- Should the dressing be changed?
- What should be included in the complete assessment?
- How frequently should an assessment be done?
- What should be documented for each assessment?
It is important to remember that this practice change is really only occurring in the adult patients. This has been the standard of practice for pediatric patients for many, many years as a set time interval for changing a peripheral catheter on an infant or child has never been applied.
In 2012, INS released a position paper on the frequency of assessing peripheral catheter sites. The paper provides detailed guidance on the frequency of assessment based on the type of fluids and medications being given and many patient factors such as age and ability to communicate with the nursing staff. The frequency of assessment ranges from every 5 minutes for a vesicant medication to every 4 hours for a nonvesicant infusion in an awake and oriented adult. This assessment should include visual assessment, palpation, and obtaining comments from the patient about how it feels. This assessment should include all signs and symptoms of infiltration/extravasation, phlebitis, thrombosis, infection, and nerve injury. To review this position paper and several others from the Infusion Nurses Society, click here.
The dressing on a peripheral catheter should be changed if it is wet, dirty or non-adherent to the skin. Otherwise, it should remain intact for the entire catheter dwell time.
I am not aware of any healthcare facilities that have greatly altered the wording of their assessment policy for peripheral catheters. Primary care nurses may only look at the site and ask the patient how it feels but this may allow for many complications being missed. The only documentation may be a check mark on a specific form or nothing at all if charting by exception is the routine practice for documentation.
Where I see problems is when I review medical records for malpractice lawsuits. In most of these cases, the catheter was used for an injection or infusion without a complete assessment. With a thorough assessment the nurse should have recognized early signs or symptoms of complications and that the catheter should not be used for infusion. Simply looking at the site will not allow the nurse to detect changes in skin temperature or induration. Often, gentle palpation will elicit tenderness that the patient may not have previously recognized. Prior to giving any drug, the INS Standards of Practice call for aspirating for a blood return. Many would argue that this is not a reliable test, but it cannot be disregarded in the complete assessment process, especially when giving a vesicant medication. This would require that the nurse understand the nature of the drug being given. Vesicants are not limited to oncology drugs. Promethazine, many vasopressors, all calcium preparations, contrast media agents, and some antibiotics are vesicants. To safely give a vesicant medication, the site must be free from all signs and symptoms of all complications, flush easily without any resistance, produce a blood return that is the color and consistency of whole blood, and allow for a free-flowing gravity infusion. It is also important to compare both extremities for changes in size. Infiltrations may not appear as a swollen area near the catheter tip. If compartment syndrome is happening, the entire forearm will appear larger than the opposite arm. None of these steps should be overlooked.
One other problem is for the nurse to ignore a patient’s complains of some type of discomfort. The nurse may tell the patient that this is “normal,” or “all patients complain about this drug.” Discomfort or pain of any kind at a peripheral catheter site is an indication of a complication and is adequate reason to change that catheter. So no complaint should be ignored!
Routine assessments that reveal no problems may not require documentation, especially if using charting by exception. However, without documentation how can the nurse prove that it was actually done? Prior to giving any vesicant medication, the complete site assessment including the presence or absence of a blood return should be documented. Nursing actions that are not documented have no proof that this assessment was done. Even an I.V. infusion of 5% dextrose in 0.45% sodium chloride can produce nerve damage when enough fluid has been pumped into the subcutaneous tissue.
At a minimum, I would recommend
- Following the assessment frequency included in the INS position paper on recommendations for frequency of site assessment.
- A thorough site assessment, including manual flushing and aspiration for a blood return prior to giving a vesicant medication.
- Daily assessment for a continued need for the peripheral catheter
- Complete documentation of a thorough site assessment each time it is done.
- These steps will protect the patient from serious, life-altering outcomes, and reduce the professional liability of the nurse and facility.
We offer a free poster which includes all the components of a catheter assessment. Download it from our website by clicking here.