nurs.2005;105(5):79-84.

7. Mirtallo J, Canada T, Johnson D, et al. Safe practices for parenter-al nutrition. J Parenter Enteral Nutr. 2004;28(suppl):S39-S70.

8. Phillips SK. Pediatric parenteral nutrition: differences in practicefrom adult care. J Infus Nurs. 2004;27(3):166-170.

9. Loff S, Subotic U, Reinick F, et al. Extraction of di-ethylhexyl-phtha-late by home total parenteral nutrition from polyvinyl chloride infu-sion lines commonly used in the home. J Pediatr Gastroenterol Nutr.2008;47(1):81-86.

10. Pak VM, Nailon RE, McCauley LA. Controversy: neonatal expo-sure to plasticizers in the NICU. MCN Am J Matern Child Nurs.2007;32(4):244-249.

11. Kambia K, Gressier B, Bah S, et al. Evaluation of childhood exposure to di(2-ethylhexyl) phthalate from perfusion kits duringlong-term parenteral nutrition. Int J Pharm. 2003;262(1-2):83-91.

12. Zempsky WT. Optimizing the management of peripheral venousaccess pain in children: evidence, impact, and implementation.Pediatrics. 2008;122:S121-S124.

13. Cohen LL. Behavioral approaches to anxiety and pain manage-ment for pediatric venous access. Pediatrics. 2008;122:S134-S139.

14. Sparks LA, Setlik J, Luhman J. Parental holding and positioningto decrease IV distress in young children: a randomized controlledtrial. J Pediatr Nurs. 2007;22(6):440-447.

15. Czaplewski L. Clinician and patient education. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:71-94.

16. Tice AD. Handbook of Outpatient Parenteral Antimicrobial Therapyfor Infectious Diseases. Tarrytown, NY: CRG Publishing; 2006.

17. Unguru Y, Coppes MJ, Kamani N. Rethinking pediatric assent:from requirement to ideal. Pediatr Clin N Am. 2008;55:211-222.

18. Sinclair SJ. Involvement of adolescents in decision making forheart transplants. MCN. 2009;34(5):276-281.

19. Jolly K, Weiss JA, Liehr P. Understanding adolescent voice as a guidefor nursing practice and research. Issues Compr Pediatr Nurs. 2007;30:3-13.

3. OLDER ADULT PATIENTS

Standard

3.1 The nurse providing infusion therapy for older adultpatients shall have clinical knowledge and technicalexpertise with respect to this population.3.2 Clinical management of older adult patients shall beestablished in organizational policies, procedures,and/or practice guidelines and shall be according toapplicable standards of practice.

Practice Criteria

A. The nurse should provide individualized, collabo-rative, and age-appropriate care to older adults—those people who are 65 years and older.1-8 (V)

B. The nurse providing infusion therapy to olderadults should have knowledge and demonstratedskill competency in the areas of:1. Anatomic changes related to older adults and

their effect on physical assessment, vascular andnonvascular access device site selection, inser-tion procedures, and use of specialized infusion-related equipment, including care and mainte-nance practices during infusion therapy.9-11 (V)

2. Physiologic changes related to older adults andtheir effect on drug dosage and volume limita-tions, pharmacologic actions, interactions, sideeffects, monitoring parameters, and responseto infusion therapy.4,9,12-14 (V)

3. Changes in cognitive abilities and dexterity;communication methods, including vision, hear-ing, and verbal changes; as well as psychosocialand socioeconomic considerations.4,9,15 (V)

4. Interaction with family members, caregivers, orlegally authorized representative as members ofthe patient’s health care team, with consent of thepatient or as necessary due to mental status.9,15 (V)

5. Potential for adverse events and drug interac-tions in older adults who may be prescribedmultiple medications.4,9,13,16 (V)

6. Safety and environmental considerations related toolder adults receiving infusion therapy and effectivemanagement of those considerations.9,13,16,17 (V)

REFERENCES

1. American Nurses Association. Nursing: Scope and Standards ofPractice. 2nd ed. Silver Spring, MD: ANA; 2010.

2. American Nurses Association. Scope and Standards of GerontologicalNursing Practice. 2nd ed. Silver Spring, MD: ANA; 2001.

3. Mezey M, Stierle L, Huba GJ, Esterson J. Ensuring competence ofspecialty nurses in care of older adults. Geriatr Nurs. 2007;28(6)(suppl 1):9-14.

4. Zwicker D, Fulmer T. Reducing adverse drug events. In: Capezuti E,Zwicker D, Mezey M, Fulmer T, eds. Evidence-Based Geriatric NursingProtocols for Best Practice. New York, NY: Springer; 2008:257-308.

5. National Gerontological Nursing Association. Definitions ofolder adults and gerontological nursing. https://www.ngna.org/about-items/definitions-of-older-adults-and-gerontological-nursing.html. Published September 2, 2008. Accessed February 23, 2010.

6. Steel K. The old-old-old. J Am Geriatr Soc. 2005;53:S314-S316.7. Woodhouse KW, Wynne H, Baillie S, et al. Who are the frail

elderly? Q J Med. 1988;68(255):505-506.8. World Health Organization. Definition of an older or elderly person.

http://www.who.int/healthinfo/survey/ageingdefnolder/en/. Published2010. Accessed August 10, 2010.

9. Fabian B. Infusion therapy in the older adult. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:

VOLUME 34 | NUMBER 1S | JANUARY/FEBRUARY 2011 S7Copyright © 2011 Infusion Nurses Society. Unauthorized reproduction of this article is prohibited.

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An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:571-582.

10. Schelper R. The aging venous system. J Assoc Vasc Access. 2003;8(3):8-10.

11. Walsh G. Hypodermoclysis. J Infus Nurs. 2005;28(2):123-129.12. Aubrun F. Management of postoperative analgesia in elderly

patients. Reg Anesth Pain Med. 2005;30:363-379.13. Francis DC. Iatrogenesis: the nurse’s role in preventing patient harm.

In: Capezuti E, Zwicker D, Mezey M, Fulmer T, eds. Evidence-Based Geriatric Nursing Protocols for Best Practice. New York, NY:Springer; 2008:223-255.

14. Goldstein PC. Assessment and treatment of hypoglycemia in elders:cautions and recommendations. Medsurg Nurs. 2009;18:215-241.

15. Lueckenotte A. Older adult. In: Potter P, Perry A, eds. Fundamentalsof Nursing. 7th ed. St Louis, MO: Mosby Elsevier; 2009:191-214.

16. Thornlow DK. Increased risk for patient safety incidents in hos-pitalized older adults. Medsurg Nurs. 2009;18:291.

17. Toth L. Monitoring infusion therapy in patients residing in long-termcare facilities. J Assoc Vasc Access. 2002;7(1):34-38.

4. ETHICS

Standard

4.1 Ethical principles shall be the foundation for deci-sion making and patient advocacy.4.2 Guidelines and resources for ethical issues shall beoutlined in organizational policies, procedures, and/orpractice guidelines.4.3 The nurse shall act as a patient advocate; maintainpatient confidentiality, safety, and security; and respect,promote, and preserve human autonomy, dignity,rights, and diversity.4.4 Principles of beneficence, nonmaleficence, fidelity,protection of patient autonomy, justice, and veracityshall dictate nursing action.

Practice Criteria

A. Ethical principles should be integrated in all areasof nursing practice.1-4 (V)

B. The nurse should use professional ethical resources,including the Guide to the Code of Ethics for Nurses:Interpretation and Application by the AmericanNurses Association and the Infusion Nursing Code ofEthics.1-4 (V)

C. The nurse should assess for and raise issues relat-ed to potential ethical problems, act as a rolemodel for ethical care, and contribute to resolvingethical issues related to patients, colleagues, or thehealth care system.1-4 (V)

D. The nurse should use organizational ethicsresources, such as ethics committees, and supportnursing participation when dealing with ethicalissues.1-4 (V)

REFERENCES

1. Fowler MDM, ed. Guide to the Code of Ethics for Nurses:Interpretation and Application. Silver Spring, MD: American NursesAssociation; 2008.

2. Infusion Nurses Society. Infusion nursing code of ethics. J InfusNurs. 2001;24(4):242-243.


4. Schroeter K. Ethics. In: Alexander M, Corrigan A, Gorski L,Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-BasedApproach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:60-70.

5. SCOPE OF PRACTICE

Standard

5.1 The scope of practice for each type of personnelinvolved with the delivery of infusion therapy shall beorganized to support patient safety and protection andshall clearly define the roles, responsibilities, tasks,range of services, and accountability for all levels of per-sonnel involved with the delivery of infusion therapy.5.2 All licensed nursing personnel with responsibilityfor infusion therapy shall possess a license in goodstanding with the state’s Board of Nursing.5.3 All personnel involved with the delivery of infusiontherapy shall practice within the legal boundaries of theindividual license or scope of practice.5.4 All personnel involved with the delivery of infusiontherapy shall possess the ability to communicate effec-tively with patients, supervisors, peers, and other mem-bers of the health care team.5.5 The role of nursing assistive personnel (NAP)involved with infusion therapy shall be limited to non-invasive and administrative tasks.5.6 Delegation of infusion therapy tasks shall be inaccordance with rules and regulations promulgated bythe state’s Board of Nursing. The registered nurse (RN)shall be responsible and accountable for all tasks delegated to NAP and licensed practical/vocationalnurses (LPN/LVN).5.7 The RN shall be accountable for patient safety inthe delivery of infusion therapy.

Practice Criteria

A. The legal scope of practice for all licensed healthcare professions is defined in the state statutesgoverning each profession. The changing healthcare system mandates overlap between profes-sional groups, with no single group claimingexclusive ownership of any skill, activity, or task.Interdisciplinary education and collaboration isknown to produce quality patient care.1-3 (IV,Regulatory)

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B. The method for making scope of practice deci-sions is different for each state’s Board of Nursingand includes a decision-tree model, declaratoryrulings, and advisory opinions. The expansion ofinfusion therapies and technologies requires thenurse to be knowledgeable of the method used inthe state(s) where one practices.4,5 (V, Regulatory)

C. Decisions about the scope of practice for eachtype of personnel involved with infusion therapyshould focus on the following:I. Nursing Assistive Personnel (NAP)

a. NAP function in assistive roles to performsupportive patient care tasks that are nonin-vasive. Job titles may include many combi-nations of the terms aides, assistants, ortechnicians. Training is provided in manydifferent settings, and requirements varyamong states. NAP working in some facili-ties and agencies receiving federal fundingare required to have a minimum amount oftraining and pass a state competency evalu-ation. Some states do require a license.6-8 (V)

b. Infusion-related tasks assigned to NAPinclude managing equipment and supplies,gathering statistics, and assisting licensedpersonnel with invasive procedures.6,7 (V)

c. NAP should not have the responsibility toperform invasive infusion therapy proce-dures such as catheter insertion, cathetermaintenance procedures, or the administra-tion of any fluid, nutrition, blood, or med-ication. A practice analysis for NAP identi-fied 119 activity statements; however, therewere no infusion-related tasks, activities, orprocedures identified.6,9 (IV)

d. State Boards of Nursing may have statementsaffirming that initiation, administration, andmonitoring of infusion therapy may not bedelegated to unlicensed personnel.6,7 (V)

e. Personnel (eg, infusion team technicians)performing catheter insertions have beenidentified as a predictor of complicationssuch as phlebitis and infiltration.10 (IV)

II. Medical Assistant (MA)a. MAs function in assistive roles to physicians

and other health care practitioners by per-forming administrative and clinical tasks.Their primary place of employment is themedical office.8,11 (V)

b. Due to the increasing frequency and types ofinfusion therapy provided in non–acute caresettings, MAs should have basic knowledge ofinfusion therapy as it applies to their role.11 (V)

c. MAs should complete a course of infusiontherapy training, including supervised clinicalpractice.11 (V)

III. Licensed Practical/Vocational Nurse (LPN/LVN)a. Successful completion of an organized educa-

tional program, including supervised clinicalpractice on infusion therapy, is required forLPN/LVNs in many states. In states withoutsuch requirements, completion of a similareducational program is recommended priorto performing infusion therapy procedures.These educational programs should apply theInfusion Nursing Standards of Practice.12-14

(V, Regulatory)b. An LPN/LVN practice analysis identified 13

of 159 activity statements as being infusiontasks, activities, and procedures. The frequen-cy of performance of each activity varies bywork practice setting, age and type ofpatients, and years of experience.9 (IV)

c. All infusion-related tasks should be per-formed under the supervision of a registerednurse with appropriate infusion therapyknowledge and skills.13 (V, Regulatory)

IV. Registered Nurse (RN)a. The RN performing infusion therapy should

have the requisite knowledge and skillsderived from application of the InfusionNursing Standards of Practice.15,16 (V)

b. Due to the lack and/or inconsistency of infu-sion therapy in basic nursing curricula, the RNshould successfully complete an organized edu-cational program on infusion therapy.15,17 (V)

c. The RN should participate in the develop-ment of policies and procedures and in qual-ity improvement activities related to infu-sion therapy.18,19 (V)

d. When the RN has received a delegatedassignment from another health care profes-sional and concludes that she or he is inade-quately prepared to perform this function,the RN must refuse this assignment and seekother means for providing the patient carerequired.20 (V)

e. Tasks delegated by the RN to other nurses orassistive personnel are required to be withinthe legal boundaries for those personnel. Tasksdelegated to assistive personnel should notrequire professional judgment, require little orno modification for each patient, and can beperformed with a predictable outcome.20,21 (V)

V. Infusion Nurse Specialist (CRNI®)a. Infusion nurse specialists are RNs who have

attained certification in infusion nursing fromthe Infusion Nurses Certification Corporation(INCC) and use the designation CRNI®

(Certified Registered Nurse Infusion). This credential signifies specialized knowledge and experience in infusion nursing. All RNs


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specializing in infusion nursing should seek toearn this credential.22-24(V)

b. Nurses earning a certification credential from aprofessional organization report benefits of per-sonal and professional growth, career advance-ment, financial rewards, and empowerment.25-27

(IV)c. In addition to the practice criteria for the RN,

the CRNI® serves as direct care provider, carecoordinator, advocate, patient and staff educa-tor, manager, and consultant on all issues relat-ed to infusion therapy.28 (V)

d. The CRNI® is recognized as expert in thisspecialty and should organize and coordi-nate quality improvement activities in infu-sion therapy and be the primary resource toguide policy and procedure developmentderived from best evidence.28 (V)

e. The CRNI® should be involved with imple-mentation of clinical decision support sys-tems (CDSS) to ensure the needs of nursingare addressed. CDSS designed for nursingmay have the potential for guiding clinicaldecisions within the nurse’s scope of practice;however, the available studies have manylimitations. Management of catheter- andinfusion-related complications could benefitfrom such systems.29 (V)

VI. Advanced Practice Nurse (APN)a. Nurse practitioners, clinical nurse specialists,

nurse midwives, and nurse anesthetists com-pose the group of advanced practice nurses.APNs may be licensed independent practi-tioners (LIPs) and function under a facility’sguidelines and procedures for medical staff.APNs may have the legal authority to pre-scribe infusion therapy and perform surgicalprocedures for insertion and removal of vas-cular access devices.30,31 (IV, Regulatory)

b. APNs should be involved with education, con-sulting, and research in infusion therapy.21,30 (IV)

REFERENCES

1. American Nurses Association; National Council of State Boardsof Nursing. Joint statement on delegation. http//www.ncsbn.org/Joint_statement.pdf. Accessed October 15, 2009.

2. McPherson K, Headrick L, Moss F. Working and learning togeth-er: good quality care depends on it, but how can we achieve it?Qual Health Care. 2001;10(suppl 2):ii46-ii53.

3. Lindeke L, Sieckert A. Nurse-physician workplace collaboration.Online J Issues Nurs. 2005;10(1):5. http://www.nursingworld.org/mainmenucategories/anamarketplace/anaperiodicals/ojin/tableofcontents/volume102005/no1jan05/tpc26_416011.aspx. AccessedJanuary 23, 2010.

4. Markovich MB. The expanding role of the infusion nurse in radi-ographic interpretation for peripherally inserted central cathetertip placement. J Infus Nurs. 2008;31(2):96-103.

5. Sutherland BM. Nursing practice: the regulatory arena. J InfusNurs. 1995;18(6):292-296.

6. Infusion Nurses Society [position paper]. The use of nursing assis-tive personnel in the provision of infusion therapy. J Infus Nurs.2009;32(1):21-22.

7. American Academy of Pediatrics [policy statement]. Guidelinesfor care of children in the emergency department. Ann EmergMed. 2009;54(4):543-552.

8. US Department of Labor. Occupational Outlook Handbook,2008-09. Washington, DC:Bureau of Labor Statistics; 2008.

9. Wendt A. Report of Findings From the 2005 LPN/VN Post Entry-Level Practice Analysis. Chicago, IL: National Council of StateBoards of Nursing; 2006.

10. Catney M, Hillis S, Wakefield B, et al. Relationship betweenperipheral intravenous catheter dwell time and the developmentof phlebitis and infiltration. J Infus Nurs. 2001;24(5):332-341.

11. Bonewit-West K. Clinical Procedures for Medical Assistants. 7thed. St Louis, MO: Saunders/Elsevier; 2008.

12. Weinstein S, ed. Plumer’s Principles & Practice of Intravenous Therapy.8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.

13. Corrigan A. Infusion nursing as a specialty. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:1-9.

14. Seago J, Spetz J, Chapman S, Dyer W. Can the use of LPNs alle-viate the nursing shortage? Yes, the authors say, but the issues—involving recruitment, education, and scope of practice—arecomplex. Am J Nurs. 2006;106(7):40.


16. Diehl-Svrjcek BC, Dawson B, Duncan LL. Infusion nursing:aspects of practice liability. J Infus Nurs. 2007;30(5):274-279.

17. Chippendale M, Gardner H. Review: a model for implementing the“Scope of Professional Practice.” J Child Health Care. 2001;5(3):105-110.

18. ECRI Institute. Failure mode and effects analysis: a hands-on guidefor healthcare facilities. Health Devices. 2004;33(7):233-243.

19. Montalvo I. The National Database of Nursing QualityIndicatorsTM (NDNQI®). Online J Issues Nurs. 2007;12(3).

20. American Nurses Association. Principles of Delegation. SilverSpring, MD: ANA; 2005.

21. Kelly-Heidenthal P, Marthaler M. Delegation of Nursing Care.Clifton Park, NY: Thomson Delmar Learning; 2005.

22. American Board of Nursing Specialties [position statement]. Thevalue of specialty nursing certification. Aurora, OH: ABNS; 2005.

23. Infusion Nurses Certification Corporation. Certification vs certifi-cate: do you know the difference? INCC Chronicle. Norwood, MA:INCC; 2009.

24. Infusion Nurses Society; Infusion Nurses Certification Corporation[joint position paper]. The value of certification in infusion nursing.J Infus Nurs. 2009;32(5):248-250.

25. Piazza I, Donahue M, Dykes P, Griffin M, Fitzpatrick J. Differencesin perceptions of empowerment among nationally certified andnoncertified nurses. J Nurs Admin. 2006;36(5):277.

26. Briggs L, Brown H, Kesten K, Heath J. Certification a benchmarkfor critical care nursing excellence. Crit Care Nurse. 2006;26(6):47.

27. Wade C. Perceived effects of specialty nurse certification: a reviewof the literature. AORN J. 2009;89(1):183-192.

28. Hadaway L. Infusion therapy equipment. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:

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An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:391-436.

29. Staggers N, Weir C, Phansalkar S. Patient safety and health informa-tion technology: role of electronic health record. In: Hughes R, ed.Patient Safety and Quality: An Evidence-Based Handbook for Nurses.Rockville, MD: Agency for Healthcare Research and Quality; 2008.

30. Kleinpell R. Acute care nurse practitioner practice: results of a 5-year longitudinal study. Am J Crit Care. 2005;14(3):211.

31. Klein T. Credentialing the nurse practitioner in your workplace:evaluating scope for safe practice. Nurs Admin Q. 2008;32(4):273.

6. COMPETENCE AND COMPETENCY VALIDATION

Standard

6.1 As a method of public protection, the nurse shall becompetent in the safe delivery of infusion therapy with-in her or his scope of practice.6.2 The nurse shall be responsible and accountable forattaining and maintaining competence with infusiontherapy within her or his scope of practice.6.3 Competency validation shall be performed initiallyand on an ongoing basis.6.4 Competency validation shall be documented in accor-dance with organizational policies, procedures, and/orpractice guidelines.

Practice Criteria

A. The nurse bears responsibility for becoming compe-tent to enter nursing practice and maintaining contin-ued competence throughout her or his career.Competence goes beyond psychomotor skills toinclude application of knowledge, critical thinkingskills, and decision-making abilities. Competencyrequires a commitment to lifelong learning, self-reflec-tion, and professional ethics. Completion of continu-ing education programs is the most common methodfor continuing competence; however, this methoddoes not prove or guarantee competence.1-10 (IV)

B. Employers should use competency validationprocesses to document that the nurse has the knowl-edge, skills, behaviors, and ability to perform theassigned job. Competence should initially be validat-ed at the time of employment, after orientation to theorganization, on an ongoing periodic basis, whenscope of practice changes, and with the introductionof new equipment or technology. Frequency of ongo-ing competence validation and performance evalua-tion is determined by the organization. Frequency forvalidation of specific skills or tasks should be basedon the associated risk and may be considered a com-ponent of the quality improvement process.11,12 (V)

C. Multiple infusion-related tasks are identified as corecompetencies for all registered nurses. Infusion-

related tasks performed by licensed practical/vocational nurses (LPN/LVNs) are determined bythe state’s Board of Nursing and vary greatlyamong states.13,14 (V, Regulatory)

D. Core competencies for the infusion nurse specialistshould be established in the written job descrip-tion and should be based on the infusion nursingcore curriculum, including:1. Technology and clinical application2. Fluid and electrolyte balance3. Pharmacology4. Infection prevention5. Neonate and pediatric patients6. Transfusion therapy7. Antineoplastic and biologic therapy8. Parenteral nutrition9. Quality improvement15,16 (V)

E. Nurses working as contracted staff (eg, peripher-ally inserted central catheter [PICC] insertion) arerequired to document competency with the tasksbeing performed and to comply with the organi-zation’s requirements for staff qualifications andpersonnel practices.11 (V)

F. Competency validation is a dynamic process thatchanges based on organizational needs. Skills ortasks for ongoing competency validation are identi-fied through use of clinical outcome data, problemsdocumented through Unusual Occurrence andSentinel Event Reports, changing patient popula-tions, and patient satisfaction data. Prioritizing thespecific tasks for competency validation is deter-mined by the frequency of performing those tasksand the risks associated with the tasks. Low-fre-quency tasks are performed rarely (eg, less thanweekly). High-risk tasks include invasive procedureswith the potential to be harmful or even life-threat-ening to the patient. Problem-prone tasks includethose that are documented to produce issues for thepatient, staff, or organization.11,12,17 (V)

G. A variety of different methods should be used forcompetency validation including, but not limitedto, written tests for evaluating knowledge, use ofclinical scenarios, and assessment of critical think-ing skills; observation in a skills laboratory; andobserving performance of the skill in the workenvironment, which is the preferred method forinvasive infusion therapy procedures.11,18 (V)

H. A skills laboratory setting involves use of simula-tion with anatomical models and computer-basedvirtual reality. Performance of invasive proce-dures (eg, venipuncture) on peers is discourageddue to health risk for the peer-volunteer.19-21 (V)

I. Documentation of observed performance requiresa well-designed form or checklist that focuses onobjective, measurable assessment of the actualperformance; however, data on the validity and


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reliability of specific forms are not available. Theform includes the competency statement, specificperformance criteria statements, or critical behav-iors; the method of demonstrating performance;the criteria for achieving success; and the signa-ture of the validator.11 (V)

J. Initial competency validation for specialized skillsnot expected of all nurses (eg, PICC insertion,chemotherapy administration) requires attentionto prior clinical experience, educating the nursefor these advanced skills, and completion of aprocedure demonstration and return demonstra-tion. This is followed by performance of an iden-tified number of successful procedures undersupervision in the clinical setting.17,22 (V)

K. The person validating the specific skill should becompetent with the skill. When no one in theorganization has the specific competency,arrangements for a skill validator from outsidethe organization may be necessary.11,18,23 (V)

L. Competency validation should include competen-cy for specific patient populations based on age.Age-based competency will address needs bychronological, functional, or life-stage groups,including physical and psychological developmentneeds and patient educational requirements.11 (V)

M. Competency validation should facilitate culturallycompetent health care by identifying and address-ing the needs of ethnically diverse patient popula-tions. Cultural competence includes health care-related beliefs and values, prevalent diseases in pop-ulations served, religious practices, language andliteracy issues, and family-based needs.11,24,25 (V)

REFERENCES

1. Vanaki Z, Memarian R. Professional ethics: beyond the clinicalcompetency. J Professional Nurs. 2009;25(5):285-291.

2. Tilley D. Competency in nursing: a concept analysis. J ContinuingEduc Nurs. 2008;39(2):58.

3. Burns B. Continuing competency: what’s ahead? J Perinat NeonatalNurs. 2009;23(3):218.

4. Allen P, Lauchner K, Bridges R, Francis-Johnson P, McBride S,Olivarez A. Evaluating continuing competency: a challenge for nurs-ing. J Continuing Educ Nurs. 2008;39(2):81-85.

5. Lazarus J, Lee N. Factoring consumers’ perspectives into policy deci-sions for nursing competence. Policy Polit Nurs Pract. 2006;7(3):195.

6. Milton C. Accountability in nursing: reflecting on ethical codes andprofessional standards of nursing practice from a global perspective.Nurs Sci Q. 2008;21(4):300.

7. Centers for Disease Control and Prevention (CDC). Progress towardstrengthening blood transfusion services: 14 countries, 2003-2007.MMWR Morb Mortal Wkly Rep. 2008;57(47):1273-1277.

8. Minarik P. Issue: competence assessment and competency assuranceof healthcare professionals. Clin Nurse Specialist. 2005;19(4):180.

9. Cowan D, Norman I, Coopamah V. Competence in nursing prac-tice: a controversial concept: a focused review of the literature.Nurse Educ Today. 2005;25(5):355-362.


11. Joint Commission Resources. Assessing Hospital Staff Competence.2nd ed. Oakbrook Terrace, IL: JCR; 2007.

12. McAdams C, Montgomery K. Narrowing the possibilities: usingquality improvement tools to decrease competence assessment over-load. J Nurs Staff Dev. 2003;19(1):40.

13. Wendt A, Alexander M. Toward a standardized and evidence-basedcontinued competence assessment for registered nurses. JONA’sHealthc Law Ethics Regul. 2007;9(3):74.

14. Gorski L, Miller C, Mortlock N. Infusion therapy across the contin-uum. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R,eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed. StLouis, MO: Saunders/Elsevier; 2010:109-126.

15. Hadaway L. Infusion therapy equipment. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:391-436.

16. Czaplewski L. Clinician and patient education. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:71-94

17. Rusche J, Besuner P, Partusch S, Berning P. Competency programdevelopment across a merged healthcare network. J Nurs Staff Dev.2001;17(5):234.

18. O’Hearne Rebholz M. A review of methods to assess competen-cy. J Nurs Staff Dev. 2006;22(5):241.

19. Hilton P, Barrett D. An investigation into students’ performanceof invasive and non-invasive procedures on each other in class-room settings. Nurse Educ Pract. 2009;9(1):45-52.

20. Landry M, Oberleitner M, Landry H, Borazjani J. Education andpractice collaboration: using simulation and virtual reality technologyto assess continuing nurse competency in the long-term acute care setting. J Nurs Staff Dev. 2006;22(4):163.

21. Beyea S, von Reyn L, Slattery M. A nurse residency program forcompetency development using human patient simulation. J NursStaff Dev. 2007;23(2):77-82.

22. Andam R, Silva M. A journey to pediatric chemotherapy compe-tence. J Pediatr Nurs. 2008;23(4):257-268.

23. Ringerman E, Flint L, Hughes D. An innovative education pro-gram: the peer competency validator model. J Nurs Staff Dev.2006;22(3):114.

24. Polacek G, Martinez R. Assessing cultural competence at a localhospital system in the United States. Health Care Manager. 2009;28(2):98.

25. Engebretson J, Mahoney J, Carlson E. Cultural competence in the eraof evidence-based practice. J Professional Nurs. 2007;24(3):172-178.

7. QUALITY IMPROVEMENT

Standard

7.1 The nurse shall participate in quality improvementactivities that advance patient care, quality, and safety.

Practice Criteria

A. Quality improvement activities include evaluatingpatient or clinical outcomes; identifying clinical

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indicators, benchmarks, and areas for improvement;providing best evidence; recommending and imple-menting changes in structures or processes; analyzingdata and outcomes against benchmarks; consideringthe use of cost analysis; or minimizing and eliminat-ing barriers to change and improvement.1-13 (V)

B. The quality improvement program should create aculture that fosters the reporting and analysis ofquality and safety indicator outcomes, near-miss-es, errors, and adverse events. The program shouldfocus on systems and processes that promote indi-vidual accountability and a just culture.12,14-22 (V)

C. The knowledge gained through this process shouldbe shared internally and externally with otherhealth care providers and organizations.13,23 (V)

REFERENCES


2. Institute of Medicine. Crossing the Quality Chasm: A NewHealth System for the 21st Century. Washington, DC: NationalAcademy Press; 2001:111-144, 231-308.

3. The Joint Commission. Comprehensive Accreditation Manuals.Edition v2.0.0.0. Oakbrook Terrace, IL: TJC; 2010.

4. Sierchio GP. Quality management. In: Alexander M, Corrigan A,Gorski L, Hankins J, Perucca R. Infusion Nursing: An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;2010:22-48.

5. Agency for Healthcare Quality and Research. NQF-EndorsedMeasures. In: National Quality Measures Clearinghouse™. http://www.qualitymeasures.ahrq.gov/browse/endorsed.aspx. AccessedJanuary 30, 2010.

6. Curtis JR, Cook DJ, Wall RJ, et al. Intensive care unit qualityimprovement: a “how-to” guide for the interdisciplinary team.Crit Care Med. 2006;34:211-218.

7. Danello SH, Maddox RR, Schaack GJ. Intravenous infusion safety tech-nology: return on investment. Hosp Pharm. 2009;44:680-687,696.

8. Dunton N, Montalvo I. Sustained Improvement in NursingQuality: Hospital Performance on NDNQI Indicators, 2007-2008. Silver Spring, MD: American Nurses Association; 2009.

9. Farquhar M. AHRQ quality indicators. In: Hughes RG, ed.Patient Safety and Quality: An Evidence-Based Handbook forNurses. AHRQ Publication No. 08-0043. Rockville, MD: Agencyfor Healthcare Research and Quality. http://www.ahrq.gov/qual/nurseshdbk/docs/FarquharM_IS.pdf. Published March 2008.Accessed July 6, 2010.

10. Galloway M. Using benchmarking data to determine vascularaccess device selection. J Infus Nurs. 2002;25(5):320-325.

11. Institute of Medicine. The State of Quality Improvement andImplementation Research: Expert Views. Washington, DC: NationalAcademy Press. 2007;53-56, 29-43.

12. Rudy EB, Lucke JF, Whitman GR, Davidson LJ. Benchmarkingpatient outcomes. J Nurs Scholarship. 2001;33(2):185-189.

13. Sierchio GP. A multidisciplinary approach for improving outcomes.J Infus Nurs. 2003;26(1):34-43.

14. Alexander M, Webster H. Legal issues of infusion nursing. In:Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds.Infusion Nursing: An Evidence-Based Approach. 3rd ed. St Louis,MO: Elsevier/Saunders; 2010:49-59.

15. Barnhill S. Clinician and patient safety. In: Alexander M, Corrigan A,Gorski L, Hankins J, Perucca R. Infusion Nursing: An Evidence-BasedApproach. 3rd ed. St Louis, MO: Elsevier/Saunders; 2010:95-108.

16. Hughes RG. Tools and strategies for quality improvement andpatient safety. In: Hughes RG, ed. Patient Safety and Quality: AnEvidence-Based Handbook for Nurses. AHRQ Publication No.08-0043. Rockville, MD: Agency for Healthcare Research andQuality. http://www.ahrq.gov/qual/nurseshdbk/docs/HughesR_QMBMP.pdf. Published March 2008. Accessed July 6, 2010.

17. Institute of Medicine. Patient Safety: Achieving a New Standard forCare. Washington, DC: National Academy Press. 2004;226-249,200-225, 279-316.

18. Mitchell PH. Defining patient safety and quality care. In: HughesRG, ed. Patient Safety and Quality: An Evidence-Based Handbookfor Nurses. AHRQ Publication No. 08-0043. Rockville, MD:Agency for Healthcare Research and Quality. http://www.ahrq.gov/qual/nurseshdbk/docs/MitchellP_DPSQ.pdf. Published March2008. Accessed July 6, 2010.

19. Shearburn P, Kratz M. Utilization of error analysis data in chemother-apy order preparation for development of a comprehensive electronicchemotherapy plan of care. Oncol Nurs Forum. 2009;36(3):76.

20. Wachter RM, Pronovost PJ. Balancing “no blame” with account-ability in patient safety. New Engl J Med. 2009;361(14):1401-1406.

21. Minimizing risk and improving performance. In: Weinstein S, ed.Plumer’s Principles & Practice of Intravenous Therapy. 8th ed.Philadelphia, PA: Lippincott Williams & Wilkins; 2007:10-23.

22. Gorski LA. Central venous access device outcomes in a homecareagency: a 7-year study. J Infus Nurs. 2004;27(2):104-111.

23. Stokowski G, Steele D, Wilson D. The use of ultrasound to improvepractice and reduce complication rates in peripherally inserted central catheter insertions. J Infus Nurs. 2009;32(3):145-155.

8. RESEARCH AND EVIDENCE-BASED PRACTICE

Standard

8.1 The nurse shall use research findings and current bestevidence to expand nursing knowledge in infusion therapy,to validate and improve practice, to advance professionalaccountability, and to enhance evidence-based decisionmaking.8.2 The nurse shall obtain approval for research andresearch-related activities in accordance with federalregulations, professional standards, and criteria setforth by accrediting agencies and organizational poli-cies, procedures, and/or practice guidelines.8.3 The nurse shall develop and revise organizationalpolicies, procedures, and/or practice guidelines based onresearch findings and current best evidence.8.4 The nurse shall integrate evidence-based nursingknowledge with clinical expertise and the patient’s pref-erences and values in the current context when provid-ing infusion therapy.

Practice Criteria

A. The nurse should actively participate in infusiontherapy research activities that advance nursing


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knowledge, such as participating on a research teamor journal club, or conducting systematic literaturereviews, in relation to the individual’s education andexperience.1-5 (V)

B. The nurse should actively participate in criticallyevaluating, interpreting, and implementing researchfindings and/or current best evidence into nursingpractice. This includes, but is not limited to, policyand procedure development and review; producttechnology selection; practice guideline implemen-tation; or abstraction of data from publishedpapers, in relation to the individual’s education andexperience.6-10 (V)

C. The nurse should be competent in using evi-dence-based nursing knowledge and identifyingpatients’ preferences and values to provideeffective and safe infusion therapy practice.7,11-14

(V)

REFERENCES


2. Infusion Nurses Society. Mission. http://www.ins1.org. AccessedAugust 2, 2010.

3. Infusion Nurses Society; Infusion Nurses Certification Corporation[position paper]. The value of certification in infusion nursing. JInfus Nurs. 2009;32(5):248-250.

4. Polit DF, Beck CT. Essentials of Nursing Research: AppraisingEvidence for Nursing Practice. 7th ed. New York, NY: LippincottWilliams & Wilkins; 2009.


6. Dos Reis PE, Silveira RC, Vasques CI, Carvalho EC. Pharmacologicalinterventions to treat phlebitis: systematic review. J Infus Nurs. 2009;32:75-79.

7. Hagle ME, Senk P. Evidence-based practice. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R. Infusion Nursing: AnEvidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;2010:10-21.

8. Hertzel C, Sousa VD. The use of smart pumps for preventingmedication errors. J Infus Nurs. 2009;32(5):257-267.

9. Titler MG. The evidence for evidence-based practice implementa-tion. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. AHRQ Publication No. 08-0043.Rockville, MD: Agency for Healthcare Research and Quality.http://www.ahrq.gov/qual/nurseshdbk/docs/TitlerM_EEBPI.pdf. Published March 2008. Accessed August 2, 2010.

10. Adams J. Utilizing evidence-based practice to support the infusionalliance. J Infus Nurs. 2010; 33(5):273-277.

11. Bays CL, Hermann CP. An evidence-based practice primer forinfusion nurses. J Infus Nurs. 2010;33(4):220-225.

12. Cox JA, Westbrook LJ. Home infusion therapy: essential character-istics of a successful education process—a grounded theory study. J Infus Nurs. 2005;28(2):99-107.

13. Infusion Nurses Society. Infusion nursing code of ethics. J InfusNurs. 2001;24(4):242-243.

14. Evidence-based infusion practice. In: Weinstein S, ed. Plumer’sPrinciples & Practice of Intravenous Therapy. 8th ed. Philadelphia, PA:Lippincott Williams & Wilkins. 2007;188-200.

9. POLICIES, PROCEDURES,AND/OR PRACTICE GUIDELINES

Standard

9.1 Infusion policies, procedures, and/or practice guide-lines shall describe the acceptable course of action,including performance and accountability, and providea basis for clinical decision making.9.2 Infusion policies, procedures, and/or practice guide-lines shall be compliant with state and federal laws andprofessional standards.9.3 Infusion policies, procedures, and/or practice guide-lines shall be written, reviewed at established intervals,and revised as needed based on best evidence, andapproved within a formal organizational process.9.4 Infusion policies, procedures, and/or practice guide-lines shall be readily available and accessible to health careteam members.

Practice Criteria

A. Infusion policies, procedures, and/or practiceguidelines should encompass all applicable areas ofinfusion therapy and should ensure patient safety,as well as minimize or mitigate patient harm.1-3 (V)

B. Infusion policies, procedures, and/or practice guide-lines should be developed in accordance with criteriaset forth in this document, in collaboration withother health care disciplines, patients, industry rec-ommendations, and in keeping with specific needs ofthe organization and criteria set forth by regulatoryand nonregulatory agencies (see Standard 8,Research and Evidence-Based Practice). 1,2 (V)

C. The organization should have a process to developpolicies, procedures, and/or practice guidelines thatare evidence based, maintains the same standard ofcare throughout the organization, and includes allstakeholders.1,2,4 (V)

D. Procedural checklist(s) should be incorporated intopolicies, procedures, and/or practice guidelines to pro-mote patient safety and desired patient outcomes.5(III)

REFERENCES

1. Sierchio G. Quality management. In: Alexander M, Corrigan A, GorskiL, Hankins J, Perucca R., eds. Infusion Nursing An Evidence-BasedApproach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:22-48.

2. Institute of Medicine. Crossing the Quality Chasm: A New Health Systemfor the 21st Century. Washington, DC: National Academy Press; 2001.


4. Agency for Healthcare Research and Quality: Charting Nursing’sFuture, July 2009, Part II—Addressing the Quality and Safety Gap—Part II: How Nurses Are Shaping, and Being Shaped by, HealthInformation Technologies. http://www.rwjf.org/files/research/20090709chartingissue11.pdf. Accessed February 26, 2010.

5. Pronovost P, Needham D, Berenholtz S, et al. An intervention todecrease catheter-related bloodstream infections in the ICU. N EnglJ Med. 2006;355(26):2725-2732.

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Introduction of information technology shouldincorporate the principles of patient safety andinvolve all stakeholders in implementing the tech-nology and required processes.2-7 (III)

C. Adherence to prescribing guidelines, such asappropriate dose ranges, population-specificdose reductions, and biochemical and microbio-logical test values, may result from the integra-tion of CDSS with CPOEs, thus facilitating nurs-ing assessment of order appropriateness.5,8 (IV)

D. The nurse should advocate for organizational proto-cols and standard order sets for patient safety.7,9-11

(IV)E. The nurse should accept verbal orders from LIPs

only when medically necessary.11,12 (IV)F. The nurse should adhere to a standard “read-

back” process when accepting verbal or telephoneorders from an LIP.6,12 (V)

REFERENCES

1. Tully MP, Ashcroft DM, Dornan T, Lewis PJ, Taylor D, Wass V.The causes of and factors associated with prescribing errors inhospital inpatients: a systematic review. Drug Saf. 2009;32(10):819-836.

2. Reckmann MH, Westbrook JI, Koh Y, Lo C, Day RO. Does com-puterized provider order entry reduce prescribing errors for hospi-tal inpatients? A systematic review. J Am Med Inform Assoc. 2009;16(5):613-623.

3. Shamliyan T, Duval S, Du J, Kane R. Just what the doctor ordered:review of the evidence of the impact of computerized physicianorder entry system on medication errors. Health Serv Res. 2008;43(1):32-53.

4. van Rosse F, Maat B, Rademaker C, van Vught A, Egberts A, BollenC. The effect of computerized physician order entry on medicationprescription errors and clinical outcome in pediatric and intensivecare: a systematic review. Pediatrics. 2009;123(4):1184-1190.

5. Yu F, Menachemi N, Berner E, Allison J, Weissman N, HoustonT. Full implementation of computerized physician order entryand medication-related quality outcomes: a study of 3364 hospi-tals. Am J Med Qual. 2009;24(4):278-286.

6. National Quality Forum. Safe Practices for Better Healthcare,2009. Update: A Consensus Report. Washington, DC: NQF; 2009.

10. ORDERS FOR THE INITIATIONAND MANAGEMENT OF INFUSION THERAPY

Standard

10.1 Infusion therapy shall be initiated, changed, ordiscontinued upon the order of a licensed independentpractitioner (LIP).10.2 The nurse shall verify that the LIP’s order is com-plete by inclusion of patient identification; fluid type,volume, and a specific infusion rate; specific medica-tion(s), dosage(s), route, and frequency of administra-tion; and any special considerations.10.3 The nurse shall verify that the LIP’s order is clear,concise, legible, and complete prior to initiation,change, or discontinuation of infusion therapy.10.4 Use of verbal and telephone orders shall be estab-lished in organizational policies, procedures, and/orpractice guidelines.10.5 The nurse shall accept only those abbreviationsapproved by the organization.10.6 Appropriateness and accuracy of the prescribed ther-apy shall be assessed and documented using the nursingprocess.10.7 All patient medications shall be reconciled at thetime of admission, transfer within or between healthcare systems, and discharge.

Practice Criteria

A. The nurse should be aware that processes of pre-scribing and transcribing medication orders areresponsible for the greatest number of adversedrug events. The nurse should advocate for a sys-tems approach for improvement.1-3 (III)

B. Technology for enhancing the process of prescrib-ing, changing, and discontinuing infusion ordersincludes computerized provider order entry (CPOE)and clinical decision support systems (CDSS).

Patient Care


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7. Migita D, Postetter L, Heath S, Hagan P, Del Beccaro M.Governing peripherally inserted central venous catheters by com-bining continuous performance improvement and computerizedphysician order entry. Pediatrics. 2009;123(4):1155-1161.

8. Mack E, Wheeler D, Embi P. Clinical decision support systems in thepediatric intensive care unit. Pediatr Crit Care Med. 2009;10(1):23-28.

9. Mickle J, Reinke D. A review of anemia management in theoncology setting: a focus on implementing standing orders. Clin JOncol Nurs. 2007;11(4):534-539.

10. Weber LM, Ghafoor VL, Phelps P. Implementation of standardorder sets for patient-controlled analgesia. Am J Health Syst Pharm.2008;65(12):1184-1191.

11. Wakefield DS, Brokel J, Ward MM, et al. An exploratory studymeasuring verbal order content and context. Qual Saf HealthCare. 2009;18(3):169-173.

12. Wakefield D, Wakefield B. Are verbal orders a threat to patientsafety? Qual Saf Health Care. 2009;18(3):165-168.

11. PATIENT EDUCATION

Standard

11.1 The nurse shall educate the patient, caregiver,and/or legally authorized representative about the pre-scribed infusion therapy and plan of care, including, butnot limited to, purpose and expected outcome(s) and/orgoals of treatment, infusion therapy administration,infusion device-related care, potential complications, oradverse effects associated with treatment or therapy,and risks and benefits, according to organizational poli-cies, procedures, and/or practice guidelines.11.2 The nurse shall document the teaching content pro-vided; to whom it was provided; and the patient, caregiv-er, or legally authorized representative’s response in thepatient’s permanent medical record according to organi-zational policies, procedures, and/or practice guidelines.

Practice Criteria

A. Teaching methods should be developed and basedupon an assessment of age, developmental and cogni-tive level, health literacy, cultural influences, and lan-guage preference; additional factors affecting readi-ness to learn such as current stressors, sensorydeficits, and functional limitations should also beassessed.1-4 (V)

B. Health literacy is a critical component of communi-cation and patient education. Written educationalmaterials and verbal presentation of teachingshould be made as simple as possible for allpatients. Use of materials such as pictures, dia-grams, and audio/video instructional aids should beconsidered for patients with low or limited literacyand/or for those who speak English as a second lan-guage. Medical jargon and abbreviations should beavoided, and simple terminology should be used.1-8

(V)

C. Education should include, but not be limited to:1. Proper care of the access device.2. Precautions for preventing infection and other

complications, including aseptic technique andhand hygiene.

3. Signs and symptoms to report, including thosethat may occur after infusion device removaland after the patient leaves the health care set-ting (eg, signs of postinfusion phlebitis, fever)and how/where to report them.

4. Ensuring that health care providers areemploying proper infection prevention meth-ods, such as hand hygiene, when providingcare.

5. For outpatients and those receiving home infusiontherapy, additional education should include:a. Safe storage, maintenance, and disposal of

solutions, supplies, and equipment.b. Infusion administration as appropriate.c. Information on how to live with an access

device, including activity limitations andprotecting the device while performing activ-ities of daily living.3,8-14 (V)

D. Patient or caregiver comprehension and perfor-mance should be initially evaluated and periodi-cally reevaluated at established intervals.1-4,11,12

(V)E. Effective education is critical to the safe provision

of infusion therapy and in reducing the risk forinfusion-related complications. Goals of infusiontherapy and the patient/caregiver role related toperformance of specific aspects of infusion careshould be mutually developed with the patient orcaregiver. 1,3,4,11,15 (IV)

REFERENCES

1. Czaplewski L. Clinician and patient education. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:71-94.

2. Bass L. Health literacy: implications for teaching the adultpatient. J Infus Nurs. 2005;28(1):15-22.

3. Gorski LA. Pocket Guide to Home Infusion Therapy. Sudbury,MA: Jones & Bartlett; 2005.


5. Walker J, Gerard PS. Assessing the health literacy levels ofpatients using selected hospital services. Clin Nurse Specialist.2010;24(1):31-37.

6. US Department of Health and Human Services. Healthy People2010: Understanding and Improving Health. 2nd ed. Washington,DC: DHHS; 2010.

7. National Network of Libraries of Medicine. Health literacy.http://nnlm.gov/outreach/consumer/hlthlit.html. Accessed December30, 2009.

8. Denham CR. SBAR for patients. J Patient Safety. 2008;4(1):38-48.



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9. National Quality Forum. Safe practice 21: central line associatedbloodstream infection prevention. In: Safe Practices for BetterHealthcare, 2009. Update: A Consensus Report. Washington,DC: NQF; 2009:225-229.

10. Registered Nurses Association of Ontario. Nursing best practiceguideline: care and maintenance to reduce vascular access compli-cations. http://www.rnao.org/Storage/39/3379_Assessment_and_Device_Selection_for_Vascular_Access._with_2008_Supplement.pdf. Revised 2008. Accessed December 30, 2009.

11. Gorski LA, Czaplewski LM. PICC and midline catheters for thehome care nurse. J Infus Nurs. 2004;27(6):399-409.

12. Tice AD. Handbook of Outpatient Parenteral AntimicrobialTherapy. Tarrytown, NY: CRG Publishing; 2006.

13. US Centers for Disease Control and Prevention (CDC). Frequentlyasked questions about “catheter associated bloodstream infec-tions.” http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/BSI_tagged.pdf. Accessed December 30, 2009.

14. Perucca R. Peripheral venous access devices. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:456-479.

15. Moller T, Borregaard N, Tvede M, Adamsen L. Patient education:a strategy for prevention of infections caused by permanent cen-tral venous catheters in patients with hematological malignancies:a randomized clinical trial. J Hosp Infect. 2005;61(4):330-341.

12. INFORMED CONSENT

Standard

12.1 The nurse shall confirm that the patient’sinformed consent was obtained for the defined proce-dure as identified in organizational policies, procedures,and/or practice guidelines and in accordance with local,state, and federal regulations.12.2 Consent shall be obtained by the health careprovider who will perform the procedure and shallinclude full details of the procedure, risks and benefits,alternatives, and complications associated with thetreatment or therapy, in a language that the patient orlegally authorized representative can understand.12.3 The nurse shall advocate for the patient’s or legallyauthorized representative’s right to accept or refuse treat-ment.

Practice Criteria

A. The nurse should be knowledgeable of the proto-col for obtaining informed consent from thepatient or legally authorized representative, bothverbally and written, and ensure that the informa-tion given to the patient or legally authorized rep-resentative has included discussion of risks, bene-fits, alternatives, and complications associatedwith the treatment or therapy. This should bedone in a method such as asking the patient torecount or “teach back” the proposed treatmentor procedure.1-7 (V)

B. The nurse should verify that informed consent wasobtained for the treatment for neonatal, pediatric,and adolescent patients from the patient’s parentor legal guardian, and should document the infor-mation given to the legally authorized representa-tive(s) and the response in the patient’s permanentmedical record.4,8-10 (V)

C. The nurse should obtain and document the child’s(age 7 or older) or teenager’s assent to the proce-dure, tailoring the information with considerationfor knowledge and developmental level.11-13(V)

D. As elements of informed consent, the nurse shouldensure that the patient, parent, or legally authorizedrepresentative, at a minimum, should be able toexplain in everyday words the diagnosis or healthproblem; the name, type, and general nature of thetreatment, service, or procedure; and the primaryrisks, benefits, and alternatives.5,11 (V)

E. The nurse should ensure that informed consentincludes the following elements:1. Documents written at or below the 5th-grade

reading level and provided in the primary lan-guage of the patient.

2. Provision of a qualified medical interpreter orreader to assist patients with limited languageproficiency, limited health literacy, and visual orhearing impairments.

3. Patient-centered information that is adequateand meaningful to the individual.

4. A dialogue with the patient and, as appropriate,the family and other decision makers, about the nature and scope of the procedure.6-8,14

(V)F. The nurse should ensure that if the patient’s con-

dition does not allow for such interaction, appro-priate documentation is provided in the patient’spermanent medical record.11 (V)

REFERENCES

1. Alexander M, Webster HK. Legal issues of infusion nursing. In:Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds.Infusion Nursing: An Evidence-Based Approach. 3rd ed. StLouis, MO: Saunders/Elsevier; 2010:49-59.

2. Nettina SM, ed. The Lippincott Manual of Nursing Practice.8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:16.

3. Smith SF, Duell DJ, Martin BC. Clinical Nursing Skills: Basic toAdvanced Skills. 6th ed. Upper Saddle River, NJ: PearsonEducation; 2004:7-8, 54-55.

4. Cheung, W Pond G, Geslegrave, R, Enright K, Potanina L, Siu L.The contents and readability of informed consent forms for oncolo-gy clinical trials. Am J Clin Oncol. 2010;33(4):387-392.

5. Sims, JM. Your role in informed consent. Dimens Crit Care Nurs.2008;7(3):118-121.

6. Holmes-Rovner M, Wills C. Improving informed consent:insights from behavioral decision research. Med Care. 2002;40(9)(suppl):V30-V38.



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7. National Quality Forum. Safe Practices for Better Healthcare—2009 Update: A Consensus Report. Washington, DC: NQF;2009.

8. Paasche-Orlow MK, Taylor HA, Brancati FL. Readability stan-dards for informed consent forms as compared with actual read-ability. N Engl J Med. 2003;348(8):721-726.

9. Simon CM, Siminoff LA, Kodish ED, Burant C. Comparison ofthe informed consent process for randomized clinical trials inpediatric and adult oncology. J Clin Oncol. 2004;22(13):2708-2729.

10. Committee on Bioethics, American Academy of Pediatrics. AAPpublications retired or reaffirmed, October, 2006. Informed con-sent, parental permission and assent in pediatric practice.Pediatrics. 2007;119:405. doi: 10.1542/peds.2006-3222.

11. Joint Commission on Accreditation of Healthcare Organizations.Comprehensive Accreditation Manual for Hospitals: The OfficialHandbook (CAMH). Oakbrook Terrace, IL: JCAHO; 2009.

12. Rossi WC, Reynolds W, Nelson RM. Child assent and parentalpermission in pediatric research. Theor Med Bioeth. 2003;24(2):131-148.

13. Szalados JE. Legal issues in the practice of critical care medicine: apractical approach. Crit Care Med. 2007;35(suppl 2):S44-S58.

14. Agre P, Rapkin B. Improving informed consent: a comparison offour consent tools. IRB. 2003;25(6):1-7.

13. PLAN OF CARE

Standard

13.1 The nurse shall collect comprehensive data perti-nent to the patient’s health care needs.13.2 The nurse shall analyze assessment data and deter-mine nursing diagnosis (problem).13.3 The nurse shall identify outcome criteria based onnursing diagnoses.13.4 The nurse shall develop a plan of care thatdescribes nursing actions to achieve expected outcomes.13.5 The nurse shall implement nursing actions identi-fied in the plan of care.13.6 The nurse shall evaluate the patient’s progresstoward expected outcomes, revising the plan of care asappropriate and at established intervals.13.7 The use of care plans shall be established in organi-zational policies, procedures, and/or practice guidelines.

Practice Criteria

A. Nursing assessment should be systematic and pri-oritized by patient needs, based on organizationalpolicies, procedures, and/or practice guidelinesusing best evidence and nursing judgment.1,2 (V)

B. The nurse should develop nursing diagnoses (actu-al or potential bio-psychosocial patient problems)based on pertinent and accurate assessments.1-4 (V)

C. The nurse should develop interventions consistentwith the established plan of care, achievable in the cur-rent patient context, and based on best evidence.1,3,5

(V)

D. The nurse should determine the type and frequen-cy of patient monitoring based on the prescribedtherapy, access device, patient’s condition andage, and care setting.1,6-8 (V)

E. The nurse should develop outcome criteria inrelation to the patient’s capabilities, availability,and accessibility to resources, and should includea time frame for achievement.1 (V)

F. The nurse should conduct an ongoing evaluationof the plan of care and revise diagnoses, interven-tions, and outcome criteria as needed.1,2 (V)

G. The nurse should develop a plan of care that isminimally composed of assessment, diagnoses,interventions, and outcome criteria; uses nursingjudgment and critical thinking; is individualized forthe patient, spanning the care continuum as need-ed; and includes, but is not limited to, age, cultur-al and linguistic appropriateness, environmentalsensitivity, and socioeconomic factors.1,3,6-11 (IV)

H. The nurse should involve the patient, caregiver, orlegally authorized representative in the develop-ment, evaluation, and revision of the plan of careto achieve expected outcomes.1,12,13 (V)

I. The nurse should collaborate with other membersof the health care team in the development, eval-uation, and revision of the plan of care and com-municate the plan to the team.1,6,14 (V)

J. The documented plan of care should be in a stan-dardized language or terminology, in a retrievableformat, and contained within the patient’s perma-nent medical record.1,10,11,15-17 (V)

REFERENCES


2. Carpenito-Moyet L. The bifocal clinical practice model. In:Carpenito-Moyet L. Nursing Care Plans & Documentation:Nursing Diagnoses and Collaborative Problems. New York, NY:Wolters Kluwer/Lippincott Williams & Wilkins; 2009:3-8.

3. Duckett K. Creating a POC from the initial assessment: tips foraccurately completing other diagnoses and orders for disciplineand treatments. Home Healthc Nurse. 2005;23(4):210-212.

4. Herdman TH, ed. Nursing Diagnoses: Definitions andClassification, 2009-2011. Ames, IA: Wiley-Blackwell; 2009.

5. Hagle M, Senk P. Evidence-based practice. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:10-21.

6. Adams-Wendling L, Piamjariyakul U, Bott M, Taunton R.Strategies for translating the resident care plan into daily practice.J Gerontol Nurs. 2008:34(8):50-56.


8. American Nurses Association. Nursing’s Social Policy Statement.2nd ed. Silver Spring, MD: ANA; 2003.

9. Cayir G, Beji N, Yalcin O. Effectiveness of nursing care after surgeryfor stress urinary incontinence. Urologic Nurs. 2007:27(1):25-33.



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10. Lang N, Hook M, Akre M, et al. Translating knowledge-basednursing into referential and executable applications in an intelli-gent clinical information system. In: Weaver C, Delaney C,Webber P, Carr R, eds. Nursing and Informatics for the 21stCentury: An International Look at Practice, Trends and theFuture. Chicago, IL: Healthcare Information and ManagementSystems Society; 2006:291-303.

11. Shearburn P, Kratz M. Utilization of error analysis data inchemotherapy order preparation for development of a comprehen-sive electronic chemotherapy plan of care. Oncol Nurs Forum.2009;36(3):76.

12. Penticuff J, Arheart K. Effectiveness of an intervention to improveparent-professional collaboration in neonatal intensive care. JPerinat Neonatal Nurs. 2005;19(2):187-202.

13. Specht J, Taylor R, Bossen, A. Partnering for care: the evidenceand the expert. J Gerontol Nurs. 2009:35(3):16-22.

14. Stewart J, Stansfield K, Tapp K. Clinical nurses’ understanding ofautonomy. J Nurs Adm. 2004;34(10):443-450.

15. Keenan G, Yakel E, Tschannen D, Mandeville M. Documentationand the nurse care planning process. In: Hughes RG, ed. PatientSafety and Quality: An Evidence-Based Handbook for Nurses.Rockville, MD: Agency for Healthcare Research and Quality:1-32. AHRQ Publication No. 08-0043. http://www.ahrq.gov/qual/nurseshdbk/. Published 2008. Accessed November 18, 2009.

16. The Joint Commission. Accreditation Program: Home Care—Standard RC.02.01.01. Oakbrook Terrace, IL: TJC; 2009.

17. The Joint Commission. Accreditation Program: Hospital—Standard RC.02.01.01. Oakbrook Terrace, IL: TJC, 2008.



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and all long-term infusion devices, include themanufacturer and lot number.5,10,11 (V)

4. Date and time of insertion, number and loca-tion of attempts, functionality of device, localanesthetic (if used), and the insertion methodol-ogy, including visualization and guidance tech-nologies.5,11 (V)

5. Identification of the insertion site by anatomi-cal descriptors, laterality, landmarks, orappropriately marked drawings.10,12 (V)

6. For midline (ML) and peripherally insertedcentral catheters (PICCs): external catheterlength and effective length of catheter insert-ed.5,13 (V)

7. Confirmation of the anatomic location of thecatheter tip for all CVADs prior to initial use andas needed for evaluation of catheter dysfunc-tion.5,11 (V)

8. Condition of the site, dressing, type of catheterstabilization, dressing change, site care, patientreport of discomfort or pain on device inser-tion and with each regular assessment of theaccess site, and patient report of changes relat-ed to the VAD or access site.4,14 (V)

9. A standardized assessment, appropriate for age-specific patient populations, for phlebitis, infiltra-tion, or extravasation, that allows for accurateand reliable assessment on initial identificationand with each subsequent site assessment (seeStandards 47, Phlebitis; 48, Infiltration andExtravasation).13,14 (V)

10. Type of therapy, drug, dose, rate, time, routeand method of administration; include condi-tion of venipuncture or access site prior to andafter infusion therapy, as well as patency.3,14-16

(V)11. Pertinent nursing diagnosis (problem), initial

and ongoing assessment, and vital signs asappropriate; patient’s response to insertionand therapy, including symptoms, side effects,or complications; laboratory test results as

14. DOCUMENTATION

Standard

14.1 Documentation shall contain accurate, factual,and complete information in the patient’s permanentmedical record regarding the patient’s infusion therapyand vascular access.14.2 Documentation shall be legible, timely, accessibleto qualified personnel, and readily retrievable.14.3 Documentation shall include factors relating toinitial and ongoing assessment, nursing diagnosis orproblem, intervention, and the patient’s response to thatintervention.14.4 Documentation shall reflect the continuity, quali-ty, and safety of care.14.5 Documentation guidelines and the confidentialityof the patient’s permanent medical record shall beestablished in organizational policies, procedures,and/or practice guidelines, according to the scope ofpractice for personnel, standards of care, accreditingagencies, and state and federal regulations.

Practice Criteria

A. Documentation should be done by appropriateclinical personnel, and identify the person provid-ing the care.1-3 (V)

B. Documentation should include, but not be limitedto, the following:1. Patient, caregiver, or legally authorized represen-

tative’s participation in and understanding of ther-apy, interventions, and patient education.3-6 (V)

2. Specific site preparation, infection prevention,and safety precautions taken, using a stan-dardized tool for documenting adherence torecommended practices.6-9 (IV)

3. For all infusion devices, type, length, and gauge/size of vascular access device (VAD) inserted;for central vascular access devices (CVADs)

Documentation


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appropriate; and barriers to patient educationor care.14,17-21 (V)

12. Daily assessment of the need for continuationof the VAD.22-25 (IV)

13. Upon removal: condition of site, condition ofthe catheter and length, reason for deviceremoval, nursing interventions during removal,dressing applied, patient response, patient edu-cation, date/time of removal.4,5 (V)

14. If cultures are obtained, document source of culture(s).4,5 (V)

15. When multiple access devices or catheterlumens are used, documentation should clearlyindicate what fluids and medications are beinginfused through each pathway.4,5 (V)

REFERENCES

1. Bravery K, Dougherty L, Gabriel J, Kayley J, Malster M, ScaiesK. Audit of peripheral venous cannulae by members of an IVtherapy forum. Br J Nurs. 2006;15(22):1244-1249.

2. Johansson M, Pilhammar E, Khalaf A, Willman A. Registerednurses’ adherence to clinical guidelines regarding peripheral venouscatheters: a structured observational study. Worldviews Evid-Based Nurs. 2008;5(3):148-159.

3. Maxwell B. Documentation and informatics. In: Potter P, Perry A.Fundamentals of Nursing. 7th ed. St Louis, MO: Mosby/Elsevier;2009:384-409.

4. Gorski L, Perucca R, Hunter M. Central venous access devices:care, maintenance, and potential complications. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:495-515.

5. Hagle M, Johnson B, Ladewig N, Montenero D, Pawlak T.Central venous access. In: Weinstein S, ed. Plumer’s Principles &Practice of Intravenous Therapy. 8th ed. Philadelphia, PA:Lippincott Williams & Wilkins; 2007:277-330.

6. Morris W, Tay M. Strategies for preventing peripheral intra-venous cannula infection. Br J Nurs. 2008;17(19)(suppl):S14-S21.

7. Aziz A. Improving peripheral IV cannula care: implementinghigh-impact interventions. Br J Nurs. 2009;18(20):1242-1246.

8. Centers for Disease Control and Prevention (CDC). Reduction incentral line-associated bloodstream infections among patients inintensive care units: Pennsylvania, April 2001-March 2005.MMWR Morb Mortal Wkly Rep. 2005;54(40):1013-1016.

9. Siegel JD, Rhinehart E, Jackson M, Chiarello L; HealthcareInfection Control Practices Advisory Committee. 2007 guideline forisolation precautions: preventing transmission of infectious agentsin healthcare settings. http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/isolation2007.pdf. Accessed February 5, 2010.

10. Ahlqvist M, Berglund B, Wiren M, Klang B, Johansson E.Accuracy in documentation: a study of peripheral venouscatheters. J Clin Nurs. 2009;18:1945-1952.

11. Bullock-Corkhill M. Central venous access devices: access andinsertion. In: Alexander M, Corrigan A, Gorski L, Hankins J,Perucca R, eds. Infusion Nursing: An Evidence-Based Approach.3rd ed. St Louis, MO: Saunders/Elsevier; 2010:480-494.

12. Ahlqvist M, Bogren A, Hagman S, et al. Handling of peripheralintravenous cannulae: effects of evidence-based clinical guide-lines. J Clin Nurs. 2006;15:1354-1361.

13. Perucca R. Peripheral venous access devices. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier;2010:456-479.

14. Dugger B. Documentation. In: Alexander M, Corrigan A, GorskiL, Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;2010:540-549.

15. Buckner S. Medication administration. In: Potter P, Perry A, eds.Fundamentals of Nursing. 7th ed. St Louis, MO: Mosby/Elsevier;2009:686-770.

16. Burke K, Asimos K. Medication administration. In: Ackley B,Ladwig G, Swan B, Tucker S, eds. Evidence-Based Nursing CareGuidelines: Medical-Surgical Interventions. St Louis, MO:Mosby/Elsevier; 2008:508-512.

17. Alfaro-LeFevre R. Applying Nursing Process: A Tool for CriticalThinking. New York, NY: Wolters Kluwer/Lippincott Williams& Wilkins; 2010:195-208.


19. Keenan G, Yakel E, Tschannen D, Mandeville M. Documentationand the nurse care planning process. In: Hughes RG, ed. PatientSafety and Quality: An Evidence-Based Handbook for Nurses.Rockville, MD: Agency for Healthcare Research and Quality;2008:1-32. AHRQ Publication No. 08-0043. http://www.ahrq.gov/qual/nurseshdbk/. Accessed June 23, 2010.

20. Potter P. Nursing assessment. In: Potter P, Perry A, eds.Fundamentals of Nursing. 7th ed. St Louis, MO: Mosby/Elsevier;2009:230-246.

21. Potter P. Evaluation. In: Potter P, Perry A. Fundamentals ofNursing. 7th ed. St Louis, MO: Mosby/Elsevier; 2009:290-300.

22. Centre for Healthcare-Related Infection Surveillance andPrevention. Peripherally inserted central catheter (PICC): recom-mended practices, version 3. http://www.health.qld.gov.au/chrisp/icare/picc_rec_prac.pdf. Published January 2009. Accessed January17, 2010.

23. Centre for Healthcare-Related Infection Surveillance andPrevention. Percutaneous central venous catheter (CVC): recom-mended practices, version 3. http://www.health.qld.gov.au/chrisp/icare/perc_cvc_rec_prac.pdf. Published January 2009. AccessedJanuary 17, 2010.

24. Joanna Briggs Institute. Management of peripheral intravasculardevices. Aust Nurs J. 2008;16(3):25-28.

25. Powell J, Tarnow K, Perucca R. The relationship between periph-eral intravenous catheter indwell time and the incidence ofphlebitis. J Infus Nurs. 2008;31(1):39-45.

15. UNUSUAL OCCURRENCE ANDSENTINEL EVENT REPORTING

Standard

15.1 The nurse shall report and document unusualoccurrences or sentinel events in practice as a result ofinfusion therapy according to organizational policies,procedures, and/or practice guidelines.15.2 Reporting of unusual occurrences and sentinelevents shall be defined in organizational policies, proce-dures, and/or practice guidelines.



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Practice Criteria

A. The Unusual Occurrence and Sentinel EventReport should be shared with the appropriateorganizational levels and departments, such as riskmanagement (RM), nursing management, andquality improvement (QI) teams.1-7 (V, Regulatory)

B. The event reporting process should incorporateand exhibit a strong culture of safety or “just cul-ture” by creating an environment that encouragesreporting, empowers the nurse to identify andimplement appropriate action to prevent adverseevents, focuses on fixing the system(s) instead ofindividual responsibility, determines cause, is con-sidered a learning opportunity, and promotesquality patient outcomes.1,8-15 (IV)

C. The adverse, significant, preventable complications,Unusual Occurrence, or Sentinel Event Reportshould be written and reviewed, with the reportedevent(s) analyzed, trends identified, and retained ina retrievable form to ensure patient safety.1,2 (V)

D. The organization should have a defined process toinvestigate an unusual occurrence or sentinel event toassess cause and improve safety. This process mayinclude such actions as a root cause analysis (RCA),peer review, or an individual action plan.1,16-18 (V)

E. The RCA, an interdisciplinary approach, shouldfocus on systems issues, procedures, humanresources, products/equipment, processes, andtraining gaps. The RCA should identify cause(s),provide an analysis of the event, and should resultin specific strategies and/or actions for improve-ment that enhance patient safety.6,16-18 (V)

F. The nurse should actively participate in the RCAprocess and in the development and implementa-tion of the action plan derived from the RCA.1(V)

G. The nurse should communicate unanticipated nurs-ing outcomes that are within the control or account-ability of the nurse to the patient, caregiver, or legal-ly authorized representative. The nurse should beinvolved in the predisclosure planning discussion andparticipate as a member of the disclosure team pro-viding information to the patient, caregiver, or legal-ly authorized representative.10,19 (V)

REFERENCES

1. Creating and sustaining a culture of safety. In: Keeping PatientsSafe: Transforming the Work Environment of Nurses.Washington, DC: National Academies Press; 2004. http://books.nap.edu/openbook.php?record_id=10851&page=286. Accessed July8, 2009.

2. Joint Commission on Accreditation of Healthcare Organizations.Sentinel Event Policy and Procedures, 2005. http://www.jcaho.org/accredited�organizations/ambulatory�care/sentinel/events/index.htm. Accessed July 8, 2009.

3. Centers for Medicare & Medicaid Services. Eliminating serious,preventable and costly medical errors—“never events.” http://www.

cms.hhs.gov/apps/media/press/release/asp?counter/1863.Published May 18, 2006. Accessed July 10, 2009.

4. Centers for Medicare & Medicaid Services. Incorporating select-ed national quality forum and never events into Medicare’s list ofhealthcare-acquired conditions. http://www.cms.hhs.gov/apps/media/press/release.asp? Published April 14, 2008. Accessed July10, 2009.

5. National Quality Forum. Serious Reportable Events in PatientSafety: A National Quality Forum Consensus Report, 2002.Washington, DC: NQF; 2002.

6. Sierchio G. Quality management. In: Alexander M, Corrigan A, GorskiL, Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-BasedApproach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:22-48.

7. Alexander M, Webster H. Legal issues of infusion nursing. In:Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds.Infusion Nursing: An Evidence-Based Approach. 3rd ed. StLouis, MO: Saunders/Elsevier; 2010: 49-59.

8. Institute of Medicine. To Err Is Human: Building a Safer HealthSystem. Washington, DC: National Academy Press; 2000.

9. Joint Commission on Accreditation of Healthcare Organizations.Sentinel Event Alert: Behaviors That Undermine a Culture ofSafety. http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm. Published July 9, 2008. Accessed July 8, 2010.

10. Shannon S, Foglia M, Hardy M, Gallagher T. Disclosing errors topatients: perspectives of registered nurses. The Joint CommissionJ Quality Patient Safety. 2009;35(1):5-12.

11. ECRI Institute. Disclosure of unanticipated outcomes. IncidentReporting and Management. 2008;5(suppl A):1-21. http://www.ecri.org. Published January 2008. Accessed July 29, 2009.

12. Krein S, Holer T, Kowalski C, et al. Use of central venouscatheter-related bloodstream infection prevention practices in UShospitals. Mayo Clin Proc. 2007;82(6):672-678.

13. American Nurses Association [position statement]. Just Culture.http://www.nursingworld.org/psjustculture. Accessed January 23,2010.

14. American Organization of Nurse Executives (AONE). GuidingPrinciples: The Role of the Nurse Executive in Patient Safety.http://www.aone.org/resource/PDF/AONE_GP_Role_Nurse_Exec_Patient_Safety.pdf. Published 2007. Accessed January 22, 2010.

15. American Nurses Association. Nursing Administration: Scopeand Standards of Practice. Silver Spring, MD: ANA; 2009.

16. Institute for Safe Medical Practice. Root causes: a roadmap toaction. ISMP Medication Safety Alert. 2004;9(17):1-3.

17. Dattilo E, Constantino R. Root Cause analysis and nursing man-agement responsibility in wrong-site surgery. Dimens Crit CareNurs. 2006;25(5):221-225.

18. McDonald, A. Leyhans T. Drill down with root cause analysis.Nurs Manage. 2005;36(10):26-31.

19. Weiss P, Miranda F. Transparency, apology and disclosure ofadverse outcomes. Obstet Gynecol Clin North Am. 2008;35:53-62.

16. PRODUCT EVALUATION,INTEGRITY, AND DEFECTREPORTING

Standard

16.1 The nurse shall be involved in the evaluation of infusion-related technologies, including attention to

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clinical application, expected outcomes, performance,infection prevention, safety, efficacy, reliability, and cost.16.2 All infusion equipment and supplies shall beinspected for product integrity before, during, and afteruse. Product integrity shall be determined by verifica-tion of expiration date, if applicable, and visual inspec-tion of the product. If a product’s integrity is compro-mised or the product is expired, it shall not be used.16.3 The nurse shall verify that preventive maintenancehas been performed on infusion equipment being used.16.4 When a defective product is identified, the nurseshall remove it from patient use and report per organi-zational policies, procedures, and/or practice guidelines.16.5 Product evaluation, integrity, defect reporting, andproduct recall shall be in accordance with organization-al policies, procedures, and/or practice guidelines andwith state and federal rules and regulations.

Practice Criteria

A. A multidisciplinary group of direct and indirectend users should be included in the product evalu-ation committee and should be oriented and edu-cated on the new product, as well as data collectiontools for analysis and ongoing monitoring.1 (V)

B. The person responsible for managing productevaluation should receive information aboutadverse outcomes and events.2 (V)

C. Identification of a product defect before, during,or upon completion of therapy requires interven-tion and removal of the product from the clinicallocation.3,4 (Regulatory)

D. Product defect reporting should include suspectedand known intrinsic and extrinsic contamination,product damage, product tampering, improper,unclear, or confusing patient or user instructionsor labeling, similar or confusing names, packag-ing problems, and errors related to reliance oncolor coding (see Standard 17, Verification ofProducts and Medications).1,3-10 (IV, Regulatory)

E. When a product defect is identified before use, thenurse should retain the product, product over-wraps, and other identifying information (modelnumber, lot number, serial number, expirationdate) for further analysis and reporting.1 (V)

F. Serial and lot numbers used in product identifica-tion, tracking, and product recall should beretained to allow for a copy of the report to be kepton file at the health care organization.3 (Regulatory)

G. When a product defect results in an unusualoccurrence or sentinel event, reporting shouldinclude, but not be limited to:1. Identification of occurrence, event, or product

problem.2. Outcomes attributed to the occurrence or event

(eg, death or serious injury).

3. Life-threatening injury or illness.4. Disability resulting in permanent impairment of

a body function or permanent damage to abody structure.

5. Injury or illness that requires intervention toprevent permanent impairment of a body struc-ture or function.

6. Date of event.7. Date of report by the initial reporter.8. Description of event or problem, including a dis-

cussion of how the device was involved, natureof the problem, patient follow-up or requiredtreatment, and any environmental conditionsthat may have influenced the event.

9. Description of relevant tests and laboratorydata, including dates.

10. Description of other relevant patient history, includ-ing preexisting medical conditions.3 (Regulatory)

H. Prevention strategies that focus on facilitatingoptimal care decisions, identifying patients or con-ditions associated with higher risk, and enablingearly detection and intervention to address riskfactors may be more effective in improving safetyand reducing preventable adverse events.4 (V)

REFERENCES

1. Miller C. Product selection and evaluation. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;2010:437-446.

2. Larsen GY. Preventable harm occurring to critically ill children.Pediatr Crit Care Med. 2007;8(4):331-336.

3. US Food and Drug Administration. Medical Devices. 3 CFR Title21. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?CFRPart�803&showFR�1&subpartNode�21:8.0.1.1.3.3. Revised April 1, 2009. Accessed September 16, 2009.

4. Patient Safety and Quality Improvement Act of 2005, 42 USC.2005. http://www.pso.ahrq.gov/statute/pl109-41.pdf. PublishedJuly 29, 2005. Accessed March 19, 2010.

5. Samore MH, Evans RS, Lassen A, et al. Surveillance of medicaldevice-related hazards and adverse events in hospitalized patients.JAMA. 2004;291(3):325-334.

6. Institute of Medicine. Crossing the Quality Chasm: A NewHealth System for the 21st Century. Washington, DC: NationalAcademy Press. 2001.

7. Radhika V, Assaf RR, Al-Assaf AF. JHQ 197: Making the PatientSafety and Quality Improvement Act of 2005 Work. NationalAssociation for Healthcare Quality. http://www.nahq.org/journal/ce/article.html?article_id�282. Accessed April 1, 2010.

8. US Department of Labor. Occupational Safety and HealthAdministration. Safe Medical Devices Act: Medical DeviceReporting for User Facilities, 21 USC § 360i (1990).

9. Deacon VL. The safe medical device act and its impact on clini-cal practice. J Infus Nurs. 2004;27(1):31-36.

10. American Nurses Association [position statement]. Safety IssuesRelated to Tubing and Catheter Misconnections. Silver Spring,MD: ANA; 2007.



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17. VERIFICATION OF PRODUCTSAND MEDICATIONS

Standard

17.1 The nurse shall identify and verify use of the cor-rect product and/or medication by reviewing the labelfor the name (trade and generic), dosage and concentra-tion, beyond-use date, expiration date, sterility state,route of administration, frequency, flow rate, and anyother special instructions.17.2 The nurse shall trace all catheters/administrationsets/add-on devices from the patient to the point of ori-gin before making additional connections of medicationsor tubing.17.3 The process of medication and product verifica-tion shall be established in organizational policies, pro-cedures, and/or practice guidelines.

Practice Criteria

A. The nurse should not use color coding, color differ-entiation, or color matching for product or medica-tion identification. Color coding can lead users torely on the color coding rather than ensuring a clearunderstanding of which tubing and catheters areconnected.1,2 (V)

B. Confusing labeling should be reported to the appro-priate department within the organization to allowfor process improvements and reporting to themanufacturer and appropriate state and federal reg-ulatory agencies.2 (V)

C. Unit-dose and premixed infusions are preferred toreduce compounding and labeling errors anddecrease medication errors.3 (V)

D. The nurse should recheck administration set/catheterconnections and trace all catheters/administrationsets/add-on devices from the patient to the point oforigin when a patient is transferred to a new settingand as part of the hand-off process.3-10(IV)

E. The nurse should instruct the patient, nonclinicalstaff, and caregivers to obtain assistance from clin-ical staff whenever there is a real or perceived needto connect or disconnect devices or infusions.5 (V)

F. The nurse should route tubing having different pur-poses in different directions (eg, IV catheters routed

toward the head; feeding tubes routed toward thefeet).11 (IV)

G. The nurse should avoid writing directly on the IV bagor use a marking pen to label the IV bag. There is thepossibility that certain chemical components of theinks used in marking pens may permeate the plasticsheeting and compromise the contained solution.Labeling in this manner may also lead to smearing, whichwould cause the labeling to be unrecognizable.1 (V)

REFERENCES

1. Phillips L. Manual of IV Therapeutics: Evidence-BasedApproach. 5th ed. Philadelphia, PA: FA Davis; 2010:237,268.

2. Hadaway L. Infusion therapy equipment. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:424-425.

3. Just S, Schepers G, Piotrowski MM, Saint S, Kauffman CA.Improving the safety of intravenous admixtures: lessons learnedfrom a Pentostam overdose. Jt Comm J Qual Patient Safety. 2006;32(7):366-372.

4. The Joint Commission announces the 2008 National patient safe-ty goals and requirements. Jt Comm Perspect. 2007;27(7):1,9-22.

5. The Joint Commission. Tubing misconnections: a persistent andpotentially deadly occurrence. 2005;36. http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_36.htm. Published April3, 2006. Accessed February 11, 2010.

6. Guenter P, Simmons D, Crowley J, et al. Enteral feeding miscon-nections: a consortium position statement. Jt Comm J QualPatient Safety. 2008;34(5):285-292.

7. Gallauresi B, Morrison A. Misconnections between medicaldevices with luer connectors: underrecognized but potentiallyfatal events in clinical practice. Safe Pract Patient Care. 2007;3(2).http://www.safe-practices.org/SafePractice8.pdf. Accessed May 23, 2009.

8. Institute for Safe Medication Practice. Problems persist with life-threatening tubing misconnections. ISMP Medication Safety Alert.2004; http://www.ismp.org/newsletters/acutecare/articles/20040617.asp. Published June 17, 2004. Accessed November 3, 2009.

9. WHO Collaborating Centre for Patient Safety Solutions.Avoiding catheter and tubing misconnections. 2007;1(7). http://www.ccforpatientsafety.org/fpdf/presskit/PSSolution7.pdf. AccessedJanuary 12, 2010.

10. US Food and Drug Administration. More patient deaths from luermisconnections. FDA Patient Safety News. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/transcript.cfm?show�68#5.Published October 2007. Accessed November 3, 2009.

11. American Nurses Association [position statement]. Safety IssuesRelated to Tubing and Catheter Misconnections. Silver Spring,MD: ANA; 2007.

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gluconate as a skin antiseptic, optimal selection ofcatheter site, and daily review of the necessity of aCVAD should be used to reduce risk of CLABSI.1-4

(II)B. The nurse should use a checklist at the time of

CVAD insertion to ensure compliance with steriletechnique and protocol. The nurse should beempowered to stop the insertion procedure if anystep(s) is/are not performed.1-3,5 (III)

C. Nurses should be involved in the organization’sinfusion-related infection prevention program andsurveillance for CLABSI. The goal is 0% infectionrate. A standard formula should be used to measurethe incidence of CLABSI (as shown below).2,4,6-8 (V)

Number of BSIs in patients with central lines � 1000 � CLABSI Rate

Total number of central line days

D. Infusion-related infection surveillance data shouldbe analyzed to serve as one component of a qual-ity improvement plan of action, and is currently amajor focus of patient safety initiatives relating tohealth care-associated infections.1,4,7,9,10 (V)

E. The nurse should reduce the manipulation of allthe components of the entire infusion system (eg,administration set junctions, catheter hub) to asfew as needed to deliver the infusion therapy.4,7 (V)

F. Infusion nurses should be represented in the organiza-tion’s infection prevention program and should partic-ipate in interdisciplinary collaboration and implemen-tation of infection prevention strategies.11,12 (V)

REFERENCES

1. Institute for Healthcare Improvement. Implement the central linebundle. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheCentralLineBundle.htm. Accessed February16, 2010.

2. Marschall J, Mermel LA, Classen D, et al. Strategies to preventcentral line-associated bloodstream infections in acute care hospi-tals. Infect Control Hosp Epidemiol. 2008;29(suppl):S22-S30.

18. INFECTION PREVENTION

Standard

18.1 Infection prevention and surveillance protocols shallbe in accordance with organizational policies, procedures,and/or practice guidelines and local, state, and federalrules and regulations.18.2 The nurse shall be competent in procedures to preventinfusion- and vascular/nonvascular access device-relatedinfections.18.3 Standard Precautions shall be used and appropri-ate personal protective equipment (PPE) shall be wornduring all infusion procedures that potentially exposethe nurse to blood and body fluids.18.4 Maximal sterile barrier precautions shall berequired for insertion of central vascular access devices(CVADs) and all methods of central vascular catheterexchange and repair.18.5 Appropriate hand hygiene shall be used.18.6 Single-patient-use items shall be used wheneverpossible and disposed of in the appropriate containerupon discontinuation of use.18.7 Morbidity and mortality rates associated with infec-tions shall be collected, reviewed, evaluated, and report-ed in compliance with state regulations as applicable.18.8 Quality improvement and monitoring programsshall include surveillance of infection prevention prac-tices to minimize health care-associated and community-acquired infections, and infection rates for central line-associated bloodstream infections (CLABSIs).18.9 The nurse shall educate the patient and caregiverabout procedures and actions to prevent infection andsigns and symptoms of infection to report to the healthcare provider.

Practice Criteria

A. Bundling of evidence-based interventions for CVADinsertion, such as hand hygiene, use of maximalsterile barrier precautions, use of chlorhexidine

Infection Prevention and Safety Compliance


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3. Pronovost P, Needham D, Berenholtz S, et al. An intervention todecrease catheter-related bloodstream infections in the ICU. NewEngl J Med. 2006;355(26):2725-2732.

4. McGoldrick M. Infection prevention and control. In: AlexanderM, Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:205-228.

5. Rhinehart E, McGoldrick M. Infection Control in Home Careand Hospice. 2nd ed. Boston, MA: Jones & Bartlett; 2006.

6. Centers for Disease Control and Prevention. National HealthcareSafety Network. Central line associated bloodstream (CLABSI) event.http://www.cdc.gov/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf.Accessed March 6, 2010.

7. The Joint Commission. Central line associated blood stream infec-tion (CLABSI). http://www.jointcommission.org/AccreditationPrograms/HomeCare/Standards/09_FAQs/NPSG/Healthcare_associated_infections. Accessed March 26, 2010.

8. US Department of Health and Human Services. Agency forHealthcare Research and Quality. On the cusp: stop bloodstreaminfections—resources. http://www.innovations.ahrq.gov/content.aspx?id=2685. Accessed March 26, 2010.

9. Centers for Disease Control and Prevention (CDC). Guidelines forhand hygiene in health-care settings. MMWR Morb Mort WklyRpt. 2002;51(RR-16):1-45.

10. US Pharmacopeia (USP). Revised General Chapter <797>Pharmaceutical Compounding: Sterile Preparations. USP 31-NF 26(suppl 2). The Pharmacists’ Pharmacopeia. 2nd ed. Rockville, MD;June 1, 2008.

11. Dunton N, Gajewski B, Klaus S, Pierson B. The relationship of nurs-ing workforce characteristics to patient outcomes. Online J IssuesNurs. 2007;12(3):7. http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume122007/No3Sept07/NursingWorkforceCharacteristics.aspx. Accessed January30, 2010.

12. Institute of Medicine. Keeping Patients Safe: Transforming the WorkEnvironment of Nurses. Washington, DC: National Academies Press;2004.

19. HAND HYGIENE

Standard

19.1 Hand hygiene shall be a routine practice establishedin organizational policies, procedures, and/or practiceguidelines.19.2 Hand hygiene shall be performed before and aftertouching a patient; before handling an invasive device;before moving from a contaminated body site to anothersite; before donning and after removing gloves; and aftercontact with inanimate objects in the immediate vicinity ofthe patient.19.3 The nurse shall not wear artificial nails when per-forming infusion therapy procedures.19.4 In cases in which the nurse’s hands are visibly contaminated with blood or body fluids or hands havebeen exposed to spore-producing pathogens, hand hygienewith either nonantiseptic or antiseptic (preferably antiseptic-containing) liquid soap and water shall be performed.

Practice Criteria

A. Alcohol-based hand rubs are preferred for routinehand hygiene unless hands are visibly soiled.1-4 (II)

B. Chosen hand hygiene products should providehigh efficiency with low potential for skin irrita-tion. Towelettes and non–alcohol-based handrubs should not be used for hand hygiene. Handhygiene products should be used according tomanufacturers’ directions for use.1-4 (V)

C. Proper hand hygiene should be taught to the patientand caregivers involved in care of the patient.1-4 (V)

D. Dispensers of liquid soap or antiseptic solutions arerecommended. Containers should be filled, discarded,and replaced according to organizational policies,procedures, and/or practice guidelines and should beaccessible at the point of care.1 (V)

E. Single-use soap scrub packets or waterless anti-septic products should be used when clean run-ning water is not ensured or is unavailable.1 (V)

F. The nurse should be involved with hand hygieneproduct evaluation to assess for product feel, fra-grance, and skin irritation. Nurses who have sensitiv-ity to a particular product should be provided withan alternative. Other products for skin care such asgloves, lotions, and moisturizers should be assessedfor compatibility with hand antisepsis products.5 (V)

G. Hand hygiene is a key component of a group of evidence-based interventions to promote better out-comes for patients with intravascular catheters.4,6 (V)

H. Artificial nails have been associated with trans-mission and outbreaks of infection.7-9 (IV)

REFERENCES

1. World Health Organization. WHO Guidelines on Hand Hygienein Health Care. Geneva, Switzerland:WHO; 2009.

2. Boyce JM. New insights for improving hand hygiene practices.Infect Control Hosp Epidemiol. 2004;25(3):187-188.

3. Registered Nurses’ Association of Ontario. Hand hygiene reviewpanel report: nursing best practices guideline program. http://www.rnao.org/Storage/19/1385_Hand_Hygiene_Review_Panel_Report.pdf. Published May 2006. Accessed June 3, 2010.

4. Institute for Healthcare Improvement. 5 Million Lives CampaignGetting Started Kit: Prevent Central Line Infections: How-toGuide. Cambridge, MA: IHI; 2008.

5. Miller C. Product selection and evaluation. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. St Louis, MO: Saunders/Elsevier;2010:437-446.


7. Gupta A, Della-Latta P, Todd B, et al. Outbreak of extended-spectrum beta-lactamase Klebsiella pneumoniae in a neonatalintensive care unit linked to artificial nails. Infect Control HospEpidemiol. 2004;25(3):210-215.



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8. Saiman L, Lerner A, Saal L, et al. Banning artificial nails fromhealth care settings. Am J Infect Control. 2002;30(4):252-254.

9. Toles A. Artificial nails: are they putting patients at risk? A reviewof the research. J Pediatr Oncol Nurs. 2002;19(5):164-171.

20. COMPOUNDING OF PARENTERAL SOLUTIONS AND MEDICATIONS

Standard

20.1 Compounding of parenteral solutions and medica-tions shall be in accordance with state and federal regu-lations and the American Society of Health-SystemPharmacists (ASHP) and United States Pharmacopoeia(USP) standards.20.2 The nurse shall perform compounding under thedirection of the pharmacy and shall adhere to com-pounding practices as defined in USP Chapter �797�.20.3 A list of medications that the nurse may compoundshall be developed in collaboration with or under thedirection of the pharmacy and shall be congruent withstandards set forth by regulatory agencies and by rules andregulations promulgated by the state’s Board of Nursing.20.4 Procedures for compounding sterile parenteralsolutions and medications shall be established in organi-zational policies, procedures, and/or practice guidelines.

Practice Criteria

A. Sterile preparations should be compounded in anappropriate environment as defined in USP Chapter�797�, state pharmacy rules and regulations, andASHP guidelines. The compounding environment isdefined by risk category.1-3 (V, Regulatory)

B. Immediate-use medication should be used within 1hour of preparation or discarded.1,2,4 (V, Regulatory)

C. Whenever possible, the nurse should administerpharmacy-prepared or commercially availableproducts.4,5 (V)

D. Access to the sterile compounding area should belimited to staff deemed competent to work in thisarea.1-3 (V, Regulatory)

E. The nurse should use appropriate technique towithdraw any sterile medications from glassampoules using a 5-micron filter needle or filterstraw. The filter needle/straw should be replacedwith a new sterile needle after the medication iswithdrawn from the ampoule, and both the topand bottom of the ampoule should be discardedin the sharps container.4,6 (V)

F. The nurse should label any multidose vials thatare used with the date opened, and the vialsshould be stored according to manufacturers’directions for use. Multidose vials should be usedfor single patients only; use of commercially pre-

pared sterile product, such as prefilled syringes orpharmacy-filled syringes, is strongly preferredwhen available. The vial must be discarded afterthe beyond-use date (BUD).4,5 (V)

G. The nurse should cleanse the tops of multidosevials and the neck of glass ampoules with 70%alcohol before inserting the needle or breaking theampoule.4-6 (V)

H. Cleaning procedures should be established to dis-infect and remove pyrogenic and endotoxic ingre-dients from work surfaces.1,2 (Regulatory)

I. Quality-control logs should be maintained to doc-ument all cleaning and calibration proceduresaccording to state and federal regulations, manufactur-ers’ directions for use, and ASHP and USP standardsand practice recommendations.1-3 (V, Regulatory)

J. Materials placed in the compounding area shouldbe limited to those essential for preparing thesolutions or medications.1-3 (V, Regulatory)

REFERENCES

1. US Pharmacopeia (USP). Revised General Chapter �797�

Pharmaceutical Compounding: Sterile Preparations. USP 31-NF 26(suppl2). The Pharmacists’ Pharmacopeia. 2nd ed. Rockville, MD: June 1, 2008.

2. Pharmaceutical compounding-sterile preparations (GeneralChapter <797>). In: The United States pharmacopeia, 27th rev.and The national formulary. 22nd ed. Rockville, MD: The UnitedStates Pharmacopeial Convention; 2004:2350-70.

3. American Society of Health-Systems Pharmacists. The ASHP discus-sion guide on USP chapter �797�: compounding sterile prepara-tions. http://www.ashp.org/s_ashp/docs/files/discguide797-2008.pdf. Accessed March 26, 2010.

4. Association for Professionals in Infection Control and Epidemiology[position paper]. Safe injection, infusion, and medication vial prac-tices in healthcare. http://www.apic.org/Content/NavigationMenu/GovernmentAdvocacy/PublicPolicyLibrary/SafeInjections_final.pdf. Published July 30, 2009. Accessed April 5, 2010.

5. Paparella S. The risks associated with the use of multidose vials.J Emerg Nurs. 2006;32(5):428-430.

6. Stein HG. Glass ampoules and filter needles: an example of imple-menting the sixth “R” in medication administration. MedsurgNurs. 2006;15:290-294.

21. SCISSORS

Standard

21.1 The use of scissors in the presence of vascular andnonvascular access devices shall be limited to sutureremoval and during the procedure of catheter repair.21.2 Scissors shall not be used to remove vascular andnonvascular access device dressings, tape, or stabiliza-tion devices due to the potential of severing the catheteror administration set and patient injury.21.3 Use of scissors shall be established in organization-al policies, procedures, and/or practice guidelines.



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Practice Criteria

A. Sterile, disposable scissors should be used forsuture removal and catheter repair; nondisposablescissors have been found to harbor bacteria andmay potentially contribute to transmission ofmicroorganisms.1-3 (IV)

B. Patient injuries and catheter damage related to theuse of scissors in the vicinity of the catheter anddressing have been reported.3,4 (V)

C. The use of scissors to alter the length of peripher-ally inserted central catheters (PICCs) was foundto result in rough, irregular surfaces and shouldbe avoided. The manufacturer’s directions for usefor altering the device length should be followedif the device requires trimming.5,6 (IV)

REFERENCES

1. Embil J, Zhanel G, Plourde P, Hoban D. Scissors: a potentialsource of nosocomial infection. Infect Control Hosp Epidemiol.2002;23(3):147-151.

2. Cleal B. Scissors: an infection risk? Emerg Nurse. 2006;14(8):22-24.3. Pennsylvania Patient Safety Authority. Snip-it safety. Patient Saf

Advis. 2004;1(4):1-3.4. Weinstein S, ed. Plumer’s Principles & Practice of Intravenous

Therapy. 8th ed. Philadelphia, PA: Lippincott Williams &Wilkins; 2007.

5. Parvez B, Parmar N, Chan AK. Trimming of peripherally insert-ed central venous catheters may increase the risk of thrombosis[letter to the editor]. Thromb Res. 2004;113(2):175-177.

6. Rutledge DN, Viele C. Insertion and care of peripherally insertedcentral catheters (PICCs) for intravenous infusions. Online J ClinInnovations. 2006; 9(2):1-73.

22. SAFE HANDLING AND DISPOSAL OF SHARPS, HAZARDOUS MATERIALS,AND HAZARDOUS WASTE

Standard

22.1 All blood-contaminated sharp items, including,but not limited to, needles or stylets, surgical blades,and syringes, shall be discarded in a nonpermeable,puncture-resistant, tamper-proof biohazard container.22.2 Sharps shall not be recapped, broken, or bent with-out use of a mechanical device or a one-handed technique.22.3 All biohazardous materials, wastes, and drugs shallbe discarded in the appropriate containers and disposedof according to local, state, and federal regulations.22.4 Sharps disposal containers shall be replaced beforethey are full to avoid disposal-related injuries.22.5 Devices that provide built-in safety controls shall beactivated during use and remain protective during disposal.22.6 Manufacturers’ directions for use, standards ofpractice, and state and federal regulations shall be

adhered to when developing organizational policies, pro-cedures, and/or practice guidelines pertaining to the safehandling of hazardous materials and hazardous waste.22.7 Protocols for safe handling of hazardous materialsand hazardous waste shall be established in organiza-tional policies, procedures, and/or practice guidelines.22.8 Exposure to potentially infectious materials or injuryfrom sharps should be identified, tracked, and analyzedfor trends per the organizational exposure control plan andin accordance with the Occupational Safety and HealthAdministration (OSHA) bloodborne pathogen standard.

Practice Criteria

A. Device components should be discarded as a singleunit after use.1-4 (V)

B. Primary prevention measures to reduce exposure tohazardous materials should include, but not be lim-ited to, the use of biological safety cabinets and per-sonal protective equipment (PPE—mask, gown,cap, drapes, gloves, and protective eyewear).1,2,5 (V)

C. All sharps should be accounted for before, during, andimmediately upon completion of a procedure.1,3,4,6 (V)

D. Nurses should be trained in the use of engineeredsharps safety mechanisms and how to properlyengage the safety mechanism.1-3,7 (V)

E. The nurse should be involved in the multidiscipli-nary team to develop, implement, and evaluate aplan to reduce needlestick injury.7,8 (Regulatory)

F. The nurse should advocate for passive safety-engineered devices for needlestick injury prevention.9(V)

REFERENCES

1. ECRI Institute. Preventing needlesticks and other sharps injuries.http://www.ecri.org/Products_and_Services/Products/Special_Reports/Sharps_Safety_and_Needlestick_Prevention.aspx. Accessed September21, 2005.


3. Jagger J, Perry J. Exposure safety: safeguarding sharps disposal.Nursing. 2000;30(10):26.

4. US Department of Labor. Occupational Safety and HealthAdministration. Disposal of contaminated needles and blood tubeholders used for phlebotomy. Washington, DC: OSHA; 2004.http://www.osha.gov/dts/shib/shib101503.html. Accessed August19, 2004.

5. NIOSH workplace solutions: Personal protective equipment forhealth care workers who work with hazardous drugs. Cincinnati,OH: DHHS (NIOSH) Publication No. 1009-106. http://www.cdc.gov/niosh/docs/wp-solutions/2009-106/default.html. AccessedAugust 6, 2010.

6. Occupational injury and wellness recording and reportingrequirements. Fed Regist. 2001;66(121):5319.

7. NIOSH Publication No. 2010-125: NIOSH Hazard Review:Occupational hazards in home healthcare. http:/www.cdc.gov/



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niosh/docs/2010-125/pdfs/2010-125.pdf. Published January 2010.Accessed May 5, 2010.

8. OSHA Bloodborne Pathogen Standard 29 CFR 1910.1030.Healthcare Wide Hazards Needlestick/Sharps Injuries. http://www.osha.gov/SLTC/etools/hospital/hazards/sharps/sharps.html#resheathingneedle. Published July 21, 2008. Accessed August 3, 2009.

9. Tossini W, Ciotti C, Goyer F, et al. Needlestick injury ratesaccording to different types of safety-engineered devices: resultsof a French multicenter study. Infect Control Hosp Epidemiol.2010;31(4):402-407.

23. DISINFECTION OF DURABLE MEDICAL EQUIPMENT

Standard

23.1 Durable medical equipment (DME) shall be cleanedto remove foreign material, followed by disinfection toeliminate microorganisms after each patient use.23.2 Cleaning and disinfection of DME shall be estab-lished in organizational policies, procedures, and/orpractice guidelines.23.3 Disinfection solutions shall be used in accordancewith equipment and manufacturers’ directions for useto prevent damage or alteration to the function or per-formance of the equipment.23.4 All cleaning solutions shall be cleared by the USFood and Drug Administration (FDA) and registeredwith the Environmental Protection Agency (EPA).

Practice Criteria

A. To prevent cross-contamination and transmission ofinfectious agents, cleaning and disinfection should beperformed prior to new patient use and at establishedintervals during long-term single-patient use.1-3 (I)

B. DME requiring cleaning and disinfection shouldinclude, but not be limited to, poles, flow-controldevices, ultrasound or infrared devices, and othernondisposable infusion-related equipment.1-3 (II)

C. Primary prevention measures to reduce exposureto disinfection solutions containing glutaralde-hyde, ortho-phthaldehyde, and other hazardouschemicals should include engineering controls,administrative controls, and personal protectiveequipment (PPE).1-3 (II)

D. DME removed from the home care setting shouldbe cleaned and disinfected before transporting toan appropriate site for terminal cleaning and disinfection.3,4 (V)

REFERENCES

1. Rutala W, Weber D; Healthcare Infection Control Practice AdvisoryCommittee (HICPAC). Guideline for disinfection and sterilization inhealthcare facilities. http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf. Accessed August 15, 2010.

2. Hadaway L. Infusion therapy equipment. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:391-436.

3. Siegel JD, Rhinehart E, Jackson M, Chiarello L; HealthcareInfection Control Practices Advisory Committee. 2007 guidelinefor isolation precautions: preventing transmission of infectiousagents in healthcare settings. http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf. Accessed August 15, 2010.

4. McGoldrick M, Rhinehart E. Managing multidrug-resistantorganisms in home care and hospice: surveillance, prevention,and control. Home Healthcare Nurse. 2007;25(9):580-586.

24. TRANSMISSION-BASED PRECAUTIONS

Standard

24.1 Transmission-based precautions shall be used toprevent transmission of infectious agents in health caresettings when the route(s) of transmission is/are notinterrupted using Standard Precautions alone.24.2 The use of transmission-based precautions shall beestablished in organizational policies, procedures,and/or practice guidelines.

Practice Criteria

A. Transmission-based precautions are implementedwhen strategies beyond Standard Precautions arerequired to reduce the risk for transmission of infec-tious agents (see Standard 18, Infection Prevention).1

(II)B. Transmission-based precautions are implemented

for patients with suspected or documented infectionor colonization with highly transmissible or epi-demiologically important pathogens for which addi-tional precautions are required to prevent diseasetransmission.1 (II)

C. Contact precautions are implemented to preventtransmission of infectious agents, including mul-tidrug-resistant organisms, which are spread bydirect or indirect contact with the patient or theenvironment, including when there are excessivebodily discharges such as wound drainage.1,2 (II)

D. Droplet precautions are implemented to preventtransmission of pathogens spread through close respi-ratory or mucous membrane contact with respiratorysecretions.1 (II)

E. Airborne precautions are implemented to preventtransmission of infectious agents that remain infectiouswhen suspended in the air over long distances.1 (II)

F. Guidelines for transmission-based precautionsshould be adapted and applied as appropriate fornon–acute care settings, including long-term carefacilities, the home care setting, and other work-places where infusion therapy is provided.1 (V)



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G. In ambulatory and home care settings, StandardPrecautions are followed for patients with multidrug-resistant organisms (MDROs).1,3 (V)

H. In home care settings for patients with MDROs,reusable patient care equipment should be limitedand left in the home until discharged, and disin-fected before removing from the home in a con-tainer (eg, plastic bag) or transported to an appro-priate site for cleaning and disinfection.1,3 (V)

REFERENCES

1. Siegel JD, Rhinehart E, Jackson M, Chiarello L; HealthcareInfection Control Practices Advisory Committee. Guideline forisolation precautions: preventing transmission of infectiousagents in healthcare settings. http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf. Published 2007. AccessedFebruary 12, 2010.

2. Siegel JD, Rhinehart E, Jackson M, and the Healthcare InfectionControl Practices Advisory Committee. Management of multi-drug-resistant organisms in healthcare settings. http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf. Published 2006.Accessed February 12, 2010.

3. McGoldrick M, Rhinehart E. Managing multidrug-resistant organ-isms in home care and hospice: surveillance, prevention, and control.Home Healthcare Nurse. 2007;25(9):580-586.

25. LATEX SENSITIVITY ORALLERGY

Standard

25.1 Exposure to latex in the health care environmentshall be minimized.25.2 Latex-free personal protective equipment (PPE) shallbe provided to latex-sensitive or latex-allergic individuals.25.3 Latex-free supplies and equipment shall be usedwith patients at risk for latex sensitization and thosewith known latex allergy.

Practice Criteria

A. The nurse should review the label on medicaldevices for the presence of latex, which is a com-ponent of product labeling required by the USFood and Drug Administration (FDA).1,2 (V)

B. Powdered gloves made of natural rubber latexshould be eliminated from the health care envi-ronment as they are associated with the greatestrisk of sensitization and subsequent allergic reac-tions in individuals. Low-protein, powder-freelatex gloves, or gloves made of nonlatex materi-als, such as neoprene or polyisophrene, willreduce exposure.3-6 (IV)

C. The nurse should assess all patients for history ofasthma, environmental allergens, medications,

and food allergies. Allergies that may create cross-reactions with latex include, but are not limited to,avocados, mangoes, pears, bananas, citrus fruits,chestnuts, and other tropical foods.7,8 (II)

D. The nurse should have knowledge of evolvingguidelines about preventing allergic reactions fromthe Centers for Disease Control and Prevention(CDC) and the Occupational Safety and HealthAdministration (OSHA).6,9,10 (Regulatory)

E. Staff and patient education programs should bedeveloped to aid in risk reduction.5,9,11 (IV)

F. Latex allergy in patients should be documented inthe patient’s permanent medical record with ade-quate patient education about avoiding futureexposure and management of an anaphylacticreaction.7-9 (IV)

G. Latex allergy in health care workers and patientsshould be reported to the appropriate depart-ments within the organization per organizationalpolicies, procedures, and/or practice guidelines.Latex allergy in health care workers should berecorded and reported according to OSHArequirements.5,9,12 (IV, Regulatory)

REFERENCES

1. US Food and Drug Administration. CFR 21: Medical Devices—Labeling. In: Center for Devices and Radiological Health, F, 8thed. Rockville, MD: FDA; 2009.

2. Emergency Nurses Association [position statement]. LatexAllergy. Des Plaines, IL: ENA; 2005.

3. Smith AM, Amin HS, Biagini RE, et al. Percutaneous reactivity tonatural rubber latex proteins persists in health-care workers fol-lowing avoidance of natural rubber latex. Clin Exp Allergy. 2007;37(9):1349-1356.

4. Brown RH, McAllister MA, Gundlach AM, Hamilton RG. Thefinal steps in converting a health care organization to a latex-safeenvironment. Jt Comm J Qual Patient Saf. 2009;35(4):224-228.

5. Ranta PM, Ownby DR. A review of natural-rubber latex allergyin health care workers. Clin Infect Dis. 2004;38(2):252-256.

6. Brown RH, Taenkhum K, Buckley TJ, Hamilton RG. Differentlatex aeroallergen size distributions between powdered surgicaland examination gloves: significance for environmental avoid-ance. J Allergy Clin Immunol. 2004;114(2):358-363.

7. Hepner DL, Castells MC. Latex allergy: an update. Anesth Analg.2003;96(4):1219-1229.

8. Reines HD, Seifert PC. Patient safety: latex allergy. Surg ClinNorth Am. 2005;85(6):1329-10, xiv.

9. Zucker-Pinchoff B, Stadtmauer GJ. Latex allergy. Mt Sinai J Med.2002;69(1-2):88-95.

10. National Institute for Occupational Safety and Health.Occupational latex allergies. NIOSH Safety and Health Topic.Atlanta, GA: Centers for Disease Control and Prevention; 2008.

11. Lankshear A, Lowson K, Harden J, Lowson P, Saxby RC.Making patients safer: nurses’ responses to patient safety alerts. JAdv Nurs. 2008;63(6):567-575.

12. Occupational Safety and Health Administration. Revision toOSHA’s Bloodborne Pathogens. Standard Technical Backgroundand Summary. Washington, DC: OSHA; 2001.



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clean devices prior to access are unresolved. Theaccess port should be accessed only with steriledevices.6,7 (V)

F. The nurse should change the add-on device withthe catheter, with each administration set replace-ment, or as defined by the organization, andwhenever the integrity of the product is compro-mised or suspected of being compromised.1 (V)

G. The use of stopcocks is not recommended due tothe increased risk of infection. When a stopcock isattached as an add-on device, the nurse shouldattach sterile caps to the ports of the stopcock toprovide a closed system when not in use andaccess sites that will allow cleaning prior toaccessing.1 (V)

REFERENCES

1. Hadaway L. Infusion therapy equipment. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R. eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:391-436.

2. The Joint Commission. Tubing misconnections: a persistent andpotentially deadly occurrence. Joint Commission Sentinel EventAlert. http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_36.htm. Accessed December 5, 2009.

3. US Food and Drug Administration. 2009 medical device safetycalendar on luer misconnections. http://www.fda.gov/medicalde-vices/Safety/AlertsandNotices/ucm134863.htm. Accessed July 8,2009.

4. Institute for Safe Medication Practices (ISMP). Problems persistwith life-threatening tubing misconnections. Medication SafAlert! June 17, 2004.

5. American Nurses Association [position paper]. Safety Issues Relatedto Tubing & Catheter Misconnections. http://www.nursingworld.org/position/practice/tube.aspx. Accessed February 13, 2010.

6. Kaler W, Chinn R. Successful disinfection of needleless mechani-cal valve access ports: a matter of time and friction. J AssocVascular Access. 2007;12(3):140-142.

7. Marschall J, Mermel L, Classen D, et al. Compendium of strategiesto prevent central line-associated bloodstream infections in acute carehospitals. Infect Control Hosp Epidemiol. 2008;29(S1):S22-S30.

26. ADD-ON DEVICES

Standard

26.1 The use of add-on devices shall be established inorganizational policies, procedures, and/or practiceguidelines and according to manufacturers’ directions foruse.26.2 The nurse shall be competent in the use of theadd-on device and shall be knowledgeable about therisk of misconnection and potential disconnections.26.3 All add-on devices shall be of luer-lock design toensure a secure junction.

Practice Criteria

A. Add-on devices may include, but are not limited to,stopcocks, single- and multilumen extension sets,manifold sets, extension loops, solid cannula caps,needleless systems, in-line filters, and manual flow-control devices.1 (V)

B. All add-on devices should be compatible with theadministration system to prevent the risk of leaks,disconnections, or misconnections.2,3 (V)

C. The nurse should be aware that the potential forcontamination exists with all add-on devices. Inan effort to decrease the risk of contamination,the number of manipulation episodes, accidentaldisconnections or misconnections, and costs,there should be limited use of these devices.1 (V)

D. To determine the appropriate placement of theselected add-on device, the nurse should trace theadministration set from the patient to the point oforigin before attaching the device.2,4,5 (IV)

E. The nurse should disinfect the ports of the add-ondevice using friction, with an appropriate disin-fectant such as 70% alcohol before accessing.Specific guidelines directing the appropriate tech-nique, disinfectant, or amount of time required to

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27. NEEDLELESS CONNECTORS

Standard

27.1 The use of needleless connectors shall be established inorganizational policies, procedures, and/or practice guide-lines and according to manufacturers’ directions for use.27.2 Needleless connectors attached to a catheter hubor access site shall be of luer-lock design to ensure asecure junction.27.3 The nurse shall be competent in the use of needle-less connector devices.27.4 The nurse shall disinfect the needleless connectorprior to each access.27.5 Needles shall not be used to access catheters, admin-istration sets, access sites, or needleless connectors.

Practice Criteria

A. The nurse should be aware that needleless con-nectors are identified by design (simple and com-plex) and function. The simple needleless connec-tor group includes the split-septum design with nointernal mechanisms, a straight fluid pathway,and can be blunt cannula or luer-lock design. Thecomplex needleless connector group includes avariety of luer-lock mechanical valve needlelessconnector with various internal mechanismdesigns and fluid pathways.1-5 (IV)

B. The nurse should be knowledgeable about thefunction of the needleless connector and the man-ufacturer’s directions for use for each needlelessconnector to reduce the risk of blood reflux intothe catheter tip upon disconnection. Currently,there are 3 categories of needleless connectorfunction: negative fluid displacement, positivefluid displacement, and neutral design.2-11 (II)

C. The nurse should be aware that the catheter hubis a known source for the development ofcatheter-related bloodstream infection (CR-BSI)and that needleless connectors are recognized sitesfor microbial contamination.5,10,12-26 (II)

D. The nurse should be aware of and implement manufacturers’ directions for use, implementappropriate infection prevention practices, andreview the research and published literature relat-ed to this issue to promote and provide qualitypatient outcomes.2,4-8,10,14-18,20,21,27-36 (II)

E. The needleless connector should be consistentlyand thoroughly disinfected using alcohol, tinctureof iodine, or chlorhexidine gluconate/alcoholcombination prior to each access. The optimaltechnique or disinfection time frame has not beenidentified.3,5,9,12,13,15-17,19,22-25,27,29,31,32,37-41 (III)

F. The nurse should change the needleless connectorin the following circumstances: if the needleless

connector is removed for any reason; if there isblood or debris within the needleless connector;prior to drawing a blood culture sample from thecatheter; upon contamination; per organizationalpolicies, procedures, and/or practice guidelines; orper the manufacturer’s directions for use. Thenurse should be knowledgeable about the manu-facturer’s directions for use and other device per-formance criteria to assist in the development ofpolicies and procedures for needleless connectorchange frequency. The optimal time frame forchanging the needleless connector has not beendetermined (see Standard 49, Infection).7,8,22,37,42-46

(IV)

REFERENCES

1. Gorski L, Perucca R, Hunter M. Central venous access devices:care, maintenance, and potential complications. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:495-515.

2. Hadaway L, Richardson D. Needleless connectors: a primer onterminology. J Infus Nurs. 2010;33(1):1-11.

3. Yebenes J, Delgado M, Sauca G, et al. Efficacy of three differentvalve systems of needle-free closed connectors in avoiding accessof microorganisms to endovascular catheters after incorrect han-dling. Crit Care Med. 2008;36(9):2558-2561.

4. Rupp M, Sholtz L, Jourdan D, et al. Outbreak of bloodstreaminfection temporally associated with the use of an intravascularneedleless valve. Clin Infect Dis. 2007;44:1408-1414.

5. Safdar N, Maki D. Lost in translation [editorial]. Infect ControlHosp Epidemiol. 2006;27(1):3-7.

6. Jasinsky L, Wurster J. Occlusion reduction and heparin elimina-tion trial using an antireflux device on peripheral and centralvenous catheters. J Infus Nurs. 2009;32(1):33-39.

7. Khalidi N, Kovacevich D, Papke-O’Donnell L, Btaiche I. Impactof the positive pressure valve on vascular access device occlusionsand bloodstream infections. J Assoc Vascular Access. 2009;14(2):84-91.

8. Association for Professionals in Infection Control andEpidemiology (APIC). Guide to the Elimination of Catheter-relatedBloodstream Infections. Washington, DC: APIC; 2009.

9. ECRI Institute. Needleless connectors. Health Devices. 2008;37(9):261-283.

10. Blake M. Update: catheter-related bloodstream infection rates inrelation to clinical practice and needleless device type. Can JInfect Control. 2008;23(3):156-160, 162.

11. Jacobs BR, Schilling S, Doellman D, et al. Central venous catheterocclusion: a prospective, controlled trial examining the impact ofa positive pressure valve device. J Parenter Enteral Nutr. 2004;28:113-118.

12. Ivy D, Calderbank M, Wagner B, et al. Closed-hub systems withprotected connections and the reduction of risk of catheter-relat-ed bloodstream infection in pediatric patients receiving intra-venous prostanoid therapy for pulmonary hypertension. InfectControl Hosp Epidemiol. 2009;30(9):823-829.

13. Buchman AL, Spapperi J, Leopold P. A new central venouscatheter cap: decreased microbial growth and risk for catheter-related bloodstream infection. J Vascular Access. 2009; 10(1):11-21.



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14. Jarvis W, Murphy C, Hall K, et al. Health-care associated blood-stream infections with negative- or positive-pressure or displace-ment mechanical valve needleless connectors. Clin Infect Dis.2009;49:1821-1827.

15. Soothill J, Braver K, Ho A, et al. A fall in bloodstream infectionsfollowed a change to 2% chlorhexidine in 70% isopropanol forcatheter connection antisepsis: a pediatric single center before/afterstudy on a hematopoietic stem cell transplant ward. Am J InfectControl. 2009;37(8):626-630.

16. Field K, McFarlane C, Cheng A, et al. Incidence of catheter-relatedbloodstream infection among patients with a needleless, mechanicalvalve-based intravenous connector in an Australian/hematology-oncology unit. Infect Control Hosp Epidemiol. 2007;28(5):610-613.

17. Menyhay S, Maki D. Disinfection of needleless catheter connec-tions and access ports with alcohol may not prevent microbialentry: the promise of a novel antiseptic-barrier cap. Infect ControlHosp Epidemiol. 2006;27(1):23-27.

18. Adams D, Karpanen T, Worthington T, et al. Infection risk asso-ciated with a closed leur access device J Hosp Infect. 2006;62(3):353-357.

19. Leon C, Alvarez-Lerma F, Ruiz-Santana S, et al. Antiseptic chamber-containing hub reduces central venous catheter-related infection:a prospective, randomized study. Crit Care Med. 2003;31(5):1318-1324.

20. Seymour VM, Dhallu TS, Moss HA, et al. A prospective clinicalstudy to investigate the microbial contamination of a needlelessconnector. J Hosp Infect. 2000;45(2):165-168.

21. Donlan RM, Murga R, Bell M, et al. Protocol for detection ofbiofilms on needleless connectors attached to central venouscatheters. J Clin Microbiol. 2001;39(2):750-753.

22. Do A, Ray B, Banerjee S, et al. Bloodstream infection associated withneedleless device use and the importance of infection-control prac-tices in the home health care setting. J Infect Dis. 1999;179:442-448.

23. Arduino M, Bland L, Danzig L, et al. Microbiologic evaluation ofneedleless and needle-access devices. Am J Infect Control. 1997;25(5):377-380.

24. Segura M, Alvarez-Lerma F, Tellado J, et al. A clinical trial on theprevention of catheter-related sepsis using a new hub model. AnnSurg. 1996;223(4):363-369.

25. Randolph A, Cook, D. Antiseptic hub connectors reduce centralvenous catheter-related sepsis. Crit Care Med. 1999;27(1)(suppl):141A.

26. Murga R, Miller JM, Donlan RM. Biofilm formation by gramnegative bacteria on central venous catheter connectors: effect ofconditioning films in a laboratory model. J Clin Microbiol. 2001;39(6):2294-2297.

27. Mermel L, Allon M, Bouza E, et al. Clinical practice guidelinesfor the diagnosis and management of intravascular catheter-relat-ed infection: 2009 update. Clin Infect Dis. 2009;49:1-45.

28. Hadaway L. Infusion therapy equipment. In: Alexander M, CorriganA, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: AnEvidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;2010:391-436.

29. Marschall J, Mermel L, Classen D, et al. Compendium of strate-gies to prevent central line-associated bloodstream infections inacute care hospitals: SHEA/IDSA practice recommendations. Infect Control Hosp Epidemiol. 2008;29(1):522-530.

30. Cherneck C, Macklin D, Casella L, Jarvis E. Caring for patientswith cancer through nursing knowledge of IV connectors. Clin JOncol Nurs. 2009;13(6):630-633.

31. Casey AL, Worthington T, Lambert PA, et al. A randomized,prospective clinical trial to assess the potential risk associated

with the PosiFlow needleless connector. J Hosp Infect. 2003;54(4):288-293.

32. Casey AL, Burnell S, Whinn H, et al. A prospective clinical trialto evaluate the microbial barrier of a needleless connector. J Hosp Infect. 2007;65(3):212-218.

33. Salgado C, Chinnes L, Paczesny T, Cantey, R. Increased rate ofcatheter-related bloodstream infection associated with use of aneedleless mechanical valve device at a long-term acute care hos-pital. Infect Control Hosp Epidemiol. 2007;8(6):684-688.

34. Jarvis WR. Choosing the best design for intravenous needlelessconnectors to prevent bloodstream infections. Infect ControlToday. http://www.infectioncontroltoday.com. Published July2010. Accessed August 5, 2010.

35. US Food and Drug Administration. Letter to infection control prac-titioners regarding positive displacement needleless connectors.http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm220459.htm. Accessed August 5, 2010.

36. Guerin K, Wagner J, Rains K, Bessesen M. Reduction in centralline-associated bloodstream infections by implementation of apostinsertion care bundle. Am J Infect Control. 2010;28(6):430-433.

37. Mathew A, Gaslin T, Dunning K, Ying, J. Central catheter bloodsampling: the impact of changing the needleless caps prior to col-lection. J Infus Nurs. 2009;32(4):212-218.

38. Kaler W, Chinn R. Successful disinfection of needleless accessports: a matter of time and friction. J Assoc Vascular Access. 2007;12(3):140-142.

39. Horvath B, Norville R, Lee D, et al. Reducing central venouscatheter-related bloodstream infections in children with cancer.Oncol Nurs Forum. 2009;36(2):232-238.

40. Zack J. Zeroing in on zero tolerance for central line-associatedbacteremia. Am J Infect Control. 2008;36(10):s176.e1-s176.e2.

41. Doellman D, Pettit J, Catudal P, Buckner J, Burns D, Frey AM.Association for Vascular Access. Best Practice Guidelines in theCare and Maintenance of Pediatric Central Venous Catheters.PEDIVAN; 2010.


43. Toscano C, Bell M, Zukerman C, et al. Gram-negative blood-stream infections in hematopoietic stem cell transplant patients:the roles of needleless device use, bathing practices, and cathetercare. Am J Infect Control. 2009;37(4):327-334.

44. Yebenes JC, Serra-Prat M. Clinical use of disinfectable needle-freeconnectors. Am J Infect Control. 2008;36(10):S175e1-S175e4.

45. Sharp MK, Mohammed SF. Hemolysis in needleless connectorsfor phlebotomy. J Am Soc Artif Intern Organs (ASAIO). 2003;49(1):128-130.

46. Sheretz R, Karchmer T, Ohl C, Palavecino E, Bischoff W. Bloodcultures (BC) drawn through valved catheter hubs have a 10-20%positivity rate with the majority being false positives. Paper pre-sented at: Fifth Decennial International Conference on Healthcare-Associated Infections; March 18-22, 2010; Atlanta, GA.

28. FILTERS

Standard

28.1 The use of bacteria- and particulate-retentive, air-eliminating, and blood and blood component filters



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shall be established in organizational policies, proce-dures, and/or practice guidelines.28.2 For nonlipid-containing solutions that require fil-tration, a 0.2-micron filter containing a membrane thatis particulate-retentive and air-eliminating shall be used.28.3 For lipid infusions or total nutrient admixtures thatrequire filtration, a 1.2-micron filter containing a membranethat is particulate-retentive and air-eliminating shall be used.28.4 Blood and blood component filters appropriate tothe therapy shall be used to reduce particulate matter,microaggregates, or leukocytes in infusions of blood orblood components.28.5 For intraspinal infusions, a 0.2-micron filter thatis surfactant-free, particulate-retentive, and air-elimi-nating shall be used.28.6 A blunted filter needle or filter straw shall be usedwhen drawing medications from glass ampoules.

Practice Criteria

A. Use of all filters should adhere to manufacturers’directions for use and filtration requirements ofthe therapy.1 (V)

B. Bacteria- and particulate-retentive and air-elimi-nating membrane filter changes should coincidewith administration set changes.2 (V)

C. Blood and blood component filters should bechanged every 4 hours or coincide with bloodadministration set changes.3 (V)

D. Add-on bacteria- and particulate-retentive and air-eliminating membrane filters should be locatedas close to the catheter insertion site as possible.2 (V)

E. When an electronic infusion device is used, con-sideration should be given to the pounds persquare inch (psi) rating of the filter.1,2,4 (V)

REFERENCES


2. Principles and use of intravenous equipment for infusion therapy.In: Weinstein S, ed. Plumer’s Principles & Practice of IntravenousTherapy. 8th ed. Philadelphia, PA: Lippincott Williams &Wilkins; 2007;45:193-230, 563.

3. AABB. Technical Manual. 16th ed. Bethesda, MD: AABB; 2008:618-621.

4. Phillips LD. Manual of I.V. Therapeutics. 5th ed. Philadelphia,PA: FA Davis; 2010:253.

29. FLOW-CONTROL DEVICES

Standard

29.1 The type of flow-control device selected shallbe based on patient age, condition, prescribed infu-

sion therapy, type of vascular access device, and caresetting.29.2 Only electronic infusion devices with administra-tion-set–based anti–free-flow mechanisms shall beused.29.3 Dose-error reduction systems shall be consideredin the selection and use of electronic infusion devices.29.4 The use of flow-control devices shall be estab-lished in organizational policies, procedures, and/or practiceguidelines.29.5 The nurse shall be competent in the use of flow-control devices, including manual devices, mechanicaldevices, and electronic infusion devices.

Practice Criteria

A. Flow-control devices should be monitored duringthe administration of infusion therapy to ensureaccurate delivery of the prescribed infusion rate.1-6

(III)B. The nurse should not rely on the electronic infu-

sion device alarms to detect IV infiltration orextravasation as these alarms are not intended todetect disruption of the fluid flow pathway.6-8 (V)

C. Safety features and dose-error reduction systemsshould be considered in the selection of all electronicflow-control devices. The nurse should be involvedin the evaluation and selection of flow-controldevices.9-15 (V)

D. Systematic methods, such as failure mode andeffects analysis (FMEA) or Six Sigma, should beincorporated into the evaluation of flow-controldevice selection and used to reduce errors andenhance safety. In addition, adverse event reports(such as those from the US Food and DrugAdministration’s Manufacturer and User FacilityDevice Experience site) should be consulted whenconsidering mechanical and electronic flow-con-trol devices for purchase.12-14,16 (V)

E. The frequency of inspection, cleaning, testing, andmaintenance of electronic flow-control devicesshould adhere to manufacturers’ direction(s) for useand directions and guidelines established by regulato-ry agencies.10,11,17,18 (V)

F. The choice of a flow-control device (manual flowregulators, pressure bags, mechanical pumps, elas-tomeric balloon pumps, spring-based pumps, negative-pressure pumps, electronic infusion pumps) for agiven clinical application should take into accountsuch factors as age and mobility of the patient,severity of illness, type of therapy, and health caresetting. Features should be consistent with recom-mendations for safe and effective use. Additionalfeatures are recommended for patient-controlledanalgesia (PCA) pumps (eg, patient ease of use,accuracy) and systems that require a higher pump-ing pressure (eg, arterial and epidural lines).11,17(V)



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G. Patient education for those using electronic flow-control devices in the home care setting shouldinclude written instructions, troubleshooting guides,whom/how to contact for assistance, signs of under-or over-infusion, and pump malfunction. Educationshould include demonstration and explanation ofinfusion pump functions followed by observation ofthe patient/caregiver performance.19,20 (V)

REFERENCES

1. Rosenthal K. Smart pumps help crack the safety code. NursManag. 2004;35(5):49-51.

2. Hertzel C, Sousa VD. Use of smart pumps for preventing medica-tion errors. J Infus Nurs. 2009;32(5):257-267.

3. Murdoch LJ, Cameron VL. Smart infusion technology: a mini-mum safety standard for intensive care? Br J Surg.2008;17(10):630-636.

4. Rothschild JM, Keohane CA, Cook EF, et al. A controlled trial ofsmart infusion pumps to improve medication safety in critically illpatients. Crit Care Med. 2005;33(3):679-680.

5. Institute for Healthcare Improvement. Reduce adverse drugevents (ADEs) involving intravenous medications: implementsmart infusion pumps. www.IHI.org. Accessed March 26, 2010.

6. Ilan R, Fowler FA, Ferguson ND, et al. Prolonged time to alarmin infusion devices operated at low flow rates. Crit Care Med.2008;36(10):2763-2765.

7. Pennsylvania Patient Safety Reporting System. IV infiltration: bealarmed even when your infusion pump isn’t. Patient SafAdvisory. 2007;4(3):1-4.

8. Huber C. IV infusion alarms: don’t wait for the beep. Am J Nurs.2009;109(4):32-33.

9. Bowcutt M, Rosenkoetter MM, Chernecky CC, Wall J, Wynn D,Serrano C. Implementation of an intravenous medication infusionpump system: implications for nursing. J Nurs Manage. 2008;16:188-197.

10. ECRI Institute. Large volume infusion pumps. Health Devices.http//www.ecri.org. Published December 2009. Accessed March15, 2010.

11. ECRI Institute. ECRI Institute’s infusion pump criteria. HealthDevices. http//www.ecri.org. Published February 2008. AccessedMarch 15, 2010.

12. Nemeth C, Nunnally M, Bitan Y, Nunnally S, Cook RI. Betweenchoice and chance: the role of human factors in acute care equip-ment decisions. Patient Saf. 2009;5(2):114-121.

13. Adachi W, Lodolce AE. Use of failure mode and effects analysisin improving the safety of I.V. drug administration. Am J Health-Syst Pharm. 2005;62(9):917-920.

14. Christopher DA, Campbell A, Dateshidze J. Working smarter withintelligent pumps. Pharm Solutions. http//www.nursingmanagement.com. Published November 2008. Accessed February 22, 2010.

15. Rothschild JM, Keohane CA, Cook EF, et al. A controlled trial ofsmart infusion pumps to improve medication safety in critically illpatients. Crit Care Med. 2005;33(3):533-540.

16. US Food and Drug Administration. Manufacturer and user facilitydevice experience (MAUDE). http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfMAUDE/search.CFM. Accessed December 30, 2009.

17. Perucca R. Infusion therapy equipment: types of infusion therapyequipment. In: Alexander M, Corrigan A, Gorski L, Hankins J,Perucca R, eds. Infusion Nursing: An Evidence-Based Approach.3rd ed. St Louis, MO: Saunders/Elsevier, 2010:411-418.

18. Rutala W, Weber D. Healthcare Infection Control PracticeAdvisory Committee (HICPAC). Guideline for Disinfection andSterilization in Healthcare Facilities, 2008. http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_Nov_2008.pdf.Accessed December 5, 2009.

19. US Food and Drug Administration. Infusion pump risk reductionstrategies for home health nurses. http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/InfusionPumps/ucm205411.htm. Published April 22,2010. Accessed June 1, 2010.

20. Gorski LA. Pocket Guide to Home Infusion Therapy. Boston,MA: Jones & Bartlett, 2005.

30. BLOOD AND FLUID WARMERS

Standard

30.1 The use of blood and fluid warmers shall be estab-lished in organizational policies, procedures, and/or prac-tice guidelines and in accordance with AABB standardsfor administration of blood.30.2 Blood and fluid warming shall be performed onlywith devices specifically designed for that purpose.30.3 Blood shall be warmed in a manner to avoidhemolysis.

Practice Criteria

A. Blood and fluid warmers should be used whenwarranted by patient history, clinical condition,and prescribed therapy, including, but not limited to,avoiding or treating hypothermia, during car-diopulmonary bypass, when the patient is knownto have cold agglutinins, or during replacement oflarge blood volumes.1-5 (III)

B. The frequency of cleaning and preventive mainte-nance of blood and fluid warming devices shouldadhere to the manufacturer’s directions for use andguidelines established by regulatory agencies.1,4,5

(V)C. Nurses should use blood and fluid warmers

equipped with warning systems, including an audi-ble alarm and visual temperature gauges.6-8 (V)

D. Other warming methods, including, but not lim-ited to, microwave ovens, hot water baths, anddevices not expressly designed for blood andfluid warming, should not be used because tem-peratures and infection risks cannot be con-trolled.9-11 (V)

REFERENCES

1. AABB. Standards for Blood Banks and Transfusion Services. 26thedition. Bethesda, MD: AABB; 2009.

2. ECRI Institute. Suggested guidelines for blood warmer use.http://www.mdsr.ecri.org/summary/detail.aspx?doc_id/8269.Accessed January 11, 2010.



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3. Hasankhani H, Mohammadi E, Moazzami F, Mokhtari M,Naghgizadh MM. The effects of intravenous fluids temperatureon perioperative hemodynamic situation, post-operative shiver-ing, and recovery in orthopaedic surgery. Can Oper Room NursJ. 2007;25(1):20-27.

4. Stainsby D, MacLennan S, Hamilton PJ. Management of massiveblood loss: a template guideline. Br J Anaesth. 2000;85:487-491.

5. US Food and Drug Administration. CFR Title 21. Hematologyand Pathology Devices. Blood and plasma warming devices(864.9205). http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCFR/CFRSearch.cfm?FR=864.9205. Accessed January 11,2010.

6. Stammers AH, Murdock JD, Klayman MH, et al. Utilization ofrapid-infuser devices for massive blood loss. Perfusion. 2005;2:65-69.

7. ASTM Standard F217-02 (2009), “Standard Specification forBlood/Intravenous Fluid/Irrigation Fluid Warmers,” ASTMInternational, West Conshohocken, PA, 2009. www.astm.org.Accessed January 22, 2010.

8. Avula RR, Kramer R, Smith CE. Air detection performance of theLevel 1 H-1200 fluid and blood warmer. Anesth Analog. 2005;101:1413-1416.

9. McEwen MP, Roxby D. Can latent heat safely warm blood? In vitrotesting of a portable prototype blood warmer. BMC Emerg Med.2007;7(8). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1988795/.Accessed April 5, 2010.

10. Riley W. BelmontTM hyperthermia pump in the conduct of intra-operative heated chemotherapy. Perfusion. 2009;24:115-118.

11. Trick N. Blood component therapy. In: Alexander M, CorriganA, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: AnEvidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:249-253.

31. TOURNIQUETS

Standard

31.1 A tourniquet shall be properly applied to promotevascular distension in preparation for peripheralvenipuncture.31.2 The use of tourniquets shall be established in orga-nizational policies, procedures, and/or practice guidelines.

Practice Criteria

A. The tourniquet should be single-patient use.1-8 (IV)B. The nurse should assess the patient for latex aller-

gy when considering tourniquet material (seeStandard 25, Latex Sensitivity or Allergy).9,10 (V)

C. The tourniquet should be applied at an appropriatelocation above the selected venipuncture site.8,11,12 (V)

D. An arterial pulse should be easily palpable distalto the tourniquet location.8,11,12 (I A/P)

E. The tourniquet should be applied in such a man-ner as to prevent circulatory impairment. 8,11,12

(I A/P)F. The nurse should assess for factors indicating that

a tourniquet should be loosely applied or its useavoided in patients who bruise easily, are at riskfor bleeding, have compromised circulation,and/or have fragile skin or veins.11-13 (V)

REFERENCES

1. Franklin GF, Bal AM, McKenzie H. Phlebotomy tourniquets andMRSA. J Hosp Infect. 2007;65:173-184.

2. Fellowes C, Kerstein R, Azadian B. Breaking the cycle. J HospInfect. 2007;65:279-280.

3. Leitch A, McCormick I, Gunn I, Gillespie T. Reducing the poten-tial for phlebotomy tourniquets to act as a reservoir for methicillin-resistant Staphylococcus aureus. J Hosp Infection. 2006;63(4):428-431.

4. Sacar S, Turgut H, Kaleli I, et al. Poor hospital infection controlpractice in hand hygiene, glove utilization, and usage of tourni-quets. Am J Infect Control. 2006;34(9):606-609.

5. Fellowes C, Kerstein R, Clark J, Azadian BS. MRSA on tourni-quets and keyboards. J Hosp Infect. 2006;64(1):86-88.

6. Rourke C, Bates C, Read RC. Poor infection control practice invenipuncture and use of tourniquets. J Hosp Infect. 2001;49(1):59-61.

7. Golder M, Chan CLH, O’Shea S, Corbett K, Chrystie IL.Potential risk of cross-infection during peripheral-venous accessby contamination of tourniquets. Lancet. 2000;355:44.

8. Hadaway LC, Millam DA. On the road to successful IV starts.Nursing. 2005;35(suppl 1):1-14.

9. Society of Gastroenterology Nurses and Associates. Guideline forpreventing sensitivity and allergic reactions to natural rubberlatex in the workplace. Gastroenterol Nurs. 2008;31(3):239-246.

10. Gavin M, Patti PJ. Issues in latex allergy in children and adultsreceiving home healthcare. Home Healthc Nurse. 2009;27(4):231-239.


12. Elkin, MK, Perry, AG, Potter, PA. Nursing Interventions and Clinical Skills. 4th ed. St Louis, MO: Mosby/Elsevier, 2007:598.

13. Moureau N. Tips for inserting an IV in an older patient. Nursing.2004;34(7):18.



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D. The use of steel winged devices should be limited toshort-term or single-dose administration.13,14 (V)

E. Therapies not appropriate for short peripheralcatheters include continuous vesicant therapy,parenteral nutrition, infusates with pH less than 5or greater than 9, and infusates with an osmolal-ity greater than 600 mOsm/L. The nurse shouldcollaborate with the pharmacist and the licensedindependent practitioner (LIP) to assist in selec-tion of the most appropriate vascular access devicebased on a projected treatment plan.5,6,13,14,18-24

(IV)F. Peripheral administration of parenteral nutrition

via a short peripheral catheter should be usedwith caution in adults.21,22 (IV)

G. The nurse should be aware that a short peripher-al catheter of 14-24 gauge for adults and 22-24gauge for pediatric or neonates can generally be usedfor administration of blood or blood products.11,12,16

(V)

Practice Criteria

II. Midline Catheters

A. The nurse should consider selection of midlinecatheters for therapies anticipated to last 1-4 weeks.Reported dwell time for midline catheters inneonates is 6-10 days.9,10,16,25,26 (V)

B. A midline catheter should be used for hydration,intravenous solutions, pain medications, and someantibiotics. Therapies not appropriate for midlinecatheters include continuous vesicant therapy, par-enteral nutrition, infusates with pH less than 5 orgreater than 9, and infusates with an osmolalitygreater than 600 mOsm/L.9,13,14 (V)

C. Midline catheters are peripheral infusion deviceswith the tips terminating in either the basilic,cephalic, or brachial vein, distal to the shoulder.The basilic vein is preferred due to vein diameter.The tip does not enter the central vasculature.

32. VASCULAR ACCESS DEVICESELECTION

Standard

32.1 Indications and protocols for vascular access devices(VADs) shall be established in organizational policies,procedures, and/or practice guidelines and according tomanufacturers’ directions for use.32.2 The nurse shall select the appropriate type of catheter(peripheral or central) to accommodate the patient’s vas-cular access needs based on the prescribed therapy or treat-ment regimen, length of treatment, duration of dwell, vas-cular integrity, patient preference, and ability andresources available to care for the device.32.3 The catheter selected shall be of the smallest gaugeand length with the fewest number of lumens and shallbe the least invasive device needed to accommodate andmanage the prescribed therapy.32.4 The nurse shall not alter the vascular access deviceoutside the manufacturer’s directions for use.

Practice Criteria

I. Short Peripheral Catheters

A. The nurse should select a short peripheralcatheter based on prescribed therapies, durationof treatment (usually for treatments of less than 1week), availability of peripheral vascular accesssites, diagnosis, known complications of thedevice, and the inserter’s experience.1-9 (V)

B. A short peripheral catheter comes in a variety ofgauge sizes (ie, 14-27); winged or nonwinged; sin-gle or double lumen; or over-the-needle catheters.The tip of a short peripheral catheter terminates ina peripheral vein.2,3,5,6,10-16 (V)

C. The nurse should use short peripheral cathetersequipped with a passive or active safety mechanismto provide sharps injury protection.12,16,17 (V)

Vascular Access Device Selection and Placement


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Midline catheters inserted via a scalp vein inneonates and pediatric patients should have thetip terminating in the external jugular vein(EJV).5,16,20,27 (V)

D. Midline catheters are available as single- or double-lumen (1.9 Fr-5 Fr) polyurethane or silicone devices.Midline catheters for pediatric patients are availablein gauge sizes of 22-24.3,9,10,12-14,16,25,28 (V)

Practice Criteria

III. Central Vascular Access Devices(CVADs) (Nontunneled, PICC, Tunneled,Implanted Port)

A. The nurse should use CVADs to administer short- orlong-term continuous or intermittent infusion solu-tions such as antineoplastic medications, vesicants orknown irritants, parenteral nutrition, a variety ofantibiotics, and any medications with a pH of lessthan 5 or greater than 9 and osmolarity of greaterthan 600mOsm/L.5,6,13,29 (V)

B. The nurse should be aware that in order to minimizethrombotic complications, the tip of a CVAD shouldterminate in the central vasculature, such as the supe-rior vena cava (SVC) or inferior vena cava (IVC).Dialysis catheter tips may terminate in the right atrium.6,20,30 (V)

C. CVADs can be manufactured as single or multilumen,silicone, or polyurethane, along with various gaugesizes and lengths; open- or closed-ended; power-injectable; and/or as anti-infective devices.6,10,13,16,31-34

(V) D. The nurse should collaborate with the multidiscipli-

nary team to consider anti-infective CVADs in thefollowing circumstances: expected dwell of morethan 5 days; catheter-related bloodstream infection(CR-BSI) rate remains high even after employingother preventive strategies; neutropenic, transplant,burn, hemodialysis, or critically ill patients; catheterinsertion or exchange in patients with infection orbacteremia; or for emergency insertions. Anti-infec-tive CVADs have shown a decrease in colonizationand/or CR-BSIs. These types of CVADs includedevices coated or impregnated with chlorhexidineand silver sulfadiazine, minocycline and rifampin,and silver ion. The nurse should be aware that anti-infective CVADs should not be used in patients withallergies to silver, chlorhexidine, silver sulfadiazine,rifampin, or tetracyclines.1,29,32,35-51 (I)

E. CVADs designed to withstand high-pressure injec-tions (up to 300 pounds per square inch [psi]) havebeen found to be feasible and effective and withpublished reports of safe use.6,10,52-57 (II)

F. The nurse should be knowledgeable about whetherthe CVAD may be trimmed (considering factors

such as open- versus closed-ended; staggered lumenexits) and should follow the manufacturer’s direc-tions for use for altering the device length, shouldthe device require trimming. The use of scissorsshould be avoided in trimming catheter length. Useof scissors to adjust the length of peripherally insert-ed central catheters (PICCs) was found to result inrough, irregular surfaces as observed with scanningelectron microscopy. If the catheter length is modi-fied, the nurse should document the length in thepatient’s permanent medical record.34,58-60 (IV)

G. The nurse should be aware that there are specificcatheter selection and placement recommendations forpatients with chronic kidney disease (CKD). Catheterswith high flow rates should be used (see Standard 40,Hemodialysis Vascular Access Devices).30 (V)

H. CVAD tip location and dwell time for CKDpatients vary based on type of catheter selected andthe specific patient condition. Short-term CVADtips should be located in the SVC; long-term (tun-neled) CVAD tips should be located in the rightatrium; femoral CVAD tip locations should be inthe IVC. Uncuffed hemodialysis CVADs should beused in hospitalized CKD patients only and dwellup to 1 week. If an uncuffed hemodialysis CVADis selected for femoral placement, it should be usedin bed-bound CKD patients and dwell for only 5days (see Standard 40, Hemodialysis VascularAccess Devices).30 (V)

Practice Criteria

IV. Arterial Catheters

A. Peripheral or pulmonary arterial catheters shouldbe considered for short-term use for hemodynamicmonitoring, obtaining blood samples, and analyz-ing blood gas in critically ill patients.28 (V)

B. The nurse should be aware that the radial artery isthe most common insertion site because of easieraccess and a lower complication rate. Other possi-ble sites are the femoral, axillary, brachial, and tib-ial posterior arteries.61-64 (I)

C. If the radial artery site is selected, a 20-gauge arte-rial catheter is preferred to decrease the risk ofthrombosis.62 (I)

D. The nurse should be aware of the potential complica-tions associated with arterial catheters and that ratesof complications, such as thrombosis and infection,appear to increase with extended dwell time.61-65 (I)

REFERENCES

1. Joanna Briggs Institute, North Terrace Australia. Management ofperipheral intravascular devices: best practice information sheet.Aust Nurs J. 2008;16(3):25-28.



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2. Peripheral infusion therapy techniques. In: Weinstein S, ed.Plumer’s Principles & Practice of Intravenous Therapy. 8th ed.Philadelphia, PA: Lippincott Williams & Wilkins; 2007:242-259.

3. Short peripheral access. In: Weinstein S, ed. Plumer’s Principles& Practice of Intravenous Therapy. 8th ed. Philadelphia, PA:Lippincott Williams & Wilkins; 2007:260-276.

4. Antineoplastic therapy. In: Weinstein S, ed. Plumer’s Principles &Practice of Intravenous Therapy. 8th ed. Philadelphia, PA:Lippincott Williams & Wilkins; 2007:474-548.


6. Bullock-Corkhill M. Central vascular access device access andinsertion. In: Alexander M, Corrigan A, Gorski L, Hankins J,Perucca R, eds. Infusion Nursing: An Evidence-Based Approach.3rd ed. St Louis, MO: Saunders/Elsevier; 2010:480-494.

7. Earhart A, Jorgensen C, Kaminski D. Accessing pediatric patientsfor vascular access and sedation. J Infus Nurs. 2007;30(4);226-231.

8. Seales K. Vascular access: a guide to peripheral venous cannula-tion. Nurs Standard. 2005;19(49):48-52.

9. Cheung E, Baerlocher M, Asch M, Myers A. Venous access: apractical review for 2009. Can Fam Physician. 2009;55:494-496.

10. Cook L. Choosing the right intravenous catheter. HomeHealthcare Nurse. 2007;25(8):523-531.

11. Transfusion therapy. In: Weinstein S, ed. Plumer’s Principles &Practice of Intravenous Therapy. 8th ed. Philadelphia, PA:Lippincott Williams & Wilkins; 2007:413-464.

12. Pediatric intravenous therapy. In: Weinstein S, ed. Plumer’sPrinciples & Practice of Intravenous Therapy. 8th ed. Philadelphia,PA: Lippincott Williams & Wilkins; 2007:583-651.


14. Perucca R. Peripheral vascular access devices. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:456-479.

15. Fabian B. Infusion therapy in older adults. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:571-582.

16. Scales K. Intravenous therapy: a guide to good practices. Br JNurs. 2008;17(19)(suppl):S4-S12.

17. Tosini W, Ciotti C, Goyer F, Lolom I et al. Needlestick injuryrates according to different types of safety-engineered devices:results of a French multicenter study. Infect Control HospEpidemiol. 2010;31(4):402-407.

18. American Society for Parenteral and Enteral Nutrition. Safe prac-tices for parenteral nutrition: practice guidelines for safe practicefor parenteral nutrition. J Parenter Enteral Nutr. 2004;28(6):S39-S70.

19. Isaacs JW, Milikan WJ, Stackhouse J, Hersh T, Rudman D.Parenteral nutrition of adults with 900-milliosmolar solutions viaa peripheral vein. Am J Clin Nutr.1977;30:552-559.

20. Pettit J, Wyckoff M. Peripherally Inserted Central Catheters:Guidelines for Practice. 2nd ed. Glenview, IL: NationalAssociation of Neonatal Nurses: 2007.

21. Gura KM. Is there still a role for peripheral parenteral nutrition?Nutr Clin Pract. 2009;24:709-717.

22. Krzywda EA, Meyer D. Parenteral nutrition. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:316-350.

23. Hayden BK, Goodman M. Chemotherapy: principles of adminis-tration. In: Yarbro CH, Frogge MH, Goodman M. CancerNursing: Principles and Practice. 6th ed. Boston, MA: Jones &Bartlett; 2005:352-412.

24. Oncology Nursing Society. Chemotherapy and Biotherapy:Guidelines and Recommendations for Practice. 2nd ed. Pittsburgh,PA: ONS; 2005.

25. Frey AM, Pettit J. Infusion therapy in children. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:550-570.

26. Dougherty L. Obtaining peripheral venous access. In: DoughertyL, Lamb J, eds. Intravenous Therapy in Nursing Practice. 2nd ed.London, England: Blackwell Publishing; 2008:223-270.

27. Infusion therapy in alternate clinical settings. In: Weinstein S, ed.Plumer’s Principles & Practice of Intravenous Therapy. 8th ed.Philadelphia, PA: Lippincott Williams & Wilkins; 2007:662-687.

28. Mermel L, Allon M, Bourza E, et al. Clinical practice guidelines for thediagnosis and management of intravascular catheter related infection:2009 update by the Infectious Diseases Society of America. Clin InfectDis. 2009;49:1-45.

29. Bishop L, Dougherty L, Bodenham A, et al. Guidelines on the inser-tion and management of central venous access devices in adults. IntJ Lab Hematol. 2007;29(4):261-278.

30. National Kidney Foundation Vascular Access Work Group.Kidney Disease Outcomes Quality Initiative (KDOQI). Clinicalpractice guidelines and recommendations for vascular access. AmJ Kidney Dis. 2006; 48(1)(suppl 1): S248-S273.

31. Catheter selection. In: Weinstein S, ed. Plumer’s Principles &Practice of Intravenous Therapy. 8th ed. Philadelphia, PA:Lippincott Williams & Wilkins; 2007:277.

32. Richardson D. Vascular access nursing: standards of care andstrategies in the prevention of infection: a primer on central venouscatheters (Part 2). J Assoc Vascular Access. 2007;12(1):19-27.

33. Doellman D, Nichols I. Modified Seldinger Technique with ultra-sound for peripherally inserted central catheter (PICC) placement inthe pediatric patient: a precise advantage. J Assoc Vascular Access.2009;14(2):93-99.

34. Pettit J. Trimming of peripherally inserted central catheters: theend result. J Assoc Vascular Access. 2006;11(4):209-214.

35. Raad I, Hanna H. Intravascular catheter related infections: new hori-zons and recent advances. Arch Intern Med. 2002;162(8):871-878.

36. McGee D, Gould M. Preventing complications of central venouscatheterization. N Engl J Med. 2003;348(12):1123-1133.

37. Maki D, Stolz S, Wheeler S, Mermel L. Prevention of centralvenous catheter-related bloodstream infection by use of an anti-septic impregnated catheter: a randomized, controlled trial. AnnIntern Med. 1997;127(4):257-266.

38. Raad I, Darouiche R, Dupuis J, et al. Central venous catheters coat-ed with minocycline and rifampin for the prevention of catheterrelated colonization and bloodstream infections: a randomized dou-ble-blind trial. Ann Intern Med. 1997;127(4):267-274.

39. Hanna H, Benjamin R, Chatzinikolaou I, et al. Long-term siliconecentral venous catheters impregnated with minocycline andrifampin decrease rates of catheter-related bloodstream infectionin cancer patients: a prospective, randomized clinical trial. J ClinOncol. 2004;22:3163-3171.



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40. Bassetti S, Hu J, D’Agostin R, et al. Prolonged antimicrobial activ-ity of a catheter containing chlorhexidine and silver sulfadiazineextends protection against catheter infection in vivo. AntimicrobAgents Chemother. 2001;45:1535-1538.

41. Logghe C, Vanossel C, Dhoore W, et al. Evaluation of chlorhex-idine and silver sulfadiazine-impregnated central venous cathetersfor the prevention of bloodstream infection in leukaemic patients:a randomized controlled trial. J Hosp Infect.1997;37:145-156.

42. Bach A, Eberhardt H, Frick A, et al. Efficacy of silver-coating cen-tral venous catheters in decreasing bacterial colonization. CritCare Med. 1999;27:515-521.

43. Bong JJ, Kite P, Wilco M, et al. Prevention of catheter related blood-stream infections by silver iontophoretic central venous catheters: arandomized controlled trial. J Clin Pathol. 2003;56:731-735.

44. Fraenkel D, Rickard C, Thomas P, et al. A prospective randomized trialof rifampin-minocycline coated and silver-platinum-carbon impregnat-ed central venous catheters. Crit Care Med. 2006;34:668-675.

45. Ranucci M, Guiseppi I, Gromarelli P, et al. Impact of oligon cen-tral venous catheters on catheter colonization and catheter-relat-ed bloodstream infections. Crit Care Med. 2003;31:52-59.

46. Crnick JC, Maki DG. Are antimicrobial-impregnated catheterseffective? When does repetition reach the point of exhaustion?Clin Infect Dis. 2005;41:681-685.

47. Kusminsky RE. Complications of central venous catheterization.J Am Coll Surg. 2007;204(4):681-696.

48. Hockenhull J, Dwan K, Smith G, et al. The clinical effectivenessof central venous catheters treated with anti-infective agents inpreventing catheter-related bloodstream infections: a systematicreview. Crit Care Med. 2009;37(2):702-712.

49. Rupp M, Lesco S, Lipsett P, et al. Effect of second generationvenous catheters impregnated with chlorhexidine and silver sulfa-diazine (CHSS) on central catheter-related infections: a random-ized controlled trial. Ann Intern Med. 2005;143:570-580.

50. Darouiche R, Raad I, Heard S, et al. A comparison of two antimicrobial-impregnated central venous catheters. N Engl J Med. 1999;340:1-8.

51. Marschall J, Mermel L, Classen D, et al. Strategies to prevent cen-tral line associated bloodstream infections in acute care hospitals:SHEA/IDSA practice recommendations. Infect Control HospEpidemiol. 2008;29:522-530.

52. Sanelli P, Deshmukh M, Dugorets I, et al. Safety and feasibility ofusing a central venous catheter for rapid contrast injection rates.Am J Roentgenology. 2004;183(6):1829-1834.

53. Coyle D, Bloomgarden D, Beres R, et al. Power injection of contrastmedia via peripherally inserted central venous catheters for computer-ized tomography. J Vascular Intervent Radiol. 2004;15(8):809-814.

54. Herts B, O’Malley C, Wirth S, Lieber M, Pohlman B. Power injec-tion of contrast media using central venous catheters: feasibility,safety and efficacy. Am J Roentgenology. 2001;176(2):447-453.

55. Ruess L, Bulas D, Rivera O, Markle B. In-line pressures generated insmall-bore central venous catheters during power injection of comput-erized tomography contrast media. Radiology. 1997;203:625-629.

56. Zamos D, Ernich T, Patton H, D’Amico F, Bansal S. Injectionrate threshold of 3-lumen central venous catheters: an in vitrostudy. Acad Radiol. 2007;14(5):574-578.

57. Rigsby C, Gasber E, Seshadri R, et al. Safety and efficacy of pressurelimited power injection of iodinated contrast medium through cen-tral lines in children. Am J Roentgenology. 2007;188(3):726-732.

58. Trottel C. Why are we trimming peripherally inserted centralvenous catheters? Neonatal Network. 2004;23(3):82-83.

59. Parvez B, Parmar N, Chan A. Trimming of peripherally inserted cen-tral venous catheters may increase the risk of thrombosis. ThrombRes. 2004;113(2):175-177.

60. Rutledge DN, Viele C. Insertion and care of peripherally insertedcentral catheters (PICCs) for intravenous infusions. Online J ClinInnovations. 2006;9(2):1-73.

61. Scheer BV, Perel A, Pfeiffer U. Clinical review: complications andrisk factors of peripheral arterial catheters used for haemodynam-ic monitoring in anaesthesia and intensive care medicine. CritCare. 2002;6(3):198-204.

62. Lorente L, Santacreu R, Martin M, Jimenez A, Mora, M. Arterialcatheter-related infection of 2,949 catheters. Crit Care. 2006;10. http://ccforum.com/content/10/3/R83. Accessed January 23, 2010.

63. Koh DB, Gowardman JR, Rickard CM, Robertson IK, Brown A.Prospective study with peripheral arterial catheter infection and com-parison with concurrently sited central venous catheters. Crit CareMed. 2008;36(2):397-402.

64. Blot F, Estphan G, Boughaba A, Soltani D, et al. Is routine chang-ing of peripheral arterial catheters justified? Clin Microbiol Infect.2008;14(9):813-815.

65. Khalifa R, Dahyot-Fizelier C, Laksiri L, et al. Indwelling time andrisk of colonization of peripheral arterial catheters in critically illpatients. Intensive Care Med. 2008;34(10):1820-1826.

33. SITE SELECTION

Standard

33.1 Site selection for all vascular access devices (VADs)shall be established in organizational policies, proce-dures, and/or practice guidelines.33.2 The vasculature shall accommodate the gauge andlength of the catheter required for the prescribed therapy.33.3 Site selection for vascular access shall include assess-ment of the patient’s condition; age; diagnosis; comorbidi-ties; condition of the vasculature at the insertion site andproximal to the intended insertion site; condition of skin atintended insertion site; history of previous venipuncturesand access devices; type and duration of infusion therapy;and patient preference.33.4 Prior to insertion of a peripherally inserted centralcatheter (PICC), anatomical measurements shall be takento determine the length of the catheter required to ensurefull advancement of the catheter to the lower third of thesuperior vena cava and the junction of the superior venacava and right atrium.33.5 Placement of central vascular access devices(CVADs) by nurses shall be established in organizationalpolicies, procedures, and/or practice guidelines and inaccordance with rules and regulations promulgated by thestate’s Board of Nursing.

Practice Criteria

I. Peripheral Venous Access via ShortPeripheral Catheters

A. For adult patients, veins that should be consid-ered for peripheral cannulation are those found onthe dorsal and ventral surfaces of the upper extremi-ties, including the metacarpal, cephalic, basilic, and



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median veins. Avoid the lateral surface of the wristfor approximately 4-5 inches because of the poten-tial risk for nerve damage. For pediatric patients,similar veins to consider are in the hand, forearm,antecubital area, and upper arm below the axilla, aswell as the veins of the scalp, foot, and fingers ininfants and toddlers. For adult and pediatricpatients: avoid the ventral surface of the wrist due tothe pain on insertion and possible damage to theradial nerve.1-5 (V)

B. Site selection should be initiated routinely in the dis-tal areas of the upper extremities; subsequent cannu-lation should be made proximal to the previouslycannulated site.3 (V)

C. Site selection should be initiated routinely in thenondominant arm. VAD sites should avoid areas offlexion; areas of pain on palpation; veins that arecompromised (eg, bruised, infiltrated, phlebitic, scle-rosed, or corded); location of valves; and areas ofplanned procedures. In infants and children, avoidthe hand or fingers, or the thumb/finger used forsucking.2,3,6,7 (V)

D. Veins of the lower extremities should not be usedroutinely in the adult population due to risk oftissue damage, thrombophlebitis, and ulceration.2

(I A/P)E. Veins in an upper extremity should be avoided on

the side of breast surgery with axillary node dissec-tion, after radiation therapy to that side, or with lym-phedema, or the affected extremity from a cere-brovascular accident. For patients with chronic kid-ney disease stage 4 or 5, avoid forearm and upper-arm veins “suitable for placement of vascularaccess.” A collaborative discussion with the patientand the licensed independent practitioner (LIP)should take place related to the benefits and risks ofusing a vein in an affected extremity.3,6,8-12 (V)

F. Veins in the right arm of infants and childrenshould be avoided after procedures treating congen-ital cardiac defects that may have decreased bloodflow to the subclavian artery.13 (V)

G. Cannulation of hemodialysis fistulas and graftsfor infusion therapy requires the order of anephrologist or LIP.3 (V)

H. The nurse should consider using visualizationtechnologies that aid in vein identification andselection.3,14(V)

Practice Criteria

II. Peripheral Venous Access via MidlineCatheters

A. Site selection should be routinely initiated in theregion of the antecubital fossa. Veins that should beconsidered for midline catheter cannulation are thebasilic, cephalic, and brachial veins. For neonate and

pediatric patients, additional site selections includeveins in the leg with the tip below the groin and in thescalp with the tip in the neck, above the thorax.1,3 (V)

B. Site selection should avoid areas of pain on palpa-tion, veins that are compromised (eg, bruised, infil-trated, phlebitic, sclerosed, or corded), and forpatients with chronic kidney disease stage 4 or 5,avoid forearm and upper-arm veins “suitable forplacement of vascular access.”2,3,8,12 (V)

C. Veins in an upper extremity should be avoided on theside of breast surgery with axillary node dissection,after radiation therapy to that side, or with lymphedema,or the affected extremity from a cerebrovascular acci-dent. For patients with chronic kidney disease stage 4or 5, avoid upper-arm veins “suitable for placement ofvascular access.” A collaborative discussion with thepatient and the licensed independent practitioner (LIP)should take place related to the benefits and risks ofusing a vein in an affected extremity.3,8,9,11 (V)

D. Veins in the right arm of infants and childrenshould be avoided after procedures treating specif-ic congenital cardiac defects that may havedecreased blood flow to the subclavian artery.13 (V)

E. The nurse should consider using visualizationtechnologies that aid in vein identification andselection.14 (V)

Practice Criteria

III. Central Venous Access via PeripherallyInserted Central Catheters (PICCs)

A. Veins that should be considered for PICC cannula-tion are the basilic, median cubital, cephalic, andbrachial veins. For neonate and pediatric patients,additional site selections include the temporal veinand posterior auricular vein in the head and thesaphenous vein in the lower extremities.13,15 (V)

B. Site selection should avoid areas of pain on palpa-tion; veins that are compromised (eg, bruised, infil-trated, phlebitic, sclerosed, or corded); and forpatients with chronic kidney disease stage 4 or 5,avoid forearm and upper-arm veins “suitable forplacement of vascular access.”2,8,12 (V)

C. Veins in an upper extremity should be avoided on theside of breast surgery with axillary node dissection,after radiation therapy to that side, or with lymphedema,or the affected extremity from a cerebrovascular acci-dent. For patients with chronic kidney disease stage 4or 5, avoid upper-arm veins “suitable for placement ofvascular access.” A collaborative discussion with thepatient and the licensed independent practitioner (LIP)should take place related to the benefits and risks ofusing a vein in an affected extremity.8,9,11 (V)

D. The nurse should consider using visualizationtechnologies that aid in vein identification andselection.14-16 (V)



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Practice Criteria

IV. Central Venous Access via NontunneledCentral Vascular Access Devices (CVADs)

A. To minimize the risk of catheter-related infectionwith a nontunneled CVAD, the subclavian vein isrecommended in adult patients, rather than the jugu-lar or femoral veins, although benefits and risksaccompany each access site. For patients with chron-ic kidney disease, the subclavian vein is not recom-mended in order to preserve the vein.8,12,17,18 (I)

B. To minimize the risk of catheter-related thromboticcomplications with a nontunneled CVAD, the sub-clavian vein is recommended in adult patients, ratherthan the femoral vein, although benefits and risksaccompany each access site.17 (I)

C. There is no preferred venous insertion site for anontunneled CVAD in infants and children tominimize the risk of infection.19 (V)

Practice Criteria

V. Central Venous Access via TunneledCentral Vascular Access Devices andImplanted Ports

A. The nurse should collaborate with the health care teamand patient in assessment and site selection for place-ment of tunneled catheters and implanted ports.11 (V)

Practice Criteria

VI. Peripheral Arterial Access

A. Criteria for selection should include the presence of apulse and assessment of distal circulation. An Allentest should be performed when selecting the appro-priate artery for cannulation, prior to device inser-tion, and for assessment of distal arterial perfusion.2

(I A/P)B. The radial artery should be considered the most

appropriate access for percutaneous cannulation inadults for its advantages and to prevent infection.Alternative arteries include ulnar, brachial, and dor-salis pedis in adults, with each having advantagesand disadvantages. These sites are preferred over thefemoral or axillary to reduce the risk of infection.For pediatric patients, site selections include radial,posterior tibial, and dorsalis pedis arteries and arepreferred over the femoral or axillary sites to reducethe risk of infection. The brachial artery should notbe used in pediatric patients due to the absence ofcollateral blood flow.2,20 (I A/P)

C. Infusion therapy is not administered in peripheralarteries via peripheral arterial catheters; these cathetersare used for hemodynamic monitoring, blood gasanalysis, and obtaining blood samples.2,14 (V)

D. The nurse should consider using visualizationtechnologies that aid in arterial identification andselection.14 (V)

Practice Criteria

VII. External Jugular Vein Access

A. Nurses who are competent in infusion therapy mayinsert short peripheral intravenous (IV) cathetersand PICCs, using the external jugular vein inpatients in acute care settings and in emergency sit-uations when other veins cannot be accessed.2,21 (V)

B. A short peripheral catheter in the external jugularvein should not be used for contrast media orwith power injectors.21 (V)

C. Central venous pressure monitoring may be performedthrough PICCs in the external jugular vein.21 (V)

D. When a short peripheral catheter is inserted intothe external jugular vein and infusion therapy isexpected to exceed 72 to 96 hours, the nurseshould collaborate with the LIP for an alternativevascular access site as soon as possible.3,21 (V)

REFERENCES


2. Hadaway L. Anatomy and physiology related to infusion thera-py: In: Alexander M, Corrigan A, Gorski L, Hankins J, PeruccaR, eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed.St Louis, MO: Saunders/Elsevier; 2010:139-177.

3. Perucca R. Peripheral venous access devices. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:456-479.

4. Laskowski-Jones L, Falkowski A. Infusion therapy. In: IgnatiaviciusDD, Workman ML. Medical-Surgical Nursing: Patient-CenteredCollaborative Care. 6th ed. St Louis, MO: Mosby/Elsevier; 2010:213-240.


6. Ostendorf W. Fluid, electrolyte, and acid-base balance. In: PotterP, Perry A. Fundamentals of Nursing. 7th ed. St Louis, MO:Mosby/Elsevier; 2009:966-1027.

7. Taylor E. Infant perioperative patients. AORN J. 2007;86:843-848.8. American Nephrology Nurses’ Association Board of Directors

[position statement]. Vascular access for hemodialysis. http://www.annanurse.org/cgibin/WebObjects/ANNANurse.woa/wa/viewSection?s_id/1073744052&ss_id/536873322&tName/vascAccess.Published 2010. Accessed March 17, 2010.

9. Felty CL, Rooke TW. Lymphedema. In: Fahey V.Vascular Nursing.4th ed. St Louis, MO: Saunders; 2004:33-46.

10. Hayden BK, Goodman M. Chemotherapy: principles of administra-tion. In: Yarbro CH, Frogge MH, Goodman M. Cancer Nursing:Principles and Practice. 6th ed. Boston, MA: Jones and Bartlett;2005;352-412.



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11. Institute of Medicine. Committee on Quality of Health Care inAmerica. Crossing the Quality Chasm: A New Health System for the21st Century. Washington, DC: National Academies Press; 2001.

12. Vascular Access Work Group. Clinical practice guidelines for vas-cular access. Am J Kidney Dis. 2006;48(suppl 1):S176-S247.

13. Beauman SS, Swanson A. Neonatal infusion therapy: preventingcomplications and improving outcomes. Newborn Infant Nurs Rev.2006;6(4):193-201.



16. Association for Vascular Access Board of Directors [position state-ment]. The use of ultrasound guidance by registered nurses forcentral venous catheter insertion. http://www.avainfo.org/website/download.asp?id/272333. Published June 17, 2010. AccessedAugust 5, 2010.

17. Hamilton HC, Foxcroft D. Central venous access sites for the pre-vention of venous thrombosis, stenosis and infection in patientsrequiring long-term intravenous therapy. Cochrane Database SystRev. 2007;(3):CD004084.

18. Ruesch S, Walder B, Tramer MR. Complications of central venouscatheters: internal jugular versus subclavian access: a systematicreview. Crit Care Med. 2002;30:454-460.

19. Koletzko B, Goulet O, Hunt J, Krohn K, Shamir R. Venous access:guidelines on paediatric parenteral nutrition of the European Society ofPaediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)and the European Society for Clinical Nutrition and Metabolism(ESPEN), supported by the European Society of Paediatric Research(ESPR). J Pediatr Gastroenterol Nutr. 2005;41(suppl 2):S54-S62.

20. Alternate access. In: Weinstein S, ed. Plumer’s Principles & Practiceof Intravenous Therapy. 8th ed. Philadelphia, PA: LippincottWilliams & Wilkins; 2007:331-357.

21. Infusion Nurses Society [position paper]. The role of the registerednurse in the insertion of external jugular peripherally inserted cen-tral catheters (EJ PICC) and external jugular peripheral intra-venous catheters (EJ PIV). J Infus Nurs. 2008;31(4):226-227.

34. LOCAL ANESTHESIA FOR VASCULAR ACCESS DEVICEPLACEMENT AND ACCESS

Standard

34.1 Local anesthesia shall be considered based upon nursingassessment of patient condition, needs, risks, and benefits.34.2 When local anesthesia is ordered or necessary, theagent and method that is least invasive and carries the leastrisk for allergic reaction or infection shall be considered first.34.3 The nurse shall be competent to administer local anes-thesia for vascular access device (VAD) placement and access.34.4 Use of local anesthesia shall be established in orga-nizational policies, procedures, and/or practice guide-lines, and in accordance with the rules and regulationspromulgated by the state’s Board of Nursing.

Practice Criteria

A. Local anesthetic agents including, but not limitedto, topical transdermal agents, intradermal lido-caine, iontopheresis, and pressure-acceleratedlidocaine, should be considered and used accord-ing to manufacturers’ directions for use.1-10 (II)

B. The nurse should consider and encourage the use ofall available and effective local anesthetic methodsand agents prior to each painful dermal procedurein children and some adults. These include topicalanesthetics as well as adjunctive and less invasiveanxiolytic, cognitive, behavioral, and complemen-tary therapies to reduce pain and discomfort.11-16 (II)

C. The nurse should assess the patient for potentialallergic reactions, tissue damage, or inadvertentinjection of the drug into the vascular systemwhen administering a local anesthetic.9,17 (V)

REFERENCES

1. Fetzer SJ. Reducing venipuncture and intravenous insertion painwith eutectic mixture of local anesthetic: a meta-analysis. NursRes. 2002;51:119-124.


3. Fry C, Aholt D. Local anesthesia prior to the insertion of peripheral-ly inserted central catheters. J Intraven Nurs. 2001;24(6):404-408.

4. Gorski L. Guideline 90: intravenous insertion. In: Ackley BJ,Ladwig GB, Swan BA, Tucker SJ. Evidence-Based Nursing CareGuidelines: Medical-Surgical Interventions. St Louis, MO: Mosby/Elsevier; 2008:477-482.


6. Hudson TL, Dukes SF, Reilly K. Use of local anesthesia for arte-rial punctures. Am J Crit Care. 2006;15:595-599.

7. McGowan D, Wood S. Developing a venous assessment tool inIV chemotherapy administration. Br J Nurs. 2008;17:158-164.

8. Migdal M, Chudzynska-Pomianowska E, Vause E, Henry E, Lazar J.Rapid, needle-free delivery of lidocaine for reducing the pain of venipunc-ture among pediatric subjects. Pediatrics. 2005;115(4):e393-e398.

9. Peripheral infusion therapy techniques. In: Weinstein S, ed.Plumer’s Principles & Practice of Intravenous Therapy. 8th ed.Philadelphia, PA: Lippincott Williams & Wilkins. 2007;242-259.

10. Zempsky WT, Cravero JP; American Academy of Pediatrics Committeeon Pediatric Emergency Medicine and Section on Anesthesiology andPain Medicine. Relief of pain and anxiety in pediatric patients in emer-gency medical systems. Pediatrics. 2004;114(5):1348-1356.

11. Bisignano A, Bush JP. Distress in pediatric hematology: oncologypatients undergoing intravenous procedures: evaluation of a CD-ROM intervention. Child Health Care. 2006;35:61-74.

12. Breiner SM. Preparation of the pediatric patient for invasive pro-cedures. J Infus Nurs. 2009;32:252-256.

13. Fanurik D, Koh JL, Schmitz ML. Distraction techniques com-bined with EMLA: effects on IV insertion pain and distress inchildren. Child Health Care. 2000;29(2):87-101.



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14. Pediatric intravenous therapy. In: Weinstein S, ed. Plumer’sPrinciples & Practice of Intravenous Therapy. 8th ed. Philadelphia,PA: Lippincott Williams & Wilkins; 2007:613-685.

15. Gold J, Kim SH, Kant AJ, Joseph MH. Effectiveness of virtualreality for pediatric pain distraction during IV placement.Cyberpsychology Behav. 2006;9:207-212.

16. Skarbek-Borowska S, Becker BM, Lovgren K, Bates A, Minugh PA.Brief focal ultrasound with topical anesthetic decreases the pain ofintravenous placement in children. Pediatr Emerg Care. 2006;22:339-345.

17. Brown D. Local anesthesia for vein cannulation: a comparison oftwo solutions. J Infus Nurs. 2004;27(2):85-88.

35. VASCULAR ACCESS SITEPREPARATION AND DEVICEPLACEMENT

Standard

35.1 The nurse shall place a vascular access device (VAD)upon the order of a licensed independent practitioner(LIP) in accordance with the rules and regulations pro-mulgated by the state’s Board of Nursing and organiza-tional policies, procedures, and/or practice guidelines.35.2 VAD placement shall be established in organiza-tional policies, procedures, and/or practice guidelinesand according to manufacturers’ directions for use.35.3 The nurse shall be competent in insertion tech-nique, infection prevention measures, identifying poten-tial complications, implementing nursing interventions,and in assisting the LIP with VAD placement.35.4 The nurse shall prepare the intended VAD insertionsite with antiseptic solution using aseptic technique.35.5 Maximal sterile barrier (MSB) precautions, includ-ing mask, sterile gown, cap, sterile gloves, protectiveeyewear, and large full-body drapes, shall be used withthe insertion of central vascular access devices(CVADs).35.6 Antiseptic solutions in a single unit configurationshall be used.35.7 Only 1 vascular access device shall be used foreach catheterization attempt.35.8 Tip location of a CVAD shall be determined radi-ographically or by other approved technologies prior toinitiation of infusion therapy.

Practice Criteria

I. General

A. Prior to inserting a vascular access device, thenurse should provide patient education, address-ing the rationale for VAD placement; insertionprocess; expected dwell time; care and mainte-nance of the device; and signs and symptoms ofcomplications to report (see Standard 12,Informed Consent).1 (V)

B. If the intended insertion site is visibly soiled, cleanthe area with soap and water prior to applicationof antiseptic solution(s).2,3 (V)

C. Clipping should be performed to remove excesshair at the insertion site with single-patient-usescissors or disposable-head surgical clippers;microabrasions produced from shaving increasethe risk for infection.4 (V)

D. The nurse should inspect the VAD for productintegrity prior to insertion.5 (V)

E. If an artery is inadvertently accessed or if the patientcomplains of paresthesias, numbness, or tingling uponVAD insertion, the catheter should be immediatelyremoved and the LIP promptly notified, as rapidattention may prevent permanent injury; nerves andarteries are often located in very close proximity to thevenipuncture site.6-8 (V)

F. No more than 2 attempts at vascular access place-ment should be made by any 1 nurse, as multipleunsuccessful attempts limit future vascular accessand cause patients unnecessary pain. Patients withdifficult vascular access require a careful assess-ment of VAD needs and collaboration with thehealth care team to discuss appropriate options.4

(V)G. Chlorhexidine solution is preferred for skin antisep-

sis. One percent to two percent tincture of iodine,iodophor (povidone-iodine), and 70% alcohol mayalso be used. Chlorhexidine is not recommendedfor infants under 2 months of age.4,9(I)

H. The nurse should consider using visualization tech-nologies that aid in vein identification and selec-tion.5,10,11(V)

Practice Criteria

II. Short Peripheral and Midline Catheters

A. The nurse should consider the use of methods topromote vascular distention in addition to theappropriate use of tourniquets, such as gravity(positioning the extremity lower than the heart forseveral minutes), having the patient open and closehis or her fist, and lightly stroking the vein down-ward (see Standard 31, Tourniquets).4,12 (I A/P)

B. The use of warmth should be considered anothermethod to promote vascular dilation. The use ofdry heat was found to increase the likelihood ofsuccessful peripheral catheter insertion.4,12-15 (II)

C. The nurse should use a new pair of disposable,nonsterile gloves in conjunction with a no-touchtechnique for peripheral IV insertion. With no-touch technique, the planned IV insertion site isnot palpated after skin cleansing unless sterilegloves are worn.16 (V)

D. Insertion techniques for midline catheter placementinclude threading the catheter through an introducer



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or using the Modified Seldinger Technique (MST),also known as the microintroducer technique.5,17-19

(V)E. The midline catheter tip location should be at or

below the axillary line.5,17-19 (V)

Practice Criteria

III. Central Vascular Access Devices (CVADs)

A. The nurse should use a standardized checklist toencourage adherence to recommended practices foraccess site preparation, infection prevention, andsafety precautions. The CVAD placement proce-dure should be stopped for any breaches in steriletechnique that occur during the procedure.9,20,21 (IV)

B. The nurse should use a standardized supply cartor kit that contains all necessary components forthe insertion of a CVAD.9,20,21 (V)

C. Ultrasound technology should be used when insert-ing PICC and percutaneous centrally insertedcatheters to increase success rates and decreaseinsertion-related complications.22-31 (III)

D. The nurse should use the Seldinger or ModifiedSeldinger Technique (MST) as the preferred methodfor CVAD (ie, peripherally inserted central catheter[PICC], subclavian) insertion due to advantages ofdecreased vein trauma, decreased insertion compli-cations, and decreased risk of arterial puncture ornerve injury.8,30-34 (V)

E. CVADs shall have the tip dwelling within the supe-rior vena cava (SVC) near its junction with the rightatrium or, if placed via the femoral vein, shall havethe tip dwell in the inferior vena cava (IVC) abovethe level of the diaphragm.8,35,36 (IV)

F. The nurse should be aware that the presence of a pace-maker requires a careful evaluation and thoroughassessment to select the appropriate catheter andinsertion site. Pacemakers are usually placed on theleft side of the chest or abdomen. The contralateralside is preferred for CVAD placement, but if ipsilater-al side is selected, a peripherally inserted centralvenous catheter may be the safest choice. It is impor-tant to have the pacemaker evaluated before and afterCVAD insertion to determine integrity of the pace-maker unit and leads. There are no published reportsof displaced leads noted during CVAD insertion, andthere are currently no practice guidelines developedrelated to pacemakers and CVADs.37,38 (V)

Practice Criteria

IV. Arterial Catheters

A. The nurse should use a cap, mask, sterile gloves,eyewear, and a large, sterile fenestrated drape whenplacing a peripheral arterial catheter.39 (II)

B. Maximal sterile barrier precautions should be usedwhen placing arterial catheters in the axillary orfemoral artery.39 (II)

REFERENCES


2. National Kidney Foundation/Dialysis Outcomes Quality Initiative.Clinical practice guidelines for vascular access: update 2000. Am JKidney Dis. 2001;37(suppl 1):S137-S181.

3. Parienti JJ. A paradigm shift to prevent nosocomial infection: “takea bath before I touch you.” Crit Care Med. 2009;37(6):2097-2098.



6. Boeson MB, Hranchook A, Stoller J. Peripheral nerve injury fromintravenous cannulation: a case report. AANA J. 2000;68(1):53-57.

7. Masoorli S. Nerve injuries related to vascular access insertion andassessment. J Infus Nurs. 2007;30(6):346-350.


9. Marschall J, Mermel LA, Classen D, et al. Strategies to preventcentral line-associated bloodstream infections in acute care hospi-tals. Infect Control Hosp Epidemiol. 2008;29(suppl 1):S22-S30.

10. Dargin JM, Rebholz CM, Lowenstein RA, Mitchell PM, FeldmanJA. Ultrasonography-guided peripheral intravenous catheter sur-vival in ED patients with difficult access. Am J Emerg Med.2010;28(1):1-7.

11. Katogridakis YL, Roopa S, Sullivan C, Waltzman M. Veinlite tran-sillumination in the pediatric emergency department: a therapeuticinterventional trial. Pediatr Emerg Care. 2008;28(2):83-88.

12. Techniques for initiation and maintenance of peripheral infusiontherapy. In: Phillips LD. Manual of IV Therapeutics: Evidence-BasedPractice for Infusion Therapy. 5th ed. Philadelphia, PA: FA Davis;2010:303-401.

13. Fink RM, Hjort E, Wenger B, et al. The impact of dry versus moistheat on peripheral IV catheter insertion in a hematology-oncologyoutpatient population. Oncol Nurs Fourm. 2009;36 (4):E198-E204.

14. Lenhardt R, Seybold T, Kimberger O, Stoiser B, Sessler DI. Localwarming and insertion of peripheral venous cannulas. BMJ.2002;325(7361):409-410.

15. Roberge RJ. Venodilatation techniques to enhance venipunctureand intravenous cannulation. J Emerg Med. 2004;27(1):69-73.

16. Betsy Lehman Center for Patient Safety and Medical ErrorReduction. JSI Research and Training Institute. Prevention ofbloodstream infections. In: Prevention and Control of Healthcare-associated Infections in Massachusetts. Part 1: Final Recomm-endations of the Expert Panel. Boston, MA: Massachusetts Departmentof Public Health; January 31, 2008:69-82.

17. Anderson NR. Midline catheters. J Infus Nurs. 2004;27(5):313-321.



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18. Infusion equipment. In: Phillips LD. Manual of IV Therapeutics:Evidence-Based Practice for Infusion Therapy. 5th ed. Philadelphia,PA: FA Davis; 2010: 230-302.

19. Rosenthal K. Bridging the IV access gap with midline catheters.Nursing. 2008;(suppl 2):4-5.

20. Institute for Healthcare Improvement. Implement the central linebundle. http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheCentralLineBundle.htm. Accessed January5, 2010.

21. Pronovost P, Needham D, Berenholtz S, et al. An intervention todecrease catheter-related bloodstream infections in the ICU. N EnglJ Med. 2006;355(26):2725-2732.

22. Hind D, Calvert N, McWilliams R, et al. Ultrasonic locatingdevices for central venous cannulation: meta-analysis. BMJ. 2003;327(2411):361.

23. Froehlich C, Rigby M, Rosenberg E, et al. Ultrasound-guided centralvenous catheter placement decreases complications and decreasesplacement attempts compared with the landmark technique in patientsin a pediatric intensive care unit. Crit Care Med. 2009;37(3):1090-1096.

24. Johnson M, McKenzie L, Tussey S, Jacobs H, Couch C. Portableultrasound: a cost-effective process improvement tool for PICCplacement. Nurs Manage. 2009;40(1):47-50.

25. Stokowski G, Steele D, Wilson D. The use of ultrasound toimprove practice and reduce complication rates in peripherallyinserted central catheter insertions. J Infus Nurs. 2009;32(3) 145-153.

26. Nichols I, Humphrey JP. The efficacy of upper arm placement ofperipherally inserted central catheters using bedside ultrasound andmicrointroducer technique. J Infus Nurs. 2008;31(3):165-175.

27. Stokowski G, Steele D, Wilson D. The use of ultrasound to improvepractice and reduce complication rates in peripherally inserted cen-tral catheter insertions. J Infus Nurs. 2009;32(3):145-153.

28. Dargin JM, Rebholz CM, Lowenstein RA, Mitchell PM, FeldmanJA. Ultrasonography-guided peripheral intravenouw catheter sur-vival in ED patients with difficult access. Am J Emerg Med. 2010;28(1):1-7.

29. Sandhu NPS, Sidhu DS. Case reports: mid-arm approach to basil-ic and cephalic vein cannulation using ultrasound guidance. Br JAnaesth. 2004;1-3.

30. Rutledge DN, Viele C. Insertion and care of peripherally insertedcentral catheters (PICCs) for intravenous infusions. Online J ClinInnovations. 2006;9(2):1-73.

31. Association for Vascular Access [position paper]. The use ofultrasound guidance by registered nurses for central venouscatheter insertion. http://www.avainfo.org/website/download.asp?id=272333. Published 2010. Accessed October 19, 2010.

32. Richardson D. Vascular access nursing: standards of care, andstrategies in the prevention of infection: a primer on central venouscatheters (Part 2). J Assoc Vascular Access. 2007;12(1):19-27.

33. Doellman D, Nichols I. Modified Seldinger technique with ultrasoundfor peripherally inserted central catheter (PICC) in the pediatric patient:a precise advantage. J Assoc Vascular Access. 2009;14(2):93-99.

34. Higgs ZC, Macafee DA, Braithwaite BD, Maxwell-Armstrong,CA. The Seldinger Technique: 50 years on. Lancet. 2005;366:1407-1409.

35. DeChicco R, Seidner DL, Brun C, et al. Tip position of long-termcentral venous access devices used for parenteral nutrition. JParenter Enteral Nutr. 2007;31(5):382-387.

36. Caers J, Fontaine C, Vinh-Hung V, et al. Catheter tip position as arisk factor for thrombosis associated with the use of subcutaneousinfusion supports. Support Care Cancer. 2005;13(5):325-331.

37. Pacana C, Durand JB. The risk of central venous placement ipsilat-eral to the permanent pacemaker. J Assoc Vascular Access. 2009;14(1):28-30.

38. McGee D, Gould M. Preventing complications of central venouscatheterization. New Engl J Med. 2003;348(12):1123-1133.

39. Koh DB, Gowardman JR, Rickard CM, Robertson IK, Brown A.Prospective study of peripheral arterial catheter infection andcomparison with concurrently sited central venous catheters. CritCare Med. 2008;36:397-402.

36. VASCULAR ACCESS DEVICESTABILIZATION

Standard

36.1 Vascular access device (VAD) stabilization shall beused to preserve the integrity of the access device, mini-mize catheter movement at the hub, and preventcatheter dislodgment and loss of access.36.2 VADs shall be stabilized using a method that doesnot interfere with assessment and monitoring of theaccess site or impede vascular circulation or delivery ofthe prescribed therapy.36.3 The use of stabilization methods shall be estab-lished in organizational policies, procedures, and/orpractice guidelines.36.4 The nurse shall be competent in proper use andapplication of VAD stabilization methods and devices.

Practice Criteria

A. The use of a catheter stabilization device should beconsidered the preferred alternative to tape orsutures when feasible. Several studies have demon-strated a reduction in overall complications andimproved dwell time with peripheral IV catheters.One study demonstrated reduced risk of infectionwith peripherally inserted central catheters (PICCs)when a catheter stabilization device was used.Sutures were associated with fewer complicationswhen compared to use of tape with PICCs in pedi-atric patients in a randomized, controlled trial thatexcluded use of stabilization devices.1-6 (III)

B. Transparent semipermeable membrane (TSM)dressings or other dressings are often cited ashelpful in stabilizing the catheter; however, thereis insufficient evidence supporting their benefits instabilization at the intravenous catheter hubalone. A randomized, controlled trial with periph-eral IV catheters demonstrated that use of aperipheral IV catheter with an integrated stabi-lization feature in combination with an IV secure-ment dressing performed as well as a standardperipheral IV with a catheter stabilization device.It is important to recognize that these results can-not be generalized to all types of short peripheralcatheters.5,7-11 (III)



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C. The use of alternative methods of VAD stabiliza-tion in lieu of sutures should be considered to miti-gate the risk of needlestick injury; the use of stapleshas been cited in the literature as an alternative tosutures, reducing exposure to contaminated sharps.Studies are limited, however; they have not demon-strated benefits and may not be appropriate in thenonsedated patient.5,6,12 (V)

D. Use of any stabilization method should be basedon evidence as well as analysis of risks versus ben-efits. While sutures may increase risk of needle-stick injury and/or risk of infection due to thepresence of suture wounds near the insertion siteand development of biofilm on the sutures,sutures may be considered appropriate in specialpopulations such as pediatric patients or thosewith skin integrity problems, precluding use oftape or an engineered stabilization device.5,10,13

(V)E. If sutures used to stabilize a VAD at placement

become loosened or no longer intact, they shouldbe removed and the VAD should be secured usinganother stabilization method or resutured asappropriate.5 (V)

F. Removal and replacement of the engineered stabi-lization device or tape should be done at estab-lished intervals according to the manufacturer’sdirections for use, and/or in conjunction withreplacement of the VAD, or with routine site careand dressing changes.5,14 (V)

G. A catheter that migrates externally should not bereadvanced into the vein prior to application of acatheter stabilization device; the VAD should bestabilized at the point of external migration andassessed for proper placement in the vasculaturebefore further use.14 (V)

REFERENCES

1. Frey AM, Schears GJ. Why are we stuck with tape and suture? Areview of catheter securement devices. J Infus Nurs. 2006;29(1):34-38.

2. Smith B. Peripheral intravenous catheter dwell times: a compari-son of 3 securement methods for implementation of a 96-hourscheduled change protocol. J Infus Nurs. 2006;29(1):14-17.

3. Yamamoto AJ, Soloman JA, Soulen MC, et al. Sutureless secure-ment device reduces complications of peripherally inserted centralvenous catheters. J Vascular Intervent Radiol. 2002;13(1):77-81.

4. Schears GJ. Summary of product trials for 10,164 patients: com-paring an intravenous stabilizing device to tape. J Infus Nurs.2006;29(4):225-231.

5. Registered Nurses Association of Ontario. Nursing best practiceguideline: Care and maintenance to reduce vascular access com-plications. http://www.rnao.org/Storage/39/3379_Assessment_and_Device_Selection_for_Vascular_Access._with_2008_Supplement.pdf. Accessed December 30, 2009.

6. Occupational Safety and Health Administration [fact sheet].Securing medical catheters. http://www.osha.gov/SLTC/blood-

bornepathogens/factsheet_catheters.pdf. Accessed February 20,2010.

7. Stephenson C. The advantages of a precision-engineered secure-ment device for fixation of arterial pressure monitoring catheters.J Assoc Vascular Access. 2005;10(3):130-132.

8. Bausone-Gazsa D, Lefaiver CA, Walters SA. A randomized con-trolled trial to compare the complications of 2 peripheral IVcatheter stabilization systems. J Infus Nurs. 2010;33(6):371-384.

9. Hadaway L. Infusion therapy equipment. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010: 391-436.

10. Ryder M. Catheter-related infections: it’s all about biofilm.Topics in Advanced Practice Nursing eJournal. 2005;5(3). http://www.medscape.com/viewarticle/508109;meddomainjsession=nBHmM5gPdD049THgwNsvQyjMCcNdM8CqRtjMTv2nh4Z8ns0sX4HZ!-228635945. Accessed February 8, 2010.


12. Vinjirayer A, Jefferson P, Ball D. Securing central venous catheters:a comparison of sutures with staples. Emergy Med J. 2004;21(5):582-583.

13. Graf JM, Newman CD, McPherson ML. Sutured securement ofperipherally inserted central catheters yields fewer complications inpediatric patients. J Parenter Enteral Nutr. 2006;30(6): 532-535.

14. Gorski L, Perrucca R, Hunt M. Central venous access devices: care,maintenance, and potential complications. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:495-515.

37. JOINT STABILIZATION

Standard

37.1 Joint stabilization, using such devices as an armboard or limb or finger splint, shall be implemented tofacilitate infusion delivery when the catheter is placed inor adjacent to an area of flexion, and is not considereda restraint.37.2 A joint stabilization device shall be considered asingle-patient-use device.37.3 The use of joint stabilization devices shall be estab-lished in organizational policies, procedures, and/orpractice guidelines and according to manufacturers’directions for use.37.4 The nurse shall be competent in the proper use andapplication of joint stabilization devices.

Practice Criteria

A. A joint stabilization device, such as an arm boardor limb or finger splint, should be padded andsupport the area of flexion (ie, finger, hand, arm,foot) in order to maintain a functional position.1-3

(V)



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B. The joint stabilization device should be applied ina manner that will provide the ability to visuallyinspect and assess the vascular access site and veinpath, prevent circulatory constriction, prevent skinimpairment, and prevent nerve pressure in the areaof flexion.1-4 (V)

C. The nurse should assess the patient’s risk for devel-opment of pressure ulcers, perform skin inspectionand assessment, and implement appropriate inter-ventions to avoid the risk of skin breakdown. Thepotential risk for skin breakdown and develop-ment of pressure ulcers exists due to pressurecreated from the device restricting vascular circula-tion.5-8 (V)

D. Joint stabilization devices should be used to minimizecomplications and maintain device patency.9 (III)

E. Documentation in the patient’s permanent med-ical record should include the application of thejoint stabilization device and the periodic removalfor assessment of circulatory status, range ofmotion, and skin integrity.1-4,10 (V)

REFERENCES



3. Fabian B. Infusion therapy in the older adult. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:571-582.


5. Lyder CH, Ayello EA. Pressure ulcers: a patient safety issue. In:Hughes RG, ed. Patient Safety & Quality: An Evidence-BasedHandbook for Nurses. Rockville, MD: Agency for HealthResearch & Quality (AHRQ): 1-33. http://www.ahrq.gov/qual/nurseshdbk/docs/LyderC_PUPSI.pdf. Published 2008. AccessedJanuary 15, 2010.

6. Defloor T. The risk of pressure sores: a conceptual scheme. J ClinNurs. 1999;8(2):206-216.

7. Wound, Ostomy and Continence Nurses Society. Guidelines forPrevention and Management of Pressure Ulcers. Mt. Laurel, NJ:WOCN; 2003.

8. Mathison CJ. Skin and wound care challenges in the hospitalized mor-bidly obese patient. J Wound Ostomy Continence Nurs. 2003;30(2):78-83.

9. Tripathi S, Kaushik V, Singh V. Peripheral IVs: factors affectingcomplications and patency: randomized controlled trial. J InfusNurs. 2008;31(3):182-188.

10. Phillips LD. Manual of I.V. Therapeutics: Evidence-Based Practicefor Infusion Therapy. 5th ed. Philadelphia, PA: FA Davis; 2010:337.

38. SITE PROTECTION

Standard

38.1 The use of site protection and/or physical immobi-lization devices, proper application, and patient moni-toring shall be established in organizational policies,procedures, and/or practice guidelines.38.2 The nurse shall be competent in the application, use,and removal of a site protection or immobilization device.38.3 The use of physical immobilization devices (ie,restraints) to protect the vascular access device (VAD)site shall not be routinely implemented and shall beavoided whenever possible.

Practice Criteria

A. Site protection methods such as mittens are recom-mended for patient populations such as pediatric,elderly, those with cognitive limitations, or when-ever there is risk of accidental dislodgment. Clearplastic site protectors specifically designed for thispurpose are used to prevent accidental dislodg-ment or vein damage in children.1,2 (V)

B. The site protection method selected should be basedon a comprehensive assessment of the patient’sphysical, behavioral, and psychological status.3-9

(III) C. Immobilization devices or site protection methods

should be used in a manner that will preserve cir-culation and provide visualization of the vascularaccess site and in accordance with manufacturers’directions for use. The selected immobilizationdevice or site protection method should not inter-fere with the prescribed infusion rate, deliverymethod, ability to assess the vascular access site, orcatheter stabilization/securement.9,10 (V)

D. The physical immobilization device should beremoved at established intervals to allow assess-ment of the extremity’s circulatory status andprovide an opportunity for supervised range-of-motion activities.3-5,9 (V, Regulatory)

E. The immobilization device should be removedas soon as the patient’s condition allows.2-7,9-11

(V, Regulatory)F. The nurse should educate the patient, caregiver, or

legally authorized representative on the need forand appropriate use of patient-protective meth-ods, including physical immobilization devices.11

(IV)G. Documentation should include, but not be limited

to, the rationale for the immobilization device;type and location of the immobilization device;release and reapplication of the device; site andcirculatory assessment; any complications causedby the immobilization device; patient’s response to



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the immobilization device; reassessment of needfor the immobilization device; patient education;and removal of the device.3-7,10 (V, Regulatory)

REFERENCES

1. Frey AM, Pettit J. Infusion therapy in children. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionTherapy: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010;550-570.

2. Mion LC. Physical restraint in critical care settings: will they goaway? Geriatr Nurs. 2008;29(6):421-423.

3. Centers for Medicare & Medicaid Services. Conditions of partic-ipation (CoP) and conditions for coverage (CfCs): hospital COPsfor patients’ rights. http://www.cms.hhs.gov/CfCsAndCoPs/02_Spotlight.asp#TopofPage. Accessed August 25, 2009.

4. Centers for Medicare & Medicaid Services. Medicare andMedicaid Program. Hospital conditions of participation: patients’rights, final rule. Fed Regist. 2006;71(236):71378-71428.Codified at 42 CFR Part 482. http://www.cms.hhs.gov/CFCsAndCOPs/downloads/finalpatientrightsrule.pdf. Published December8, 2006. Accessed February 12, 2010.

5. Joint Commission on Accreditation of Healthcare Organizations.Restraints and seclusion in hospitals: acute medical/surgical care restraintstandards PC.03.02.01-PC.03.02.11. http://www.jointcommission.org/AccreditationPrograms/BehavioralHealthCare/Standards/09_FAQS/PC/Restraint�_Seclusion.htm. Published December 29, 2009.Accessed March 10, 2010.

6. Joint Commission on Accreditation of Healthcare Organizations.Standards for Behavioral Healthcare. Oak Brook, IL. Joint CommissionResources; 2009.

7. Sparks L, Setlick J, Luhman J. Parental holding and positioningto decrease IV distress in young children: a randomized controlledtrial. J Pediatr Nurs. 2007;22(6):440-447.

8. Antonelli MT. Restraint management: moving from outcome toprocess. J Nurs Care Quality. 2008;23(3):227-232.

9. Phillips LD. Manual of I.V. Therapeutics: Evidence-Based Practicefor Infusion Therapy. 5th ed. Philadelphia, PA: FA Davis; 2010:337.

10. Nadler-Moodie M. Clinical practice guideline: 1-hour face-to-faceassessment of a patient in a mechanical restraint. J Psychosoc Nurs.2009;47(6):37-43.

11. Martin A, Krieg H, Esposito F, Stubbe D, Cardona L. Reductionof restraint and seclusion through collaborative problem solving:a five-year prospective inpatient study. Psychiatr Serv. 2008;59(12):1406-1412.



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tion, palpation of the port should not be the onlyidentification method used.1,2 (V)

B. The nurse should be aware of the potential forcatheter rupture, which can lead to extravasation,catheter fragment emboli, and the need for portremoval and replacement. The most common riskfactors include pinch-off syndrome and powerinjection through ports not approved for this pur-pose (see Standard 51, Catheter Embolism).1-6 (V)

C. Aseptic technique, including the use of sterilegloves, should be used when accessing animplanted port. The use of a mask during accessis often recommended; however, it remains anunresolved issue due to lack of research.7-9(V)

D. The implanted vascular access port should beaccessed with the smallest-gauge noncoring nee-dle to accommodate the prescribed therapy. Toreduce risk of needle dislodgment during access,the noncoring needle should be of a length thatallows the needle to sit flush to the skin andsecurely within the port.8 (V)

E. Prior to use of the implanted vascular access portfor infusion, patency should be confirmed; thisshould include presence of a blood return andability to flush the port with preservative-free0.9% sodium chloride (USP) without evidence ofinfiltration (see Standard 48, Infiltration andExtravasation).8 (V)

F. When using an implanted vascular access port forcontinuous infusions, there is insufficient evidenceto support the optimal time for replacement of thenoncoring needle; the most common practice is toreplace the needle every 7 days.7,8 (V)

G. When an implanted vascular access port isaccessed, a transparent semipermeable membrane(TSM) dressing or gauze dressing should coverthe needle and access site. If gauze is used to sup-port the wings of an access needle and it does notobscure the needle insertion site under a TSMdressing, it can be considered a TSM dressing andchanged every 7 days (see Standard 46, VascularAccess Device Site Care and Dressing Changes).8

(V)

39. IMPLANTED VASCULARACCESS PORTS

Standard

39.1 Placement and removal of an implanted vascularaccess port shall be considered surgical procedures andmust be performed by a licensed independent practi-tioner (LIP) with validated competency operating with-in the state’s rules and regulations for professional prac-tice and according to organizational policies, proce-dures, and/or practice guidelines.39.2 The nurse shall be competent in implanted vascu-lar access port use and maintenance, including portaccess, identification of potential complications, andappropriate nursing interventions, including patient andcaregiver education and according to organizationalpolicies, procedures, and/or practice guidelines.39.3 Noncoring safety needles shall be used to accessan implanted vascular access port.39.4 Only implanted vascular access ports and noncor-ing needles designed for power injection shall be usedwith power-injection equipment for radiologic imagingin accordance with manufacturers’ directions for use.39.5 A sterile transparent semipermeable membrane(TSM) dressing or gauze dressing shall be maintainedover the access site if the implanted vascular access portremains accessed.

Practice Criteria

A. When planning to use an implanted vascularaccess port for power injection, power-injectioncapability should be identified at the time ofaccess and immediately prior to power injection.At least 2 identification methods should be used,including presence of identification cards, wrist-bands, or key chains provided by the manufactur-er; review of operative procedure documentation;and palpation of the port. While some power-injection-capable implanted vascular access portshave unique characteristics identifiable by palpa-

Access Devices


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H. The use of positive pressure during noncoring needlewithdrawal should be used to reduce blood refluxand risk of thrombotic catheter occlusion.10,11 (V)

I. General patient and/or caregiver education shouldinclude placement procedure; type of port placed(eg, power injectable, number of lumens); impor-tance of carrying port identification card (eg, in wal-let); routine care, including frequency of flushing;expectations of aseptic technique during access; useof only noncoring needles (including appropriatetype for power injection); and identification ofpotential complications and interventions.1,12 (V)

J. For patients who are receiving infusions at home viaan accessed port, patient and/or caregiver educationshould include checking the dressing daily; how todress and undress to avoid pulling at the needle site;protecting the site during bathing; making surewomen’s bra straps do not rub over the accessedarea; immediately reporting any signs or symptomsof pain, burning, stinging, or soreness at the site;and recognizing the importance of stopping the infu-sion pump and immediately reporting any wetness,leaking, or swelling noted at the site.9,13 (V)

REFERENCES

1. Smith LH. Implanted ports, computed tomography, power injec-tors, and catheter rupture. Clin J Oncol Nurs. 2008;12(5):809-812.

2. US Food and Drug Administration. Caution on CT power injec-tion MRI and CT contrast media. http://www.accessdata.fda.gov/psn/printer.cfm?id=462. Accessed May 17, 2010.

3. Dillon PA, Foglia RP. Complications associated with an implantablevascular access device. J Pediatr Surg. 2006;41(9):1582-1587.

4. Vandoni RE, Guerra A, Sanna P, et al. Randomised comparisonof complications from three different permanent central venousaccess systems. Swiss Med Wkly. 2009;139:313-316.

5. Lin CH, Wu HS, Chan DC, et al. The mechanisms of failure oftotally implantable central venous access system: analysis of 73cases with fracture of catheter. Eur J Surg Oncol. 2010;36(1):100-103.

6. Ho CL, Chou CM, Chang TK, et al. Dislodgment of port-a-cathcatheters in children. Pediatr Neonatol. 2008;49(5):179-182.

7. Karamanoglu A, Yumuk PF, Gumus M, et al. Port needles: dothey need to be removed as frequently in infusional chemotherapy?J Infus Nurs. 2003;26(4):239-242.

8. Gorski L, Perrucca R, Hunt M. Central venous access devices:care, maintenance, and potential complications. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:495-515.

9. Schulmeister L, Camp-Sorrell D. Chemotherapy extravasationfrom implanted ports. Oncol Nurs Forum. 2000;27(3):531-538.

10. Lapalu J, Losser MR, Albert O, et al. Totally implantable portmanagement: impact of positive pressure during needle with-drawal on catheter tip occlusion (an experimental study). JVascular Access. 2010;11(1):46-51.

11. Camp-Sorrell D. Access Device Guidelines: Recommendationsfor Nursing Practice and Education. 2nd ed. Pittsburgh, PA:Oncology Nursing Society; 2004.

12. Arch P. Port navigation: let the journey begin. Clin J Oncol Nurs.2007;11(4):485-488.

13. Gorski LA. Pocket Guide to Home Infusion Therapy. Sudbury,MA: Jones & Bartlett, 2005.

40. HEMODIALYSIS VASCULAR ACCESS DEVICES

Standard

40.1 Placement and removal of a tunneled or implantedhemodialysis vascular access device (VAD), including anarteriovenous (AV) fistula, and insertion of an arteriove-nous graft shall be considered surgical procedures and shallbe performed by a licensed independent practitioner (LIP)with validated competency operating within the state’srules and regulations for professional practice and accord-ing to organizational policies, procedures, and/or practiceguidelines.40.2 The nurse shall be competent in hemodialysisVAD use and maintenance, including device access,identification of potential complications, and appropri-ate nursing interventions, including patient and caregiv-er education, and according to organizational policies,procedures, and/or practice guidelines.40.3 Administration of medications and solutionsthrough a hemodialysis VAD, including AV fistulas orgrafts, shall be upon the order of a licensed independentpractitioner (LIP).40.4 Removal of a temporary nontunneled or nonim-planted hemodialysis VAD shall be performed by thenurse with validated competency, in accordance withrules and regulations promulgated by the state’s Boardof Nursing and organizational policies, procedures,and/or practice guidelines.40.5 Hemodynamic monitoring and venipuncture shallnot be performed on the extremity containing an AVfistula or graft.

Practice Criteria

A. The decision to place a hemodialysis VAD or createa means of long-term vascular access for the pur-pose of hemodialysis is ideally made collaborative-ly between the nurse, physician responsible for care,and the patient/caregiver. General order for vascu-lar access preference is fistula, arteriovenous graft,and long-term VAD.1-4 (V)

B. The nurse should be knowledgeable about vein-preservation techniques for patients who are like-ly to need vascular access for hemodialysis.1,3,5 (V)

C. The nurse should wear sterile gloves and maskwhen performing dressing changes for hemodial-ysis VADs, including AV fistulas and grafts.3,6

(V)



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D. Povidone-iodine antiseptic ointment or bacitracin/neomycin/polymyxin B ointment can be used for theexit site of a hemodialysis VAD at the end of eachdialysis session only if this ointment does not interactwith the material of the hemodialysis catheter permanufacturer’s directions for use.7 (V)

E. To minimize the potential for catheter-relatedcomplications, consideration should be given tothe size and length of the hemodialysis VAD.3 (V)

F. Hemodialysis VADs should have their tips locat-ed in the superior vena cava or right atrium andconfirmed by chest radiograph or fluoroscopy.Right atrial thrombosis is a serious complicationwith VADs placed in the right atrium.3 (V)

REFERENCES

1. American Nephrology Nurses’ Association [position statement].Vascular access for hemodialysis. http://www.nncc-exam.org/cgi-bin/WebObjects/ANNANurse.woa/wa/viewSection?s_id�

1073744052&ss_id�536873322&tName�vascAccess. AdoptedFebruary 2003. Revised February 2009. Accessed March 2, 2010.

2. Sidawy A, Spergel L, Besarab A, et al. The Society for VascularSurgery: clinical practice guidelines for the surgical placement andmaintenance of arteriovenous hemodialysis access. J Vasc Surg. 2008;48:2S-25S.

3. National Kidney Foundation. KDOQI Clinical Practice Guidelines.Selection and placement of hemodialysis access.NKF;2006.

4. Chan M, Sanchez R, Young H, Yevzlin A. Vascular access out-comes in the elderly hemodialysis population: a USRDS study.Semin Dial. 2007;20(6):606-610.

5. McCann M, Einarsdottir H, Van Waeleghem JP, Murphy F,Sedgewick J. Vascular access management 1: an overview. J RenalCare. 2008;32(2):77-84.

6. Burrows-Hudson S, Prowant Barbara, eds. Standards of Practiceand Guidelines for Care. Pitman, NJ: American NephrologyNurses’ Association; 2005.

7. National Kidney Foundation. KDOQI Guidelines. 15: Cathetercare and accessing the patient’s circulation.NKF: 2000.

41. UMBILICAL CATHETERS

Standard

41.1 Placement and removal of an umbilical arterial orvenous catheter shall be considered a surgical procedureand must be performed by a licensed independent prac-titioner (LIP) with validated competency, operatingwithin the state’s rules and regulations for professionalpractice and according to organizational policies, proce-dures, and/or practice guidelines.41.2 The nurse shall be competent in umbilical catheteruse and maintenance, including catheter access, identifi-cation of potential complications, and appropriate nurs-ing interventions, including patient and caregiver educa-tion according to organizational policies, procedures,and/or practice guidelines.

41.3 Tincture of iodine shall not be used to cleanse theumbilical catheter site because of the potential deleteri-ous effect on the neonatal thyroid.41.4 Catheter tip location shall be radiologically con-firmed before catheter use and documented in thepatient’s permanent medical record.

Practice Criteria

A. Prior to insertion, the umbilical catheter siteshould be cleansed with an appropriate antisepticsolution such as povidone-iodine.1-3 (V)

B. Umbilical artery catheters should be placed sothat the tip is located in the descending aortaabove the level of the diaphragm and below theleft subclavian artery (high positioned catheter).1-

4 (V)C. Umbilical venous catheters should be placed so

that the tip is located in the inferior vena cava,above the level of the diaphragm.1-5 (V)

D. Removal of the catheter should be performedaseptically and slowly over several minutes, andfollowed by manual compression with sterilegauze applied to the umbilical stump until hemo-stasis occurs.1-5 (V)

E. The site should be monitored after catheterremoval for at least 12 hours, and then daily forsigns of complication development.1-5 (V)

F. Infusion of medications into the umbilical arterialcatheter should be avoided.1-6 (V)

G. The nurse should be knowledgeable of the signs,symptoms, and management of potential compli-cations related to the use of umbilical cathetersincluding, but not limited to, bleeding from theumbilical stump, hemorrhage, air embolism, infec-tion, thrombosis, vascular perforation, and periph-eral vascular constriction. The nurse should reportcomplications to the LIP and document them in thepatient’s permanent medical record.1-6 (V)

REFERENCES

1. Barrington KJ. Umbilical artery catheters in the newborn: effectsof position of the catheter tip (Cochrane Review). In: TheCochrane Library.(3);2004. Chichester, UK: John Wiley & Sons.


3. Smith L, Dills R. Survey of medication administration throughumbilical arterial and venous catheters. Am J Health-Syst Pharm.2003;60(15):1569-1572.

4. Jackson J, Biondo D, Jones J, et al. Can an alternative umbilicalarterial catheter solution and flush regimen decrease iatrogenichemolysis while enhancing nutrition? A double-blind, randomizedclinical trial comparing an isotonic amino acid with a hypotonicsalt infusion. Pediatrics. 2004;114;377-383.

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5. Shah P, Shah V. Continuous heparin infusion to prevent throm-bosis and catheter occlusion in neonates with peripherally placedpercutaneous central venous catheters Cochrane Database SystRev. 2005;(3):CD002772.

6. Shah PS, Ng E, Sinha AK. Heparin for prolonging peripheralintravenous catheter use in neonates (Cochrane Review) In: TheCochrane Library. (2);2004. Chichester, UK: John Wiley & Sons.

42. APHERESIS AND ULTRAFILTRATIONCATHETERS

Standard

42.1 Placement and removal of apheresis or ultrafiltra-tion catheters shall be performed by a nurse or licensedindependent practitioner (LIP) with validated compe-tency operating within the state’s rules and regulationsfor professional practice and according to organization-al policies, procedures, and/or practice guidelines.42.2 Indications and protocols for the insertion of orassisting with, use, and care of apheresis or ultrafiltra-tion catheters shall be established in organizational poli-cies, procedures, and/or practice guidelines.42.3 The nurse shall be competent in apheresis andultrafiltration catheter use and maintenance, includingidentification of potential complications, and appropriateinterventions, including patient and caregiver education.42.4 Apheresis or ultrafiltration catheters shall not beused for medication or solution administration.

Practice Criteria

A. A large-bore central catheter, percutaneously orsurgically placed, designed to maintain high flowrates and accommodate large blood volumesshould be selected and inserted in patients withinadequate peripheral vein access (adult or pedi-atric) for the purpose of apheresis.1-7 (IV)

B. If using a peripheral approach for apheresis, 2large-gauge intravenous catheters should beinserted for collection and reinfusion. A multilu-men apheresis central catheter should allow forrepeated apheresis procedures and provide a mul-tipurpose approach to accommodate long-terminfusion needs and supportive care.4,6,8 (IV)

C. The tip of the apheresis central catheter, if placedin the subclavian or internal jugular vein, shouldreside at the junction of the superior vena cavaand right atrium.8-15 (V)

D. Ultrafiltration is used to remove excess salt andwater in patients with fluid overload, particularlyin patients with congestive heart failure in whichconventional treatments have not been effective.This process typically uses a dual-lumen vascularaccess device.16-18 (V)

E. The nurse should be knowledgeable of potentialcomplications of apheresis/ultrafiltration cathetersand the apheresis/ultrafiltration process, alongwith appropriate nursing interventions. Potentialcomplications include, but are not limited to, cen-tral vascular access device (CVAD) mechanicaldysfunction; thrombosis; infection; hypotension;electrolyte imbalance; fluid overload; thrombocy-topenia; hypocalcemia; photosensitivity, and cit-rate toxicity.1-5,12,14,15 (IV)

F. The nurse should provide the patient and caregivereducation related to apheresis/ultrafiltration catheterinsertion procedure; reason for the CVAD; use,maintenance, and care; expected dwell time of thecatheter; potential insertion; mechanical or infectiouscomplications; and document teaching in thepatient’s permanent medical record.1-3 (V)

REFERENCES

1. Leighton S. The spin on apheresis. Nursing. 2008;38(4):29-31.2. Lopez J, Hausz M. Therapeutic apheresis. Am J Nurs. 1982;82(10):

1572-1578.3. Meehan K, Areman E, Ericson S, et al. Mobilization, collection

and processing of autologous peripheral blood stem cells: devel-opment of a clinical process with associated costs. J HematotherapyStem Cell Res. 2000;9:767-771.

4. Madero L, Diaz MA, Benito A, Villa M, Valdivielso A. Non-tunneledcatheters for the collection and transplantation of peripheral bloodstem cells in children. Bone Marrow Transplant. 1997;20(1):53-59.

5. Fontana S, Groebli R, Leibundgut K, et al. Progenitor cell recruit-ment during individualized high-flow, very large-volume aphere-sis for autologous transplantation improves cell efficiency.Transfusion. 2006;46(8):1408-1416.

6. Lazarus HM, Trehan S, Miller R, Fox RM, Creger RF, Raaf JH.Multi-purpose silastic dual-lumen central venous catheters forboth collection and transplantation of hematopoietic progenitorcells. Bone Marrow Transplant. 2000;25(7):779-785.


8. Restrepo A, Devore P, Encarnacion CE, et al. Performance of ahybrid central venous catheter utilized for both progenitor bloodstem cell harvest and transplant support of patients undergoingautologous peripheral blood stem cell transplantation. BoneMarrow Transplant. 2002;30(6):389-395.

9. Kapustay P. Blood cell transplantation: concepts and concerns.Semin Oncol Nurs. 1997;13(3):151-163.

10. Mareiras-Plaza M, Albo C, Ares C. Efficacy and safety of femoralvascular access for peripheral blood stem cell (PBSC) collection.Bone Marrow Transplant. 2004;33(3):347-350.

11. Canuad B. Long-term catheters for dialysis and apheresis: a dou-ble-edged weapon. Ther Apheresis Dial. 2003;7(2):147-149.

12. Stephens LC, Haire WD, Tarantolo S, et al. Normal saline versusheparin flush for maintaining central venous catheter patencyduring apheresis collection of peripheral blood stem cells (PBSC).Transfus Sci.1997;18(2):187-193.

13. Meisenberg B, Callaghan M, Sloan C, et al. Complications associat-ed with central venous catheters used for the collection of peripheral



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blood progenitor cells to support high-dose chemotherapy andautologous stem cell rescue. Support Care Cancer. 1997;5:223-227.

14. Young E, Contreras G, Robert N, Vogt N, Courtney T. Incidenceand influencing factors associated with exit site infections in tem-porary catheters for hemodialysis and apheresis. Nephrol Nurs J.2005;32(1):41-62.

15. Saif MW, Leitman SF, Cusack G, et al. Thromboembolism fol-lowing removal of femoral venous apheresis catheters in patientswith breast cancer. Ann Oncol. 2004;15:1366-1372.

16. Hunt SA, Abraham WT, Chin M, et al. 2009 focused update:ACCF/AHA guidelines for the diagnosis and management of heartfailure in adults. J Am Coll Cardiol. 2009;53(15):1343-1382.

17. Walsh CT, Wagemester D. Peripheral ultrafiltration for patientswith volume overload: a center’s 4-year experience. Crit Care NursQ. 2007;30:329-336.

18. Andrade JG, Stadnick E, Virani SA. The role of peripheral ultra-filtration in the management of acute decompensated heart fail-ure. Blood Purif. 2010;29:177-182.

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or blood products should be changed no more fre-quently than every 96 hours. There is strong evi-dence that changing the administration sets more fre-quently does not decrease the risk of infection.2-3 (I)

B. Extending the administration set change to every7 days may be considered when an anti-infectivecentral vascular access device (CVAD) is beingused or if fluids that enhance microbial growthare not administered through the set.3,4 (II)

C. If a secondary administration set is detached fromthe primary administration set, the secondaryadministration set is considered a primary inter-mittent administration set and should be changedevery 24 hours (see Practice Criteria III, PrimaryIntermittent Infusions).1 (V)

D. When compatibility of infusates is verified, use ofsecondary administration sets that use back-prim-ing infusion methods are preferred due to reducedneed for disconnecting secondary intermittentadministration sets.1 (V)

Practice Criteria

III. Primary Intermittent Infusions

A. Primary intermittent administration sets should bechanged every 24 hours. When an intermittentinfusion is repeatedly disconnected and reconnect-ed for the infusion, there is increased risk of cont-amination at the catheter hub, needleless connec-tor, and the male luer end of the administrationset, potentially increasing risk for catheter-relatedbloodstream infection. There is an absence ofstudies addressing administration set changes forintermittent infusions. In a meta-analysis of 12randomized, controlled trials that supportedincreasing the time interval for administration setchanges to 96 hours, at least 2 of the studiesexcluded administration sets used for heparin-locked catheters and in sets disconnected for morethan 4 hours. In several others, exclusions werenot stated.1,5 (V)

B. A new, sterile, compatible covering device shouldbe aseptically attached to the end of the adminis-tration set after each intermittent use. The practice

43. ADMINISTRATION SETCHANGE

Standard

43.1 Administration set changes shall be performed rou-tinely, based on factors such as type of solution adminis-tered, type of the infusion (continuous versus intermittent),immediately upon suspected contamination, or when theintegrity of the product or system has been compromised.43.2 The administration set shall be changed wheneverthe peripheral catheter site is rotated or when a newcentral vascular access device is placed.43.3 Add-on devices used as part of the administration set,such as single- and multilumen extension sets and filters,shall be changed at the same time as the administration set.43.4 The frequency of performing administration setchanges and the system used to promote adherence toadministration set change (eg, labeling/electronic) shallbe established in organizational policies, procedures,and/or practice guidelines.43.5 A vented administration set shall be used for solutionssupplied in glass or semi-rigid containers, and a nonventedadministration set shall be used for plastic fluid containers.43.6 All administration sets shall be of luer-lock designto ensure a secure junction.

Practice Criteria

I. General

A. The use of add-on devices for administration setsshould be minimized as each device is a potentialsource of contamination, misuse, and disconnection;it is preferable to use an administration set withdevices as an integral part of the set (see Standard26, Add-on Devices).1 (V)

Practice Criteria

II. Primary and Secondary ContinuousInfusions

A. Primary and secondary continuous administrationsets used to administer fluids other than lipid, blood,

Site Care and Maintenance


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of attaching the exposed end of the administrationset to a port on the same set (“looping”) should beavoided.1,5 (V)

Practice Criteria

IV. Parenteral Nutrition

A. Administration sets used for nonlipid-containing par-enteral nutrition (PN) solutions should be routinelychanged no more often than every 96 hours.2,6 (I)

B. Administration sets used for total nutrient admix-tures (TNA) containing intravenous fat emulsions(IVFE) with the amino acid and dextrose solutionshould be routinely changed every 24 hours.2,6 (III)

C. When primary administration sets used for PNare exposed to IVFE, consideration should bemade to changing the administration set every 24hours. Limited evidence suggests an increased riskfor infection when duration of administration setsis extended beyond 24 hours.7 (III)

Practice Criteria

V. Intravenous Fat Emulsions (IVFE) andOther Lipid Product Infusions

A. When units of IVFE are administered intermit-tently, the administration set should be changedwith each new container; the characteristics ofIVFE (iso-osmotic, near neutral-alkaline pH, andcontaining glycerol) are conducive to the growthof microorganisms.6,8 (III)

B. When units of IVFE are administered consecutive-ly, the administration set should be routinelychanged every 24 hours.6 (III)

C. A dedicated administration set should be used toadminister propofol infusions and should bereplaced every 12 hours, when the vial is changed,and according to the manufacturer’s directions foruse.8 (Regulatory)

D. Administration sets used to administer lipid-basedinfusates, such as IVFE or TNA, should be free of di-ethylhexyl-phthalate (DEHP). DEHP is lipophilic andis extracted into the lipid solution with commonlyused polyvinyl chloride administration sets and con-tainers. DEHP is considered a toxin, and studies havedemonstrated increased DEHP levels in lipid solu-tions, which is especially a risk with neonatal, pedi-atric, and long-term home care patients.6,9-13 (IV)

Practice Criteria

VI. Blood and Blood Components

A. Administration sets used for blood and blood com-ponents should be specific to blood transfusion and

include a filter; the administration sets should bereplaced every 4 hours (see Standard 28, Filters).14

(IV)

Practice Criteria

VII. Hemodynamic and Arterial PressureMonitoring

A. The disposable or reusable transducer and/ordome and other components of the system, includ-ing the administration set, continuous flush device,and flush solution used for invasive hemodynamicpressure monitoring, are considered a closed sys-tem and should be changed every 96 hours, imme-diately upon suspected contamination, or whenthe integrity of the product or system has beencompromised. The number of manipulations andentries into the system should be minimized.15 (III)

REFERENCES

1. Hadaway L. Infusion therapy equipment. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing:An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:391-436.

2. Gillies D, O’Riordan L, Wallen M, Morrison A, Rankin K, NagyS. Optimal timing for intravenous administration set replace-ment. Cochrane Database Syst Rev. 2005;(4):CD003588.

3. Rickard CM, Lipman J, Courtney M, et al. Routine changing ofintravenous administration sets does not reduce colonization or infec-tion in central venous catheters. Infect Control Hosp Epidemiol.2004;25;650-655.

4. Raad I, Hanna HA, Awas A, et al. Optimal changing of intra-venous administration sets: is it safe to prolong use beyond 72hours? Infect Control Hosp Epidemiol. 2001;22(3):136-139.

5. Institute for Safe Medication Practices. Failure to cap IV tubingand disconnect IV ports place patients at risk for infections.Medication Safety Alert! Published July 26, 2007. Accessed June17, 2010.

6. Mirtallo J, Canada T, Johnson D, et al. Safe practices for parenter-al nutrition. J Parenter Enteral Nutr. 2004;28(suppl):S39-S70.

7. Matlow AG, Kitai I, Kirpalani H, et al. A randomized trial of 72-versus 24-hour intravenous tubing set changes in newborns receiv-ing lipid therapy. Infect Control Hosp Epidemiol. 1999;20(7):487-493.

8. Diprivan injectable emulsion [package insert]. Wilmington, DE:Astrazeneca; 2008. http://www.accessdata.fda.gov/drugsatfda_docs/label/2008/019627s046lbl.pdf. Accessed January 30, 2010.

9. Loff S, Subotic U, Reinick F, et al. Extraction of di-ethylhexyl-phthalate from perfusion lines of various material, length, andbrand by lipid emulsions. J Pediatr Gastroenterol Nutr. 2004;39(4):341-345.

10. Loff S, Subotic U, Reinick F, et al. Extraction of di-ethylhexyl-phthalate by home total parenteral nutrition from polyvinyl chlo-ride infusion lines commonly used in the home. J PediatrGastroenterol Nutr. 2008;47(1):81-86.

11. Pak VM, Nailon RE, McCauley LA. Controversy: neonatal expo-sure to plasticizers in the NICU. MCN Am J Maternal ChildNurs. 2007;32(4):244-249.



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12. Kambia K, Gressier B, Bah S, et al. Evaluation of childhood expo-sure to di(2-ethylhexyl) phthalate from perfusion kits during longterm parenteral nutrition. Int J Pharm. 2003;262(1-2):83-91.

13. US Food and Drug Administration. FDA public health notification:PVC devices containing the plasticizer DEHP, 2002. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/UCM062182. Accessed March 2, 2010.

14. AABB. Standards for Blood Banks and Transfusion Services. 26thed. Bethesda, MD: AABB; 2009.

15. Centers for Disease Control and Prevention (CDC). Guidelines forthe prevention of intravascular catheter-related infections.MMWR Morb Mortal Wkly Rep. 2002;51(RR-10):18.

44. VASCULAR ACCESS DEVICE REMOVAL

Standard

44.1 Removal of a vascular access device (VAD) shallbe performed upon the order of the licensed indepen-dent practitioner (LIP), in accordance with the rules andregulations as promulgated by the state’s Board ofNursing, organizational policies, procedures, and/orpractice guidelines, or immediately upon suspected con-tamination or complication.44.2 The nurse shall be competent in the process of VADremoval, including identification of potential complica-tions, and appropriate nursing interventions and/or emer-gency measures as needed, and patient and caregiver edu-cation.44.3 VADs shall be removed upon unresolved compli-cation, therapy discontinuation, or if deemed unneces-sary.44.4 VADs placed in an emergency situation shall bereplaced as soon as possible and not later than 48 hours.44.5 The frequency of short peripheral catheter removalfor the purpose of site rotation shall be established inorganizational policies, procedures, and/or practice guide-lines.44.6 Removal of an implanted port shall be considereda surgical procedure and shall be performed by an LIPwith validated competency operating within the state’srules and regulations for professional practice, andaccording to organizational policies, procedures, and/orpractice guidelines.

Practice Criteria

I. Short Peripheral Catheters

A. The nurse should consider replacement of theshort peripheral catheter when clinically indicatedand when infusion treatment does not includeperipheral parenteral nutrition. The decision toreplace the short peripheral catheter should be

based on assessment of the patient’s condition;access site; skin and vein integrity; length and typeof prescribed therapy; venue of care; integrity andpatency of VAD; dressing; and stabilizationdevice.1-10 (I)

B. The nurse should not routinely replace shortperipheral catheters in pediatric patients.11 (IV)

C. Caution should be used in the removal of a shortperipheral catheter. Digital pressure should beapplied until hemostasis is achieved, and a dress-ing should be applied to the access site.1 (V)

D. With any patient reports of discomfort or painrelated to the short peripheral catheter, thecatheter should be removed. The LIP should benotified if unable to restart the short peripheralcatheter or a delay in medication administrationoccurs.1,12 (V)

E. If a catheter-related bloodstream infection (CR-BSI) is suspected, consideration should be given toculturing the catheter after removal (see Standard49, Infection).2,12 (V)

F. If a vesicant medication has extravasated, treatmentshould be determined prior to catheter removal.The nurse should aspirate the remaining drug fromthe catheter prior to removal (see Standard 48,Infiltration and Extravasation).2,13 (V)

Practice Criteria

II. Midline Catheters

A. The midline catheter is indicated for those periph-eral infusion therapies prescribed for a durationof 1-4 weeks. For therapies requiring catheterdwell times greater than 4 weeks, extension ofcatheter dwell should be based on the profession-al judgment of the nurse after consideration of thefollowing factors including, but not limited to,length and type of therapy remaining, peripheralvascular status, condition of the vein in which thecatheter is indwelling, skin integrity, and patientcondition.2,14 (V)

B. Removal of a midline catheter should be deter-mined by patient condition, completion or changeof therapy administered, presence of infectious orinflammatory process, catheter malposition, orcatheter dysfunction. Midline catheters should beremoved if the tip location is no longer appropri-ate for the prescribed therapy.1,2,12 (V)

C. Caution should be used in the removal of a mid-line catheter. Digital pressure should be applieduntil hemostasis is achieved, and a petroleum-based ointment and a sterile dressing should beapplied to the access site to seal the skin-to-veintract and decrease risk of air embolus.1 (V)

D. If a catheter-related complication is suspected, anassessment of the patient and catheter should



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occur. If unable to resolve the complication, orthe complication warrants removal, after collabo-ration with the health care team, the midlinecatheter should be removed.1 (V)

E. With any patient reports of discomfort or painrelated to the midline catheter, the patient andcatheter should be assessed and appropriate inter-ventions performed. The LIP should be notified.When interventions are unsuccessful, the cathetershould be removed.1,2,12 (V)

Practice Criteria

III. Nontunneled Central Vascular AccessDevices (CVADs)*

A. Daily assessment of CVAD need and removal whenno longer needed are components of the central linebundle known to decrease risk of infection. Themaximum dwell time of a nontunneled CVAD isunknown; ongoing and daily monitoring of thedevice necessity should be performed.12,15-17 (II)

B. Removal of a nontunneled CVAD should be deter-mined by patient condition, completion of therapy,presence of infectious or inflammatory process,catheter malposition, or catheter dysfunction.12,17

(V)C. The decision to remove or salvage a catheter due

to suspected or confirmed catheter-related blood-stream infection (CR-BSI) should be based onblood culture results, specific type of culturedorganism, patient’s current condition, availablevascular access sites, effectiveness of antimicro-bial therapy, and LIP direction (see Standard 49,Infection).12 (V)

D. The CVAD should be removed after patientassessment and in collaboration with the healthcare team if a catheter-related complication is sus-pected and interventions are unsuccessful.17 (V)

E. A CVAD with a malpositioned catheter tip loca-tion that cannot be repositioned to a central veinshould be removed.17 (V)

F. Caution should be used in the removal of a non-tunneled CVAD, including precautions to preventair embolism. Digital pressure should be applieduntil hemostasis is achieved by using manualcompression and/or other adjunct approachessuch as hemostatic pads, patches, or powders thatare designed to potentiate clot formation. Thenurse should apply petroleum-based ointmentand a sterile dressing to the access site to seal theskin-to-vein tract and decrease the risk of airembolus. When removing the CVAD, the nurseshould position the patient so that the CVADinsertion site is at or below the level of the heart

to reduce the risk of air embolus (see Standard 50,Air Embolism).17-22 (IV)

G. If resistance is encountered when the catheter isbeing removed, the catheter should not be forciblyremoved, and the LIP should be notified and dis-cussion should occur related to initiating appropri-ate interventions for successful removal.2,23,24 (V)

H. With any patient reports of discomfort or painrelated to the CVAD, the patient and CVAD shouldbe assessed, appropriate interventions performed,and the LIP notified. When interventions are unsuc-cessful, the CVAD should be removed.17-18 (V)

I. Coagulation studies, such as the InternationalNormalized Ratio (INR), are not routinely neces-sary for the removal of a CVAD.25 (IV)

Practice Criteria

IV. Surgically Placed CVADs:Tunneled/Implanted Ports

A. The maximum dwell time of a surgically placedCVAD is unknown; ongoing and frequent monitor-ing of the access site should be done as well as ongo-ing assessment of need. When no longer necessary,the surgically placed CVAD should be removed.17 (V)

B. The decision to remove or salvage a CVAD due tosuspected or confirmed CR-BSI should be based onblood culture results, specific type of cultured organ-ism, patient’s current condition, available vascularaccess sites, effectiveness of antimicrobial therapy,and LIP direction (see Standard 49, Infection).11,13 (V)

C. If a catheter-related complication occurs (eg, cuffexposure, dislodgment, infection) and interven-tions are unsuccessful, the catheter should beremoved after patient assessment and in collabo-ration with the health care team.2,11-13 (V)

D. If resistance is encountered when the tunneledCVAD is being removed, the device should not beforcibly removed, and further collaboration withthe health care team should occur.17,23,26 (IV)

E. After removal, the nurse should continue to mon-itor the site, implement interventions as necessary,provide patient education, and document obser-vations and actions in the patient’s permanentmedical record.17,18 (V)

F. Coagulation studies, such as the InternationalNormalized Ratio (INR), are not routinely necessaryfor the removal of a tunneled catheter or implantedport.25 (IV)

Practice Criteria

V. Arterial Catheters

A. Arterial catheters should not be routinelyremoved or replaced.27 (V)



*Includes PICCs.

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B. When a peripheral arterial catheter is removed,digital pressure should be applied until hemostasisis achieved by using manual compression and/orother adjunct approaches such as hemostatic pads,patches, or powders that are designed to potenti-ate clot formation. A sterile dressing should beapplied to the access site. Prolonged digital pres-sure and adjunct hemostatic approaches may needto be applied in patients with coagulation abnor-malities or femoral arterial catheters.2,20-22 (IV)

C. The nurse should assess and document the circu-latory status distal to the area of cannulation afterremoval of the peripheral arterial catheter.2 (V)

REFERENCES


2. Camp-Sorrell D, ed. Access Device Guidelines: Recommendationsfor Nursing Practice and Education. 2nd ed. Pittsburgh, PA:Oncology Nursing Society; 2004.

3. Gallant P, Schultz A. Evaluation of a visual infectious phlebitisscale for determining appropriate discontinuation of peripheralintravenous catheters. J Infus Nurs. 2006;9(6):338-345.

4. White S. Peripheral intravenous therapy-related phlebitis rates inan adult population. J Infus Nurs. 2001;24(1):19-24.

5. Idvall E, Gunningberg L, Idvall E, Gunningberg L. Evidence forelective replacement of peripheral intravenous catheters to pre-vent thrombophlebitis: a systematic review. J Adv Nurs. 2006;55(6):715-722.

6. Webster J, Osborne S, Rickard C, Hall J. Clinically indicatedreplacement versus routine replacement of peripheral venouscatheters. In: The Cochrane Collaboration. Chichester, England:John Wiley & Sons, The Cochrane Library; 2010(3).

7. Lee W, Chen H, Tsai T, et al. Risk factors for peripheral intra-venous infections in hospitalized patients: a prospective study of3165 patients. Am J Infect Control. 2009;37(8):683-686.

8. Powell J, Tarnow KG, Perucca R. The relationship betweenperipheral intravenous catheter dwell time and the incidence ofphlebitis. J Infus Nurs. 2008;31(1):39-45.

9. Zingg W, Pittet, D. Peripheral venous catheters: an under-evalu-ated problem. Int J Antimicrob Agents. 2009;34S:S38-S42.

10. Bregenzer T, Conen D, Sakiman P, Widmer A. Is routine replace-ment of peripheral intravenous catheters necessary? Arch IntMed. 1998;158(2):151-156.

11. Pediatric intravenous therapy. In: Weinstein S, ed. Plumer’sPrinciples & Practice of Intravenous Therapy. 7th ed. Philadelphia,PA: Lippincott Williams & Wilkins; 2007:621.

12. Mermel l, Allon M, Bouza E, et al. Clinical practice guidelines forthe diagnosis and management of intravascular catheter-relatedinfection: 2009 update by the Infectious Disease Society ofAmerica. Clin Infect Dis. 2009;49:1-45.

13. Schulmeister L. Antineoplastic therapy. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:351-371.

14. Infusion Nurses Society [position paper]. Midline and midclavic-ular catheters. J Infus Nurs. 1997;20(4):175.

15. Institute for Healthcare Improvement. 100,000 Lives campaign,2005-2006. www.ihi.org. Accessed January 30, 2010.

16. Pronovost PJ, Goeschel CA, Colantuoni E, et al. Sustaining reduc-tions in catheter related bloodstream infections in Michigan inten-sive care units: observational study. Br Med J. 2010;340:c309.

17. Gorski L, Perucca R, Hunter M. Central venous access devices:care, maintenance, and potential complications. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:495-515.

18. Managing central venous catheter therapy. In: Doyle R, Nale P,eds. Handbook of Infusion Therapy. Springhouse, PA:Springhouse; 1999:114-141.

19. Boer W, Hene R. Lethal air embolus following removal of a dou-ble lumen jugular vein catheter. Nephrol Dial Transplant.1999;14(8):1850-1852.

20. Wang DS, Chu LF, Olson SE, et al. Comparative evaluation ofnoninvasive compression adjuncts for hemostasis in percutaneousarterial, venous, and arteriovenous dialysis access procedures. JVascular Intervent Radiol. 2008;19(1):72-79.

21. Pahari M, Moliver R, Lo D, et al. QuikClot interventional hemo-static bandage (QCI): a novel hemostatic agent for vascularaccess. Cath Lab Digest. January 2010.

22. Kheirabadi BS, Scherer MR, Estep S, et al. Determination of effi-cacy of new hemostatic dressings in a model of extremity arterialhemorrhage in swine. J Trauma Inj Infect Crit Care. 2009;67(3):450-460.

23. Makhiza N, Choudhury M, Kiran U, et al. The stuck centralvenous catheter: a word of caution. Heart Lung Circ. 2008;17:417-436.

24. Petit J, Wyckoff M. National Association of Neonatal Nurses.Peripherally Inserted Central Catheter Guidelines for Practice.2nd ed. Glenview, IL: National Association of Neonatal Nurses;2007.

25. Stecker M, Johnson M, Ying J, et al. Time to hemostasis aftertraction removal of tunneled cuffed central venous catheters. J Vascular Intervent Radiol. 2007;18(10):1232-1239.

26. Lee AC. Elective removal of cuffed central venous catheters inchildren. Support Care Cancer. 2007;15:897-901.

27. Centers for Disease Control and Prevention (CDC). Guidelinesfor he prevention of intravascular catheter-related infections.MMWR Morb Mort Wkly Rpt. 2002;51(RR-10):1-26.

45. FLUSHING AND LOCKING

Standard

45.1 Vascular access devices shall be flushed prior to each infusion as part of the steps to assess catheter function.45.2 Vascular access devices shall be flushed after eachinfusion to clear the infused medication from thecatheter lumen, preventing contact between incompati-ble medications.45.3 Vascular access devices shall be locked after com-pletion of the final flush solution to decrease the risk ofocclusion.45.4 Flushing and locking of all vascular access devicesshall be established in organizational policies, procedures,



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and/or practice guidelines and in accordance with manu-facturers’ directions for use.

Practice Criteria

A. Single-use systems include single-dose vials and prefilledsyringes and are the preferred choices for flushing andlocking. If multiple-dose containers must be used, eachcontainer should be dedicated to a single patient.1-3 (IV)

B. Flushing is accomplished with preservative-free0.9% sodium chloride (USP). When the medicationis incompatible with preservative-free 0.9% sodi-um chloride (USP), 5% dextrose in water should beused and followed by flushing with preservative-free 0.9% sodium chloride (USP) and/or heparinlock solution. Dextrose should be flushed from thecatheter lumen because it can provide nutrients forbiofilm growth.4 (IV)

C. Bacteriostatic 0.9% sodium chloride contains ben-zyl alcohol as the preservative. The maximum vol-ume that can be tolerated by adult and pediatricpatients is undetermined; however, one study sug-gests that this should not exceed 30 mL in a 24-hourperiod for adults.1,2 (IV)

D. The minimum volume of preservative-free 0.9%sodium chloride (USP) for catheter flushing dependsupon the type and size of catheter, age of the patient,and type of infusion therapy being given. A minimumvolume of twice the internal volume of the cathetersystem is recommended; however, a larger volumemay be needed for blood sampling or blood transfu-sion procedures.3-5 (V)

E. The nurse should aspirate the catheter for blood returnas a component of assessing catheter function prior toadministration of medications and solutions (seeStandard 61, Parenteral Medication and SolutionAdministration) 6-8 (V)

F. Due to varying degrees of physiologic maturity fordrug metabolism and excretion in the neonate,solutions used for flushing and/or locking cathetersshould not contain the preservative benzyl alco-hol.5,7,8 (IV)

G. If resistance is met and/or no blood return noted,the nurse should take further steps to assesspatency of the catheter prior to administration ofmedications and solutions. The catheter shouldnot be forcibly flushed (see Standard 56, CatheterClearance).3,6 (V)

H. To prevent catheter damage, the size of the syringeused for flushing and locking should be in accor-dance with the catheter manufacturer’s directionsfor use. Patency is assessed with a minimum 10-mLsyringe filled with preservative-free 0.9% sodiumchloride (USP). Flush syringes holding a smallervolume and/or designed to generate lower amountsof pressure may also be used to assess patency.

Administration of small quantities of medicationshould be given in a syringe appropriately sized forthe dose required following confirmation ofcatheter lumen patency.9-11 (V)

I. Prefilled syringes filled with preservative-free0.9% sodium chloride (USP) should not be usedfor dilution of medications. Due to risk of seriousmedication errors, syringe-to-syringe drug trans-fer is not recommended.12-14 (V)

J. Short peripheral catheters should be locked withpreservative-free 0.9% sodium chloride (USP) fol-lowing each catheter use in adults and children.15-17(I)

K. No specific recommendation can be made about theuse of heparin lock solution or preservative-free0.9% sodium chloride (USP) for locking shortperipheral catheters in neonatal patients. Data areinconsistent and inadequate to make specific recom-mendations.18-21 (V)

L. The nurse should assess for contraindications for theuse of heparin lock solution including, but not lim-ited to, presence or risk for heparin-induced throm-bocytopenia, heparin’s impact on laboratory studiesdrawn from the catheter, and systemic anticoagula-tion. Heparin-induced thrombocytopenia (HIT) hasbeen reported with the use of heparin flush solu-tions, although the exact rates are unknown. Allpatients should be monitored closely for signs andsymptoms of HIT. If present or suspected, heparinand all sources of heparin (ie, heparin-coatedcatheters) should be discontinued.22-30 (IV)

M.For postoperative patients receiving heparin locksolutions of any concentration, monitoringplatelet counts for heparin-induced thrombocy-topenia (HIT) is recommended every 2 to 3 daysfrom day 4 through day 14 or until the heparin isstopped. For medical patients receiving heparinlock solutions, routine platelet count monitoringis not recommended.31 (II)

N. The use of preservative-free 0.9% sodium chloride(USP) for locking catheters with an integral pres-sure-sensitive valve system is recommended bymanufacturers’ directions for use, although thecontinued use of heparin lock solution has alsobeen suggested. There are multiple designs of thesevalves located on the internal catheter tip and theexternal catheter hub. Available data are inconclu-sive and conflicting.32-38 (II)

O. While many studies report equivalent outcomes incentral vascular access catheters when lockedwith heparin lock solution or preservative-free0.9% sodium chloride (USP), others have report-ed greater complications with saline locking. Dueto the risk and costs associated with central vas-cular access device (CVAD) insertion, heparinlock solution 10 units/mL is the preferred locksolution after each intermittent use.26,39-44(III)



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P. Before removal of an access needle from animplanted port and/or for periodic access andflushing, the device should be locked with heparinlock solution 100 units/mL.3,45 (V)

Q. Catheters used for hemodialysis should be lockedwith heparin lock solution 1000 units/mL aftereach use.30,46 (IV)

R. Catheters used for apheresis procedures are large-bore catheters and require rapid flow rates; theprocedure has an impact on coagulation factors.The flushing and locking procedures for thesecatheters should follow the same practices ashemodialysis catheters.47,48 (V)

S. Patency of arterial catheters used for hemody-namic monitoring is greater when heparin solu-tion is infused, although existing studies areinconclusive due to variations in the catheter’slocation (peripheral versus pulmonary), durationof catheter use, and differences in patency mea-surement. The decision to use preservative-free0.9% sodium chloride (USP) instead of heparininfusion should be based on the clinical risk ofcatheter occlusion, the anticipated length of timethe arterial catheter will be required, and patientfactors such as heparin sensitivities.49 (II)

T. Concentrations of heparin less than or equal to 1unit/mL should be used as an infusion in umbilicalarterial catheters in neonates; however, heparinizedflush or locking solution is not effective.50 (II)

U. Positive fluid displacement within the lumen of thecatheter should be maintained to prevent reflux ofblood upon luer disconnection. This is accom-plished with either a flushing technique or aneedleless connector designed to overcome bloodreflux.11,51 (V)

V. Alternative locking solutions may be consideredin patients with HIT including, but not limited to,ethanol, sodium citrate, taurolidine, ethylenedi-amine-tetraacetate (EDTA), or combinations ofthese solutions. These solutions are not commer-cially available in single-use containers and do nothave a labeled indication for maintaining catheterpatency. These locking solutions should beobtained from a compounding pharmacy.52-63 (II)

W. Antibiotic lock solution may be used for salvageof an infected long-term CVAD in the absence ofa tunnel or port-pocket infection. High concen-trations of vancomycin, ceftazidime, cefazolin,ciprofloxacin, gentamicin, and ampicillin havebeen reported to be effective when used in con-junction with systemic antibiotics. Drug precipita-tion is possible when heparin is added to theselock solutions. The length of dwell time for thelock solution and the duration of treatmentdepends on the need to use the catheter for infu-sion and the clinical response. Use of antibiotic

lock solution is not recommended as a routineprophylactic measure due to the possibility ofdevelopment of resistant strains of microorgan-isms and adverse reactions to the high concentra-tion of lock solution. Prophylactic use may beconsidered in patients with a history of catheter-related bloodstream infections or those with otherrisk factors such as a prosthetic heart valve.63-66 (I)

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62. Bradshaw JH, Puntis JW. Taurolidine and catheter-related blood-stream infection: a systematic review of the literature. J PediatrGastroenterol Nutr. 2008;47(2):179-186.

63. Labriola L, Crott R, Jadoul M. Preventing haemodialysiscatheter-related bacteraemia with an antimicrobial lock solution:a meta-analysis of prospective randomized trials. Nephrol DialTransplant. 2008;23(5):1666-1672.

64. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelinesfor the diagnosis and management of intravascular catheter-relat-ed infection: 2009 update by the Infectious Diseases Society ofAmerica. Clin Infect Dis. 2009;49(1):1-45.

65. Marschall J, Mermel LA, Classen D, et al. Strategies to preventcentral line-associated bloodstream infections in acute care hospi-tals. Infect Control Hosp Epidemiol. 2008;29(suppl 1):S22-S30.

66. Barsanti MC, Woeltje KF. Infection prevention in the intensivecare unit. Infect Dis Clin North Am. 2009;23(3):703-725.

46. VASCULAR ACCESS DEVICESITE CARE AND DRESSINGCHANGES

Standard

46.1 Vascular access device (VAD) site care and dress-ing changes, including frequency of procedure and typeof antiseptic and dressing, shall be established in orga-nizational policies, procedures, and/or practice guide-lines.46.2 The nurse shall be competent in performing VADsite care and dressing changes.46.3 VAD site care and dressing changes shall be per-formed at established intervals and immediately if thedressing integrity becomes compromised, if moisture,

drainage, or blood is present, or if signs and symptomsof site infection are present.46.4 A sterile dressing shall be applied and maintainedon VADs.

Practice Criteria

A. Routine site care and dressing changes are notperformed on short peripheral catheters unlessthe dressing is soiled or no longer intact.1 (V)

B. Central vascular access device (CVAD) site careand dressing changes should include the follow-ing: removal of the existing dressing, cleansing ofthe catheter-skin junction with appropriate anti-septic solution(s), replacement of the stabilizationdevice if used, and application of a sterile dressing(see Standard 36, Vascular Access DeviceStabilization).2-4 (V)

C. Chlorhexidine solution is preferred for skin antisep-sis as part of VAD site care. One percent to two per-cent tincture of iodine, iodophor (povidone-iodine),and 70% alcohol may also be used. Chlorhexidineis not recommended for infants under 2 months ofage.2,5-8 (I)

D. For infants under 2 months of age or pediatricpatients with compromised skin integrity, driedpovidone-iodine should be removed with normalsaline wipes or sterile water.9 (V)

E. CVAD site care frequency is based on the type ofdressing; transparent semipermeable (TSM) dress-ings should be changed every 5-7 days, and gauzedressings should be changed every 2 days. Whilethe evidence does not support one type of dress-ing over another, gauze is preferable to TSM if thepatient is diaphoretic, or if the site is oozing orbleeding. In the event of drainage, site tenderness,other signs of infection, or loss of dressing integri-ty, the dressing should be changed sooner, allow-ing the opportunity to closely assess, cleanse, anddisinfect the site.2,3,8,10 (II)

F. Placement of a gauze dressing under a transpar-ent dressing should be considered a gauze dress-ing and changed every 2 days. If gauze is used tosupport the wings of a noncoring needle in animplanted port and does not obscure the inser-tion site, it is not considered a gauze dressing.3

(V)G. The use of a chlorhexidine-impregnated dressing

with short-term CVADs should be considered inpatients older than 2 months of age as an addi-tional catheter-related bloodstream infection(CR-BSI) prevention measure.2,11-13 (I)

H. With a well-healed tunneled CVAD, considera-tion may be given to no dressing.14 (III)

I. The catheter-skin junction site should be visuallyinspected or palpated daily for tenderness through



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the intact dressing; for patients receiving outpa-tient or home care, the patient should be instruct-ed to check the VAD site and dressing every dayfor signs of infection and to report such changes ordressing dislodgment immediately to the healthcare provider.1,3 (V)

J. Gauze, bandages, or any dressing material thatmay obstruct visualization of the catheter-skinjunction and/or constrict the extremity should notbe used (see Standard 38, Site Protection).1,4 (V)

K. The dressing should be labeled with the followinginformation: date, time, and initials of the nurseperforming the dressing change.1,3,4 (V)

L. Sterile gloves should be worn when performingCVAD site care. The use of a mask during accessis often recommended; however, it remains anunresolved issue due to lack of research.2,3,15,16

(IV)

REFERENCES


2. Marschall J, Mermel LA, Classen D, et al; Society for HospitalEpidemiology. Strategies to Prevent CLABSI. Strategies to pre-vent central line-associated bloodstream infections in acute carehospitals. Infect Control Hosp Epidemiol. 2008;29 (suppl 1):S22-S30.

3. Gorski L, Hunter M. Central venous access devices: care, mainte-nance and potential complications. In: Alexander M, Corrigan A,Gorski L, Hankins J, Perucca, R. eds. Infusion Nursing: AnEvidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;2010:496-498.

4. Phillips, LD. Techniques for initiation and maintenance ofperipheral infusion therapy. In: Manual of I.V. Therapeutics:Evidence-Based Practice for Infusion Therapy. 5th ed. Philadelphia,PA: FA Davis; 2010:303-401.

5. Chaiyakunapruk N, Veenstra DL, Lipsky BA, Saint S. Chlorhexidinecompared with povidone-iodine solution for vascular catheter-sitecare: meta-analysis. Ann Intern Med. 2002;136(11):792-801.

6. Hibbard JJ. Analysis comparing the antimicrobial activity and safe-ty of current antiseptic agents. J Infus Nurs. 2005;28(3):194-207.

7. National Kidney Foundation/Dialysis Outcomes QualityInitiative. Clinical practice guidelines for vascular access: update2000. Am J Kidney Dis. 2001;37(suppl 1):S137-S181.

8. Safdar N, Kluger DM, Maki DG. A review of risk factors forcatheter-related bloodstream infection caused by percutaneouslyinserted, noncuffed central venous catheters: implications for pre-ventive strategies. Medicine (Baltimore). 2002;81(6):466-479.

9. Doellman D, Pettit J, Catudal P, Buckner J, Burns D, Frey AM;Association for Vascular Access. Best practice guidelines in thecare and maintenance of pediatric central venous catheters. 2010;PEDIVAN.

10. Gilles D, O’Riordan L, Carr D, et al. Gauze and tape and trans-parent polyurethane dressings for central venous catheters.Cochrane Review. In: The Cochrane Library, Chichester, UK:John Wiley & Sons; 2004.

11. Yong-Gang L, Hong-Lin D, Wang L. Chlorhexidine-impregnatedsponges and prevention of catheter-related infections. JAMA.2009;302(4):379.

12. Ho KM, Litton E. Use of chlorhexidine-impregnated dressing toprevent vascular and epidural catheter colonization and infection:a meta-analysis. J Antimicrob Chemother. 2006;58:281-287.

13. Garland JS, Alex CP, Mueller CD, et al. A randomized trial com-paring povidone-iodine to a chlorhexidine gluconate-impregnat-ed dressing for prevention of central venous catheter infections inneonates. Pediatrics. 2001;107(6):1431-1436.

14. Olson K, Rennie RP, Hanson J, et al. Evaluation of a no-dressingintervention for tunneled central catheter exit sites. J Infus Nurs.2004;27(1):37-44.

15. Phillips, LD. Techniques for initiation and maintenance of centralvenous access. In: Manual of I.V. Therapeutics: Evidence-BasedPractice for Infusion Therapy. 5th ed. Philadelphia, PA: FA Davis;2010:458-545.

16. Oncology Nursing Society (ONS). Access Device Guidelines:Recommendations for Nursing Practice and Education. 2nd ed.Pittsburgh, PA: ONS; 2004.



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C. When any VAD is removed, the nurse shouldmonitor the vascular access site for 48 hours todetect postinfusion phlebitis; or upon discharge,the patient and/or caregiver should be giveninstructions about signs and symptoms of phlebitisand the person to contact if this occurs.6 (V)

D. The nurse should use a standardized phlebitis scalethat is valid, reliable, and clinically feasible. Twophlebitis scales have demonstrated validity and reli-ability and have been used for adult patients. Thepopulation for which the scale is appropriate shouldbe identified: adult or pediatric patients.1,2,6,9,17-21 (IV)1. The Phlebitis Scale has concurrent validity,

inter-rater reliability, and is clinically feasible(below).22 (IV)

2. The Visual Infusion Phlebitis (VIP) scale has con-tent validity, inter-rater reliability, and is clinicallyfeasible. This scale includes suggested actionsmatched to each scale score.2,23 (IV)

E. The nurse should participate in quality improvementactivities or outcomes evaluation regarding the occur-rence and reporting of phlebitis with infusion therapy(see Standard 7, Quality Improvement).6,9,10,15,20,24-28 (V)

47. PHLEBITIS

Standard

47.1 The assessment and treatment of phlebitis shall beestablished in organizational policies, procedures, and/orpractice guidelines.47.2 The nurse shall assess the vascular access site forphlebitis; determine the need for and type of intervention;educate the patient and/or caregiver about phlebitis, theintervention, and any follow-up; and assess patientresponse to treatment.47.3 The nurse shall document in the patient’s permanentmedical record the signs and symptoms of phlebitis usinga standardized scale, interventions implemented, andpatient response to treatment.

Practice Criteria

A. The nurse should routinely assess all vascular access sitesfor signs and symptoms of phlebitis based on patientpopulation, type of therapy, type of device, and riskfactors. Signs and symptoms of phlebitis include pain,tenderness, erythema, warmth, swelling, induration,purulence, or palpable venous cord; the number orseverity of signs and symptoms that indicate phlebitisdiffer among published clinicians and researchers.1-9 (IV)

B. If phlebitis occurs, the nurse should:1. Assess the vascular access site for signs, symptoms,

and severity of phlebitis using a standardizedscale.6,8,9 (V)

2. Determine the possible etiology of the phlebitis—chemical, mechanical, bacterial, or postinfusion—and implement appropriate interventions formidline and peripherally inserted centralcatheters. Remove the short peripheral catheter(see Standard 44, Vascular Access DeviceRemoval).1,6,10-15 (V)

3. Assess and document patient response to inter-vention(s).6,8 (V)

4. When the vascular access device (VAD) isremoved, consider the need to collaborate withthe licensed independent practitioner (LIP)regarding the need for continued or alternativevascular access.6,13,16 (V)

Infusion-Related Complications


TABLE 1

Phlebitis Scale Grade Clinical Criteria

0 No symptoms

1 Erythema at access site with or without pain

2 Pain at access site with erythema and/or edema

3

Pain at access site with erythema

Streak formation

Palpable venous cord

4

Pain at access site with erythema

Streak formation

Palpable venous cord �1 inch in length

Purulent drainage

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F. The nurse should advocate for ongoing improve-ment in phlebitis rates.2,14,17,20-25,28-31 (IV)

G. The nurse should use a consistent, standard, andclinically feasible calculation for short peripheralcatheter phlebitis, which may be reported as aphlebitis rate based on point prevalence of shortperipheral catheters.2,8,17,18,28,32 (V)

One clinically feasible calculation for point prevalence(measurement at 1 point in time) of peripheral VADphlebitis rate is:

REFERENCES

1. Finlay T. Safe administration and management of peripheral intra-venous therapy. In: Dougherty L, Lamb J, eds. Intravenous Therapyin Nursing Practice. 2nd ed. Malden, MA: Blackwell; 2008:143-166.

2. Gallant P, Schultz A. Evaluation of a visual infusion phlebitisscale for determining appropriate discontinuation of peripheralintravenous catheters. J Infus Nurs. 2006;29(6):338-345.

3. Gorski L. Intravenous therapy. In: Ackley BJ, Ladwig GB, Swan BA,Tucker SJ. Evidence-Based Nursing Care Guidelines: Medical-SurgicalInterventions. St Louis, MO: Mosby/Elsevier; 2008:482-488.

4. Lamb J, Dougherty L. Local and systemic complications of intra-venous therapy. In: Dougherty L, Lamb J, eds. Intravenous Therapyin Nursing Practice. 2nd ed. Malden, MA: Blackwell; 2008:167-196.

5. Maki DG, Ringer M. Risk factors for infusion-related phlebitis withsmall peripheral venous catheters. Ann Int Med. 1991;114:845-854.


7. Tagalakis V, Kahn SR, Libman M, Blostein M. The epidemiolo-gy of peripheral vein infusion thrombophlebitis: a critical review.Am J Med. 2002;113(2):146-151.

8. Zingg W, Pittet D. Peripheral venous catheters: an under-evaluat-ed problem. Int J Antimicrob Agents. 2009;34S:S38-S42.

9. Dougherty L, Bravery K, Gabriel J, et al. Standards for InfusionTherapy: The RCN IV Therapy Forum. 3rd ed. London,England: Royal College of Nursing; 2010:17,35,60-61,80.

10. Di Giacomo M. Comparison of three peripherally-inserted cen-tral catheters: pilot study. Br J Nurs. 2009;18(1):8-16.

11. dos Reis P, Silveira R, Vasques C, de Carvalho E. Pharmacologicalinterventions to treat phlebitis: a systematic review. J Infus Nurs.2009;32(2):74-79.

12. Eppert H, Goddard K. Administration of amiodarone during resusci-tation of ventricular arrhythmias. J Emerg Nurs. 2010;36(1):26-28.

13. Gabriel J. Long-term central venous access. In: Dougherty L,Lamb J, eds. Intravenous Therapy in Nursing Practice. 2nd ed.Malden, MA: Blackwell; 2008:321-351.

14. Liu H, Han T, Zheng Y, Tong X, Piao M, Zhang H. Analysis ofcomplication rates and reasons for nonelective removal of PICCsin neonatal intensive care unit preterm infants. J Infus Nurs. 2009;32(6):336-340.

15. Slim A, Roth J, Duffy B, Boyd S, Rubal B. The incidence ofphlebitis with intravenous amiodarone at guideline dose recom-mendations. Milit Med. 2007;172(12):1279-1283.

Number of Phlebitis IncidentsTotal Number of IV Peripheral Catheters� 100 � % Peripheral Phlebitis

16. Joanna Briggs Institute. Management of peripheral intravasculardevices. Austral Nurs J. 2008;16(3):25-28.

17. Powell J, Tarnow KG, Perucca R. The relationship betweenperipheral intravenous catheter indwell time and the incidence ofphlebitis. J Infus Nurs. 2008;31(1):39-45.

18. Van Donk P, Rickard C, McGrail M, Doolan G. Routine replace-ment versus clinical monitoring of peripheral intravenous cathetersin a regional hospital in the home program: a randomized con-trolled trial. Infect Control Hosp Epidemiol. 2009;30(9):915-917.

19. Doran DM, Pringle D. Patient outcomes as an accountability. In:Doran DM, ed. Nursing Outcomes: The State of the Science. 2nded. Sudbury, MA: Jones & Bartlett Learning; 2011:1-27.

20. Schultz AA, Gallant P. Evidence-based quality improvement pro-ject for determining appropriate discontinuation of peripheralintravenous cannulas. Evid Based Nurs. 2005;8(1):8.

21. Uslusoy E, Mete S. Predisposing factors to phlebitis in patientswith peripheral intravenous catheters: a descriptive study. J AmAcad Nurse Pract. 2008;20(4):172-180.

22. Groll D, Davies B, MacDonald J, Nelson S, Virani T. Evaluationof the psychometric properties of the phlebitis and infiltrationscales for the assessment of complications of peripheral vascularaccess devices. J Infus Nurs. 2010;33(6):385-390.

23. Bravery K, Dougherty L, Gabriel J, Kayley J, Malster M, ScalesK. Audit of peripheral venous cannulae by members of an IVtherapy forum. Br J Nurs. 2006;15:1244-1249.

24. Ahlqvist M, Bogren A, Hagman S, et al. Handling of peripheralintravenous cannulae: effects of evidence-based clinical guide-lines. J Clin Nurs. 2006;15:1354-1361.

25. Birk S. Needleless IV access means fewer costs. Mate ManagHealth Care. 2007;16(7):46-48.

26. Biswas J. IV nursing care. Clinical audit documenting insertiondate of peripheral intravenous cannulae. Br J Nurs. 2007;16(5):281-283.

27. Collins AS. Preventing health care-associated infections. In: HughesRG, ed. Patient Safety and Quality: An Evidence-Based Handbook forNurses. AHRQ Publication No. 08-0043. Rockville, MD: Agency forHealthcare Research and Quality; March 2008:2–547-2–575.

28. Leone M, Dillon L. Catheter outcomes in home infusion. J InfusNurs. 2008;31(2):84-91.

29. Zarate L, Mandleco B, Wilshaw R, Ravert P. Peripheral intra-venous catheters started in prehospital and emergency depart-ment settings. J Trauma Nurs. 2008;15(2):47-52.

30. Barría R, Lorca P, Muñoz S. Randomized controlled trial of vas-cular access in newborns in the neonatal intensive care unit. JObstet Gynecol Neonatal Nurs. 2007;36(5):450-456.

31. Bravery K. Paediatric intravenous therapy in practice. In: DoughertyL, Lamb J, eds. Intravenous Therapy in Nursing Practice. 2nd ed.Malden, MA: Blackwell; 2008:408-460.

32. Malach T, Jerassy Z, Rudensky B, et al. Prospective surveillanceof phlebitis associated with peripheral intravenous catheters. AmJ Infect Control. 2006;34(5):308-312.

48. INFILTRATION AND EXTRAVASATION

Standard

48.1 The assessment and treatment of infiltration andextravasation shall be established in organizationalpolicies, procedures, and/or practice guidelines.



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48.2 The nurse shall assess the vascular access site forinfiltration and extravasation; determine the need forand type of intervention; educate the patient and/orcaregiver about infiltration and extravasation, the inter-vention, and any follow-up; and assess patient responseto treatment.48.3 The nurse shall document in the patient’s perma-nent medical record the signs and symptoms of infiltra-tion and extravasation, interventions implemented, andpatient response to treatment.

Practice Criteria

A. Infiltration and extravasation are reported withall types of peripheral and central vascular accessdevices (CVADs) and intraosseous devices. Thenurse should routinely assess all vascular accesssites for signs and symptoms of infiltration andextravasation based on patient population, typeof therapy, type of device, and risk factors.1-3 (V)

B. The nurse should determine possible causes ofinfiltration and extravasation, which includemechanical, pharmacologic, obstructive, andinflammatory factors.1,4,5 (IV)

C. The nurse should immediately stop all infusionswhen the patient complains of any type of pain,burning, or stinging, at or around the insertion site,catheter tip, or entire venous pathway as this shouldnot be considered within normal limits with anyinfusion. These symptoms require further assessmentto determine appropriate intervention(s).5,6 (IV)

D. The nurse should use a standardized scale forassessing and documenting infiltration/extravasa-tion from all types of vascular access devices(VADs). This measurement should occur initiallyand regularly until resolution, based on patient con-dition and age; type of fluid; severity of infiltration/extravasation; type of device; and anatomical loca-tion. Signs and symptoms progress from simple tocomplex, and the clinical presentation can easily beconfused with phlebitis or irritant and flare reac-tions. Early recognition of infiltration/extravasationis critical to limit the amount of fluid that escapesinto the subcutaneous tissue and potential subse-quent tissue injury.1,6-10 (III)

E. Frequency of site assessment after infiltration/extravasation depends upon the drugs involvedand the individual patient needs. All changesshould be reported to the licensed independentpractitioner (LIP).1 (V)

F. The nurse should not rely on alarms from electron-ic infusion pumps to identify infiltration/extravasation because these alarms are not designed todetect the presence or absence of these complications.Electronic infusion pumps do not cause infiltration/extravasation; however, they will exacerbate theproblem until the infusion is stopped.11,12 (V)

G. All infusions through the peripheral catheter orCVAD should be discontinued at the first sign ofinfiltration/extravasation, the administration set dis-connected, and all fluid aspirated from the catheterwith a small syringe (eg, 3 mL). The peripheralcatheter or implanted port needle should be removedafter aspiration. Timing of CVAD removal dependson the plan of care. The nurse should notify the LIPabout the complication and activate the treatmentprotocol or other prescribed treatments.6,10,13 (I)

H. The nurse should estimate the volume of fluid thathas escaped into the tissue based on the rate ofinjection or infusion and the length of time sincethe last assessment. Large volumes (eg, greaterthan 25-50 mL) of escaped fluid increase the riskof tissue damage, and consultation with a plasticsurgeon may be necessary.14 (V)

I. Treatment of infiltration depends on the severitywhen it is recognized. Treatment may includeextremity elevation, thermal manipulation, use ofantidotes, and surgical interventions.2 (IV)

J. The nurse should educate the patient and caregiverabout the possible progression of the signs andsymptoms of infiltration/extravasation, changesthat should be reported to the LIP (eg, changes inextremity mobility and sensation, elevated temper-ature, and other signs of infection), to protect thesite from sunlight, and the frequency of follow-upvisits to the LIP and/or other medical consultants asneeded (see Standard 11, Patient Education).1 (V)

K. There is insufficient evidence for the managementof infiltration/extravasation in neonates and otherpediatric patients. Thermal manipulation is a con-troversial issue, and skin maceration with moistheat is possible.6 (IV)

L. The nurse should monitor clinical outcomes asso-ciated with infiltration, which may include com-partment syndrome with the need for rapid surgi-cal intervention, and nerve injury from excessivecompression producing neuropathies and com-plex regional pain syndrome.15-21 (V)

M. The nurse should monitor clinical outcomes asso-ciated with extravasation that may include forma-tion of blisters over a prolonged period (eg, 7-14days), skin sloughing and tissue necrosis, function-al and sensory loss in the injured area, disfigure-ment and loss of limb, or mastectomy.4,5,22-27 (V)

REFERENCES

1. Polovich M, Whitford J, Olsen M, eds. Chemotherapy andBiotherapy Guidelines and Recommendations for Practice. 3rded. Pittsburgh, PA: Oncology Nursing Society; 2009.

2. Hadaway L. Emergency: infiltration and extravasation—preventing acomplication of IV catheterization. Am J Nurs. 2007;107(8):64-72.

3. Dasgupta S, Playfor S. Intraosseous fluid resuscitation in meningo-coccal disease and lower limb injury. Pediatr Rep. 2010;2(1):e5.



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4. Sauerland C, Engelking C, Wickham R, Corbi D. Vesicantextravasation part I: mechanisms, pathogenesis, and nursing careto reduce risk. Oncol Nurs Forum. 2006;33(6):1134-1141.

5. Schulmeister L, Camp-Sorrell D. Chemotherapy extravasationfrom implanted ports. Oncol Nurs Forum. 2000;27(3):531-538.

6. Doellman D, Hadaway L, Bowe-Geddes LA, et al. Infiltration andextravasation: update on prevention and management. J InfusNurs. 2009;32(4):203-211.

7. Webster J, Clarke S, Paterson D, et al. Routine care of peripher-al intravenous catheters versus clinically indicated replacement:randomised controlled trial. BMJ. 2008;337:a339.

8. Catney M, Hillis S, Wakefield B, et al. Relationship betweenperipheral intravenous catheter dwell time and the developmentof phlebitis and infiltration. J Infus Nurs. 2001;24(5):332-341.


10. Wickham R, Engelking C, Sauerland C, Corbi D. Vesicantextravasation part II: evidence-based management and continu-ing controversies. Oncol Nurs Forum. 2006;33(6):1143-1150.

11. Hadaway L. Infusion therapy equipment. In: Alexander M, Corrigan A,Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-BasedApproach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:391-436.

12. Pennsylvania Patient Safety Authority. IV infiltration: be alarmedeven when your infusion pump isn’t. Patient Saf Advis. 2007;4:1-4.

13. Schulmeister L. Antineoplastic therapy. In: Alexander M, Corrigan A,Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-BasedApproach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:351-371.

14. Wang C, Cohan R, Ellis J, Adusumilli S, Dunnick N. Frequency,management, and outcome of extravasation of nonionic iodinat-ed contrast medium in 69,657 intravenous injections. Radiology.2007;243(1):80-87.

15. Gourgiotis S, Villias C, Germanos S, Foukas A, Ridolfini M. Acutelimb compartment syndrome: a review. J Surg Educ. 2007;64(3):178-186.

16. Atanda Jr A, Statter M. Compartment syndrome of the leg afterintraosseous infusion: guidelines for prevention, early detection, andtreatment. Am J Orthop. 2008;37(12):E198.

17. Schmit B, Freshwater M. Pediatric infiltration injury and com-partment syndrome. J Craniofac Surg. 2009;20(4):1021.

18. Tiwari A, Haq A, Myint F, Hamilton G. Acute compartment syn-dromes. Br J Surg. 2002;89(4):397-412.

19. Hooshmand H, Hashmi M, Phillips E. Venipuncture complex region-al pain syndrome type II. Am J Pain Manage. 2001;11:112-124.

20. Hubbard J. Reflex sympathetic dystrophy syndrome. J Infus Nurs.2002;25(2):121.

21. Stanton-Hicks M. Complex regional pain syndrome. AnesthesiolClin North Am. Dec 2003;21(4):733-744.

22. Schrijvers D. Extravasation: a dreaded complication ofchemotherapy. Ann Oncol. 2003;14(suppl 3):iii26-iii30.

23. Schulmeister L. Managing extravasations. Clin J Oncol Nurs. 2005;9(4):472-475.

24. Schulmeister L. Extravasation management. Semin Oncol Nurs.2007;23(3):184-190.

25. Schulmeister L. Vesicant chemotherapy extravasation antidotesand treatments. Clin J Oncol Nurs. 2009;13(4):395-398.

26. Schummer W, Schummer C, Bayer O, Muller A, Bredle D, KarzaiW. Extravasation injury in the perioperative setting. AnesthAnalg. 2005;100(3):722-727.

27. Pennsylvania Patient Safety Authority. Extravasation of radiolog-ic contrast. Patient Safety Advisory. 2004;1(3):1-6.

49. INFECTION

Standard

49.1 The assessment and treatment of infusion- and vas-cular access device (VAD)-related infections shall beestablished in organizational policies, procedures,and/or practice guidelines.49.2 The nurse shall assess the patient for suspected infusion-and VAD-related infections; provide timely and appropriateinformation to the licensed independent practitioner (LIP);educate the patient and/or caregiver about infusion- andVAD-related infections, the intervention, and follow-up; andassess patient response to treatment.49.3 The nurse shall document in the patient’s perma-nent medical record the signs and symptoms of infusion-and VAD-related infections, interventions implemented,and patient response to treatment.49.4 The nurse shall implement infection preventionmeasures with the goal of preventing all infusion- andVAD-related infections.

Practice Criteria

A. VAD-related infection includes exit-site, tunnel,port pocket, and catheter-related bloodstreaminfection (CR-BSI). Infusate-related bloodstreaminfections are caused by intrinsic or extrinsic con-tamination of the administration delivery system,infusing fluids and medications.1-7 (IV)

B. The nurse should immediately notify the LIP ofsigns and symptoms of infection including, but notlimited to, erythema, edema, induration, or drainageat the VAD insertion site, and/or body temperatureelevation, and take appropriate interventions.1,2 (V)

C. Routine culturing of all central vascular accessdevice (CVAD) tips upon removal is not recom-mended. Catheter colonization may be detected butdoes not indicate the presence of bloodstream infec-tion. This practice results in inappropriate use ofanti-infective medications, thus increasing the riskof emergence of antimicrobial resistance.3,4 (I)

D. Immediate removal of a functioning CVAD is notrecommended based solely on temperature elevation.Clinical findings, such as temperature elevation withor without chills or inflammation and purulence atthe insertion site, are unreliable indicators of blood-stream infection.3 (I)

E. When present, purulent exudates from a peripher-al or CVAD insertion site should be collected forculture and Gram-staining to determine gram-negative or gram-positive bacteria.4 (IV)

F. The goal of catheter salvage should be a collaborativedecision among the LIP, nurse, and patient based on:1. The type of VAD (eg, percutaneous versus sur-

gically inserted long-term catheter);



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2. Difficulty with inserting a new CVAD;3. Presence of bleeding disorders;4. The infecting organism(s) as confirmed by

paired blood cultures;5. The presence of other complicating conditions

including, but not limited to, severe sepsis, suppu-rative thrombophlebitis, endocarditis, or the pres-ence of vascular hardware (eg, a pacemaker).4 (IV)

G. Infection in a subcutaneous tunnel or implantedport pocket requires removal of the CVAD; how-ever, uncomplicated exit-site infection withoutsystemic infection, positive blood culture, or puru-lence may be treated with topical antimicrobialointment as indicated by the culture results.4 (IV)

H. The nurse should ensure that all blood cultureshave been obtained prior to initiation of anti-infective agents.4 (IV)

I. Use of phlebotomy teams for collecting peripher-al blood cultures is recommended.4 (IV)

J. Skin preparation for blood cultures obtained from aperipheral venipuncture should be done with alco-hol, tincture of iodine, or chlorhexidine gluconate/alcohol combination. Antiseptic agents should beapplied with adequate contact and drying time.Povidone-iodine is not recommended.4 (IV)

K. When a sample for blood culture is drawn from thecatheter, the used needleless connector should bechanged prior to obtaining the sample. The newneedleless connector should be thoroughly scrubbedwith alcohol, tincture of iodine, or chlorhexidine glu-conate/alcohol combination. The first drawn sampleshould be collected and used to inoculate the culturebottles without discarding the initial blood sample.5-7

(IV)L. Short-term central vascular and arterial catheters

suspected of being the cause of a BSI should havethe tip cultured using a semiquantitative (roll-plate) method or quantitative (sonication) methodupon removal. A suspected BSI from a pulmonaryartery catheter requires culture of the introducer/sheath tip.4 (IV)

M. If an implanted port is removed for suspected CR-BSI, the port body should also be sent for culture ofthe reservoir contents along with the catheter tip.4

(IV)N. For short- and long-term catheters, paired blood

cultures have been shown to accurately diagnoseCR-BSI.3,4 (I)

O. In a patient with a CR-BSI, the insertion of a newCVAD at a new site should be a collaborative deci-sion based on the specific risks and benefits for eachpatient. There is insufficient evidence for a definitiverecommendation for the insertion of a new CVAD.4

(IV)P. A catheter exchange procedure may be chosen when

other vascular access sites are limited and/or bleed-ing disorders are present. The removed CVAD

should be sent for culture and the new catheterremoved if tip culture results produce significantgrowth (see Standard 55, Central Vascular AccessDevice Exchange).4 (IV)

Q. The use of thrombolytic/fibrinolytic agents as anadjunctive treatment for CR-BSI is not recom-mended.4 (IV)

REFERENCES


2. Gorski L, Miller C, Mortlock N. Infusion therapy across the con-tinuum. In: Alexander M, Corrigan A, Gorski L, Hankins J,Perucca R, eds. Infusion Nursing: An Evidence-Based Approach.3rd ed. St Louis, MO: Saunders/Elsevier; 2010:109-126.

3. Safdar N, Fine J, Maki D. Meta-analysis: methods for diagnosingintravascular device-related bloodstream infection. Ann InternMed. 2005;142(6):451.

4. Mermel LA, Allon M, Bouza E, et al. Clinical practice guidelinesfor the diagnosis and management of intravascular catheter-relat-ed infection: 2009 update by the Infectious Diseases Society ofAmerica. Clin Infect Dis. 2009;49(1):1-45.

5. Mathew A, Gaslin T, Dunning K, Ying J. Central catheter bloodsampling: the impact of changing the needleless caps prior to col-lection. J Infus Nurs. 2009;32(4):212-218.

6. Sherertz R, Karchmer T, Ohl C, Palavecino E, Bischoff W. Bloodcultures (BC) drawn through valved catheter hubs have a 10-20%positivity rate with the majority being false positives. Paper pre-sented at: Fifth Decennial International Conference on Healthcare-Associated Infections; March 18-22, 2010; Atlanta, GA.

7. Wilson M, Mitchell M, Morris A, et al. Principles and proceduresfor blood cultures: approved guideline. Wayne, PA: Clinical andLaboratory Standards Institute; 2007.

50. AIR EMBOLISM

Standard

50.1 The prevention, identification, and management of airembolism during the insertion, care, and removal of vascu-lar access devices (VADs) shall be established in organiza-tional policies, procedures, and/or practice guidelines.50.2 The nurse shall be competent to insert, manage,and remove all types of VADs toward the goal of pre-venting air emboli.50.3 Luer-locking connections shall be used on allcatheter-administration set junctions.50.4 All air shall be purged from syringes, administra-tion sets, needleless connectors, and all other piecesadded to the catheter.50.5 The nurse shall document in the patient’s perma-nent medical record the signs and symptoms of airembolism, interventions implemented, and patientresponse to treatment.50.6 Patients and/or caregivers managing infusion ther-apy in non–acute care settings shall be taught how to



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prevent an air embolism and how to manage thecatheter if an air embolism is suspected.

Practice Criteria

A. The nurse should suspect air embolism with the sud-den onset of dyspnea, continued coughing, breath-lessness, chest pain, hypotension, jugular venousdistension, tachyarrhythmias, wheezing, tachypnea,altered mental status, altered speech, changes infacial appearance, numbness, and paralysis. Clinicalevents from air emboli produce cardiopulmonaryand neurological signs and symptoms.1,2 (V)

B. The nurse should immediately take the necessaryaction to prevent more air from entering thebloodstream by closing, folding, or clamping theexisting catheter or by occluding the puncture siteif the catheter has been removed.3 (V)

C. The nurse should immediately place the patient inthe left lateral decubitus position if not con-traindicated by other conditions such as increasedintracranial pressure or respiratory diseases. Thegoal is to trap the air in the lower portion of theright ventricle; however, animal studies have notshown any benefit from this position. Data onhumans are not available.1,4 (V)

D. The nurse should assess for conditions that con-traindicate use of the Valsalva’s maneuver includ-ing, but not limited to, aortic stenosis, recentmyocardial infarction, glaucoma, and retinopathy.When these conditions are present, ensure that acatheter clamp is present before changing admin-istration sets or needleless connectors. Duringcatheter removal, the nurse must rely upon thepatient’s position and the petroleum-based oint-ment dressing to prevent air embolism.5,6 (V)

E. The nurse should instruct the patient and caregiv-er not to disconnect or reconnect any IV adminis-tration sets or connectors from the catheter hub,as reconnecting the wrong type of tubing has beendocumented to cause air embolism.7,8 (V)

REFERENCES

1. Mirski MA, Lele AV, Fitzsimmons L, Toung TJ. Diagnosis andtreatment of vascular air embolism. Anesthesiology. 2007;106(1):164-177.

2. Heckmann J, Lang C, Kindler K, Huk W, Erbguth F, NeundorferB. Neurologic manifestations of cerebral air embolism as a com-plication of central venous catheterization. Crit Care Med. 2000;28(5):1621-1625.


4. Souders J. Pulmonary air embolism. J Clin Monit Comput. 2000;16(5):375-383.

5. Wysoki M, Covey A, Pollak J, Rosenblatt M, Aruny J, Denbow N.Evaluation of various maneuvers for prevention of air embolismduring central venous catheter placement. J Vasc Intervent Radiol.2001;12(6):764-766.

6. Hebert JL, Coirault C, Zamani K, Fontaine G, Lecarpentier Y,Chemla D. Pulse pressure response to the strain of the valsalvamaneuver in humans with preserved systolic function. J Appl Physiol.Sep 1998;85(3):817-823.

7. Tien I, Drescher M. Pulmonary venous air embolism followingaccidental patient laceration of a hemodialysis catheter. J EmergMed. 1999;17(5):847-850.

8. Laskey A, Dyer C, Tobias J. Venous air embolism during homeinfusion therapy. Pediatrics. 2002;109(1):1-3.

51. CATHETER EMBOLISM

Standard

51.1 The prevention, identification, and management ofcatheter embolism during the insertion, care, and removalof vascular access devices shall be addressed in organiza-tional policies, procedures, and/or practice guidelines.51.2 The nurse shall be competent to insert, manage,and remove all types of vascular access devices towardthe goal of preventing catheter embolism.51.3 The nurse shall document in the patient’s perma-nent medical record the signs and symptoms of catheterembolism, interventions implemented, and patientresponse to treatment.51.4 Patients and/or caregivers managing infusion ther-apy in non–acute care settings shall be taught how toprevent catheter embolism and how to manage thecatheter if a catheter embolism is suspected.

Practice Criteria

A. Nursing interventions to prevent catheter embolisminclude:1. No catheter should be withdrawn through a

needle during insertion.2. A stylet should not be reinserted into a catheter.3. The nurse should not use power injection for

vascular access devices that are not designed forthis purpose.

4. To prevent catheter damage, the size of thesyringe used for flushing should be in accordancewith the catheter manufacturer’s directions foruse (see Standard 45, Flushing and Locking).

5. Be aware of early signs and symptoms of pinch-offsyndrome in subclavian vein insertion sites.1-4 (II)

B. The nurse should suspect catheter embolism whenthe patient exhibits symptoms such as palpitations,arrhythmias, dyspnea, cough, or thoracic painwhen not associated with the patient’s primary dis-ease or comorbidities.1,2,4,5 (II)

C. The nurse should be aware that catheter dysfunc-tion, such as inability to aspirate blood or fluid



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with localized pain and/or subcutaneous swelling,may be a precursor to catheter embolism, or leakingat the site can indicate catheter rupture. In the pres-ence of these symptoms, the nurse should furtherevaluate catheter integrity before using the vascularaccess device for infusions or blood draws. Themost frequent mechanisms of catheter fragmenta-tion are catheter pinch-off syndrome, catheter dam-age during catheter exchange, separation of thecatheter from an implanted port, and fracture of adistal portion of an implanted port catheter.1-6 (II)

D. Because catheter embolism is often asymptomatic,when chest radiographs of patients with vascularaccess devices are obtained as part of care, theradiographs should be assessed for catheter frag-ment, catheter pinch-off, and infraclavicularcatheter compression.1-5 (II)

E. Upon removal, vascular access catheters shouldbe examined for damage and possible fragmenta-tion. If damage is seen, a chest radiograph or fur-ther evaluation may be warranted.1,2,4,5 (II)

F. The nurse should carefully assess the patient forsigns or symptoms of catheter embolism and forcatheter damage when vascular access deviceremoval is difficult.7,8 (V)

REFERENCES

1. Surov A, Wienke A, Carter JM, et al. Intravascular embolizationof venous catheter: causes, clinical signs, and management—-asystematic review. J Parenter Enteral Nutr. 2009;23(6):677-685.

2. Surov A, Buerke M, Endres J, Kosling S, Spielman R-P, BehrmannC. Intravenous port catheter embolization: mechanisms, clinicalfeatures, and management. Angiology. 2008;59(1)90-97.

3. Mirza B, Vanek VW, Kupensky DT. Pinch-off syndrome: case reportand collective review of the literature. Am Surg. 2004;70(7):635-644.

4. Gorski L, Perruca R, Hunter M. Central venous access devices:care, maintenance and complications. In: Alexander M, CorriganA, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: AnEvidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:516-524.

5. Schummer W, Schummer C, Schelenz C. Case report: the malfunction-ing implanted venous access device. Br J Nurs. 2003;12(4):210-214.

6. Chow LM, Friedman JN, MacArthur C, et al. Peripherally insert-ed central catheter (PICC) fracture and embolization in the pedi-atric population. J Pediatr. 2003;142:141-144.

7. Mahadeva S, Cohen A, Bellamy M. The stuck central venous catheter:beware of potential hazards. Br J Anesth. 2002;89(4):650-652.

8. Dhanani J, Senthuran S, Olivotto R, Boots RJ, Lipman J. Theentrapped central venous catheter. Br J Anesth. 2007;98(1):89-92.

52. CATHETER-ASSOCIATEDVENOUS THROMBOSIS

Standard

52.1 The assessment and treatment of catheter-associat-ed venous thrombosis shall be established in organiza-tional policies, procedures, and/or practice guidelines.

52.2 The nurse shall assess the patient for suspectedcatheter-associated venous thrombosis; provide timely andappropriate information to the licensed independent prac-titioner (LIP); educate the patient and/or caregivers aboutcatheter-associated venous thrombosis, the intervention,and follow-up; and assess patient response to treatment.52.3 The nurse shall be competent in venipunctureinsertion procedures toward the goal of preventingcatheter-associated venous thrombosis.52.4 The nurse shall document in the patient’s perma-nent medical record the signs and symptoms of catheter-associated venous thrombosis, interventions implement-ed, and patient response to treatment.

Practice Criteria

A. Skillful venipuncture insertion procedures by thenurse decreases the risk of vein wall trauma andassociated thrombus development.1 (I A/P)

B. Before central vascular access device (CVAD) inser-tion, the nurse should assess the patient for risk factorsfor venous thrombosis including, but not limited to:1. Presence of chronic diseases that produce a

hypercoagulable state such as cancer, diabetes,irritable bowel syndrome, or end-stage renalfailure;

2. Known presence of genetic coagulation abnor-malities (eg, Factor V Leiden, prothrombin muta-tion);

3. Pregnancy or the use of oral contraceptives,surgery, and immobility;

4. Age extremes in young children and older adults;5. History of multiple CVADs, especially with dif-

ficult or traumatic insertion and the presence ofother intravascular devices (eg, pacemakers).1-5

(II)C. Decisions about VAD choices impact the rate of

catheter-associated venous thrombosis including,but not limited to:1. Peripherally inserted central catheter (PICC)

insertion sites in the antecubital fossa havehigher rates of catheter-associated venousthrombosis than mid-upper arm insertion sites.

2. Suboptimal CVAD tip location in the mid-to-upper portion of the superior vena cava is asso-ciated with greater rates of catheter-associatedvenous thrombosis.2,6 (II)

D. The nurse should encourage the patient to usenonpharmacologic strategies for thrombosis pre-vention whenever possible, including early mobi-lization of the catheterized extremity, perfor-mance of normal activities of daily living, gentlelimb exercise, and adequate hydration.2 (II)

E. The nurse should be aware that the majority ofcatheter-associated venous thromboses are clinical-ly silent and do not produce overt signs and symp-toms, although pulmonary emboli have been linked



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to catheter-associated venous thrombosis. Clinicalsigns and symptoms of catheter-associated venousthrombosis are related to obstruction of venousblood flow and include, but are not limited to:1. Pain in the extremity, shoulder, neck, or chest;2. Edema in the extremity, shoulder, neck, or chest;3. Engorged peripheral veins on the extremity,

shoulder, neck or chest wall;4. Difficulty with neck or extremity motion.2,7 (II)

F. VAD flushing and locking procedures have noeffect on catheter-associated venous thrombosisas the technique and solutions used are directed tothe internal CVAD lumen rather than the veinlumen.7,8 (V)

G. Usual management of catheter-associated venousthrombosis includes systemic anticoagulationwith or without CVAD removal.2,9 (I)

H. Prophylaxis with anticoagulant therapy is not recommended for patients at risk for catheter-associ-ated venous thrombosis; the use of anticoagulantprophylaxis is controversial due to the risk of bleed-ing. The use of an assessment tool to predictcatheter-associated venous thrombosis could be ben-eficial to identify patients that could benefit fromprophylactic anticoagulation. The patient’s prefer-ences and the burden of anticoagulant therapy (eg,subcutaneous injection) should be considered.2,10-13 (I)

REFERENCES

1. Hadaway L. Anatomy and physiology related to infusion thera-py. In: Alexander M, Corrigan A, Gorski L, Hankins J, PeruccaR, eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed.St Louis, MO: Saunders/Elsevier; 2010:139-177.

2. Yacopetti N. Central venous catheter-related thrombosis: a sys-tematic review. J Infus Nurs. 2008;31(4):241-248.

3. Dentali F, Gianni M, Agnelli G, Ageno W. Association betweeninherited thrombophilic abnormalities and central venouscatheter thrombosis in patients with cancer: a meta-analysis. JThromb Haemost. 2008;6(1):70-75.

4. Flinterman LE, Van Der Meer FJ, Rosendaal FR, Doggen CJ.Current perspective of venous thrombosis in the upper extremity.J Thromb Haemost. 2008;6(8):1262-1266.

5. Dubois J, Rypens F, Garel L, David M, Lacroix J, Gauvin F.Incidence of deep vein thrombosis related to peripherally insertedcentral catheters in children and adolescents. Can Med Assoc J.2007;177(10):1185.

6. Stokowski G, Steele D, Wilson D. The use of ultrasound to improvepractice and reduce complication rates in peripherally inserted cen-tral catheter insertions: final report of investigation. J Infus Nurs.2009;32(3):145-155.

7. Gorski L, Perucca R, Hunter M. Central venous access devices: care,maintenance, and potential complications. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;2010:495-515.

8. Hadaway L. Technology of flushing vascular access devices. J InfusNurs. 2006;29(3):137-145.

9. Kearon C, Kahn SR, Agnell G. American College of ChestPhysicians Evidence-Based Clinical Practice Guidelines. 8th ed.Antithrombotic therapy for venous thromboembolic disease. Chest.2008;133:S454-S545. http://chestjournal.chestpubs.org/content/133/6_suppl/454S.full.htm. Accessed March 10, 2010.

10. Kirkpatrick A, Rathbun S, Whitsett T, Raskob G. Prevention ofcentral venous catheter-associated thrombosis: a meta-analysis. AmJ Med. 2007;120(10):901.e1-901.e13.

11. Seeley MA, Santiago M, Shott S. Prediction tool for thrombi asso-ciated with peripherally inserted central catheters. J Infus Nurs.2007;30(5):280-286.

12. Akl EA, Kamath G, Yosuico V, et al. Thromboprophylaxis forpatients with cancer and central venous catheters: a systematicreview and a meta-analysis. Cancer. 2008;112(11):2483-2492.

13. Geerts WH, Bergqvist D, Pineo GF. American College of ChestPhysicians Evidence-Based Clinical Practice Guidelines. 8th ed.Prevention of venous thromboembolism. Chest. 2008;133:S381-S453. http://chestjournal.chestpubs.org/content/133/6_suppl/381S.full.htm. Accessed March 2, 2010.

53. CENTRAL VASCULAR ACCESSDEVICE MALPOSITION

Standard

53.1 Central vascular access device (CVAD) reposition-ing techniques shall be addressed in organizational poli-cies, procedures, and/or practice guidelines.53.2 The nurse shall be competent with the chosenCVAD repositioning techniques.53.3 The nurse shall know the anatomic location of theCVAD tip prior to initial infusion through the catheter.53.4 The nurse shall know the clinical signs and symp-toms of CVAD malposition and report the condition tothe licensed independent practitioner (LIP).53.5 The nurse shall document in the patient’s perma-nent medical record CVAD malposition, interventionsimplemented, and patient response to treatment.

Practice Criteria

A. The nurse should be knowledgeable of aberrantCVAD tip locations from primary and secondarymalpositioning and catheter dislodgment.1,2 (V)

B. Primary CVAD malposition occurs during theinsertion procedure with the catheter passing intonumerous aberrant locations, including contralat-eral innominate and subclavian veins, ipsilateral orcontralateral internal jugular veins, azygos vein,right or left internal thoracic vein, pericardio-phrenic vein, and the right atrium or ventricle.2-7

(IV)C. Inadvertent arterial insertion may be a location for

primary CVAD malposition, even with the use ofdynamic ultrasound during the insertion procedure(see Standard 35, Vascular Access Site Preparationand Device Placement).8-10 (V)

D. Repeated radiographic identification of a malpo-



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sitioned tip may be due to anatomical anomaliessuch as persistent left superior vena cava.11 (V)

E. The nurse’s awareness of primary CVAD malposi-tion during the insertion procedure is enhanced byuse of tip location technology; however, a post-procedure chest radiograph remains the recom-mended method to identify tip location. While aposterior-anterior chest radiograph is preferred,an anterior-posterior chest radiograph may beneeded for bedridden patients. A lateral chest radiograph may be required to confirm some aber-rant tip locations (eg, azygos vein) or if clinicallyindicated.12-14 (V)

F. During the insertion procedure, ultrasound maybe used to rule out tip location in the internaljugular vein (see Standard 35, Vascular Access SitePreparation and Device Placement).12,13,15 (III)

G. The inserter/operator should know the results ofthe chest radiograph, properly reposition theCVAD if required, obtain a confirming repeat chestradiograph, and document all actions taken.7,12 (IV)

H. Secondary CVAD malposition, also known as tipmigration, may occur at any time during thecatheter dwell time and is related to sporadicchanges in intrathoracic pressure (eg, coughing,vomiting); presence of congestive heart failure;neck or arm movement; positive-pressure ventila-tion; high-pressure injection; or flushing tech-niques. The most common locations for secondaryCVAD malposition include internal jugular,innominate, subclavian, axillary, and azygos veins,and the right atrium.1,16-18 (V)

I. The nurse should assess for catheter function priorto each use, observing for clinical signs and symp-toms such as lack of blood return; difficulty orinability to flush the CVAD; unusual shoulder,chest, or back pain; edema; complaints of hearinggurgling or flow stream sounds on the ipsilateralside; paresthesia; and neurological effects due to retrograde infusion into the intracranial venoussinuses.1,3,6,9,16,19,20 (V)

J. Primary and secondary CVAD malposition mayproduce atrial and ventricular tachyarrhythmias.Peripherally inserted central catheter (PICC) tipmigration into the heart is associated with armadduction and flexion.21-25 (IV)

K. The nurse should notify the LIP immediately ofany signs or symptoms related to CVAD malposi-tion and obtain orders for diagnostic procedures.Procedures include, but are not limited to, chestradiograph and contrast injection through thecatheter under fluoroscopy.1,16,18,26 (V)

L. The nurse should perform procedures for reposi-tioning percutaneous CVADs or prepare thepatient for radiologic or surgical intervention forrepositioning the catheter tip.26-28 (V)

M. Infusion through a malpositioned catheter should

be withheld until proper tip position has beenestablished. The nurse should assess the infusiontherapy being administered and, if possible, inserta short peripheral catheter to continue therapy. Ifthe infusion therapy is not possible through aperipheral vein, the nurse should assess the poten-tial risk for discontinuing therapy, or seek ordersto change the infusion therapy until the properCVAD tip location can be reestablished.28 (V)

N. Extravascular CVAD tip location has been reported tobe the cause of cardiac tamponade and severe intratho-racic infiltration and extravasation injury.25,29-32 (V)

O. CVAD dislodgment is caused by arm movement,body habitus, patient manipulation (eg, Twiddler’ssyndrome), and inadequate catheter stabilization,resulting in changes of the external catheter lengthand alteration of CVAD tip location.1,33 (V)

P. The nurse should not advance any external portionof the CVAD that has been in contact with skininto the insertion site. Skin cannot be rendered ster-ile, and no studies have established an acceptablelength of time after insertion for such cathetermanipulation.34,35 (V)

Q. The nurse should measure the external CVADlength and compare to the external CVAD lengthdocumented at insertion. Dislodgment could indi-cate the tip location is suboptimal, increasing therisk for catheter-related thrombosis.1 (V)

R. CVAD malposition and dislodgment may requirea catheter exchange procedure or removal andinsertion at a new site.1 (V)

S. CVAD migration and dislodgment increase the riskfor thrombosis, thrombophlebitis, pericardial effu-sion, cardiac tamponade, and cerebrovascular acci-dents. If complications are present, the cathetershould be removed and inserted at a new site ifinfusion therapy is to be continued.17,22,23,36 (V)

REFERENCES


2. Lum P, Soski M. Management of malpositioned central venouscatheters. J Intraven Nurs. 1989;12(6):356-364.

3. Webb J, Simmonds S, Chan-Yan C. Central venous catheter mal-position presenting as chest pain. Chest. 1986;89(2):309.

4. Zenker M, Rupprecht T, Hofbeck M, Schmiedl N, Vetter V, RiesM. Paravertebral and intraspinal malposition of transfemoral cen-tral venous catheters in newborns. J Pediatr. 2000;136(6):837-840.

5. Izuishi K, Hashimoto S, Uchinomura S, Usuki H, Masaki T,Maeta H. Malposition of femoral venous cannulation. Am J Surg.2005;189(1):47-48.

6. Mai C, Leissner K. Acute back pain and paresthesia after femoralvenous catheter placement. J Cardiothoracic Vasc Anesth. 2007;21(2):317-318.



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7. Trerotola SO, Thompson S, Chittams J, Vierregger KS. Analysisof tip malposition and correction in peripherally inserted centralcatheters placed at bedside by a dedicated nursing team. J VascIntervent Radiol. 2007;18(4):513-518.

8. Parikh S, Narayanan V. Misplaced peripherally inserted central catheter:an unusual cause of stroke. Pediatr Neurol. 2004;30(3):210-212.

9. Shah P, Leong B, Babu S, Goyal A, Mateo R. Cerebrovascularevents associated with infusion through arterially malpositionedtriple-lumen catheter: report of three cases and review of literature.Cardiol Rev. 2005;13(6):304.

10. Blaivas M. Video analysis of accidental arterial cannulation withdynamic ultrasound guidance for central venous access. J UltrasoundMed. 2009;28(9):1239.

11. Kamola P, Seidner D. Peripherally inserted central catheter malpo-sition in a persistent left superior vena cava. J Infus Nurs. 2004;27(3):181-184.

12. Bullock-Corkhill M. Central venous access cevices: access and inser-tion. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R,eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed. StLouis, MO: Saunders/Elsevier; 2010:480-494.


14. Hadaway L. Anatomy and physiology related to infusion therapy.In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R,eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed. StLouis, MO: Saunders/Elsevier; 2010:139-177.

15. Schweickert W, Herlitz J, Pohlman A, Gehlbach B, Hall J, Kress J.A randomized, controlled trial evaluating postinsertion neck ultra-sound in peripherally inserted central catheter procedures. Crit CareMed. 2009;37(4):1217-1221.

16. Muhm M, Sunder-Plassmann G, Kuhrer I, Muller M, Kalhs P,Druml W. Secondary migration: a complication of Hickman centralvenous catheters. Bone Marrow Transplant (Basingstoke). 1996;18(3):651-654.

17. Collin GR, Ahmadinejad AS, Misse E. Spontaneous migration of sub-cutaneous central venous catheters. Am Surg. 1997;63(4):322-326.

18. Wu P, Yeh Y, Huang C, Lau H, Yeh H. Spontaneous migration ofa Port-a-Cath catheter into ipsilateral jugular vein in two patientswith severe cough. Ann Vasc Surg. 2005;19(5):734-736.

19. Jacobs W, Zaroukian M. Coughing and central venous catheter dis-lodgement. J Parenter Enteral Nutr. 1991;15(4):491-493.

20. Rasuli P, Hammond DI, Peterkin IR. Spontaneous intrajugularmigration of long-term central venous access catheters. Radiology.1992;182(3):822-824.

21. Bivins M, Callahan M. Position-dependent ventricular tachycardiarelated to a peripherally inserted central catheter. Mayo Clin Protocol.2000;75:414-416.

22. Orme RM, McSwiney MM, Chamberlain-Webber RF. Fatal car-diac tamponade as a result of a peripherally inserted central venouscatheter: a case report and review of the literature. Br J Anaesth.2007;99(3):384-388.

23. Suresh N, Namasivayam S. Pericardial tamponade in neonate follow-ing migration of a sialastic central venous catheter. N Engl J Med.1993;329:1365-1369.

24. Elsharkawy H, Lewis BS, Steiger E, Farag E. Post placement posi-tional atrial fibrillation and peripherally inserted central catheters.Minerva Anestesiol. 2009;75(7-8):471-474.

25. Nadroo A, Glass R, Lin J, Green R, Holzman I. Changes in upperextremity position cause migration of peripherally inserted centralcatheters in neonates. Pediatrics. 2002;110(1 pt 1):131-136.

26. Barnacle A, Arthurs O, Roebuck D, Hiorns M. Malfunctioningcentral venous catheters in children: a diagnostic approach. PediatrRadiol. 2008;38(4):363-378.

27. Warner BW, Ryckman FC. A simple technique to redirect malpo-sitioned silastic central venous catheters. J Parenter Enteral Nutr.1992;16(5):473-476.

28. Banks N. Positive outcome after looped peripherally inserted centralcatheter malposition: a case study. J Intraven Nurs. 1999;22(1):14-18.

29. Mitsufuji N, Matsuo K, Kakita S, Ikuta H. Extravascular collec-tion of fluid around the vertebra resulting from malpositioning ofa peripherally inserted central venous catheter in extremely lowbirth weight infants. J Perinat Med. 2002;30(4):341-344.

30. Hohlrieder M, Oberhammer R, Lorenz I, Margreiter J, KuhbacherG, Keller C. Life-threatening mediastinal hematoma caused byextravascular infusion through a triple-lumen central venouscatheter. Anesth Analg. 2004;99(1):31-35.

31. O’Sullivan P, Brown M, Hartnett B, Mayo J. Central line pumpinfusion and large volume mediastinal contrast extravasation inCT. Br J Radiol. 2006;79(944):e75-e77.

32. Schulmeister L. A complication of vascular access device insertion:a case study and review of subsequent legal action. J IntravenNurs. 1998;21(4):197-202.

33. Frey A, Schears G. Dislodgment rates and impact of securement meth-ods for peripherally inserted central catheters (PICCs) in children.Pediatr Nurs. 2001;27(2):185-189, 193.

34. McGoldrick M. Infection prevention and control. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:204-228.

35. Murphy C, Andrus M, Barnes S, Garcia R, Juraja M. Guide to theElimination of Catheter-Related Bloodstream Infections. Washington,DC: APIC; 2009.

36. Nadroo A, Lin J, Green R, Magid M, Holzman I. Death as a compli-cation of peripherally inserted central catheters in neonates. J Pediatr.2001;138(4):599-601.



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tion. If catheter repair is chosen, it should be per-formed as soon as possible to reduce the risk ofthese complications.1,4 (V)

E. The selected repair kit should be specificallydesigned for the device being repaired. If no device-specific repair kit is available, the nurse should con-sider other alternatives, such as catheter exchangeor insertion of a new catheter.3 (V)

F. Ongoing assessment after repair should be routine-ly performed to confirm the integrity of the repairand identify any continuing problems, as therepaired catheter may not have the same strength asthe original catheter. The access device should beremoved if the repair was unsuccessful or the deviceis unable to be repaired.2,4 (V)

G. Access device repair should be documented in thepatient’s permanent medical record.2 (V)

H. Data on the causes of device damage should beanalyzed to identify the root cause(s) including,but not limited to, flushing technique, syringe size,and use of scissors during dressing changes.1-3 (V)

REFERENCES

1. Hwang FR, Stavropoulos SW, Shlansky-Goldberg RD, et al.Tunneled infusion catheter breakage: frequency and repair kitoutcomes. J Vasc Intervent Radiol. 2008;19(2, pt 1):201-206.


3. Weinstein S. Plumer’s Principles & Practice of Intravenous Therapy.8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007;324.


55. CENTRAL VASCULAR ACCESSDEVICE EXCHANGE

Standard

55.1 Central vascular access device (CVAD) exchangeshall be initiated upon the order of a licensed independent

54. VASCULAR ACCESS DEVICE REPAIR

Standard

54.1 Vascular access device (VAD) repair shall be initiatedupon the order of a licensed independent practitioner (LIP).54.2 Guidelines and resources for repair of the externalsegment of a central venous catheter shall be establishedin organizational policies, procedures, and/or practiceguidelines.54.3 The nurse shall be competent in access device repair.54.4 The device shall be repaired according to the man-ufacturer’s directions for use.54.5 Assessment of the patient’s risk-to-benefit ratioshall be performed prior to repair of the access device.

Practice Criteria

A. Immediately upon discovery of catheter damage, thedevice should be clamped or sealed (eg, closing anexisting clamp, adding a clamp, covering the dam-aged area with adhesive dressing material, foldingthe external segment, and securing) between thepatient and the damaged area to prevent airembolism or bleeding from the device. The damagedcatheter should be labeled “Do Not Use” while wait-ing for the repair procedure to be performed.1 (V)

B. Options to consider for managing a damaged or rup-tured catheter include use of a repair procedure, anexchange procedure, or insertion of a new catheter ata different site. Factors to consider in making thisdecision include, but are not limited to, the patient’simmune status; length of time remaining on infusiontherapy; characteristics of infusion therapy (eg, pHand osmolarity); external catheter length; and result-ing changes in proper tip location with repair.2 (V)

C. Patient and caregiver education should includehow to prevent catheter damage, how to assess forcatheter damage, and what immediate actions totake if catheter damage is found.2,3 (V)

D. Catheter damage increases the risk for catheterfracture and embolization, air emboli, bleeding,catheter-lumen occlusion, and bloodstream infec-

Other Infusion-Related Procedures


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practitioner (LIP) in accordance with the rules and reg-ulations promulgated by the state’s Board of Nursing,organizational policies, procedures, and/or practiceguidelines, and according to the manufacturer’s direc-tions for use.55.2 The nurse shall be competent to perform or assistwith a CVAD exchange.55.3 The nurse shall implement maximal sterile barrier(MSB) precautions for the CVAD exchange procedure.55.4 After completion of the exchange procedure, theCVAD tip location shall be determined radiographical-ly or by other approved technologies and documentedprior to resumption of the prescribed therapy.

Practice Criteria

A. Prior to performing a CVAD exchange, the nurseshould assess the risk-benefit of the procedure,particularly in high-risk patient populations, suchas burn or transplant patients.1 (IV)

B. CVAD exchange should be considered to replace anontunneled catheter for the following reasons:need for a different type of catheter, malposi-tioned or malfunctioning catheter, or when thereis no evidence of a site infection.2,3(V)

C. Assessment along with a risk-benefit analysis shouldoccur prior to performing an exchange procedureon a catheter with infection or suspected infection.If venous access is limited or other sites unavailableand there is no evidence of exit site or tunnel infec-tion, a catheter exchange procedure may be consid-ered. An anti-infective catheter should be consideredfor placement when exchanging a catheter for infec-tion or suspected infection.4-7 (II)

D. The nurse’s responsibilities for a CVAD exchangeprocedure should include, but are not limited to,positioning the patient to facilitate the procedure;ensuring MSB precautions are in place; ensuringthat techniques to reduce the risk of air embolismare employed; and obtaining a radiograph orusing other approved technologies to confirm cor-rect CVAD tip location prior to initiating orresuming prescribed therapies.8 (IV)

E. The nurse should be aware that routine exchangesare not necessary for CVADs that are functioningand without evidence of local or systemic compli-cations.7,9,10 (I)

REFERENCES

1. O’Mara M, Reed N, Palmieri T, Greenhalgh D. Central venouscatheter infections in burn patients with scheduled catheterexchange and replacement. J Surg Res. 2007;142:341-350.

2. Pettit J. Technological advances for PICC placement and manage-ment. Adv Neonatal Care. 2007;7(3):122-131.

3. Richardson D, Chiu M. Nurse-performed overwire exchanges: anadvanced practice procedure. J Vasc Access Dev. 1997;2(2):8-12.

4. Casey J, Davies J, Balshaw-Greer A, et al. Inserting tunneledhemodialysis catheters using elective guidewire exchange from non-tunnelled catheters: is there a greater risk of infection when com-pared with new-site replacement? Hemodialysis Int. 2008;12:52-54.

5. K/DOQI Clinical Practice Guidelines for chronic kidney disease.Am J Kidney Dis. 2002;29(suppl 1):S1-S246.

6. Safdar N, Kluger D, Maki D. A review of risk factors for catheter-related bloodstream infection caused by percutaneously insertednoncuffed central venous catheters: implications for preventivestrategies. Medicine. 2002;81(6):466-479.

7. Mermel L, Allon M, Bouza E, et al. Clinical practice guidelinesfor the diagnosis and management of intravascular catheter-relat-ed infection: 2009 update by the Infectious Diseases Society ofAmerica. Clin Infect Dis. 2009;49:1-45.

8. Kolbeck K, Stavropoulos W, Trerotola, S. Overwire catheterexchanges: reduction of the risk of air emboli. J VascularIntervent Radiol. 2008;19:1222-1226.

9. Cook D, Randolph A, Kernerman P, et al. Central venouscatheter replacement strategies: a systematic review of the litera-ture. Crit Care Med. 1997;25(8):1417-1424.

10. Marschall J, Mermel L, Classen D, et al. Compendium of strate-gies to prevent central line-associated bloodstream infection inacute care hospitals. Infect Control Hosp Epidemiol. 2008;29(suppl 1):S22-S30.

56. CATHETER CLEARANCE:OCCLUDED CENTRAL VASCULAR ACCESS DEVICES

Standard

56.1 Medications and/or solutions used to dissolvethrombotic deposits or precipitate in central vascularaccess devices (CVADs) shall be administered upon theorder of a licensed independent practitioner (LIP) inaccordance with organizational policies, procedures,and/or practice guidelines.56.2 The nurse shall be competent in performing proce-dures used in catheter clearance.56.3 The nurse shall assess the patient and the patient’sCVAD for appropriateness of the use of catheter clear-ance medications and/or solutions in relation to the sus-pected cause of catheter occlusion.

Practice Criteria

A. The nurse should assess for and identify signs ofCVAD occlusion, including the inability to with-draw blood, sluggish flow, and/or inability to flushor infuse through the device.1-6 (III)

B. The nurse should assess for potential causes ofcatheter occlusion and consider the use of anappropriate catheter clearance procedure in orderto preserve the patient’s CVAD.1-7 (III)

C. The responsibility of the nurse performingcatheter clearance should include, but not be lim-ited to, knowledge of medication and/or solutiondosage, contraindications, side effects, techniques



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for instillation, potential complications, and patientand caregiver education.1-7 (V)

D. The instillation of low-dose alteplase is effective inrestoring blood flow and has been found to be safefor use in both adult and pediatric patients.7-14 (II)

E. Infusions of low doses of alteplase over 1-2 hourshave been found successful in restoring patency tohemodialysis catheters.13,15,16 (IV)

F. Instillation of 0.1 N hydrochloric acid into theoccluded catheter lumen has been used to dissolvelow pH drug precipitates, and instillation of sodiumbicarbonate has been used to dissolve high pH drugprecipitates.17-19 (V)

G. Instillation of ethanol, ethyl alcohol, and sodiumhydroxide into the occluded catheter lumen has beenused to restore patency to catheters with suspectedbuildup of intravenous fat emulsions particularlyassociated with administration of total nutrientadmixtures.20-22 (V)

H. Instillation of alcohol solutions such as ethanol orethyl alcohol may damage catheters made of sometypes of polyurethane; manufacturers’ directionsfor use should be reviewed and followed.2 (V)

I. Consideration should be given to the potential pres-sure exerted on an occluded CVAD when medica-tions and/or solutions used for catheter clearanceare instilled. The syringe size used for catheter clear-ance procedures should be no smaller than 10 mLand should be in accordance with the catheter man-ufacturer’s directions for use. Instillation methodsthat use a negative-pressure approach should beconsidered.3-6 (V)

J. If the catheter clearance procedure does not result inpatency of the CVAD, the LIP should be notified; alter-native actions such as a referral to interventional radi-ology should be considered; and catheter removalshould be considered if catheter patency is notrestored.1-7 (V)

REFERENCES

1. McKnight S. Nurse’s guide to understanding and treating throm-botic occlusion of central venous access devices. Medsurg Nurs.2004;13(6):377-382.

2. Hadaway LC. Reopen the pipeline for I.V. therapy. Nursing.2005;35(8):54-61.

3. Gorski LA. Central venous access device occlusions: part I: thrombot-ic causes and treatment. Home Healthc Nurse. 2003;21(2):115-121.

4. Gorski, LA. Central venous access device occlusions: part II: non-thrombotic causes and treatment. Home Healthc Nurse. 2003;21(3):168-171.

5. Registered Nurses’ Association of Ontario. Care and maintenance toreduce vascular access complications. http://www.rnao.org/Page.asp?PageID=924&ContentID=796. Accessed January 15, 2010.

6. National Kidney Foundation. Clinical Practice Guidelines andClinical Practice Recommendations. 2006 Updates: VascularAccess. http://www.kidney.org/Professionals/kdoqi/guideline_upHD_PD_VA/index.htm. Accessed January 15, 2010.

7. Baskin JI, Pui CH, Reiss U, et al. Management of occlusion andthrombosis associated with long-term indwelling central venouscatheters. Lancet. 2009;374:159-169.

8. Deitcher SR, Fesen MR, Kiproff PM, et al. Safety and efficacy ofalteplase for restoring function in occluded central venouscatheters: results of the cardiovascular thrombolytic to openoccluded lines trial. J Clin Oncol. 2002;20(1):317-324.

9. Ponec D, Irwin D, Haire WD, et al. Recombinant tissue plas-minogen activator (alteplase) for restoration of flow in occludedcentral devices: a double-blind placebo controlled trial—the car-diovascular thrombolytic to open occluded lines (COOL) efficacytrial. J Vascular Iintervent Radiol. 2001;12(8):951-955.

10. Blaney M, Shen V, Kerner JA, et al. Alteplase for the treatment ofcentral venous catheter occlusion in children: results of a prospec-tive, open-label, single-arm study (The Cathflo Activase PediatricStudy). J Vasc Intervent Radiol. 2006;17(11):1745-1751.

11. Ng R, Li X, Tu T, Semba CP. Alteplase for treatment of occlud-ed peripherally inserted central catheters: safety and efficacy in240 patients. J Vasc Intervent Radiol. 2004;15(1):45-49.

12. Fisher AA, Deffenbaugh C, Poole RL, Garcia M, Kerner JA. The useof alteplase for restoring patency to occluded central venous accessdevices in infants and children. J Infus Nurs. 2004;27(3):171-174.

13. Clase CM, Crowther MA, Ingram AJ, Cina CS. Thrombolysis forrestoration of patency to haemodialysis central venous catheters:a systematic review. J Thromb Thrombolysis. 2001;11:127-136.

14. Jacobs BR, Maygood M, Hingl J. Recombinant tissue plasmino-gen activator in the treatment of central venous catheter occlusionin children. J Pediatr. 2001;139:593-596.

15. Bamgbola OF, del Rio M, Kaskel FJ, Flynn JT. Recombinant tis-sue plasminogen activator infusion for hemodialysis catheterclearance. Pediatr Nephrol. 2005;20(7):989-993.

16. Dowling K, Sansivero G, Stainken B, et al. The use of recombinanttissue plasminogen activator infusion to re-establish function of tun-neled hemodialysis catheters. Nephrol Nurs J. 2004;31(2):199-200.

17. Breaux CW, Duke D, Georgeson KE, et al. Calcium phosphatecrystal occlusion of central venous catheters used for total par-enteral nutrition in infants and children: prevention and treat-ment. J Pediatr Surg. 1987;22:829-832.

18. Shulman RJ, Reed T, Pitre D, et al. Use of hydrochloric acid toclear obstructed central venous catheters. J Parenter EnteralNutr. 1988;12:509-510.

19. Duffy LF, Kerzner B, Gebus V, et al. Treatment of central venouscatheter occlusions with hydrochloric acid. J Pediatr. 1989;114:1002-1004.

20. Bader SG, Balke P, Jonkers-Schuitema CF, Tas TA, SauerweinHP. Evaluation of 6 years use of sodium hydroxide solution toclear partially occluded central venous catheters. Clin Nutr.2007;26:141-144.

21. Werlin SL, Lausten T, Jessen S, et al. Treatment of central venouscatheter occlusions with ethanol and hydrochloric acid. JParenter Enteral Nutr. 1995;19:416-418.

22. Pennington CR, Pithie AD. Ethanol lock in the management ofcatheter occlusion. J Parenter Enteral Nutr. 1987;11:507-508.

57. PHLEBOTOMY

Standard

57.1 Phlebotomy and blood sampling via vascular accessdevices (VADs) shall be performed upon the order for



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laboratory tests by a licensed independent practitioner(LIP) in accordance with organizational policies, proce-dures, and/or practice guidelines.57.2 Therapeutic phlebotomy shall be performed uponthe order of an LIP in accordance with organizationalpolicies, procedures, and/or practice guidelines.57.3 The nurse shall be competent in performing phle-botomy procedures.57.4 The blood sample shall be identified at the time ofcollection at the patient’s bedside or ambulatory settingand clearly labeled with patient identifiers.57.5 All hazardous waste, including discarded bloodfrom VAD sampling and therapeutic phlebotomy, shallbe disposed of in an acceptable biohazard container.

Practice Criteria

I. Phlebotomy via Direct Venipuncture

A. The nurse should assess the patient for anxiety,understanding of the purpose of venipuncture forblood testing, and for any history of vasovagalreactions with venipuncture. The nurse should pro-vide education and reassurance as needed and beprepared to manage a vasovagal reaction inpatients at risk (see Standard 12, InformedConsent).1-5 (V)

B. Venipuncture for the purpose of phlebotomyshould be drawn from the opposite extremity of aninfusion. Should venipuncture be required on theextremity with a VAD infusion, it should be per-formed in a vein below the device or infusion.2,6 (V)

C. Venipuncture should be avoided on the side ofbreast surgery with axillary node dissection, afterradiation therapy to that side, or with lymphede-ma; the affected extremity from a cerebrovascularaccident; or the extremity with an actual orplanned fistula access.7-9 (V)

D. The nurse should select an appropriate vein forphlebotomy; the most common veins include themedian cubital, the cephalic, and the basilic veins inthe antecubital area. Skin-puncture blood collectingmethods (eg, heel/finger stick) may be used withinfants or adults/children with difficult venousaccess and with point-of-care testing methods;venipuncture was found to be less painful than heelpunctures in term neonates.2,6,10,11 (V)

E. The nurse should be knowledgeable about techni-cal factors involved in blood specimen collectionsuch as the need for patient fasting prior to collec-tion, minimal tourniquet time to avoid hemocon-centration and hemolysis, use of appropriateblood collection tubes in the correct sequence, andtimeliness of dispatch to the laboratory.2,6,12 (V)

F. Only the volume of blood needed for accurate test-ing should be obtained; phlebotomy contributes toiron deficiency and blood loss in neonates and criti-

cally ill patients. Efforts to conserve blood should beconsidered; these may include use of low-volumeblood collection tubes; recording the volume ofblood obtained for laboratory testing; avoidance ofroutine testing; use of point-of-care testing methods;and consolidation of all daily tests with 1 draw.13-16

(V)G. Pressure should be applied with a sterile dressing

following the venipuncture and maintained untilbleeding stops.2,6 (V)

Practice Criteria

II. Blood Sampling via a Vascular AccessDevice

A. Blood sampling for laboratory testing from a centralvascular access device (CVAD) should be consideredbased on an evaluation of benefits versus risks.Benefits include avoidance of anxiety, discomfort,and dissatisfaction associated with venipuncture inpatients who require frequent blood tests and/orthose with difficult vascular access. Risks includeincreased risk for occlusion and catheter-relatedbloodstream infection (CR-BSI) due to increasedhub manipulation and potential for inaccurate lab-oratory results, although there was no significantincrease in occlusion, infection, or other complica-tions in peripherally inserted central catheters(PICCs) used for blood sampling in one study.17-19

(V)B. Sampling of blood through short peripheral

catheters has been found to be reliable for manyroutine blood tests, including coagulation studies,and may be considered for pediatric patients, thosewho require multiple laboratory tests includingpatients with risk for bleeding, and/or those whohave difficult vascular access.18,20-22 (IV)

C. Caution should be exercised when interpretingdrug levels with a CVAD-obtained blood sample.When questionable results are obtained (eg, unex-pected high levels that would necessitate a medica-tion dosage change), the nurse should collaboratewith the LIP in retesting via direct venipuncture.Some studies have shown elevated drug levels withblood sampling from CVADs; factors negativelyinfluencing accuracy include sampling fromimplanted ports, silicone catheters, and from thesame catheter lumen used for drug infusion.18,23-30

(IV)D. Caution should be exercised when interpreting

coagulation values with a blood sample obtainedfrom a heparinized CVAD. Current literature doesnot support blood sampling for coagulation levelsvia heparinized CVADs; literature is inconsistentin relation to sampling from heparinized arterialcatheters. With hemodialysis catheters, accurate



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coagulation levels were obtained using the arterialport of the catheter. When questionable results areobtained (eg, unexpected high levels that wouldnecessitate a medication dosage change), the nurseshould collaborate with the LIP in retesting via directvenipuncture.18,31-38 (IV)

E. The nurse should be knowledgeable about techni-cal factors involved in blood specimen collection,such as changing the needleless connector, needfor patient fasting prior to collection, use ofappropriate blood collection tubes in the correctsequence, and timeliness of dispatch to the labora-tory.1,2,6 (V)

F. The reinfusion method for blood withdrawalshould not be used due to risk of contaminationand blood clot formation, as this method includesreinfusion of the discard specimen following bloodwithdrawal.18,39,40 (IV)

G. Prior to blood sampling from a VAD, infusionsshould be stopped and the VAD flushed with preser-vative-free 0.9% sodium chloride (USP). The largestlumen should be used for blood sampling with mul-tilumen CVADs. For CVADs with staggered lumenexit sites, the sample should be drawn from the onehighest in the superior vena cava; for drug levels, thesample should be preferentially drawn from thecatheter lumen not being used for the drug infu-sion.18,26,30 (IV)

H. Only the volume of blood needed for accurate test-ing should be obtained; phlebotomy contributes toiron deficiency and blood loss in critically illpatients and neonates, so efforts to conserve bloodshould be considered. These may include use oflow-volume blood collection tubes, recording thevolume of blood obtained for laboratory testing,and avoidance of routine testing, use of point-of-care testing methods, consolidation of all dailytests with 1 draw, and consideration of the use ofthe mixing method for blood sampling fromCVADs.13-16,18,37,41-43 (V)

Practice Criteria

III. Therapeutic Phlebotomy

A. Orders for therapeutic phlebotomy should includefrequency of phlebotomy and amount of blood tobe withdrawn; orders for fluid replacement mayalso be included and if ordered, should include thetype of fluid, amount, and rate of infusion.44-46 (V)

B. Patient education should address potential sideeffects such as syncope and nausea/vomiting, needfor increased fluid intake postprocedure unless con-traindicated, and when to resume normal activi-ties.44,47 (V)

C. Use of a short peripheral catheter for therapeuticphlebotomy is preferred. Adequate blood flow is

based upon size of the vein and catheter size; 18-to 20-gauge catheters are acceptable and cause lessinsertion pain and less bleeding after catheterremoval. To ensure the best results and reduce therisk of trauma to the vein, the catheter should beplaced immediately before phlebotomy andremoved upon completion.44,48 (V)

D. The use of CVADs is not recommended for thera-peutic phlebotomy due to risk of thromboticocclusion or catheter damage. In patients whorequire multiple phlebotomies, an apheresiscatheter may be placed for this purpose.44 (V)

E. Blood collection receptacles may include collectionbags used for volunteer blood donation or bagsspecifically designated for therapeutic phlebotomy;use of vacuum containers to facilitate blood flow iscontroversial due to risk of air embolism and veincollapse.44 (V)

F. After completion of the phlebotomy, hemostasisshould be maintained at the venipuncture site afterremoval of a peripheral catheter, and the patientshould remain in a reclining position for several min-utes.44 (V)

G. Documentation should include total volume ofblood withdrawn, patient response to the proce-dure, and patient education.44,46 (V)

REFERENCES

1. Czaplewski L. Clinician and patient education. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St Louis, MO:Saunders/Elsevier; 2010:71-94.

2. Phlebotomy techniques. In: Phillips LD, ed. Manual of IVTherapeutics: Evidence-Based Practice for Infusion Therapy. 5thed. Philadelphia, PA: FA Davis; 2010:402-457.

3. Cho EJ, Rho TH, Kim HY, et al. Recurrent asystoles associatedwith vasovagal reaction during venipuncture. Korean J InternMed. 2000;15(3):232-235.

4. Deacon B, Abramowitz J. Fear of needles and vasovagal reactionsamong phlebotomy patients. J Anxiety Disord. 2006;20(7):946-960.

5. Wakita R, Ohno Y, Yamazaki S, Kohase H, Umino M. Vasovagalsyncope with asystole associated with intravenous access. Oral SurgOral Med Oral Pathol Oral Radiol Endod. 2006;102(6):e28-e32.

6. Laboratory tests and values. In: Weinstein S, ed. Plumer’sPrinciples & Practice of Intravenous Therapy. 8th ed.Philadelphia, PA: Lippincott Williams & Wilkins; 2007:63-93.


8. American Nephrology Nurses’ Association [position statement].Vascular access for hemodialysis. http://www.annanurse.org/cgi-bin/WebObjects/ANNANurse.woa/wa/viewSection?s_id=1073744052&ss_id=536873322&tName=vascAccess. AdoptedFebruary 2003. Revised February 2009. Accessed March 3, 2010.

9. Felty CL, Rooke TW. Lymphedema. In: Fahey V. VascularNursing. 4th ed. St Louis, MO: Saunders; 2004:33-46.



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10. Lewandrowski, K. Point-of-care testing: an overview and a look tothe future (circa 2009, United States). Clin Lab Med. 2009;29(3):421-432.

11. Shah V, Ohlsson A. Venipuncture versus heel lance for bloodsampling in term neonates. Cochrane Database Syst Rev. 2007;(4):CD001452.

12. Saleem S, Mani V, Chadwick MA, Creanor S, Ayling RM. Aprospective study of causes of haemolysis during venipuncture:tourniquet time should be kept to a minimum. Ann Clin Biochem.2009;46(pt 3):244-246.

13. Ezzie ME, Aberegg SK, O’Brien JM. Laboratory testing in theintensive care unit. Crit Care Clin. 2007;23:435-465.

14. Thavendiranathan P, Baga A, Ebidia A. Do blood tests cause ane-mia in hospitalized patients? The effect of diagnostic phlebotomyon hemoglobin and hematocrit levels. J Gen Intern Med. 2005;20:520-524.

15. Woodhouse S. Complications of critical care: lab testing andiatrogenic anemia. MLO Med Lab Obs. 2001;33:28-31.

16. Sullivan K, Gropper MA. Laboratory testing guidelines in theintensive care unit: less red and more green. Crit Care Med. 2008;36(11):3102-3103.

17. Mahieu LM, De Dooy JJ, Lenaerts AE, Ieven MM, De MuynckAO. Catheter manipulations and the risk of catheter-associatedbloodstream infection in neonatal intensive care unit patients. JHosp Infect. 2001;48(1):20-26.

18. Frey AM. Drawing blood samples from vascular access devices:evidence-based practice. J Infus Nurs. 2003;26(5):285-293.

19. Knue M, Doellman D, Rabin K, Jacobs BR. The efficacy and safe-ty of blood sampling through peripherally inserted centralcatheter devices in children. J Infus Nurs. 2005;28(1):30-35.

20. Zengin N, Enc N. Comparison of two blood sampling methods inanticoagulation therapy: venipuncture and peripheral venouscatheter. J Clin Nurs. 2008;17(3):386-393.

21. Fincher R, Strong J, Jackson J. Accuracy of measurements ofhemoglobulin and potassium in blood samples from peripheralcatheters. Am J Crit Care. 1998;7(6):439-443.

22. Arrants J, Willis ME, Stevens B. Reliability of an intravenousintermittent access port (saline lock) for obtaining blood samplesfor coagulation studies. Am J Crit Care. 1999;8:344-348.

23. Boodhan S, Maloney AM, Dupuis LL. Extent of agreement ingentamicin concentration between serum that is drawn peripher-ally and from central venous catheters. Pediatrics. 2006;118(6):e1650-e1656.

24. Grouzmann E, Buclin T, Biollaz J. Misleading tacrolimus concen-tration value in blood taken from a catheter used for tacrolimusadministration. Am J Health-Syst Pharm. 2008;65(3):226-228.

25. Shulman RJ, Ou C, Reed T, Gardner P. Central venous cathetersversus peripheral veins for sampling blood levels of commonlyused drugs. J Parenter Enteral Nutr. 1998;22(4):234-237.

26. McBeth CL, McDonald RJ, Hodge MB. Antibiotic sampling fromcentral venous catheters versus peripheral veins. Pediatr Nurs.2004;30(3):200-202.

27. Senner AM, Johnston K, McLachlan AJ. A comparison of periph-eral and centrally collected cyclosporine blood levels in pediatricpatients undergoing stem cell transplant. Oncol Nurs Forum.2005;32(1):73-77.

28. Franson TR, Ritch PS, Quebbeman EJ. Aminoglycoside serum con-centration sampling via central venous catheters: a potential sourceof clinical error. J Parenter Enteral Nutr. 1987;11(1):77-79.

29. Ritzmo C, Albertioni F, Cosic K, Soderhall S, Eksborg S.Therapeutic drug monitoring of methotrexate on the pediatriconcology ward: can blood sampling from central venous accesses

substitute for capillary finger punctures? Ther Drug Monit.2007;29(4):447-451.

30. Mogayzel PJ, Pierce E, Mills J, et al. Accuracy of tobramycin lev-els obtained from central venous access devices in patients withcystic fibrosis is technique dependent. Pediatr Nurs. 2008;34(6):464-468.

31. Hinds P, Quargnenti A, Gattuso J, Srivastava D. Comparing theresults of coagulation tests on blood drawn by venipuncture andthrough heparinized tunneled venous access devices in pediatricpatients with cancer. Oncol Nurs Forum. 2002;29(3):E26-E34.

32. Mayo DJ, Dimond EP, Kramer W, McDonald KH. Discard volumesnecessary for clinically useful coagulation studies from heparinizedHickman catheters. Oncol Nurs Forum. 1996;23(4):671-675.

33. McLaren G, Hanna C, Mills L, Bourdeau J, Cowin R.Comparison of sampling methods for obtaining accurate coagu-lation values in hemodialysis patients with heparinized centralvenous catheters. Nephrol Nurs J. 2001;28(6):632-636.

34. Boyd A, Dunne A, Townsend K, Pai AB. Sampling for interna-tional normalized ratios in patients on hemodialysis with centralvenous catheters. Nephrol Nurs J. 2006;33(4):408-411.

35. Thomas-Hawkinds C, Welch JL. Statistical analysis for article:comparison of sampling methods for obtaining accurate coagula-tion values in hemodialysis patients with heparinized centralvenous catheters. Nephrol Nurs J. 2002;29(2):109,194.

36. Rioux JP, DeBortoli B, Querin S, et al. measurement of the inter-national normalized ratio (INR) in hemodialysis patients withheparin-locked central venous catheters: evaluation of a novelblood sampling method. J Assoc Vasc Access. 2009;10(3):180-182.

37. Hoste EA, Roels NR, Decruyenaere JM, Colardyn FA. Significantincrease of activated partial thromboplastin time by hepariniza-tion of the radial artery catheter flush solution with a closed arte-rial catheter system. Crit Care Med. 2002;30(5):1030-1034.

38. Laxson CJ, Titler MG. Drawing coagulation studies from arteri-al lines: an integrative literature review. Am J Crit Care. 1994;3(1):16-22.

39. Camp-Sorrell D. Clinical dilemma: vascular access devices. SeminOncol Nurs. 2007;23:232-239.

40. Cosca P, Smith S, Chatfield S, et al. Reinfusion of discard bloodfrom venous access devices. Oncol Nurs Forum. 2002;29:E26-E34.

41. Adlard K. Examining the push-pull method of blood samplingfrom central venous access devices. J Pediatr Oncol Nurs. 2008;25(4):200-207.

42. Huning BM, Horsch S, Roll C. Blood sampling via umbilical veincatheters decreases cerebral oxygenation and blood volume inpreterm infants. Acta Paediatr. 2007;96(11):1617-1621.

43. Roll C, Huning B, Kaunicke M, et al. Umbilical artery cathetersampling volume and velocity: impact on cerebral blood volumeand oxygenation in very low birthweight infants. Acta Paediatr.2006;95(1):68-73.

44. Cook LJ. Therapeutic phlebotomy: a review of diagnoses andtreatment considerations. J Infus Nurs. 2010;33(2):81-88.

45. Weinstein S. Short peripheral access. In: Weinstein S, ed. Plumer’sPrinciples & Practice of Intravenous Therapy. 8th ed. Philadelphia,PA: Lippincott Williams &Wilkins, 2007:260-276.

46. Parker DM, Deel PC, Arner SS. Iron out the details of therapeu-tic phlebotomy. Nursing. 2007;34(2):46-47.

47. Markham M, Lottenberg R, Zumberg M. Role of phlebotomy inthe management of hemoglobin SC disease: case report andreview of the literature. Am J Hematol. 2003;73:121-125.

48. Guidelines and Protocols Advisory Committee. Iron overload:investigation and management. http://www.bcguidelines.ca/gpac/pdf/ironoverload.pdf. Published 2006. Accessed March 2, 2010.



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with spasticity due to spinal cord injury or multiplesclerosis unresponsive to oral therapy.1-6 (IV)

B. Preservative-free medications administered via theintrathecal or epidural route include, but are notlimited to, morphine, fentanyl, hydromorphone,ziconotide, clonidine, bupivacaine, and baclofen.Infusions may include opioids alone, opioids incombination with dilute local anesthetics, andopioids in combination with local anesthetics andclonidine. Antineoplastic agents and pain medica-tions may be administered via an intraventricularaccess device.1-6 (IV)

C. The responsibility of the nurse in caring for apatient with an intraspinal access device includes,but is not limited to, knowledge of anatomy andphysiology; device placement; care and mainte-nance practices; implanted port/reservoir/pumpfilling and/or access; potential complications; andpatient and caregiver education.3 (V)

D. Careful titration is required when initiating med-ications, when converting from one route to anoth-er (eg, intravenous to epidural to intrathecal),when converting from one medication to another,and when adding adjuvant medications. Dosingand opioid conversion guidelines should be used,and dosing should start extremely low when con-verting from one medication to another.1,2 (IV)

E. Epidural access devices should be aspirated toascertain the absence of spinal fluid and blood priorto medication administration. Intrathecal and ven-tricular access devices should be aspirated to ascer-tain the presence of spinal fluid and the absence ofblood prior to medication administration.3 (V)

F. Medication compounding, accessing, and fillingof an implanted intraspinal delivery system with amedication reservoir should be performed at reg-ular intervals in accordance with the manufactur-er’s directions for use.2,7,8 (V)

G. Infusion medication delivery via an intraspinalaccess device may be a single administration, anintermittent injection, or a continuous infusion.Continuous infusions should be administeredusing an electronic infusion device with anti-free-flow protection. Patient-controlled analgesia maybe used with epidural infusions.3,7,8 (V)

58. INTRASPINAL ACCESSDEVICES

Standard

58.1 Intraspinal medication administration and care andmaintenance of intraspinal access devices shall be initiat-ed upon the order of a licensed independent practitioner(LIP) in accordance with the rules and regulations pro-mulgated by the state’s Board of Nursing, and organiza-tional policies, procedures, and/or practice guidelines.58.2 Removal of temporary intraspinal access devices(intrathecal and epidural) shall be performed upon theorder of an LIP in accordance with rules and regulationspromulgated by the state’s Board of Nursing and orga-nizational policies, procedures, and/or practice guide-lines. Removal of long-term implanted ports/reservoirs/pumps or tunneled intraspinal devices shall be consid-ered a surgical procedure.58.3 Medications administered via an intraspinal routeshall be preservative-free.58.4 A 0.2-micron surfactant-free, particulate-retentivefilter shall be used for intraspinal medication adminis-tration.58.5 Alcohol, antiseptics containing alcohol, or acetoneshall not be used for site preparation or for cleansingthe catheter hub due to potential deleterious effects as aneurotoxin.58.6 The nurse shall be competent in the care of apatient with an intraspinal access device.58.7 Intraspinal access devices and administration setsshall be identified and labeled as a specialized infusionadministration system and differentiated from otherinfusion administration and access systems.

Practice Criteria

A. Intraspinal administration of opioids and adjuvantmedications via the intrathecal, epidural, or ven-tricular space may be used to control pain with sur-gical procedures, for patients in labor, and withcancer and chronic pain conditions when pain con-trol has not been achieved through less-invasiveroutes. Intrathecal baclofen may be used to controlspasticity in children with cerebral palsy and adults

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H. The patient should be carefully monitored for thefirst 24 hours after initiating or restartingintraspinal infusions. High-risk patients such asthe elderly, the very young, the opioid naive, andthose with cardiac and/or respiratory diseaseshould be monitored in a hospital setting for thefirst 24 hours.2 (V)

I. The patient should be assessed for response to ther-apy at established intervals. Recommendationsinclude assessing the following hourly for the first24 hours and then every 4 hours; assessment ofoutpatients and patients receiving home careshould occur with every patient encounter:1. Pain rating using a validated, appropriate pain

scale (eg, 0-10), with regard to patient age andcondition, both at rest and with activity

2. Blood pressure, pulse, respiratory rate, temperature3. Level of sedation if opioid is being administered4. Number of bolus doses, if used (eg, patient-

controlled epidural analgesia)5. Fetal status and response to intraspinal infu-

sion for the patient in labor6. Presence of any side effects: pruritis, nausea, urinary

retention, orthostatic hypotension, motor block7. Signs of catheter insertion site infection or epidur-

al abscess such as back pain, tenderness, erythe-ma, swelling, drainage, fever, malaise, neck stiff-ness, progressive numbness, or motor block

8. Dressing for intactness and absence of moisture/leakage

9. Catheter and administration set connections10. Changes in sensory or motor function that

may indicate an epidural hematoma, includingunexplained back pain, leg pain, bowel orbladder dysfunction, motor block

11. Oxygen saturation levels via pulse oximeterand/or carbon dioxide levels, if prescribed

12. Electronic infusion device for history of analgesicuse and correct administration parameters.3,9-11

(V)J. The potential for catheter tip migration should be

routinely assessed by checking for changes in exter-nal catheter length. Migration of the catheter mayresult in changes including decrease in pain control(eg, intrathecal migration to epidural space) orincrease in side effects (eg, epidural migration tointrathecal space).3,6 (V)

K. A dressing should cover the intraspinal access site;routine dressing changes on short-term epidural andintrathecal access devices are not recommended dueto risk of dislodgment and infection. Transparentsemipermeable membrane (TSM) dressings are mostoften used for tunneled and implanted epiduraldevices and are changed every 7 days; after the first24 hours postplacement of a ventricular reservoir,the site is generally left open to air.3,7,10 (V)

L. Use of chlorhexidine-impregnated dressings shouldbe considered for patients with epidural accessdevices; use of these dressings is associated with asignificant reduction in epidural exit site/cathetercolonization with microorganisms and with atrend toward decreased central nervous systeminfection.12 (I)

M. After intraspinal access device removal, a steriledressing should be applied.10 (V)

REFERENCES

1. American Pain Society. Principles of Analgesic Use in the Treatmentof Acute Pain and Cancer Pain. 5th ed. Glenview, IL: APS; 2008.

2. Deer T, Krames ES, Hassenbusch SJ, et al. Polyanalgesic consensusconference 2007: recommendations for the management of pain byintrathecal (intraspinal) drug delivery—reports of an interdisciplinaryexpert panel. Int Neuromodular Soc. 2007;10(4):300-328.

3. Stearns CK, Brant JM. Intraspinal access and medication admin-istration. In: Alexander M, Corrigan A, Gorski L, Hankins J,Perucca R, eds. Infusion Nursing: An Evidence-Based Approach.3rd ed. St Louis, MO: Saunders/Elsevier; 2010:525-539.

4. Simpson KH, Jones I. Intrathecal drug delivery for management ofcancer and noncancer pain. J Opioid Manag. 2008;4(5):293-304.

5. Reisfield GM, Wilson GR. Intrathecal drug therapy for pain. 2nded. End of Life/Palliative Education Resource Center. http://www.eperc.mcw.edu/fastfac/ff_098.htm. Published November 2007.Accessed February 22, 2010.

6. Patel VB, Manchikanti L, Singh V, et al. Systematic review ofintrathecal infusion systems for long-term management of chron-ic non-cancer pain. Pain Physician. 2009;12:345-360.

7. Du Pen A. Care and maintenance of intrathecal and epiduralcatheters. J Infus Nurs. 2005;28(6):377-381.

8. Ghafoor VL, Epshteyn M, Carlson GH, et al. Intrathecal drugtherapy for long-term pain management. Am J Health-SystPharm. 2007;64(23):2447-2461.

9. Gordon D, Schroeder M. Epidural analgesia. 2nd ed. End ofLife/Palliative Education Resource Center. http://www.eperc.mcw.edu/fastfact/ff_098.htm. Published November 2007.Accessed February 22, 2010.

10. Pasero C, Eksterowicz N, Primeau M, Cowley C. Registerednurse management and monitoring of analgesia by catheter tech-niques [position statement]. Pain Manag Nurs. 2007;8(2):48-54.

11. Gorski LA. Pocket Guide to Home Infusion Therapy. Sudbury,MA: Jones & Bartlett; 2005.

12. Ho MH, Litton E. Use of chlorhexidine-impregnated dressing toprevent vascular and epidural catheter colonization and infection:a meta-analysis. J Antimicrob Chemother. 2006;58:281-287.

59. INTRAOSSEOUS ACCESSDEVICES

Standard

59.1 Intraosseous (IO) access and infusion of medica-tions or fluids via the IO route shall be initiated uponthe order of a licensed independent practitioner (LIP) inaccordance with rules and regulations promulgated bythe state’s Board of Nursing.



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59.2 The use of IO access and infusion shall be estab-lished in organizational policies, procedures, and/orpractice guidelines.59.3 The nurse shall be competent in the care of apatient requiring IO access.

Practice Criteria

A. In situations of adult or pediatric cardiac arrest,the IO route should be used if vascular access isnot available or cannot be quickly obtained.1-6 (IV)

B. The IO route may be considered for emergent andnonemergent use in patients with limited or no vas-cular access and when the patient may be at risk ofincreased morbidity or mortality if access is notobtained. Use of IO infusion is reported in pediatricanesthesia.7-11 (IV)

C. The site most often used for IO access in bothadults and children is the proximal tibia; othersites for adults include the proximal humerus,sternum, distal femur, humeral head, radius, ulna,pelvis, and clavicle; in children, distal tibia or dis-tal femur are also used.5-8,12,13 (V)

D. The responsibility of the nurse caring for apatient requiring intraosseous access includes,but is not limited to, knowledge of anatomy andphysiology; IO device placement and removal;care and maintenance practices; potential com-plications; and patient and caregiver education.13

(V)E. IO access should be avoided in the following sites:

previously used IO sites or where IO access haspreviously been attempted; fractures at or abovethe site where previous surgery has been performedon the bone; presence of infection at the insertionsite; and local vascular compromise. Bone diseasessuch as osteogenesis imperfecta, osteopetrosis, andsevere osteoporosis may be a contraindication,depending on the device.7,8,13,14 (V)

F. Pain management during insertion and infusionshould be considered especially in the consciouspatient. Lidocaine is recommended prior to inser-tion (subcutaneously at the intended site) and intothe IO space prior to infusion initiation.8-13,15 (V)

G. Proper placement of the IO device is confirmed byassessment of the needle position and flushingwith 5-10 mL of preservative-free 0.9% sodiumchloride (USP) that should enter by free flow orinfuse without resistance.7,13 (V)

H. The dwell time of the IO device should be limitedto no longer than 24 hours. Assessment should bemade for a replacement vascular access device(VAD).8 (V)

I. Complications associated with IO access are relative-ly rare but include extravasation from dislodgment,iatrogenic fracture, growth plate injury, infection, fat

emboli, compartment syndrome, and osteomyelitis.Infectious complications were more likely to occurwith prolonged infusion or if bacteremia was presentduring the time of insertion.1,6,7,10-13 (V)

J. The IO device should be covered with a steriledressing after placement.10,12 (V)

REFERENCES

1. American Heart Association. American Heart Association guide-lines for cardiopulmonary resuscitation and emergency cardiovas-cular care (part 7.2): management of cardiac arrest. Circulation.2005;112:IV58-IV66.

2. American Heart Association. American Heart Association guide-lines for cardiopulmonary resuscitation and emergency cardiovas-cular care (part 12): pediatric advanced life support. Circulation.2005;112:IV167-IV187.

3. National Association of EMS Physicians [position statement].Prehosp Emerg Care. 2007;11(1):1-8.

4. Von Hoff DD, Kuhn JG, Burris HA, Miller LJ. Does intraosseousequal intravenous? A pharmacokinetic study. Am J Emerg Med.2008;26:31-38.

5. Leidel BA, Kirchhoff C, Bogner V, et al. Is the intraosseous accessroute fast and efficacious compared to conventional central venouscatheterization in adult patients under resuscitation in the emer-gency department? A prospective observational pilot study. PatientSafety Surg. 2009;3(1):24.

6. Fowler R, Gallagher JV, Isaacs SM, et al. The role of intraosseousvascular access in the out-of-hospital environment (resource docu-ment to NAEMSP position statement). Prehosp Emerg Care. 2007;11:63-66.

7. Tobias JD, Ross AK. Intraosseous infusions: a review for the anesthe-siologist with a focus on pediatric use. Anesth Analg. 2010;110:391-401.

8. Infusion Nurses Society [position paper]. The role of the regis-tered nurse in the insertion of intraosseous access devices. J InfusNurs. 2009;32(4):187-188.

9. Neuhaus D, Weiss M, Engelhardt T, et al. Semi-electiveintraosseous infusion after failed intravenous access in pediatricanesthesia. Pediatr Anesth. 2010;20:168-171.

10. Vizcarra C, Clum S. Intraosseous route as alternative access forinfusion therapy. J Infus Nurs. 2010;33(3):162-174.

11. The Consortium on Intraosseous Vascular Access for Emergent andNonemergent Situations in Various Healthcare Settings [positionpaper]. Recommendations for the use of intraosseous access foremergent and nonemergent situations in various healthcare settings:a consensus paper. J Infus Nurs. 2010;33(6):346-351.

12. Holleran RS. Intraosseous infusion. In: Proehl JA, ed. EmergencyNursing Procedures. 4th ed. Philadelphia, PA: Elsevier/Saunders;2009:306-313.

13. Parker M, Henderson K, Alternative infusion access devices. In:Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds.Infusion Nursing: An Evidence-Based Approach. 3rd ed. StLouis, MO: Saunders/Elsevier; 2010:516-524.

14. Paxton JH, Knuth TE, Krausner HA. Proximal humerus intraosseousinfusion: a preferred emergency venous access. J Trauma. 2009;67(3):606-611.

15. Davidoff J, Fowler R, Gordon D, et al. Clinical evaluation of anovel intraosseous device for adults. J Emerg Med Serv. 2005;30(10)(suppl):20-23.



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60. CONTINUOUS SUBCUTANEOUSINFUSION AND ACCESSDEVICES

Standard

60.1 Administration of continuous subcutaneous infu-sion of medications or hydration fluids shall be initiatedupon the order of a licensed independent practitioner(LIP) in accordance with organizational policies, proce-dures, and/or practice guidelines.60.2 The use of continuous subcutaneous infusionaccess shall be established in organizational policies,procedures, and/or practice guidelines.60.3 The nurse shall be competent in the care of a patientrequiring continuous subcutaneous infusion therapy.60.4 The nurse shall assess the patient for appropriate-ness of the subcutaneous route in relation to the pre-scribed medication or fluid and to the patient’s clinicalcondition and presence of adequate subcutaneous tissue.

Practice Criteria

A. Isotonic dextrose or 0.9% sodium chloride fluidsmay be administered as a continuous infusion via asubcutaneous access device (hypodermoclysis) fortreatment of mild to moderate dehydration.1-3 (II)

B. The most common types of medications used incontinuous infusion via a subcutaneous device areopioids for pain management.4-10 (III)

C. The responsibility of the nurse caring for a patientrequiring continuous subcutaneous infusion ther-apy includes, but is not limited to, knowledge ofanatomy and physiology; care and maintenancepractices; potential complications; and patientand caregiver education.11 (V)

D. Site selection for subcutaneous access should includeareas with adequate subcutaneous tissue with intactskin such as the upper arm, subclavicular chest wall,abdomen, upper back, and thighs.1,4,8,12-14 (III)

E. A small-gauge (25- to 27-gauge) subcutaneousinfusion device should be used to establish subcu-taneous access.1,4,8,12-14 (III)

F. Nonmetal subcutaneous access devices are prefer-able to metal devices; advantages include extend-ed dwell time and decreased risk for health careprovider needlestick injury.15-18(IV)

G. The subcutaneous infusion access device should beaspirated to ascertain the absence of blood prior tomedication and fluid administration.8,13 (V)

H. Hyaluronidase may be considered for use in increasingabsorption and dispersion of subcutaneously adminis-tered medications and/or hydration fluids.1,3,19-21 (III)

I. The optimal subcutaneous infusion rate isunknown. Medication infusion rates of 3-5 mL perhour are reported, and hydration infusion rates of

up to 1500 mL over 24 hours are reported. Morethan 1 infusion site may be used to accomplish alarger infusion volume.1,4,8,10,12-14,22 (IV)

J. Medications infused via a subcutaneous accessdevice should be administered using an electronicinfusion device; syringe pumps are used most oftenfor subcutaneous immunoglobulin infusions. 8,9,12

(V)K. Hydration fluids infused via a subcutaneous access

device should be administered via a manual flow-con-trol device or an electronic infusion device.13,14 (V)

L. The subcutaneous access site used for medicationadministration should be rotated every 2-7 days andas clinically indicated based on the integrity of theaccess site.8,11-13,22 (IV)

M.The subcutaneous access site used for hydration flu-ids should be rotated every 24-48 hours or after 1.5-2 liters of infused fluid and as clinically indicated.1,3,14

(II)N. A transparent semipermeable membrane (TSM)

dressing should be applied over the subcutaneousaccess site and changed with each subcutaneous siterotation, and immediately if the integrity of thedressing is compromised.8,13,23 (V)

O. Subcutaneous sites should be assessed for androtated when there is erythema, swelling, leaking,bruising, burning, or pain.1,8,13 (II)

REFERENCES

1. Remington R, Hultman T. Hypodermoclysis to treat dehydration:a review of the evidence. J Am Geriatr Soc. 2007;55:2051-2055.

2. Turner T, Cassano AM. Subcutaneous dextrose for rehydration ofelderly patients: an evidence-based review. BMC Geriatr. 2004;4:2.

3. Thomas DR, Cote TR, Lawhorne L, et al. Understanding clinicaldehydration and its treatment. J Am Med Dir Assoc. 2008;9:292-301.

4. Weissman DE. Subcutaneous opioid infusions. 2nd ed. End ofLife/Palliative Education Resource Center. http://www.eperc.mcw.edu. Published July 2005. Accessed December 20, 2009.

5. Anderson S, Shreve S. Continuous subcutaneous infusions of opi-ates at the end of life. Ann Pharmacother. 2004;38(6):1015-1023.

6. Koshy RC, Kuriakose R, Sebastian P, Koshy C. Continuous mor-phine infusions for cancer pain in resource-scarce environments:comparison of the subcutaneous and intravenous routes of admin-istration. J Pain Palliat Care Pharmacother. 2005;19(1):27-33.

7. Neafsey P. Efficacy of continuous subcutaneous infusion in patientswith cancer pain. Home Healthc Nurse. 2005;23(7):421-423.

8. Justad M. Continuous subcutaneous infusion: an efficacious, cost-effective analgesia alternative at the end of life. Home HealthcNurse. 2009;27(3):140-147.

9. Herndon CM, Fike DS. Continuous subcutaneous infusion prac-tices of United States hospices. J Pain Symptom Manag. 2001;22(6):1027-1034.

10. American Pain Society. Principles of Analgesic Use in the Treatmentof Acute Pain and Cancer Pain. 5th ed. Glenview, IL: APS; 2008.

11. Parker M, Henderson K. Alternative infusion access devices. In:Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds.Infusion Nursing: An Evidence-Based Approach. 3rd ed. St Louis,MO: Saunders/Elsevier; 2010:516-524.



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12. Kirmse J. Subcutaneous administration of immunoglobulin. JInfus Nurs. 2006;29(suppl 3):S15-S20.

13. Lybarger EH. Hypodermoclysis in the home and long-term caresettings. J Infus Nurs. 2009;32(1):40-44.

14. Walsh G. Hypodermoclysis: an alternative method for rehydra-tion in long-term care. J Infus Nurs. 2005;28(2):123-129.

15. Torre MC. Subcutaneous infusion: non-metal cannulae vs metalbutterfly needles. Br J Community Nurs. 2002;7(7):365-369.

16. Dawkins L, Britton D, Johnson I, Higgins B, Dean T. A random-ized trial of winged Vialon cannulae and metal butterfly needles.Int J Palliat Nurs. 2000;6(3):110-116.

17. Abbas SQ, Yeldman M, Bell S. The use of metal or plastic needlesin continous subcutaneous infusion in a hospice setting. Am JHosp Palliat Care. 2005;22(2):134-138.

18. Ross J, Saunders Y, Cochrane M, et al. A prospective, within-patientcomparison between metal butterfly needles and Teflon cannulae in sub-

cutaneous drugs to terminally ill hospice patients. Palliat Med. 2002;16(1):13-16.

19. Bookbinder LH, Hofer A, Haller MF, et al. A recombinant humanenzyme for enhanced interstitial transport of therapeutics. J ControlRelease. 2006;114:230-241.

20. Pirrello RD, Ting CC, Thomas SH. Initial experiences with subcu-taneous recombinant human hyaluronidase. J Palliat Med. 2007;10(4):861-864.

21. Thomas JR, Yocum RC, Haller MF, von Gunten CF. Assessingthe role of human recombinant hyaluronidase in gravity drivensubcutaneous hydration: the INFUSE-LR study. J Palliat Med.2007;10(6):1312-1320.

22. Pasero C. Subcutaneous opioid infusion. Am J Nurs. 2002;102(7):61-62.

23. Cote TR. How to perform subcutaneous hydration. J Am MedDir Assoc. 2008;9:291.



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or expiration date), and in the home care setting, verify appropriate storage/refrigeration (see Standard20, Compounding of Parenteral Solutions andMedications).4,5 (V)

F. The nurse should reduce the manipulation of allthe components of the entire infusion system (eg,administration set junctions, catheter hub) to asfew as needed to deliver the infusion therapy.6 (V)

G. The nurse should administer solutions and medica-tions prepared and dispensed from the pharmacy oras commercially prepared solutions and medicationswhenever feasible. Medications admixed outside ofthe pharmacy, pharmacy-labeled solutions, and med-ications labeled for emergent use should be adminis-tered within 1 hour of preparation. Multidose vial useshould be avoided. Filter needles or filter strawsshould be used when withdrawing medications fromglass ampoules.4,7-12 (IV)

H. The nurse should trace the administration set fromthe patient to the point of origin before makingconnections and on admission or transfer of apatient to a new setting.12,13 (V)

I. The nurse should advocate for the use of engineer-ing controls, protocols, and technology that isintended and has been shown to reduce medica-tion errors including, but not limited to, electron-ic order entry, smart pumps with drug libraries,bar coding, procedures for distraction-free med-ication administration, establishment of protocolsfor high-risk intravenous drugs, and standardizeddrug concentrations or standard order sets.14-18

(IV)J. The nurse should exercise particular care when

administering solutions and medications to pedi-atric and neonatal patients, as medication errors aresignificantly higher in incidence for these patients.The use of standardized drug concentrations isstrongly recommended for this population.2,15 (IV)

K. The nurse should be accountable for evaluatingand monitoring the effectiveness of prescribed ther-apy; documenting patient response, adverse events,and interventions; communicating the results oflaboratory tests; and achieving effective delivery ofthe prescribed therapy.2,14 (V)

61. PARENTERAL MEDICATIONAND SOLUTION ADMINISTRATION

Standard

61.1 The administration of parenteral medications andsolutions shall be initiated upon the order of a licensedindependent practitioner (LIP) in accordance with therules and regulations promulgated by the state’s Board ofNursing, and organizational policies, procedures, and/orpractice guidelines.61.2 The nurse shall be competent in the administrationof parenteral medications and solutions.61.3 Prior to the initiation of therapy, a Keep Vein Open(KVO) order shall contain a specific infusion rate.

Practice Criteria

A. The nurse should review the order for appropriate-ness of prescribed therapy for the patient’s age andcondition, access device, dose, rate and route ofadministration, and follow the rights of medicationadministration.1,2 (V)

B. The nurse should aspirate for a positive bloodreturn from the vascular access device (VAD) toconfirm device patency prior to administration ofparenteral medications and solutions.3 (V)

C. A list of approved parenteral medications and solu-tions for each type of administration method androute (eg, continuous, intermittent, or push/directinjection; intravenous, intra-arterial, subcutaneous,hypodermoclysis, intraspinal, intraosseous, intrathe-cal) should be established in organizational poli-cies, procedures, and/or practice guidelines.1 (V)

D. The nurse administering parenteral medicationsand solutions should have knowledge of indica-tions for therapy, side effects, potential adversereactions, and appropriate interventions.1 (V)

E. The nurse should inspect solutions and medicationsfor appropriate labeling, integrity (no leakage/discol-oration/open packaging), accuracy (right drug orsolution and right dose), sterility (within beyond-use

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L. Documentation of administration of intravenoussolutions and medication should include date; drugname/concentration; time administered/started; timediscontinued/stopped; route of administration; VADused; presence of blood return; patient’s responseand tolerance, including any signs and symptoms ofadverse reaction; patient/caregiver instructionspostadministration; and name and title of the nurseadministering the medication.1,19-21 (V)

M. Discontinuation of therapy may occur when thenursing assessment determines that intervention isnecessary (eg, in the event of an adverse reaction,complication such as phlebitis or infiltration, sus-pected VAD malposition, or loss of VAD patency);the LIP should be notified of the assessment andintervention immediately.21 (V)

N. Discontinuation of therapy, including amountinfused, time, date, condition of the site, integrityof the catheter if removed, and reason for discon-tinuation, should be documented in the patient’spermanent medical record.19,20 (V)

O. The nurse should provide instruction to the patientand caregiver about observations and care of theinfusion and catheter site and potential postinfu-sion complications, such as postinfusion phlebitisor infiltration, and document such instructions inthe patient’s permanent medical record.19,20 (V)

REFERENCES

1. Turner M, Hankins J. Pharmacology In: Alexander M, Corrigan A, GorskiL, Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-BasedApproach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:263-298.

2. The Joint Commission. Sentinel Event Alert: Preventing PediatricMedication Errors. April 11, 2008, Issue 39. http//www.jointcom-mission.org/SentinelEvents/SentinelEventAlert/sea_39.htm.Accessed March 26, 2010.


4. US Pharmacopeia. Pharmaceutical compounding-sterile prepara-tions (General Chapter �797�). In: The US Pharmacopeia, 27threv., and the national formulary, 22nd ed. Rockville, MD: The USPharmacopeial Convention, 2004:2350-2370.

5. Institute for Safe Medication Practices. Principles for Designing aMedication Label for Injectable Syringes for Patient-Specific,Inpatient Use. http//www.ismp.org. Accessed March 26, 2010.


7. The US Pharmacopeia (USP). Revised General Chapter �797� phar-maceutical compounding: Sterile preparations. USP 31-NF 26. ThePharmacists’ Pharmacopeia. 2nd ed. Rockville, MD: 2008;(suppl).

8. Paparella S. Risks associated with the use of multidose vials. JEmerg Nurs. 2006;32:428-430.

9. Stein HG. Glass ampules and filter needles: an example of imple-menting the sixth “R” in medication administration. MedsurgNurs. 2006;15:290-294.

10. Aronson JK. Medication errors: what they are, how they happen,and how to avoid them. Q J Med. 2009;102:513-521.

11. Institute for Safe Medication Practices. Errors with InjectableMedications: Unlabeled Syringes are Surprisingly Common. 2007.http//www.ismp.org. Accessed March 26, 2010.

12. Institute for Safe Medication Practices. Principles of Designing aMedication Label for Intravenous Piggyback Medication forPatient Specific, Inpatient Use. www.ismp.org. Accessed March16, 2010.

13. American Nurses Association [position statement]. Safety issuesrelated to tubing and catheter misconnections. http://www.nursingworld.org/NursingPractice. Published 2007. Accessed March 23,2010.

14. Institute for Safe Medication Practices. ISMP’s List of High-AlertMedications, 2000. http//www.ismp.org. Accessed March 26, 2010.

15. Hilmas E, Sowan A, Gaffoor M, Viady V. Implementation andevaluation of a comprehensive system to deliver pediatric continu-ous infusion medications with standardized concentrations. Am JHealth-Syst Pharm. 2010;67:58-69.

16. Institute for Safe Medication Practices. Nurses’ rights regarding safemedication administration. Nurse Advise-ERR. http//www.ismp.org. Published July 2007. Accessed March 26, 2010.

17. Institute for Safe Medication Practices. A Call to Action: EliminateHandwritten Prescriptions within 3 Years. 2000. http//www.ismp.org.Accessed March 26, 2010.

18. Institute for Safe Medication Practices. ISMP’s Guidelines forStandard Order Sets. http//www.ismp.org. Accessed March 26,2010.

19. Smelzer SC, Bare BG, Hinkle JL, Cheever, KH. Brunner &Suddarth’s Textbook of Medical-Surgical Nursing. 12th ed.Philadelphia, PA: Lippincott Williams & Wilkins; 2010.


21. Ahlqvist M, Berglund B, Wiren M, Klang B, Johansson E.Accuracy in documentation: a study of peripheral venous catheters.J Clin Nurs. 2009;18:1945-1952.

62. ANTINEOPLASTIC THERAPY

Standard

62.1 The administration of antineoplastic agents shall beinitiated upon the orders of a licensed independent prac-titioner (LIP) in accordance with the rules and regulationspromulgated by the state’s Board of Nursing and organi-zational policies, procedures, and/or practice guidelines.62.2 The nurse administering antineoplastic agents shallbe competent and have knowledge of and protocols forprescribed therapies.62.3 The nurse shall administer antineoplastic agents delin-eated by written orders only, including new orders orchanges to existing orders. Verbal orders are acceptable onlyif antineoplastic agents are to be placed on hold or stopped.



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62.4 Clinical management of potential adverse events,including treatment and management of anaphylactic andanaphylactoid reactions, shall be addressed in organiza-tional policies, procedures, and/or practice guidelines.

Practice Criteria

A. The patient and caregiver should be informed of allaspects of antineoplastic therapy, including physi-cal and psychological effects, side and adverseeffects, risks, and benefits.1-5 (V)

B. Prior to administration of antineoplastic agents, lab-oratory data should be reviewed and the patientassessed in collaboration with the health care team.1-5

(V)C. Validation by 2 registered nurses prior to administra-

tion of antineoplastic agents should include body sur-face area (BSA) and weight if applicable, medication,dose, concentration, rate, route of infusion, and con-firmation of the calculation for dosing to reduce therisk of adverse outcomes and medication errors.5-12 (V)

D. The nurse should participate in monitoring any cumu-lative chemotherapy dose to ensure that the drug isdiscontinued if the maximum lifetime dose isreached.1-5 (V)

E. The nurse should use electronic infusion devices(EIDs) for specific types of antineoplastic adminis-tration and for all continuous administrations.13 (V)

F. When administering a vesicant medication:1. A low-pressure flow-control infusion device

should be the instrument of choice.2. Prior to administration, positive blood return

should be confirmed and documented.3. A new access site should be initiated prior to

any peripheral vesicant administration and doc-umented.

4. Peripheral access devices should not be used forthe continuous infusion of vesicants (see Standard48, Infiltration and Extravasation).3,13 (V)

G. Scalp veins should not be used for administration ofvesicant therapy in the neonate and pediatric patient.3

(V)H. Drug administration sets should be attached and

primed prior to the addition of the antineoplasticagent within the biological safety cabinet (BSC). Thiseliminates the need to prime the set in a less well-con-trolled environment and ensures that any fluid thatescapes during priming contains no drug. If primingmust occur at the site of administration, the adminis-tration set should be primed with non–drug-contain-ing fluid.13,14 (V)

I. Nurses planning for a family or who are pregnantshould be advised of the potential risks associatedwith handling antineoplastic agents and should begiven the opportunity to refrain from preparing oradministering these agents.5,14,15 (V)

J. Safe handling of antineoplastic agents shouldinclude access to personal protective equipment,material safety data sheets (MSDS), spill kits, con-tainment bags, and disposal containers in all areaswhere hazardous drugs are handled.1,2,13-16 (V)

REFERENCES

1. Goodman M. Chemotherapy: principles of administration. In:Yarbro CH, Frogge MR, Goodman M, Groenwald SL, eds. CancerNursing: Principles and Practice. 5th ed. Boston, MA: Jones &Bartlett; 2000:385-443.

2. Jacobson JO, Polovich M, McNiff K, et al. American society ofclinical oncology/oncology nursing society. Chemotherapy admin-istration safety standards. J Clin Oncol. 2009;10;27(32):5469-5475.

3. Polovich M, Whitford J, Olsen M, ed. Chemotherapy andBiotherapy Guidelines and Recommendations for Practice. 3rd ed.Pittsburgh, PA. Oncology Nursing Society; 2009.

4. Temple SV, Poniatowski BD. Nursing implications of antineoplas-tic therapy. In: Itano JK, Taoka KN, eds. Core Curriculum forOncology Nursing. 4th ed. St Louis, MO: Elsevier; 2005:785-802.

5. Schulmeister L. Antineoplastic therapy. In: Alexander M, CorriganA, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: AnEvidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;2010:351-371.

6. Branowicki P, O’Neill J, Dwyer J, Marino B, Houlahan K, BillettA. Improving complex medication systems: an interdisciplinaryapproach. J Nurs Adm. 2003;33(4):199-200.

7. de Jongh FE, Verweij J, Loos WJ, et al. Body-surface area–baseddosing does not increase accuracy of predicting cisplatin exposure.J Clin Oncol. 2001;19(17):3733-3739.

8. Cohen MR, Anderson RW, Attilio RM, et al. Preventing medica-tion errors in cancer chemotherapy. Am J Health-Syst Pharm.1996;53:737-746.

9. Opfer KB, Wirtz DM, Farley K. A chemotherapy standard orderform: preventing errors. Oncol Nurs Forum. 1999;26:123-128.

10. Gilmore CE, Suresky P. Development and implementation of achemotherapy error-prevention policy. Hosp Pharm. 1998;33:1213-1218.

11. Dinning C, Branowicki P, O’Neill JB, et al. Chemotherapy errorreduction: a multidisciplinary approach to create templated ordersets. J Pediatr Oncol Nurs. 2005;22:20-30.

12. Kaestner S, Sewell G. Chemotherapy dosing, part I: scientific basisfor current practice and use of body surface area [review]. ClinOncol (R Coll Radiol). 2007;19(1):23-37.

13. American Society of Health-System Pharmacists. ASHP guidelineson handling hazardous drugs. Am J Health-Syst Pharm.2006;63:1172-1193.

14. US Department of Labor. Controlling occupational exposure tohazardous drugs. OSHA Technical Manual. Occupational Safetyand Health Administration. http://www.osha.gov/dts/osta/otm/otm_vi/otm_vi_2.html#app_vi:2_1. Accessed February 24, 2010.

15. US Department of Health and Human Services. NIOSH Alert: pre-venting occupational exposures to antineoplastic and other hazardousdrugs in health care settings. Cincinnati, OH: Centers for DiseaseControl and Prevention, National Institute for Occupational Safetyand Health, NIOSH Publication No. 2004-165. http://www.cdc.gov/niosh/docs/2004–165/pdfs/2004–165.pdf. Accessed February 24,2010.

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16. American Society for Testing and Materials. Standard practiceassessment of resistance of medical gloves to permeation bychemotherapy drugs. West Conshohocken, PA: ASTM. 2005:6978-6905.

63. BIOLOGIC THERAPY

Standard

63.1. The administration of biologic medication(s) shallbe initiated upon the order of a licensed independentpractitioner (LIP) in accordance with the rules and regu-lations promulgated by the state’s Board of Nursing, andorganizational policies, procedures, and/or practiceguidelines.63.2 The nurse administering biologic medications shallbe competent and have knowledge of and protocols forprescribed therapies. This knowledge shall include, butnot be limited to, appropriate drug dose, volume, concen-tration, adverse and expected reactions, and rate androute of delivery with regard to the patient’s conditionand vascular access.63.3 Clinical management of potential adverse events,including treatment and management of anaphylactic andanaphylactoid reactions, shall be addressed in organiza-tional policies, procedures, and/or practice guidelines.

Practice Criteria

A. The patient and caregiver should be informed of allaspects of biologic therapy, including physical andpsychological effects, side and adverse effects, andmanagement of adverse events, such as infusion reac-tions, risks, and benefits.1-4 (V)

B. Prior to administration of biologic medications, laboratory data should be reviewed and the patientassessed for appropriateness of the prescribed therapy.1-7 (V)

C. The nurse should be prepared to manage acuteinfusion-related hypersensitivity reactions.1,3-9 (V)

D. The nurse should consider using an electronic infu-sion device for the administration of biologic med-ications to ensure the correct rate of infusion dur-ing initial and subsequent infusions.1,3 (V)

E. The nurse handling and administering biologic med-ications should strictly adhere to safe handling pro-tocols and USP Chapter �797� protocols.1,6,10 (V)

F. For self-administration of a subcutaneous biologicinfusion, the patient should be educated in drugpreparation, subcutaneous injection administra-tion, the importance of site rotation, what to dowith missed doses, and what to monitor or reportduring or after the injection (see Standard 60,Continuous Subcutaneous Infusion and AccessDevices).1 (V)

G. The nurse should educate the patient and caregiveron the pharmacologic and nonpharmacologicmanagement of delayed infusion reactions.1 (V)

REFERENCES

1. Vizcarra C, Belcher D. Management of the patient receiving par-enteral biologic therapy. J Infus Nurs. 2006;29(2):63-71.

2. Barr C. A nursing guide to infusion therapy with abatacept for thetreatment of rheumatoid arthritis. J Infus Nurs. 2007;30(2):96-104.

3. Sweiss N, Hushaw L. Biologic agents for rheumatoid arthritis:2008 and beyond. J Infus Nurs. 2009;(suppl)32(1):S4-S17.

4. Menter A, Gottlieb A, Feldman S, et al. Guidelines of care for themanagement of psoriasis and psoriatic arthritis: overview of psori-asis and guidelines of care for the treatment of psoriasis with bio-logics. J Am Acad Dermatol. 2008;58(5):826-850.

5. Lee S, Chinen J, Kavanaugh A. Immunomodulator therapy: mon-oclonal antibodies, fusionproteins, cytokines, and immunoglobu-lins. Jnl Allergy Clin Immunol. 2010;125(2):S314-S323.

6. Vizcarra C. Biologic therapy. In: Alexander M, Corrigan A, GorskiL, Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;2010:299-315.

7. Doherty S, Van Voorhees A, Lebwohl M, Korman N, Young M,Hsu S. National Psoriasis Foundation consensus statement onscreening for latent tuberculosis infection in patients with psoriasistreated with systemic and biologic agents. J Am Acad Dermatol.59(2):209-217.

8. Timoney J, Eagan M, Sklarin N. Establishing clinical guidelines forthe management of acute hypersensivity reactions secondary to theadministration of chemotherapy/biologic therapy. J Nurs CareQual. 2003;18(1):80-86.

9. Stone W. Comprehensive nursing approach to infliximab infusiontherapy. J Infus Nurs. 2003;26(6):380-387.

10. Geddie P. Nononcologic use of chemotherapy. J Infus Nurs. 2008;31(1):28-38.

64. PATIENT-CONTROLLED ANALGESIA

Standard

64.1 The administration of patient-controlled analgesia(PCA) shall be initiated upon the order of a licensed inde-pendent practitioner (LIP) in accordance with the state’sNurse Practice Act, rules and regulations promulgated bythe state’s Board of Nursing, and organizational policies,procedures, and/or practice guidelines.64.2 The nurse shall be competent in the care of patientsreceiving PCA. The nurse shall have knowledge of theappropriate drugs used with PCA, including pharmaco-kinetics and equianalgesic dosing, contraindications, sideeffects and their management, appropriate administra-tion modalities, and anticipated outcomes.64.3 The patient and caregiver shall be educated in theuse of PCA. The patient’s and caregiver’s comprehension



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and ability to comply with procedures shall be evaluatedand documented prior to, and on initiation of therapy.64.4 The use of infusion devices for PCA shall adhere tomanufacturers’ directions for use. Dose-error reductioninfusion systems shall be considered when available.

Practice Criteria

A. The nurse should assess the patient for the appropriate-ness of PCA therapy and the patient’s comprehension of,and ability to participate in, the intended therapy.1-8 (I)

B. If the patient is unable to actively participate inPCA, the nurse should assess the patient for appro-priateness of using Authorized Agent ControlledAnalgesia (AACA).9-11 (IV)

C. The nurse should advocate for the use of standard-ized medication concentrations and standardized orpreprinted order sets for PCA and AACA.1,8,11-16 (IV)

D. Patient risk factors should be identified and appro-priate monitoring implemented to prevent respirato-ry depression and other adverse events. Risk factorsinclude, but are not limited to, elderly patients, mor-bid obesity, obstructive sleep apnea, chronicobstructive pulmonary disease, renal insufficiency,and continuous background infusions for patientswith obstructive sleep apnea. The use of pulseoximetry and/or capnography should be consideredwhen monitoring for respiratory depression.1,7,16-26

(IV)E. A double check by another clinician using indepen-

dent verification should be considered prior to initi-ation of the PCA, and when the syringe, solutioncontainer, drug, or rate is changed. Special attentionshould be given to drug, concentration, dose, andrate of infusion according to the order and as pro-grammed into the electronic infusion device (EID),in order to reduce the risk of adverse outcomes andmedication errors.6,7 (V)

F. Patient and caregiver education should be appro-priate to duration of therapy and care setting andshould include the purpose of PCA therapy, oper-ating instructions for the EID, expected outcomes,precautions, potential side effects, and contactinformation for support services.7,8,27,28 (IV)

G. Nursing interventions should include evaluatingthe effectiveness of PCA therapy using valid andreliable monitoring and assessment methods orscales and documentation tools:1. Regular assessment and reassessment of patient

self-report of pain using a consistent painassessment scale appropriate to the patient

2. Monitoring for potential adverse effects includ-ing, but not limited to, sedation and respiratorydepression

3. Regular evaluation of PCA injections and attempts4. Considering the need for change in treatment

methods as necessary.8,10,19,29-32 (V)

H. The nurse should participate in selection and evalua-tion of PCA EIDs to promote patient safety, whichmay include dose-error reduction systems and bar-coding technology.19,29,33 (V)

REFERENCES

1. American Pain Society. Principles of Analgesic Use in theTreatment of Acute Pain and Cancer Pain. 6th ed. Glenview, IL:Author; 2008.

2. Bainbridge D, Martin J, Cheng DC. Patient-controlled versusnurse-controlled analgesia after cardiac surgery: a meta-analysis.Can J Anesth. 2006;53(5):492-499.

3. Herr K, Bjoro K, Steffensmeier J, Rakel B. Acute Pain Managementin Older Adults. Iowa City, IA: University of Iowa GerontologicalNursing Interventions Research Center, Research Translation andDissemination Core. http://www.guidelines.gov/summary/summary.aspx?doc_id�10198&nbr�005382&string�pain�AND�man-agement. Published 2006. Accessed February 17, 2010.

4. Horgas AL, Yoon SL. Pain management. In: Capezuti E, Zwicker D,Mezey M, Fulmer T. Evidence-Based Geriatric Nursing Protocolsfor Best Practice. New York, NY: Springer; 2008:199-222.

5. Hudcova J, McNicol ED, Quah CS, Lau J, Carr DB. Patient con-trolled opioid analgesia versus conventional opioid analgesia forpostoperative pain. Cochrane Database Syst Rev. 2006(4).CD003348. doi: 10.1002/14651858.CD003348.pub2.

6. San Diego Patient Safety Taskforce. Tool kit: Patient ControlledAnalgesia (PCA) Guidelines of Care for the Opioid Naïve Patient.http://www.hasdic.org/documents/Tool-Kit-PCA.pdf. Published2008. Accessed February 5, 2010.

7. Simpson MH. Pain management. In: Alexander M, Corrigan A,Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;2010:372-390.

8. Wells N, Pasero C, McCaffery M. Improving the quality of carethrough pain assessment and management. In: Hughes RG, ed.Patient Safety and Quality: An Evidence-Based Handbook forNurses. AHRQ Publication No. 08–0043. Rockville, MD: Agencyfor Healthcare Research and Quality;. http://www.ahrq.gov/qual/nurseshdbk/docs/WellsN_SMTEP.pdf. Published March 2008. AccessedFebruary 5, 2010.

9. Czarnecki ML, Ferrise AS, Jastrowski Mano KE. Parent/nurse-con-trolled analgesia for children with developmental delay. Clin JPain. 2008;24(9):817-824.

10. Pasero C, McCaffery M. Authorized and unauthorized use of PCApumps. Am J Nurs. 2005;107(7):30-31,33.

11. Wuhrman E, Cooney M, Dunwoody C, Eksterowicz N, Merkel S,Oakes L. Authorized and unauthorized (“PCA by proxy”) dosingof analgesic infusion pumps: position statement with clinical prac-tice recommendations. Pain Manage Nurs. 2007;8(1):4-11.

12. Eden B, Gilley B, Neff J. Implementation of evidence-based guide-lines and PCA order sets for opioid-naıve and opioid-tolerantpatients. Pain Manage Nurs. 2009;10(1):e2.

13. Ehringer G, Duffy B. Promoting best practice and safety throughpreprinted physician orders. In: Henriksen K, Battles JB, Keyes MA,Grady ML, eds. Advances in Patient Safety: New Directions andAlternative Approaches, vol. 2. AHRQ Publication No. 08–0034-2.Rockville, MD: Agency for Healthcare Research and Quality.http://www.ahrq.gov/downloads/pub/advances2/vol2/Advances-Ehringer_17.pdf. Published August 2008. Accessed February 26,2010.

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14. Institute for Safe Medication Practices. Guidelines for standardorder sets. http://www.ismp.org/Tools/guidelines/StandardOrderSets.pdf. Published 2010. Accessed February 26, 2010.

15. Schein JR, Hicks RW, Nelson WW, Sikirica V, Doyle DJ. Patient-controlled analgesia-related medication errors in the postoperativeperiod: causes and prevention. Drug Saf. 2009;32(7):549-559.

16. Weber LM, Ghafoor VL, Phelps P. Implementation of standardorder sets for patient-controlled analgesia. Am J Health-SystPharm. 2008;65:1184-1191.

17. Francisco NA. Control of breathing: how to better understand therespiratory effects of opioids. Eur J Pain. 2007;(suppl 1):61-65.

18. Hutchison R, Rodriguez L. Capnography and respiratory depres-sion. AJN. 2008;108(2):35-39.

19. Maddox RR, Oglesby H, Williams CK, Fields M, Danello S.Continuous respiratory monitoring and a “smart” infusion systemimprove safety of patient-controlled analgesia in the postoperativeperiod. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds.Advances in Patient Safety: New Directions and AlternativeApproaches, vol. 4. AHRQ Publication No. 08–0034-4. Rockville,MD: Agency for Healthcare Research and Quality; 2008.

20. McCarter T, Shaik Z, Scarfo K, Thompson LJ. Capnography mon-itoring enhances safety of postoperative patient-controlled analge-sia. Am Health Drug Benefits. 2008;1(5):28-35.

21. Overdyk FJ, Carter R, Maddox RR, Callura J, Herrin AE,Henriquez C. Continuous oximetry/capnometry monitoring revealsfrequent desaturation and bradypnea during patient-controlled anal-gesia. Anesth Analg. 2007;105:412-418.

22. Smetzer J, Cohen MR, Jenkins R. APSF offers recommendationsfor safe post-op opioid administration and monitoring. ISMPMedication Safety Alert! 2009;14(19):3.

23. Smetzer J, Cohen MR, Jenkins R. Beware of basal opioid infusionswith PCA therapy. ISMP Medication Safety Alert! 2009;14(5):1-3.

24. Gross JB, Bachenberg KL, Benumof JL, et al. Practice guidelines forthe perioperative management of patients with obstructive sleepapnea. Anesthesiology. 2006;104:1081-1083.

25. Gordon DB. Patient-controlled analgesia (PCA) assistance. In:Ackley BJ, Ladwig GB, Swan BA, Tucker SJ. Evidence-BasedNursing Care Guidelines: Medical-Surgical Interventions. St Louis,MO: Mosby/Elsevier; 2008:600-604.

26. Hankin CS, Schein J, Clark JA, Panchal S. Adverse events involv-ing intravenous patient-controlled analgesia. Am J Health-SystPharm. 2007;64:1492-1499.

27. Cranwell-Bruce LA. PCA delivery systems. Medsurg Nurs. 2009;18(2):127-133.

28. Yankova Z. Patients’ knowledge of patient-controlled analgesia(PCA) and their experience of postoperative pain relief: a review ofthe impact of structured preoperative education. J Adv PerioperCare. 2008;3(3):91-99.

29. Maddox RR, Danello S, Williams CK, Fields M. IntravenousInfusion Safety Initiative: Collaboration, Evidence-Based BestPractices, and “Smart” Technology Help Avert High-Risk AdverseDrug Events and Improve Patient Outcomes. In: Henriksen K,Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety:New Directions and Alternative Approaches. vol. 4 AHRQPublication No. 08–0034-4. Rockville, MD: Agency for HealthcareResearch and Quality; 2008.

30. McCaffery M, Pasero C. Assessment—underlying complexities, mis-conceptions, and practical tools. In: McCaffery M, Pasero C. Pain:Clinical Manual. 2nd ed. New York, NY: Mosby; 1999:35-102.

31. Nisbet AT, Mooney-Cotter F. Comparison of selected sedationscales for reporting opioid-induced sedation assessment. PainManage Nurs. 2009;10(3):154-164.

32. Voepel-Lewis T, Marinkovic A, Kostrzewa A, Tait AR, Malviya S.The prevalence of and risk factors for adverse events in childrenreceiving patient-controlled analgesia by proxy or patient-con-trolled analgesia after surgery. Anesth Analg. 2008;107:70-75.

33. Institute for Safe Medication Practices. Proceedings from theISMP summit on the use of smart infusion pumps: guidelines forsafe implementation and use. http://www.ismp.org/Tools/guidelines/smartpumps/comments/printerVersion.pdf. Published 2009.Accessed March 30, 2010.

65. PARENTERAL NUTRITION

Standard

65.1 The administration of parenteral nutrition shall be initiated upon the order of a licensed independentpractitioner (LIP) in accordance with the rules and regu-lations promulgated by the state’s Board of Nursing, andorganizational policies, procedures, and/or practiceguidelines.65.2 The nurse shall be competent in the administrationand monitoring of patients receiving parenteral nutrition.65.3 Non–fat-emulsion-containing parenteral nutritionsolutions shall be filtered using a 0.2-micron filter, andfat-emulsion-containing parenteral nutrition solutionsshall be filtered using a 1.2-micron filter.65.4 Parenteral nutrition containing dextrose and aminoacids alone or with fat emulsion added as a 3-in-1 formu-lation shall have a hang time not to exceed 24 hours. Fatemulsions alone shall have a hang time not to exceed 12hours.65.5 Parenteral nutrition shall be administered using anelectronic infusion device (EID) with anti–free-flow control.65.6 Parenteral nutrition solutions shall be prepared,labeled, and managed according to pharmacy law andregulations.65.7 The nurse shall not add medications to the par-enteral nutrition solution once it is actively infusing.

Practice Criteria

A. The nurse should collaborate with the patient orcaregiver and other members of the health careteam on the development and implementation ofthe nutrition plan of care. The nurse should rec-ommend that the enteral route of feeding be usedwhen feasible, especially in the critically ill adultor child.1-5 (II)

B. Parenteral nutrition solutions containing final con-centrations exceeding 10% dextrose should beadministered through a central vascular accessdevice (CVAD) with the tip located in the centralvasculature, preferably the superior vena cava-rightatrium junction for adults.2,5,6 (III)

C. Parenteral nutrition solutions with a final concen-tration of 10% dextrose or lower administered via



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a short peripheral or midline catheter should bereserved for situations in which a CVAD is notcurrently feasible and delay of feeding would bedetrimental to the patient. The solution’s osmolar-ity should not exceed 600 mOsm. Clinical trialsdemonstrate that peripheral parenteral nutritioncauses phlebitis. The literature also shows that thefrequency and severity of phlebitis can be mitigat-ed by the addition of heparin and steroids to theparenteral nutrition, coadministration with fatemulsion, cyclical infusion, keeping the osmolari-ty of the parenteral nutrition solution less than600 mOsm, frequent catheter site changes (every24-48 hours), and limiting the duration of periph-eral parenteral nutrition use. The risk/benefit deci-sion to use peripheral parenteral nutrition shouldinclude as many phlebitis-mitigating techniques aspossible. The most conservative approach of amaximum of 600 mOsm final concentration is rec-ommended for peripheral parenteral nutrition asthat recommendation appears to be the limit oftolerance not requiring mitigation for mostpatients.2,5,7-11 (V)

D. The nursing assessment of patients who are receiv-ing long-term parenteral nutrition should includeboth physiological and psychological aspects ofresponse to therapy.2,12 (IV)

E. Parenteral nutrition solutions should be removedfrom the refrigerator 30 minutes to 1 hour priorto infusion.2,13 (V)

F. Parenteral nutrition solutions should be com-pounded in the pharmacy using sterile techniqueunder a horizontal laminar flow hood in compli-ance with pharmacy rules and regulations.2,14,15

(Regulatory)G. Medications added to parenteral nutrition solu-

tions prior to administration of the solution shouldbe assessed for compatibility in compliance withpharmacy rules and regulations.2,14,15 (Regulatory)

H. Medications added to parenteral nutrition solu-tions should be documented on the label affixed tothe infusate container in compliance with pharma-cy rules and regulations.2,14,15 (V)

I. The nurse’s monitoring of the patient receivingparenteral nutrition should include, but not belimited to, body weight; fluid and electrolyte bal-ance; metabolic tolerance, especially glucose con-trol; organ function; nutrition therapy-relatedcomplications; functional performance; and psy-chological responses. The nurse should educatethe home patient or caregiver about signs andsymptoms of metabolic intolerance, infection,and access device complications to report to thehealth care team.1-5,16 (V)

J. Documentation in the patient’s permanent medicalrecord should include, but not be limited to, type of

access device, parenteral nutrition formulation,additives, volume, rate, patient assessment, andresponse to therapy.1 (V)

REFERENCES

1. American Society for Parenteral and Enteral Nutrition. Standardsof practice for nutrition support nurses. Nutr Clin Pract.2007;22:458-465.

2. Krzywda E, Meyer D. Parenteral nutrition. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R. Infusion Nursing: AnEvidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;2010:316-350.

3. McClave SA, Martindale RG, Vanek VW, et al. Guidelines forthe provision and assessment of nutrition support therapy in theadult critically ill patient. J Parenter Enteral Nutr. 2009;33(3):277-316.

4. Mehta NM, Compher C; A.S.P.E.N. Board of Directors.A.S.P.E.N. clinical guidelines: support of the critically ill child. JParenter Enteral Nutr. 2009;33(3):260-276.

5. Pittiruti M, Hamilton H, Biffi R, MacFie J, Pertkiewicz M.A.S.P.E.N. guidelines on parenteral nutrition: central venouscathethers (access, care, diagnosis, and therapy of complications).Clin Nutr. 2008;28:365-377.

6. Krzywda EA. Parenteral nutrition access and infusion equipment. In:The A.S.P.E.N Nutrition Support Practice Manual. 2nd ed. SilverSpring, MD: American Society for Parenteral and Enteral Nutrition;2005.

7. Gazitua R, Wilson K, Bistrian BR, Blackburn GL. Factors deter-mining peripheral vein tolerance to amino acid infusions. ArchSurg. 1979;114:897-900.

8. Hoheim DF, O’Callaghan TA, Joswiak BJ, et al. Clinical experi-ence with three-in-one admixtures administered peripherally. NutrClin Pract. 1990;5:118-122.

9. Isaacs JW, Millikan WJ, Stackhouse J, Hersh T, Rudman D.Parenteral nutrition of adults with 900-milliosmolar solution viaperipheral vein. Am J Clin Nutr. 1977;30:552-559.

10. Hoffmann E. A randomized study of central venous versus periph-eral intravenous nutrition in the postoperative period. Clin Nutr.1989;8:179-180.

11. Stranz M, Kastango E. A review of pH and osmolarity. Int J PharmCompounding. 2002;6(3):216-220.

12. Stern JM, Jacyna N, Lloyd DAJ. Review article: psychologicalaspects of home parenteral nutrition, abnormal illness behaviorand risk of self-harm in patients with central venous catheters.Aliment Pharmacol Ther. 2008;27:910-918.

13. Sacks GS, Mayhew S, Johnson D. Parenteral nutrition implemen-tation and management. In: The A.S.P.E.N. Nutrition SupportPractice Manual. 2nd ed. Silver Spring, MD: American Society forParenteral and Enteral Nutrition; 2005.

14. US Pharmacopeia (USP). Revised General Chapter �797�

Pharmaceutical compounding: sterile preparations, USP 31-NF 26,The Pharmacists’ Pharmacopeia. 2nd ed. 2008;(suppl 2).

15. Pharmaceutical compounding-sterile preparations (GeneralChapter �797�). In: US Pharmacopeia. 27th rev., and the nation-al formulary, 22nd ed. Rockville, MD: The US PharmacopeialConvention, 2004:2350-2370.

16. Cahill NE, Dhaliwal R, Day AG, Jiang X, Heyland DK. Nutritiontherapy in the critical care setting: what is “best achievable” prac-tice? An international multicenter observational study. Crit CareMed. 2010;38(2):395-401.

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66. TRANSFUSION THERAPY

Standard

66.1 The administration of transfusion therapy shall beinitiated upon the order of a licensed independent practi-tioner (LIP) in accordance with the rules and regulationspromulgated by the state’s Board of Nursing, state regu-lations, AABB standards, and organizational policies,procedures, and/or practice guidelines.66.2 The nurse shall be competent in transfusion admin-istration, identification of transfusion reactions, and/orcomplications associated with transfusion therapy andimplementation of appropriate interventions.66.3 Validation of correct patient and blood productshall be simultaneously performed at the bedside by 2qualified clinicians prior to administration.66.4 Blood and blood components shall be filtered using anin-line or add-on filter appropriate to the prescribed therapy.

Practice Criteria

A. The nurse administering transfusion therapy shouldhave knowledge and understanding of immunohema-tology; blood grouping; blood and its components;administration equipment, including vascular accessdevices (VADs) and filters; techniques appropriate foreach component; transfusion reactions and nursinginterventions; and associated risks of transfusiontherapy.1-5 (V)

B. The nurse should administer blood componentsusing an in-line or add-on filter that is appropriatefor the prescribed component. Standard, microag-gregate, and leukocyte-depleting blood filters aredesigned with different filtering capability (20-260microns). The filter should not be used beyond 4hours. The nurse should follow the manufacturer’sdirections for use of the selected filter (see Standard28, Filters).1,4,6,7 (V)

C. The transfusion administration set and filter shouldbe changed after the completion of each unit orevery 4 hours. If more than 1 unit can be infused in4 hours, the transfusion set can be used for a 4-hourperiod (see Standard 43, Administration SetChange).1,4,6,8 (IV)

D. Single units of blood should be administered andcompleted within a 4-hour time period. Plateletsshould be administered over 30 minutes to 4hours.1,4,6,8-11 (V)

E. The nurse should initiate the administration ofblood or blood components within 30 minutesfrom the time of its release from transfusion ser-vices or blood bank or its removal from a con-trolled environment.1,4,11 (V)

F. Blood or blood components should be adminis-tered only with 0.9% sodium chloride. No other

solutions or medications should be added to bloodor blood component products.1,4,6,11 (V)

G. Prior to transfusion therapy, the nurse should per-form a patient assessment to identify and verifycurrent status and appropriateness of the indwellingVAD, and/or select and initiate a peripheral VAD,and/or collaborate with the health care team forplacement of a central vascular access device(CVAD).1,4,6 (V)

H. Blood or blood components may be transfused via a14- to 24-gauge short peripheral catheter. Transfusionfor neonate or pediatric patient populations is usual-ly given using a 22- to 24-gauge peripheralVAD.4,6,8,10,12 (IV)

I. Blood or blood components may be transfused via a CVAD as small as 1.9 French. Umbilicalvenous catheters or small saphenous vein cathetersare commonly used in infants and/or pediatricpatients. The clinician should be aware thatcatheter length will decrease the rate of infusion.(IV) 4,8,10,12-17

J. Electronic infusion devices (EIDs) can be used todeliver blood or blood components without signif-icant risk of hemolysis of red blood cells. However,the EID should be analyzed to evaluate the safetyand rate of hemolysis. The nurse should follow themanufacturer’s directions for use of EIDs for bloodand blood component administration.4,8,18,19 (IV)

K. Blood warmers should be used for large-volume orrapid transfusions, exchange transfusions, patientswith clinically significant conditions, and theneonate/pediatric population. Microwaves, hotwater or another heat source, or devices not specifi-cally designated and approved by the US Food andDrug Administration for warming blood should notbe used (see Standard 30, Blood and FluidWarmers).1,4,8,11,19,20 (V)

L. The nurse should be aware that external compres-sion devices, if used, should be equipped with apressure gauge, totally encase the blood bag, andapply uniform pressure against all parts of theblood container. A blood pressure cuff should notbe used as it is unable to apply uniform pressure.4,9

(V)M.The nurse should check the blood bag for any signs of

contamination (ie, clumping, gas bubbles) and returnit to the blood bank if any contamination is observedor if any questions are raised about the blood component. 4,11 (V)

N. The nurse should have an appropriate level ofknowledge and skill in identification, detection, andmanagement of adverse transfusion events. Adverseevents can be classified into immunologic and non-immunologic categories (ie, transfusion-related acutelung injury [TRALI] and iron overload).1,3,5,6,14,21-32

(V)



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O. In the event of an adverse reaction, the transfusionshould be stopped, the LIP and blood bank noti-fied, and interventions implemented.1,5,21,23,33 (V)

P. The nurse should monitor and assess the patientfor 1 hour after the transfusion for signs and symp-toms of delayed transfusion reaction. Educate thepatient and caregiver about signs and symptoms ofdelayed transfusion reactions.4 (V)

Q. The nurse should be aware that for the administra-tion of transfusion therapy in the alternative caresetting, a well-planned program with safety featuresis required, in addition to trained and competentstaff in the administration of blood componentsand patient monitoring; the ability to appropriate-ly dispose of medical waste; immediate access tothe LIP by phone; another competent adult presentand available to assist with patient identificationand calling for medical assistance if needed; docu-mentation showing no identified adverse eventsduring previous transfusions; ability to transportblood product in cooling containers verified forcorrect temperature; and a well-designed patientand caregiver education process.4,34,35 (V)

R. Misidentification of the patient is one of the mostimportant factors in transfusion errors. Barcodingsystems have been found to improve compliance anddecrease errors during the transfusion process.36-38 (V)

REFERENCES

1. Trick N. Blood component therapy. In: Alexander M, Corrigan A,Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: AnEvidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;2010:242-262.

2. Gray A, Hart M, Dalrymple K, Davies T. Promoting safe transfu-sion practice: right blood, right patient, right time. Br J Nurs. 2008;17(13):812-817.

3. Gray A, Hearnshaw K, Izatt C, Kirwan M, Murray S, Shreeve K.Safe transfusion of blood and blood components. Nurs Standard.2007;21(51):40-47.

4. Sink B. Administration of blood components. In: Roback J, CombsM, Grossman B, Hillyer C, eds. American Association of BloodBanks Technical Manual. 16th ed. Bethesda, MD; 2008:613-624.

5. Mazzei C, Popovsky M, Kopko P. In: Roback J, Combs M,Grossman B, Hillyer C, eds. American Association of Blood BanksTechnical Manual. 16th ed. Bethesda, MD; 2008:715-749.

6. Weinstein S. Transfusion therapy. In: Weinstein S, ed. Plumer’sPrinciples & Practice of Intravenous Therapy. 8th ed. Philadelphia,PA: Lippincott Williams & Wilkins; 2007.

7. National Clearinghouse Guideline (NCG). Blood transfusions:indications & administration. http//www.guidelines.gov/summa-ry/summary.aspx?doc_id=12787. Accessed June 4, 2009.

8. Josephson C. Neonatal and pediatric transfusion practice. In:Roback J, Combs M, Grossman B, Hillyer C. eds. AmericanAssociation of Blood Banks Technical Manual. 16th ed. Bethesda,MD; 2008:639-663.

9. Lieb M, Aldridge L. Blood transfusion. In: Blood Banking andTransfusion Medicine: Basic Principles and Practice. 2nd ed.Philadelphia, PA: Churchill Livingstone; 2007.

10. Frey AM, Pettit J. Infusion therapy in children. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. InfusionNursing: An Evidence-Based Approach. 3rd ed. St. Louis, MO:Saunders/Elsevier; 2010:550-570.

11. Administering blood and blood products. In: Handbook of InfusionTherapy. Springhouse: Springhouse Corporation; 1999:192-216.

12. Wong E, Schreiber S, Criss V, et al. Feasibility of red blood celltransfusion through small bore central venous catheters used inneonates. Pediatr Crit Care Med. 2004;5:69-74.

13. de la Roche MR, Gautheir L. Rapid transfusion of red blood cells:effects of dilution, pressure, and catheter size. Ann Emerg Med.1993;22:1551-1555.

14. Calkins JM, Vaughan RW, Cork RC, et al. Effects of dilution, pres-sure and apparatus on hemolysis on flow rate in transfusion ofpacked erythrocytes. Anesth Analg. 1982;61:776-780.

15. Bowes-Geddes L, Nichols H. An overview of PICCs. Top AdvPract Nurs. e-journal 2005:5. http//www.medscape.com/viewarti-cle/508939. Accessed June 4, 2009.

16. Griffiths V, Philpot P. PICCS: do they have a role in the care of thecritically ill patient? Intensive Crit Care Nurs. 2002;18(1):37-47.

17. Houck D, Whiteford J. Improving patient outcomes: transfusionwith infusion pump for PICCs and other vascular access devices. JInfus Nurs. 2007;30(6):341-344.

18. Frey B, Eber S, Weiss M. Changes in red blood cell integrity relat-ed to infusion pumps: a comparison of 3 different pump mecha-nisms. Pediatr Crit Care Med. 2003;4(4):465-470.

19. Rudman S. Blood warmers. In: Textbook of Blood Banking andTransfusion Medicine. 2nd ed. Philadelphia, PA: Elsevier/Saunders;2005.

20. Price TH, ed. Standards for Blood Banks & Transfusion Services.25th ed. Bethesda, MD: AABB; 2008.

21. Clark C. Transfusion-related acute lung injury: clinical featuresand diagnostic dilemmas. J Infus Nurs. 2009;32(3):132-136.

22. Klunman S, Gajic O, Nunes E. Promoting recognitions and preven-tions of TRALI. Crit Care Nurse. 2007;27(4):49-53.

23. Knippen MA. Transfusion-related acute lung injury. Am J Nurs.2006;106(6):61-64.

24. Bernard G, Artigas A, Brigham K, et al. The American-EuropeanConsensus Conference on ARDS: definitions, mechanisms, relevantoutcomes and clinical trial coordination. Am J Respir Crit CareMed. 1994;149:818-824.

25. Webert K, Kleinman S, Blajchman M. TRALI. In: Blood Bankingand Transfusion Medicine: Basic Principles and Practices. 2nd ed.Philadelphia, PA: Churchill Livingstone; 2007.

26. Eder A, Benjamin R. TRALI risk reduction: donor and componentmanagement strategies. J Clin Apheresis. 2009;24:122-129.

27. Andrews NC. Disorders of iron metabolism. New Engl J Med.1999;341(26):1986-1995.

28. Heddle N, Webert K. Febrile, allergic and other non-infectioustransfusion reactions. In: Blood Banking and Transfusion Medicine:Basic Principles and Practices. 2nd ed. Philadelphia, PA: ChurchillLivingstone; 2007:677-690.

29. Kushner JP, Porter JP, Olivieri NF. Secondary iron overload. Am SocHematol. http://askeducationbook.hematologylibrary.org/cqi/content/full/2001/1/47. Published 2001. Accessed August 30, 2009.

30. Gabutti V, Piga A. Results of long-term iron-chelating therapy.ACTA Hematol. 1996;95(1):26-36.

31. Lindsey WT, Olin BR. Deferasirox for transfusion-related ironoverload: a clinical review. Clin Ther. 2007;29(10):2154-2166.

32. US Food and Drug Administration. Center for Biologics Evaluation& Research. Alert letter issued on the risks of TRALI, 2001.www.fda.gov/cber/ltr/trali101901.htm. Accessed August 30, 2009.

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33. US Biovigilance Network. National Hemovigilance Pilot Program,May 7, 2009. http://www.aabb.org/Content/News_and_Media/Press_Releases/pr0. Accessed June 4, 2009.

34. Evans CS. Out-of-hospital transfusion. Transfusion. 1997;37:756-767.

35. Fridey JL. Practical aspects of out-of-hospital transfusion. Am JClin Pathol. 1997;107(suppl 1):S64-S71.

36. Douglas J, Larrabee S. Bring barcoding to the bedside. NursManag. 2003;34(5):36-40.

37. Dohnalek LJ, Cusaac, L, Westcott J, Langeberg A, Sandler SG. Thecode to safer transfusions. Nurs Manag. 2004;35(6):33-36.

38. Murphy MF, Kay JOS. Barcode identification for transfusion safety.Curr Opinion Hematol. 2004;11:334-338.

67. MODERATE SEDATION/ANALGESIA USING INTRAVENOUS INFUSION

Standard

67.1 The administration of moderate sedation/analgesiausing intravenous (IV) infusion shall be initiated upon theorder of a licensed independent practitioner (LIP) inaccordance with the rules and regulations promulgatedby the state’s Board of Nursing, state and federal regula-tions, standards for sedation by nonanesthesiologists,and organizational policies, procedures, and/or practiceguidelines.67.2 Moderate sedation/analgesia using IV infusion shallbe provided only in a setting with appropriate equipmentfor administering therapy, monitoring the patient, andmanaging complications.67.3 The nurse shall be competent in the administrationof moderate sedation/analgesia using IV infusion and inairway management and resuscitation.67.4 An emergency cart and reversal agents shall beimmediately accessible, and personnel shall be availablewith expertise in airway management, emergency intuba-tions, cardiopulmonary life support, and management ofpotential complications.

Practice Criteria

A. The nurse should be knowledgeable about medica-tions and reversal agents for moderate sedation/analgesia, as well as competent in airway manage-ment and resuscitation through age-appropriatecardiac life support validation.1-5 (V)

B. Vascular access should be initiated, if not alreadyavailable, and maintained throughout the proce-dure and recovery period.1,5,6 (V)

C. The patient receiving moderate sedation/analgesia byIV infusion should be continuously monitoredthroughout the procedure by a nurse, and one whois other than the person performing the proce-dure.1,2,4,5 (V)

D. The nurse should provide patient and caregivereducation prior to, and reinforcement after the pro-cedure, about the sedation/analgesia infusion; pro-cedure; information about any restrictions relatedto eating or driving; signs and symptoms of compli-cations related to the infusion site and the proce-dure; emergency instructions; and contact phonenumber.7-12 (V)

E. The moderate sedation/analgesia infusion andprocedure should be documented in the patient’spermanent medical record including, but not lim-ited to, patient identification and verification;patient and caregiver education; informed con-sent; assessments; interventions; patient responses;and, if needed, complications and interventions.5,8

(V)

REFERENCES

1. American Association of Nurse Anesthetists [position statement].Considerations for policy guidelines for registered nurses engaged inthe administration of sedation and analgesia. http://www.aana.com/practicedocuments.aspx. Published June 2003. Accessed March 7,2010.

2. American Society of Anesthesiologists. Practice guidelines for seda-tion and analgesia by non-anesthesiologists. Anesthesiology.2002;96:1004-1017.

3. Broussard M, Bass PF III, Arnold CL, McLarty JW, Bocchini JA Jr.Preprinted order sets as a safety intervention in pediatric sedation. J Pediatr. 2009;154:865-868.

4. Emergency Nurses Association. Procedural sedation consensusstatement. 2008; http://www.ena.org/SiteCollectionDocuments/Position%20Statements/Procedural_Sedation_Consensus_Statement_ENA_PS.pdf

5. Simpson MH. Pain management. In: Alexander M, Corrigan A,Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier;2010:372-390.

6. I.V. bolus injection; I.V. secondary line drug infusion. In: Lippincott’sNursing Procedures and Skills (online version). Baltimore, MD:Lippincott Williams & Wilkins; 2010.

7. Association of periOperative Registered Nurses. AORN RecommendedPractices Committee. Recommended practices for managing thepatient receiving moderate sedation/analgesia. AORN J. 2002;75:642-646, 649-652.

8. The Joint Commission. Hospital, ambulatory care. In: ComprehensiveAccreditation Manual. E-dition v2.5.0.0. PC.03.01.05. OakbrookTerrace, IL: TJC. 2010.

9. Association of periOperative Registered Nurses. AORN guidancestatement: postoperative patient care in the ambulatory surgery set-ting. AORN J. 2005;81:881-884,886-888.

10. Hayes A, Buffum M. Educating patients after conscious sedationfor gastrointestinal procedures. Gastroenterol Nurs. 2001;24(2):54-57.

11. Ip HY, Chung F. Escort accompanying discharge after ambulatorysurgery: a necessity or a luxury? Curr Opinion Anaesthesiol. 2009;22:748-754.

12. Czaplewski L. Clinician and patient education. In: Alexander M,Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:An Evidence-Based Approach. 3rd ed. St. Louis, MO: Saunders/Elsevier; 2010:71-94.



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68. ADMINISTRATION OF PARENTERAL INVESTIGATIONAL DRUGS

Standard

68.1 The administration of parenteral investigationaldrugs shall be initiated upon the order of a licensed inde-pendent practitioner (LIP) in accordance with the rules andregulations promulgated by the state’s Board of Nursing,and organizational policies, procedures, and/or practiceguidelines.68.2 The nurse administering parenteral investigationaldrugs shall be competent and have knowledge of and proto-cols for prescribed therapies. This knowledge shall include,but not be limited to, appropriate drug dose, volume, concen-tration, adverse and expected reactions, and rate of deliverywith regard to the patient’s condition and vascular access.68.3 Informed consent of the patient or legally autho-rized representative shall be confirmed prior to theadministration of these agents and shall be documentedin the patient’s permanent medical record.

Practice Criteria

A. The nurse administering parenteral investigation-al drugs should have available informationincluding, but not limited to, drug informationfor all study medications, including formulation;drug stability; storage requirements; administra-tion information; pharmacologic indications;actions; side effects; route and rate of delivery;dosage and dilution; known toxicities; and poten-tial complications and interventions.1-8 (V)

B. Documentation of the informed consent processprior to the administration of parenteral investiga-tional drugs should include, but not be limited to,patient identification and verification; education;informed consent; assessment; adverse reactionsand interventions; anticipated patient response totherapy; and monitoring.1-8 (V)

C. The nurse shall ensure that all aspects of riskevaluation and mitigation strategy (REMS) relat-ed to the investigational drug are followed. Thismay include, but not be limited to, special label-ing requirements, medication guides, communi-cations planning, elements to ensure safe use, andimplementation system.1-3,8 (V)

D. The nurse administering the parenteral investiga-tional drug should be aware of potential adverseevents and report any adverse event to the sponsorinvestigator (see Standard 15, Unusual Occurrenceand Sentinel Event Reporting).1,8 (V)

REFERENCES

1. American Society of Health-System Pharmacists. Guidelines on clini-cal drug research. http://www.ashp.org/DocLibrary/BestPractices/ASHPGuidelinesClinicalDrugResearch.aspx Accessed August 27,2009.

2. US Food and Drug Administration. Use of investigational productswhen subjects enter a second institution: FDA/office of sciencecoordination and communication. http://www.fda.gov/ScienceResearch/SpecialTopics/RunningClinicalTrials/GuidancesInformationSheetsandNotices/ucm113709.htm. Updated April 30, 2009. AccessedMarch 10, 2010.

3. US Food and Drug Administration. Guidance for institutionalreview boards and clinical investigators. http://www.fda.gov/downloads/ScienceResearch/SpecialTopics/RunningClinicalTrials/GuidancesInformationSheetsandNotices/UCM118085.pdf.Published January 2006. Accessed March 10, 2010.

4. Moore, SW. An overview of drug development in the United Statesand current challenges. South Med J. 2003;96(12):1244-1255.

5. Oncology Nursing Society. Chemotherapy and Biotherapy: Guidelinesand Recommendations for Practice. Pittsburgh, PA: ONS; 2001.

6. US Department of Labor. Occupational Safety and HealthAdministration. OSHA Technical Manual. http://www.osha.gov/dts/osta/otm/otm_vi/otm_vi_2.html#1. Accessed February 27, 2010.

7. Devine S, Dagher RN, Weiss KD, Santana VM. Good clinical prac-tice and the conduct of clinical studies in pediatric oncology. PediatrClin North Am. 2008;55(1):187-209, xi-xii.

8. US Food and Drug Administration Approved risk evaluation andmitigation strategies (REMS). http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm111350.htm. Accessed April 5, 2010.

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Illustrations


Figure 1 Veins of the head and neck.From Dorland’s Illustrated Medical Dictionary, 30th ed., Plate 51, p. 2013, © 2003, used with permission from Elsevier.

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Figure 2 Principal veins of the body.From Dorland’s Illustrated Medical Dictionary, 30th ed., Plate 52, p. 2014, © 2003, used with permission from Elsevier.

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Figure 3 Superficial veins of the upper limb.From Dorland’s Illustrated Medical Dictionary, 30th ed., Plate 53, p. 2015, © 2003, used with permission from Elsevier.

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Figure 4 Superficial veins of the lower limb.From Dorland’s Illustrated Medical Dictionary, 30th ed., Plate 54, p. 2016, © 2003, used with permission from Elsevier.

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the administration set is removed from the flow-con-trol device.

Anti-Infective Central Vascular Access Device (CVAD).A central vascular access device that is coated orimpregnated with antiseptic or antimicrobial agents.

Antineoplastic Agent. Medication that prevents thedevelopment, growth, or proliferation of malignantcells.

Antineoplastic Therapy. In oncology practice, the term isused synonymously with cytotoxic (cell-killing) drugtherapy.

Antiseptic. An agent that inhibits the growth of, or kills,microorganisms on the external surfaces of the body.

Antiseptic Ointment. A semisolid preparation that pre-vents the pathogenic action of microbes.

Apheresis. A process of separating whole blood into 4components—plasma, platelets, red blood cells, andwhite blood cells—by removing one of the compo-nents and then reinfusing the remaining components.Types of apheresis include peripheral blood progeni-tor cell collection, leukapheresis, granulocyte collec-tion, plateletpheresis, plasmapheresis, and erythrocy-topheresis.

Arterial Pressure Monitoring. Monitoring of arterial pres-sure through an indwelling arterial catheter connectedto an electronic monitor.

Arteriovenous (AV) Fistula. A surgical anastomosisbetween an artery and a vein, creating an access forhemodialysis.

Arteriovenous (AV) Graft. A surgical structure connect-ing an artery and a vein with synthetic material tocreate an access for hemodialysis.

Aseptic Technique. A set of specific practices and proce-dures performed under carefully controlled conditionsin order to minimize contamination by pathogens.

Assent. Agreement by an individual not competent togive legally valid informed consent (eg, a child orcognitively impaired person).

Authorized Agent Controlled Analgesia (AACA). Amethod of pain control in which a consistently avail-able and competent individual is authorized by alicensed independent practitioner and properly educat-ed to activate the dosing button of an analgesic infu-sion pump when a patient is unable, in response to thatpatient’s pain.

A

Add-on Device. An additional component such as an in-line filter, stopcock, y-site, or needleless connector thatis added to the administration set or vascular accessdevice.

Administration Set. A device used to administer fluidsfrom a container to a vascular access device.

Admixing. The preparation or compounding of medications.Advanced Practice Nurse (APN). A nurse practitioner,

clinical nurse specialist, nurse anesthetist, or nurse-midwife.

Adverse Event. Any unintended or untoward event thatoccurs with a patient receiving medical treatment; canbe related to medications, products, equipment, andprocedures.

Air Embolism. The presence of air in the vascular system.Airborne Precautions. Methods used to prevent transmis-

sion of infectious agents that remain infectious over longdistances when suspended in the air; examples includemeasles (rubeola), varicella zoster virus infections,Legionella infection, disseminated zoster, and tuberculo-sis.

Allen Test. A test performed on a radial artery prior to arte-rial puncture to ascertain adequate arterial perfusion.

Ambulatory Infusion Device. An electronic infusiondevice specifically designed to be worn on the bodyto promote patient mobility and independence.

Amino Acids. Organic components of protein.Ampoule. A hermetically sealed glass medication con-

tainer that must be broken at the neck to access themedication.

Analgesic Infusion Pump. An electronic microprocessingmachine that can be programmed to deliver a pre-scribed amount of medication via continuous infu-sion, at specified intervals, or on demand by activa-tion of a button; also referred to as a PCA pump.

Anastomosis. The surgical formation of a passage between2 normally distant structures (eg, 2 blood vessels).

Anti–Free-Flow Administration Set. An administration setthat stops the flow of intravenous fluid when removedfrom the infusion device, yet allows gravity flow whenthe user manipulates the regulatory mechanism.

Anti–Free-Flow Protection. Technology that preventsintravenous fluid from flowing into the patient when

Glossary


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B

Bacteria. A microorganism that may be nonpathogenic(normal flora) or pathogenic (disease-causing).

Beneficence. An ethical principle referring to actionsthat promote the well-being of others.

Beyond-Use Date. The date added to a product labelduring the admixing process after which a productmay not be used based on the fact that the manufac-turer’s original container has been opened andexposed to ambient atmospheric conditions and maynot have the integrity of the original packaging.

Biohazardous Waste. Blood, body fluids, body parts, ormaterials that have come in contact with blood, bodyfluids, or body parts and have the potential to carrybloodborne pathogens.

Biologic Agent. A medicinal preparation made from liv-ing organisms and their products, including serums,vaccines, antigens, and antitoxins.

Biological Safety Cabinet. A ventilated cabinet usinghigh-efficiency particulate air filtration, laminar airflow, and containment to provide protection againstparticulates or aerosols from biohazardous agents.

Biotherapy. A treatment using biological agents madeby the process of genetic engineering.

Blood Warmer. An electronic device that raises refrigeratedblood to a desired temperature during administration.

Body Surface Area. The surface area of the bodyexpressed in square meters; used in calculating pedi-atric dosages, managing burn patients, and determin-ing radiation and chemotherapy doses.

Bolus. A concentrated medication and/or solution givenover a short period of time.

C

Caregiver Controlled Analgesia (CCA). A nonprofes-sional individual (eg, parent, significant other) whohas been authorized to administer medications to thepatient via a PCA pump.

Catheter. A tube for injection or evacuating fluids; hol-low tube made of plastic, silastic, rubber, or metalthat is used for accessing the body.

Catheter-Associated Venous Thrombosis. A secondaryvein thrombosis related to the presence of a centralvascular access device; includes extraluminal fibrinsheath, mural thrombosis overlying the fibrin sheath,and veno-occlusive thrombosis.

Catheter Clearance. The process to reestablish catheterlumen patency using medications or chemicalsinstilled into the lumen.

Catheter Dislodgment. A catheter movement into andout of the insertion site indicating tip movement to asuboptimal position.

Catheter Dysfunction. The inability to withdraw bloodor infuse solutions via the catheter; may result frommechanical obstruction or catheter damage.

Catheter Exchange. The replacement of an existing cen-tral vascular access device with a new central vascu-lar access device using the same catheter tract.

Catheter Malposition. The catheter tip is in a subopti-mal position.

Catheter-Related Bloodstream Infection (CR-BSI). Abacteremia or fungemia in a patient with a vascularaccess device and no apparent source for the blood-stream infection other than the vascular accessdevice. There must be at least 1 positive blood cul-ture (obtained from a peripheral vein) in addition toclinical manifestations of infection (ie, fever, chills,and/or hypotension).

Catheter Stabilization Device. A device/system specifi-cally designed and engineered to control movementat the catheter hub, thereby decreasing cathetermovement within the vessel and risk of catheter mal-position.

Central Line-Associated Bloodstream Infection (CLABSI).A primary bloodstream infection that occurs in apatient with a central vascular access device insertedwithin 48 hours prior to the development of thebloodstream infection.

Central Vascular Access Device (CVAD). A device thatpermits access to the central vascular system. Acatheter is inserted with the tip residing in the lowerone-third of the superior vena cava, or above the levelof the diaphragm in the inferior vena cava.

Chemical Incompatibility. A change in the molecularstructure or pharmacologic properties of a substancethat may or may not be visually observed.

Clinical Decision Support System (CDSS). An electron-ic system that provides guidance on medications,dosage, formulary support, drug allergy, and otherdosing parameters based on patient factors and/ornursing protocols.

Closed System. An administration system with nomechanism for external entry after initial setup andassembly.

Closed System Transfer. The movement of sterile prod-ucts from one container to another in which the con-tainer’s closure system and transfer devices remainintact through the entire transfer process, compro-mised only by the penetration of a sterile, pyrogen-free needle or cannula through a designated closureor port to effect transfer, withdrawal, or delivery.

Color Coding. A system developed by manufacturersthat identifies products and medications by the use ofa color system. Color code systems are not standard-ized (since each manufacturer uses different colorcode systems).

Compatibility. Capable of being mixed and administeredwithout undergoing undesirable chemical and/orphysical changes or loss of therapeutic action.

Competence. The capability of the nurse to applyknowledge, critical thinking, interpersonal decision



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making, and psychomotor skills to the performanceof infusion therapy; maintenance of the requiredknowledge, skills, and attitudes to provide safe, com-petent care from the time of initial licensure.

Competency. An integration of behaviors in the variedcircumstances of the work environment demonstrat-ing the individual’s ability to perform the desired job-related activities and tasks.

Competency Assessment. The process of reviewing and doc-umenting the individual’s demonstrated ability to performa job, role, specific tasks, or other patient-care activities.

Complex Needleless Connector. A device that contains aninternal mechanism that allows both the injection andaspiration of fluids; commonly referred to as a mechanicalvalve.

Compound. To form or make by combining different ele-ments, ingredients, or parts; as to compound a medicine.

Computerized Prescriber Order Entry (CPOE). A comput-er-based system with varying levels of sophistication forautomating and standardizing medication orders.

Conscious Sedation. A minimally depressed level of con-sciousness in which the patient retains the ability to main-tain a patent airway independently and continuously andto respond appropriately to physical stimulation and ver-bal commands. The drugs, doses, and techniques used arenot intended to produce loss of consciousness.

Contact Precautions. Methods used to prevent the transmis-sion of infectious agents by direct contact (person to per-son) or indirect contact (medium to susceptible person).

Contamination. The introduction or transference of pathogensor infectious material from one source to another.

Continuing Competence. Maintenance of the required knowl-edge and skills to provide safe, competent care since thetime of initial licensure.

Corrective Action. A defined plan to eliminate deficiencies.Criteria. Relevant, measurable indicators.Cross Contamination. The movement of pathogens from

one source to another.

D

Delivery System. Product(s) that allows for the administra-tion of medication. The system can be integral or canhave component parts, and it includes all products usedin the administration, from the solution container to thecatheter.

Disclosure. The process of revealing to the patient andfamily all the facts necessary to ensure an understand-ing of what occurred when a patient experiences a sig-nificant complication from a medical error or mistake;information that is necessary for the patient’s well-being or relevant to future treatment.

Disinfectant. An agent that eliminates all microorganismsexcept spores.

Distal. Farthest from the center, or midline of the body ortrunk, or from the point of attachment; the opposite ofproximal.

Distention. An increase in size because of pressure fromwithin; a stretching out or inflation.

Document. A written, printed, or electronic record con-taining original, official, or legal information.

Documentation. The act of recording information on awritten, printed, or electronic form.

Dome. A plastic component used in hemodynamic monitoring.Dose Error Reduction System. Electronic flow-control

devices manufactured with drug libraries containingdrug name and soft and hard infusion limits, designedto prevent errors in solution and medication delivery;often called “smart pumps.”

Droplet Precautions. Methods used to prevent the trans-mission of infectious agents from the respiratory tract.

Durable Medical Equipment. Equipment that may be consid-ered property or capital equipment; it is reusable and cleanedbetween patient use; examples include intravenous poles,flow-control devices, and ultrasound machines.

Dwell Time. The suggested length of time a vascular accessdevice may remain in place.

E

Electronic Infusion Device (EID). A programmable devicepowered by electricity or battery used to regulate infu-sion rate and volume.

Emancipated Minor. A child who has been granted thestatus of adulthood by a court order or other formalarrangement, such as marriage.

Embolus. A mass of clotted blood or other material, such ascatheter fragments or air, brought by the blood from one ves-sel and forced into a smaller one, obstructing the circulation.

Epidemiology. A study of the distribution and determinants ofhealth-related states and events in populations; defines andexplains the interrelationships among the host, agent, andenvironment.

Epidural Space. The area surrounding the spinal cord andits coverings that may be used for the infusion of anes-thesic agents or opioids.

Epithelialized. The healing of a wound or catheter site bythe process of epithelial growth.

Erythema. A redness of skin along a vein track that resultsfrom vascular irritation or capillary congestion inresponse to irritation; may be a precursor to phlebitis.

Exit Site Infection. An erythema or induration within 2 cmof the catheter exit site without evidence of a blood-stream infection or purulent drainage.

Expiration Date. The date beyond which a manufacturer hasdesignated a product not to be used.

Extravasation. The inadvertent infiltration of vesicantsolution or medication into surrounding tissue.

Extrinsic Contamination. Contamination that occurs afterthe manufacturing process of a product.

F

Failure Mode and Effects Analysis (FMEA). A method-ology for analyzing potential reliability problems.



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Fidelity. Faithfulness to obligations, duties, or observances.Filter. A porous device integrated or added to an administra-

tion set to prevent the passage of air or other undesiredsubstances into the vascular system.

Flow-Control Device. A manual, mechanical, or electronicinfusion device used to regulate flow rate.

Fluid Warmer. An electronic device that raises parenter-al fluids to a desired temperature during administra-tion.

Flushing. The act of moving fluids, medications, blood,blood products, and nutrients out of a vascular accessdevice into the bloodstream, ensuring delivery of thosecomponents and verifying device patency.

Free Flow. The unintentional, nonregulated administration offluid.

G

Grade. A degree of standing or value.

H

Health Care-Associated Infection (HAI). An infection that isnot present when a patient is admitted into the healthcare system.

Health Literacy. The degree to which individuals have thecapacity to obtain, process, and understand basichealth care information and services needed to makeappropriate decisions.

Hemodynamic Pressure Monitoring. The use of a pul-monary artery catheter to directly measure intracardiacpressure changes, cardiac output, blood pressure, andheart rate.

Hemolysis. The destruction of the membrane of the red bloodcells.

Hemostasis. An arrest of bleeding from a blood vessel.Heparin-Induced Thrombocytopenia (HIT). A potentially

life- and limb-threatening immunologic reaction causedby platelet activation resulting in a hypercoagulablestate with a strong association to vascular and arterialthrombosis as a result of heparin exposure.

High-Risk Tasks. Invasive procedures that may be harmfulor life-threatening to a patient.

Hypertonic. Having a concentration greater than the nor-mal tonicity of plasma; solution of higher osmotic con-centration than that of an isotonic solution.

Hypodermoclysis. The subcutaneous administration ofisotonic fluids for the treatment or prevention of dehy-dration.

Hypotonic. Having a concentration less than the normal tonic-ity of plasma; solution of lower osmotic concentration thanthat of an isotonic solution.

I

Immediate-Use Medication. Medication that is administeredwithin 1 hour of preparation.

Immunocompromised. Having an immune system withreduced capability to react to pathogens or tissue damage.

Immunohematology. The study of blood and blood reactionswith respect to the immune system.

Immunologic Transfusion Reaction. Untoward effects of ablood transfusion that are not unexpected and in manycases are benign.

Implanted Port. A catheter that is surgically placed into avessel, body cavity, or organ and is attached to a reser-voir located under the skin.

Implanted Pump. A catheter that is surgically placed intoa vessel, body cavity, or organ and is attached to areservoir located under the skin that contains a pump-ing mechanism for medication administration.

Incompatible. Incapable of being mixed or used simul-taneously without undergoing chemical or physicalchanges or producing undesirable effects.

Infection. The presence and growth of a pathogenic micro-organism.

Infiltration. The inadvertent administration of a nonvesi-cant solution or medication into surrounding tissue.

Informed Consent. A person’s voluntary agreement,based on adequate knowledge and understanding ofrelevant information, to participate in research or toundergo a diagnostic, therapeutic, or preventive proce-dure. In giving informed consent, subjects may notwaive or appear to waive any of their legal rights, orrelease or appear to release the investigator, the spon-sor, the institution, or agents thereof from liability fornegligence.

lnfusate. A parenteral solution administered into thevascular or nonvascular systems.

Infusate-Related Bloodstream Infection. An infectioncaused by intrinsic or extrinsic contamination of theadministration delivery system, infusing fluids, and/ormedications.

Infusion-Related Hypersensitivity Reactions. Any signor symptom experienced by the patient during theinfusion of a pharmacologic or biologic agent thatresults in an immediate hypersensitivity reaction andanaphylactic or anaphylactoid response.

INR (International Normalization Ratio). A systemestablished by the World Health Organization forreporting the results of blood coagulation tests.

Intermittent Infusion. The administration of intravenousmedications or solutions at prescribed intervals.

Intradermal. Within or between the layers of skin.Intraosseous (IO). The space located in the marrow of

the bone that may be accessed for the administrationof solutions and medications.

Intrathecal. Inside the spinal cord; within the spinal canal.Intravenous Fat Emulsion (IVFE). A preparation of lipids

administered intravenously to maintain or supportnutrition.

Intrinsic Contamination. Contamination that occursduring the manufacturing process of a product.

Introducer. A needle used to control, direct, and place acatheter into a blood vessel.



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Investigational Drug. An intravenous drug that has notbeen approved for general use by the US Food andDrug Administration but is under investigation inclinical trials to evaluate its safety and efficacy.

Iontophoresis. A noninvasive transdermal method ofadministering medication via an electrical charge.

Iron Overload. Abnormally high levels of iron that maycause life-threatening organ damage; a side effect offrequent blood transfusions.

Irritant. An agent capable of producing discomfort or painalong the internal lumen of the vein.

Isotonic. Having the same osmotic concentration as plasma.

J

Joint Stabilization. A device used to stabilize or restrictmovement of the joint.

Just Culture. An environment that recognizes humanpotential for error and clearly defines acceptablebehavior in a consistent manner.

L

Laminar Flow Hood. A contained workstation with fil-tered airflow; assists in preventing bacterial contamina-tion and collection of hazardous chemical fumes in thework area.

Latex Precautions. Measures taken to prevent and eradicatelatex allergy.

Latex-Safe Environment. A health care setting in which allproducts containing natural rubber latex intended forcontact with mucosa or nonintact skin are removed orcovered.

Legally Authorized Representative. An individual person,judicial body, or other body of individuals authorizedunder state and federal laws to consent on behalf of alegally designated person.

Licensed Independent Practitioner. An individual permittedby law to provide care and services without direction orsupervision within the scope of the individual’s grantedclinical privileges, license, and organizational policies.

Locking. The instillation of a solution into a vascularaccess device to maintain device patency.

Low-Frequency Tasks. Tasks that are performed infre-quently (less than weekly).

Lumen. The interior space of a tubular structure, such as ablood vessel or catheter.

M

Manual Flow-Control Device. A manually operateddevice to control the flow rate of the infusion.

Mature Minor. Someone who has not reached adulthood(as defined by state law) but who may be treated as anadult for certain purposes, such as consenting to med-ical care. A mature minor is not necessarily an emanci-pated minor.

Maximal Sterile Barrier Protection. Equipment and cloth-ing used to avoid exposure to pathogens, including

mask, gown, protective eyewear, cap, sterile gloves,sterile drapes, and towels.

Mechanical Infusion Device. A device that uses a nonelec-tronic method to regulate infusion flow rates; examplesinclude the elastomeric balloon device and the springcoil piston syringe device.

Mechanical Valve Device. A needleless connector with aninternal mechanical device that provides a fluid path-way capable of infusion and aspiration.

Medication Reconciliation. The process of collecting anddocumenting complete and accurate medication infor-mation for each patient, including prescribed, over-the-counter, and herbal medications that the patient is cur-rently taking.

Microabrasion. A superficial break in skin integrity thatmay predispose the patient to infection.

Microaggregate. A microscopic collection of particles,such as platelets, leukocytes, and fibrin that occurs instored blood.

Microaggregate Blood Filter. A filter that removesmicroaggregates and reduces the occurrence of non-hemolytic febrile reactions.

Microintroducer. A dilator/introducer assembly used inthe Modified Seldinger Technique for insertion of aperipherally inserted central catheter.

Micron. A unit of length equal to one millionth of a meteror one thousandth of a millimeter.

Microorganism. An extremely small living body notperceptible to the naked eye.

Mid-Arm Circumference. Measurement of the upper arm ata predetermined distance above the insertion of a periph-erally inserted central catheter or midline catheter.

Midline (ML) Catheter. A vascular access device measuring8 inches or less with the distal tip dwelling in the basil-ic, cephalic, or brachial vein, at or below the level of theaxilla and distal to the shoulder.

Milliosmoles (mOsm). One thousandth of an osmole;osmotic pressure equal to one thousandth of the mol-ecular weight of a substance divided by the number ofions that the substance forms in 1 L of solution.

Modified Seldinger Technique. A method of percutaneousinsertion of a catheter into a blood vessel. A needle is insert-ed into the vein and a guidewire is threaded through theneedle. The needle is removed, and a small nick is made inthe skin. A dilator/introducer unit is threaded over theguidewire. The guidewire and dilator are removed, and thecatheter is advanced through the introducer, followed byremoval of the introducer. This technique reduces trauma tothe vein as well as the risk of artery or nerve injury.

N

Needleless Connector. A device designed to accommodateneedleless devices for the administration of solutionsinto the vascular system.

Needleless System. An umbrella term used to encompassall types of needleless devices or products.



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Negative Displacement. Blood reflux into the catheter lumenupon disconnection with movement of valve mechanism,or when a fluid container empties and remains connectedto the administration set.

Neonate. Pertaining to the first 4 weeks of life.Neutral Connector. A needleless connector with an inter-

nal mechanism designed to prevent blood reflux uponconnection or disconnection.

No-Touch Technique. A method to ensure the asepticpreparation of a peripheral insertion site. Once the sitehas been prepared, it is not to be touched unless sterilegloves are used.

Noncritical Equipment. Items that touch only intact skin,not mucous membranes, or that do not directly touchthe patient.

Nonimmunologic Transfusion Reaction. An infusionreaction that is not related to the immune systemincluding, but not limited to, circulatory overload,hypothermia, electrolyte imbalance, or iron overload.

Nonmaleficence. An ethical principle based on the Hippocraticmaxim, primum non nocere, or “first, do no harm.”

Nonpermeable. Impervious to the passage of substances.Nontunneled Central Vascular Access Device. A vascular

access device inserted by puncture directly through theskin and to the intended location without passingthrough subcutaneous tissue.

Nurse-Controlled Analgesia (NCA). A nurse who has beenauthorized to administer medications to the patient viaa PCA pump.

Nurse Practice Act. Legislation that defines the practice ofregistered nurses and licensed practical or vocationalnurses within each state.

Nursing Diagnosis. A clinical judgment of a patient’s experi-ences and responses to actual or potential health issues.

Nursing Interventions. Concepts that link specific nursingactivities and actions to expected outcomes.

Nursing Process. An orderly, logical approach to admin-istering nursing care so that the patient’s needs forsuch care are met comprehensively and effectively;includes the steps of assessment, problem identifica-tion, planning, intervention, and evaluation.

O

Occlusion. The state of being occluded; the inability toinfuse or inject fluid into a catheter; the inability toaspirate blood from a catheter or both.

Off-Label Use. The use of an approved drug in the treat-ment of a condition or for a purpose for which it hasnot been approved or cleared for use by the US Foodand Drug Administration.

Older Adult. Greater than 65 years of age as defined by theAmerican Society of Geriatrics.

Osmolality. The number of milliosmoles per kilogram ofsolvent.

Osmolarity. The number of milliosmoles per liter of solution.Outcome. The interpretation of documented results.

P

Paired Blood Samples. Blood samples are drawn from acatheter and from a peripheral venipuncture site; bothsamples should be of the same volume and obtainedwithin a 10-minute period.

Palpable Cord. A vein that is rigid and hard to the touch.Palpation. An assessment technique used to evaluate the

condition of a vessel.Parenteral. Admixtures containing macronutrients and

micronutrients that are vital for the maintenance ofmetabolism and growth.

Parenteral Nutrition. The intravenous provision of total nutri-tional needs for a patient who is unable to take appropriateamounts of food enterally; typical components include car-bohydrates, proteins, and/or fats, as well as additives suchas electrolytes, vitamins, and trace elements.

Particulate Matter. Matter relating to or composed of fineparticles.

Pathogen. A microorganism or substance capable of pro-ducing disease.

Patient-Controlled Analgesia (PCA). A method of paincontrol designed to allow the patient the ability toadminister bolus doses of an analgesic as needed.

PCA by Proxy. Activation of the analgesic infusion pumpby anyone other than the patient.

Pediatric. Newborn to 21 years of age.Percutaneous. Technique performed through the skin.Peripheral. Pertaining to a vessel located outside the

central circulation.Peripherally Inserted Central Catheter (PICC). A central

vascular access device inserted into an extremity andadvanced until the tip is positioned in the vena cava.

Personal Protective Equipment (PPE). Specialized equipmentworn by an individual for protection against health andsafety hazards; examples include, but are not limited to,face masks, caps, goggles, gloves, or fluid-resistant gowns.

pH. The degree of acidity or alkalinity of a substance.Phlebitis. Inflammation of a vein; may be accompanied by

pain, erythema, edema, streak formation, and/or a pal-pable cord.

Phlebotomy. Withdrawal of blood from a vein.Physical Incompatibility. An undesirable, visible reaction

within a solution such as a change in color, clarity,presence of precipitate, or gas formation.

Physical Restraint. Physical, mechanical, or manualdevice that immobilizes or decreases the ability of thepatient to move arms, legs, body, or head freely.

Pocket Infection. A purulent fluid found in the subcuta-neous pocket of an implanted port or pump without evi-dence of a bloodstream infection. It may or may not beassociated with spontaneous rupture and drainage ornecrosis of the overlying skin.

Point-of-Care Testing. Diagnostic testing that is per-formed at or near the site of patient care.

Policy. Written statement(s) of a course of action intendedto guide decision making.



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Positive Displacement. The result of a small amount offluid being pushed out of the end of the catheterlumen, clearing any blood reflux resulting from thedisconnection of an administration set or syringe.

Pounds per Square Inch (psi). A measurement of pressure;1 psi equals 50 mm mercury (Hg) or 68 cm water(H2O).

Power-Injectable Central Vascular Access Device. Adevice capable of withstanding high-pressure injec-tions up to 300 psi.

Practice Guidelines. Direct clinical care decisions based onthe current state of knowledge about a specific diseasestate or therapy.

Precipitation. The act or process of a substance or drug insolution to settle in solid particles.

Preservative-Free. Containing no added substance capableof inhibiting bacterial growth.

Primary Catheter Malposition. A tip location of any cen-tral vascular access device found to be in a suboptimalposition as determined by the initial chest radiograph.

Primary Continuous Administration Set. The mainadministration set used to deliver solutions and med-ications to the patient.

Primary Intermittent Administration Set. An administra-tion set that is connected and disconnected with eachuse.

Problem-Prone Tasks. Tasks that are documented toproduce issues for the patient, staff, or organization.

Procedure. A written statement of a series of steps requiredto complete an action.

Product Integrity. The condition of an intact, uncom-promised product suitable for intended use.

Proximal. Closest to the center or midline of the body ortrunk, nearer to the point of attachment; the oppositeof distal.

Psychomotor. Characterizing behaviors that place primaryemphasis on the various degrees of physical skills anddexterity as they relate to the thought process.

Purulent. Containing or producing pus.Push. Manual administration of medication under pressure.

Q

Quality Improvement. An ongoing, systematic processfor monitoring, evaluating, and problem solving.

Quantitative Culture Technique. A laboratory protocolused for isolating and identifying microorganisms inwhich a catheter segment is flushed or soaked in brothfollowed by serial dilutions and surface plating on agar.

R

Radiopaque. Impenetrable to x-rays or other forms ofradiation; detectable by radiographic examination.

Risk Evaluation Mitigation Strategies (REMS). A strategyto manage a known or potential serious risk associat-ed with a drug or biological product. REMS caninclude a medication guide, patient package insert, a

communication plan, elements to ensure safe use, andan implementation system; must include a timetablefor assessment of the REMS.

Risk Management. The process that centers on identifica-tion, analysis, treatment, and evaluation of real andpotential hazards.

Root Cause Analysis (RCA). The process for identifyingfactors that contribute to variations in performance.

S

Safety Device System. An engineered physical attributeof a device that effectively reduces the risk of blood-borne pathogen exposure.

Scale. A tool to measure gradations.Sclerosis. Thickening and hardening of the layers in the

wall of the vessel.Secondary Catheter Malposition or Tip Migration. Tip

location of any central vascular access device foundto be in a different, suboptimal position followinginitial correct positioning.

Secondary Continuous Administration Set. An adminis-tration set attached to the primary administration setfor a specific purpose, usually to administer medica-tions; also known as a piggyback set.

Seldinger Technique. A method of percutaneous insertionof a vascular access catheter into a blood vessel. Thevessel is accessed with a needle, and a guidewire isplaced through the needle. The needle is removed. Acatheter is placed into the vessel over the guidewire andadvanced to the desired location. The guidewire isremoved, leaving the catheter in place.

Semiquantitative Culture Technique. A laboratory proto-col used for isolating and identifying microorganisms inwhich a catheter segment is rolled across the surface ofan agar plate, and colony-forming units are countedafter overnight incubation.

Sentinel Event. An unexpected occurrence involving death,serious physical or psychological injury; serious injuryspecifically includes loss of limb or function.

Sepsis. The presence of infectious microorganisms ortheir toxins in the bloodstream.

Sharps. Any device or item having corners, edges, orprojections capable of cutting or piercing the skin.

Simple Needleless Connector. A device with a straightfluid pathway that contains no internal mechanismsor moving pieces.

Single-Use Product. A device, such as a vial or syringe,that is intended for 1 entry or use.

Single-Use Vial. A bottle that is hermetically sealed witha rubber stopper and is intended for one-time use.

Site Protection. A method or product used to protect thecatheter insertion site.

Six Sigma. A data-driven, fact-based philosophy of quali-ty improvement that values prevention over detection.

Skill Validator. An individual with documented compe-tency in a specific skill who is qualified by training



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and education to objectively assess the performanceof others.

Split-Septum Device. A simple needleless connectorwith a prepierced septum that can be of blunt cannu-la or luer-lock design.

Standard. An authoritative statement enunciated andpromulgated by the profession by which the qualityof practice, service, or education can be judged.

Standard Precautions. Guidelines designed to protectworkers with occupational exposure to bloodbornepathogens; all blood and body fluids are treated aspotentially infectious.

Statistics. The systematic science of collection, organizing,analysis, and interpretation of numerical data.

Sterile. Free from living organisms.Stylet. A rigid metal object within a catheter designed to

facilitate insertion.Subcutaneous Infusion. Administration of medications

or solutions into the tissues beneath the skin.Surfactant. A surface-active agent that lowers the sur-

face tension of fluid.Surveillance. Active, systematic, ongoing observation of the

occurrence and distribution of disease within a popula-tion and of the events or conditions that increase ordecrease the risk of such disease occurrence.

T

Tamper-Proof. Unable to be altered.Therapeutic Phlebotomy. Removal of a specific volume

of blood from a patient for the treatment of a specif-ic condition or disease.

Thrombolytic Agent. A pharmacologic agent capable ofdissolving blood clots.

Thrombophlebitis. Inflammation of the vein in conjunc-tion with formation of a blood clot (thrombus).

Thrombosis. The formation, development, or existenceof a blood clot within the vascular system.

Thrombus. A clot composed of fibrin and blood cells thatis attached to a vessel. The thrombus may grow to sur-round a vascular access device, eventually obstructingthe device as well as the vessel. Factors that promote theformation of a thrombus are vascular endothelial dam-age, venous stasis, and hypercoaguable states(Virchow’s Triad).

Transducer. An electronic device that converts one form ofenergy to another.

Transfusion Reaction. A complication of a blood transfu-sion in which there is an immune response against thetransfused blood cells or other components of the trans-fusion.

Transfusion-Related Acute Lung Injury (TRALI). Apotentially fatal acute lung injury characterized bynoncardiogenic pulmonary edema following transfu-sion of blood products.

Transmission-Based Precautions. Methods used to protecthealth care workers when patients are suspected or known

to be infected or colonized with infectious agents that can-not be controlled with standard precautions alone.

Transparent Semipermeable Membrane (TSM) Dressing.A sterile dressing that allows moisture to pass throughthe dressing away from the skin while preventingexternal moisture from contacting the insertion site ofthe vascular access device.

Tubing Misconnection. An inadvertent connection of a tub-ing to the wrong catheter, port, or lumen that may resultin serious injury or death; examples include enteral oroxygen tubing connected to an intravenous administra-tion set, or an intravenous administration set connectedto a feeding tube.

Tunnel Infection. Tenderness, erythema, and/or indura-tion 2 cm from the catheter exit site, along the subcu-taneous tract of a tunneled catheter with or without aconfirmed bloodstream infection.

Tunneled Catheter. A vascular access device whose proxi-mal end is tunneled subcutaneously from the insertionsite and brought out through the skin at an exit site.

U

Ultrafiltration. A method used to remove excessiveamounts of sodium and water from patients with fluidoverload, such as patients with congestive heart failure.

Unusual Occurrence. An event determined to have animpact on patient care, and/or any practice felt to beoutside the norm of acceptable patient care accordingto the organization.

Unusual Occurrence Report. Documentation of an eventthat requires action because of potential or impliedconsequences.

V

Vascular Access Device (VAD). Catheters, tubes, ordevices inserted into the vascular system, includingveins, arteries, and bone marrow.

Veracity. A legal principle that states that a health careprofessional should be honest, give full disclosure tothe patient, abstain from deceit or misrepresentation,and report known lapses of the standards of care tothe proper agencies.

Vesicant. An agent capable of causing blistering, tissuesloughing, or necrosis when it escapes from the intend-ed vascular pathway into surrounding tissue.

Virchow’s Triad. The pathophysiological explanation forthe development of vascular thrombosis. The triadconsists of the following components: vessel wall dam-age or injury, alterations in blood flow, and hyperco-agulability of the blood.

Visual Infusion Phlebitis (VIP) Scale. A tool developedby the Royal College of Nursing in the UnitedKingdom to determine the degree of phlebitis.

Visualization Technology. A device that employs theuse of sound waves or light to allow for the locationand identification of blood vessels.



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A

Access devices. See also Vascularaccess devices apheresis catheters, S53hemodialysis vascular access

devices, S51implanted vascular access ports,

S50intraosseous, S82intraspinal, S81subcutaneous, S84ultrafiltration catheters, S53umbilical catheters, S52

Add-on devices, S31Administration set change, S55Air embolism, S69Antineoplastic therapy, S87Apheresis catheters, S53

B

Biologic therapy, S89Blood sampling, S78Blood warmer, S35

C

Catheter-associated venousthrombosis, S71

Catheter clearance: occludedcentral vascular access devices, S76

Catheter embolism, S70Central vascular access device

exchange, S75Central vascular access device

malposition, S72Competence and competency

validation, S11Complications. See Infusion-

related complications

Compounding of parenteralsolutions and medications, S27

Continuous subcutaneous infusionand access devices, S84

D

Disinfection of durable medicalequipment, S29

Documentationdocumentation, S20product evaluation, integrity,

and defect reporting, S22unusual occurrence and sentinel

event reporting, S21verification of products and

medications, S24

E

Equipmentadd-on devices, S31blood and fluid warmers, S35filters, S33flow-control devices, S34needleless connectors, S32tourniquets, S36

Ethics, S8External jugular vein access, S42Extravasation, S66

F

Filters, S33Flow-control devices, S34Fluid warmer, S35Flushing, S59

H

Hand hygiene, S26Hemodialysis vascular access

devices, S51

I

Implanted vascular access ports,S50

Infection, S68Infection prevention

compounding of parenteral solutions, S27

disinfection of durable medical equipment, S29

hand hygiene, S26transmission-based precautions,

S29Infiltration, S66Informed consent, S17Infusion-related complications

air embolism, S69catheter-associated venous

thrombosis, S71catheter embolism, S70central vascular access device

malposition, S72extravasation, S66infection, S68infiltration, S66phlebitis, S65

Intraosseous access devices,S82

Intraspinal access devices, S81Investigational drugs, S96

J

Joint stabilization, S47

L

Latex sensitivity or allergy, S30Local anesthesia for vascular

access device placement andaccess, S43

Locking, S59

Index


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M

Moderate sedation/analgesia, S95

N

Needleless connectors, S32Neonatal and pediatric patients,

S6Nonvascular infusion devices

continuous subcutaneous, S84intraosseous access devices,

S82 intraspinal access devices, S81

Nursing practice standardscompetence and competency

validation, S11ethics, S8neonatal and pediatric patients,

S6older adult patients, S7policies, procedures, and

practice guidelines, S14practice setting, S6quality improvement, S12research and evidence-based

practice, S13scope of practice, S8

O

Older adult patients, S7Orders for the initiation and

management of infusiontherapy, S15

P

Parenteral medication and solutionadministration, S86

Parenteral nutrition, S91Patient care standards

informed consent, S17orders for the initiation and

management of infusiontherapy, S15

patient education, S16plan of care, S18

Patient-controlled analgesia, S89Patient education, S16

Phlebitis, S65Phlebotomy

blood sampling via a vascular access device, S78

therapeutic, S79via direct venipuncture, S78

Plan of care, S18Policies, S14Practice guidelines, S14Practice setting, S6Procedures, S14Product evaluation, integrity, and

defect reporting, S22

Q

Quality improvement, S12

R

Removal, vascular access devicesarterial catheters, S58midline catheters, S57nontunneled central vascular

access devices, S58short peripheral catheters, S57surgically placed central

vascular access devices, S58Research and evidence-based

practice, S13

S

Safe handling and disposal ofsharps, hazardous materials, andhazardous waste, S28

Safety compliancecompounding, S27handling and disposal of sharps,

hazardous materials, andhazardous waste, S28

latex sensitivity or allergy, S30scissors, S27

Scissors, S27Scope of practice, S8Sentinel event reporting, S21Site care and maintenance

administration set change, S55dressing changes, S63flushing, S59

locking, S59site care, S63

Site selection, S40

T

Therapeutic phlebotomy, S79Tourniquets, S36Transfusion therapy, S93Transmission-based precautions,

S29

U

Ultrafiltration catheters, S53Umbilical catheters, S52Unusual occurrence reporting,

S21

V

Vascular access devicesanesthesia for placement and

access, S43removal, S57repair, S75selection, S37site care and dressing changes,

S63site preparation and device

placement, S44site protection, S48site selection, S40stabilization, S46types

arterial catheters, S38central vascular access

devices, S38implanted ports, S38midline catheters, S37nontunneled catheters, S38peripherally inserted central

catheters, S38short peripheral catheters,

S37tunneled catheters, S38

Verification of products andmedications, S24

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