• Remain free from vascular trauma

• Remain free from signs and symptoms that indicate vascular trauma

• Remain free from impaired tissue and/or skin

• Maintain skin integrity, tissue perfusion, usual tissue temperature, color and pigment

• Report any altered sensation or pain

• State site is comfortable

 Verify objective and estimate duration of treatment. Check physician’s order. Verify if client will remain hospitalized during the whole treatment or will go home with the device (Phillips, 2010).

• Assess client’s clinical situation when venous infusion is indicated. Consider possible clinical conditions that cause changes in temperature, color, and sensitivity of the possible venous access site. Verify situations that alter venous return (e.g., mastectomy, stroke) (Phillips, 2010). The site of catheter insertion influences the risk of infection and phlebitis, such as preexisting catheters, anatomic deformity, and bleeding diathesis (Joanna Briggs Institute, 2008).

• Assess if client is prepared for an IV procedure. Explain the procedure if necessary to decrease stress. Stress may cause vasoconstriction that can interfere in the visualization of the vein and flow of the infused solution (Wells, 2008).

• Provide privacy and make the client comfortable during the intravenous insertion. Privacy and comfort help to decrease stress (Phillips, 2010). The nurse should minimize discomfort to the client and utilize measures to reduce the fear, pain, and anxiety associated with intravenous insertion (RCN, 2010).

• Teach the client what symptoms of possible vascular trauma he should be alert to and to immediately inform staff if they notice any of these symptoms. Prompt attention to adverse changes decreases chance of adverse effects from complications (Dougherty, 2008).

• Wash hands before and after touching the client, as well as when inserting, replacing, accessing, repairing or dressing an intravascular catheter (O’Grady et al, 2011).

• Maintain aseptic technique for the insertion and care of intravascular catheters. Use gloves and always reduce the number of staff present in the environment during the procedure if possible. CEB: These measures reduce the risk of infection (Ingram & Lavery, 2007).

• Assess the condition of the client’s veins, possible age-related influence, and previous intravenous site use. In order to minimize the risk of complications, thorough patient assessment and careful catheter management are essential (McCallum & Higgins, 2012).

• In cases of hard-to-access veins, consider strategies such as the use of ultrasound (US) to assist in vein localization and safe venipuncture. Ultrasound-guided cannulations have a high success rate in clients with difficult venous access (Elia et al, 2012).

• Avoid areas of joint flexion or bony prominences. Movement in these sites can cause mechanical trauma in veins (RCN, 2010).

• Choose an appropriate vascular access device (VAD) based on the types and characteristics of the devices and insertion site. Consider the following:

 Choose a device with consideration of the nature, volume, and flow of prescribed solution. EBN: Choosing the right gauge size reduces the risk of vascular trauma (Trim, 2005). Verify that the osmolarity of the solution to be infused is compatible with the available access site and device (Phillips, 2010).

• If possible, choose the venous access site considering the client’s preference.

• Select the gauge of the venous device according to the duration of treatment, purpose of the procedure, and size of the vein. Emergency situations require short, large-bore cannulae. Hydration fluids and antibiotics can be delivered through much smaller cannulae (Scales, 2008). Select the smallest gauge necessary to achieve the prescribed flow rate (INS, 2011). The time of infusion of the drug, especially chemotherapy agents, can contribute to the occurrence of phlebitis (Kohno et al, 2008). EB: The use of an infusion pump is a factor that predisposes the occurrence of phlebitis (Uslusoy & Mete, 2008).

• Verify if client is allergic to fixation or device material.

• Disinfect the venipuncture site. Assess that skin is dry before puncturing.

• Provide a comfortable, safe, hypoallergenic, easily removable stabilization dressing, allowing for visualization of the access site. Catheter stabilization should be used to preserve the integrity of the access device, to minimize catheter movement at the hub, and to prevent catheter migration and loss of access (INS, 2011). Some peripheral cannulae have stabilization wings (which increase the external surface area) and/or ports (which are used to administer bolus medication) incorporated into their design (Gabriel, 2008).

• Use either sterile gauze or sterile, transparent, semipermeable dressing to cover catheter site. Replace dressing used on short-term CVC sites every 2 days for gauze dressings and replace it at least every 7 days for transparent dressings (INS, 2011; O’Grady et al, 2011). The use of a transparent occlusive dressing can facilitate regular monitoring by visually inspecting the vascular access device (Lavery & Ingram, 2006). If the client has local tenderness or signs of possible CRBSI, an opaque dressing should be removed and the site inspected visually (O’Grady et al, 2011). Use of gauze is preferable if the client is diaphoretic, if the site is oozing or bleeding, or if it becomes damp (INS, 2011; O’Grady et al, 2011).

• Document insertion date, site, type of VAD, number of punctures performed, other occurrences, and measures/arrangements taken.

• Always decontaminate the device before infusing medication or manipulating IV equipment (Scales, 2008).

 Verify the sequence of drugs to be administrated. Vesicants should always be administered first in a sequence of drugs (Dougherty, 2008).

• Monitor permeability and flow rate at regular intervals.

• Monitor catheter-skin junction and surrounding tissues at regular intervals, observing possible appearance of burning, pain, erythema, altered local temperature, infiltration, extravasation, edema, secretion, tenderness, or induration. Remove promptly. The infusion should be discontinued at the first sign of infiltration or extravasation, the administration set disconnected, and all fluid aspirated from the catheter with a small syringe (INS, 2011).

 Replace device according to institution protocol. EB: Note: There are variations regarding catheter permanence time in the literature. Recommended catheter permanence time varies from 72 (Scales, 2008) to 96 hours or less if there are any clinical signs (Ingram & Lavery, 2007). EBN: In a systematic review including five trials (3408 participants) on the replacement of peripheral venous catheters, authors did not identify evidence of the benefit of the replacement of catheters between 72 and 96 hours; thus, it is recommended that catheters be replaced only when presenting clinical signs (Webster et al, 2010).

 Flush vascular access according to organizational policies and procedures, and as recommended by the manufacturer. Vascular access devices should be flushed after each infusion to clear the infused medication from the catheter lumen, preventing contact between incompatible medications (INS, 2011). Sodium chloride 0.9% or heparinized sodium chloride have been applied in peripheral IV cannulae, although there are controversies regarding the best choice (Tripathi, Kaushik, & Singh, 2008).

• Remove catheter on suspected contamination, if the client develops signs of phlebitis, infection, or a malfunctioning catheter, or when no longer required. Vascular access devices should be removed on unresolved complication, therapy discontinuation, or if deemed unnecessary (INS, 2011). Replace any SPVC inserted under emergency conditions within 24 hours (Couzigou et al, 2005).

• Clients need to be encouraged to report any discomfort such as pain, burning, swelling, or bleeding (Joanna Briggs Institute, 2008).

Pediatric:

Geriatric:

Home Care:

• Maintain arterial blood gases within safe parameters

• Remain free of dyspnea or restlessness

• Effectively maintain airway

• Effectively mobilize secretions

 Explain the intubation and mechanical ventilation process to the client and family as appropriate, and during intubation administer sedation for client comfort according to the physician’s orders. EBN: Explanation of the procedure decreases anxiety and reinforces information; premedication allows for a more controlled intubation with decreased incidence of insertion problems (Burns, 2011).

• Secure the endotracheal tube in place using either tape or a commercially available device, auscultate bilateral breath sounds, use a CO₂ detector, and obtain a chest radiograph to confirm endotracheal tube placement. EBN: Secure taping is needed to prevent inadvertent extubation. Nursing studies have shown conflicting results regarding the preferable way to secure the endotracheal tube (Goodrich, 2011a). EB: Auscultation alone is an unreliable method for checking endotracheal tube placement. A CO₂ detector can be used to confirm tube placement in the trachea (Goodrich, 2011b); however, correct position of the endotracheal tube in the trachea (3 to 5 cm above the carina) must be confirmed by chest radiograph (Goodrich, 2011b). Calorimetric CO₂ detectors have also been used successfully to detect inadvertent airway intubation during gastric tube placement (Goodrich, 2011b).

• Ensure that ventilator settings are appropriate to meet the client’s minute ventilation requirements (Grossbach, Stanberg, & Chlan, 2011). Ventilator settings should be adjusted to prevent hyperventilation or hypoventilation. A variety of new modes of ventilation are currently available that are responsive to client effort (pressure support). Few data are available to support the best use of these ventilator modes or their effect on client outcome (Burns, 2008, 2011; Grossbach, Stanberg, & Chlan, 2011).

 Suction as needed and hyperoxygenate according to unit policy. Refer to the care plan Ineffective Airway Clearance for further information on suctioning.

• Check that monitor alarms are set appropriately at the start of each shift. This action helps ensure client safety (Burns, 2011).

• Respond to ventilator alarms promptly. If unable to immediately locate the source/cause of an alarm, use a manual self-inflating resuscitation bag to ventilate the client while waiting for assistance. Common causes of a high-pressure alarm include secretions, condensation in the tubing, biting of the endotracheal tube, decreased compliance of the lungs, and compression of the tubing. Common causes of a low-pressure alarm are ventilator disconnection, leaks in the circuit, and changing compliance. Using a manual self-inflating resuscitation bag with supplemental oxygen, the nurse can provide immediate ventilation and oxygenation as needed (Burns, 2011, Goodrich, 2011a; Grossbach, Stanberg, & Chlan, 2011).

• Prevent unplanned extubation by maintaining stability of endotracheal tube with careful taping or use of a device for stabilization of the tube, also use of restraints if needed with physician’s order. EB: Prevent unplanned extubation with use of weaning protocol (Jarachovic et al, 2011).

• Drain collected fluid from condensation out of ventilator tubing as needed. This action reduces the risk of infection by decreasing inhalation of contaminated water droplets (Burns, 2011).

• Note ventilator settings of flow of inspired oxygen, peak inspiratory pressure, tidal volume, and alarm activation at intervals and when removing the client from the ventilator for any reason (Burns, 2011; Grossbach, Stanberg, & Chlan, 2011). Checking the settings ensures that safety measures are taken and that the client is not left on 100% oxygen after suctioning (Burns, 2011).

 Administer analgesics and sedatives as needed to facilitate client comfort and rest. Pain and sedation scales provide a consistent way of monitoring sedation levels and ensuring that therapeutic outcomes are being met (Girard et al, 2008; Grap, 2009). Clients receiving mechanical ventilation require sedation to help attenuate the anxiety, pain, and agitation associated with this intervention (Grap, 2009). The overall goal of sedation in critical care settings is to provide physiological stability, ventilator synchrony, and comfort for clients (Grap, 2009).

 Initiate a “sedation vacation” daily, with lightening of analgesics and sedatives until the client becomes awake. During this time carefully monitor the client to protect from inadvertent self-extubation, pain and anxiety, and periods of desaturation from asynchrony of breathing with the ventilator. EB: Sedation vacations have been associated with decreased length of intubation, and decreased incidence of ventilator-associated pneumonia (Institute for Health Care Improvement, 2012). CEB: A randomized controlled trial found that use of a sedation vacation resulted in decreased days of intubation (Kress, 2000).

• Utilize tools such as the Riker Sedation-Agitation Scale, the Motor Activity Assessment Scale, the Ramsey Scale, or the Richmond Agitation-Sedation Scale because they can be useful in monitoring levels of sedation (Grap, 2009). EB: Each of these instruments has established reliability and validity and can be used to monitor the effect of sedative therapy (Girard et al, 2008; Grap, 2009). However, recent research suggests that the use of sedation and pain scales may not decrease duration of mechanical ventilation (Williams et al, 2008). Actigraphy measurements correlate well with clients’ observed activity and with subjective scores on agitation and sedation scales, and may be important for use in recognizing excessive agitation (Grap, 2009).

• Alternatives to medications for decreasing anxiety should be attempted, such as music therapy with selections of the client’s choice played on headphones at intervals. EBN: Music therapy has been reported to decrease anxiety and reduce heart and respiratory rate in critically ill and intubated clients (Hunter et al, 2010; Tracy & Chlan, 2011).

• Analyze and respond to arterial blood gas results, end-tidal CO₂ levels, and pulse oximetry values. Ventilatory support must be closely monitored to ensure adequate oxygenation and acid-base balance. EBN: End-tidal CO₂ monitoring is best used as an adjunct to direct client observation and is used to monitor a client’s ventilatory status and pulmonary blood flow (Burns, 2011; Rasera et al, 2011).

• Use an effective means of verbal and nonverbal communication with the client such as an alphabet board, picture board, electronic voice output communication aids, computers, and writing slates. Ask the client for input into his or her care as appropriate. Barriers to communication include endotracheal tubes, sedation, and general weakness associated with a critical illness. Basic technologies should be readily available to the client, including eyeglasses and hearing aids (Grossbach, Stanberg, & Chlan, 2011; Henneman, 2009; Khalaila et al, 2011). Inadequate communication with the client and family may increase the risk for medical errors and adverse events (Kleinpell et al, 2008).

• Move the endotracheal tube from side to side every 24 hours, and tape it or secure it with a commercially available device. Assess and document client’s skin condition, and ensure correct tube placement at lip line (Vollman & Sole, 2011).

• Implement steps to prevent ventilator-associated pneumonia (VAP), including continuous removal of subglottic secretions, elevation of the head of bed to 30 to 45 degrees (Siela, 2010; Vollman & Sole, 2011) unless medically contraindicated, change of the ventilator circuit no more than every 48 hours, and handwashing before and after contact with each client (Lacherade et al, 2010). See details in the sections that follow. The accumulation of contaminated oropharyngeal secretions above the endotracheal tube may contribute to the risk of aspiration.

 Use endotracheal tubes that allow for the continuous aspiration of subglottic secretions (Siela, 2010; Vollman & Sole, 2011). EB: Subglottic secretion drainage during mechanical ventilation results in a significant reduction in VAP, including late-onset VAP (Lacherade et al, 2010; Vollman & Sole, 2011). Use of continuous subglottic suctioning endotracheal tubes for intubation in clients who are predicted to require intubation for more than 48 hours likely results in decreased incidence of VAP and costs of care (Speroni et al, 2011).

• Position the client in a semirecumbent position with the head of the bed at a 30- to 45-degree angle to decrease the aspiration of gastric, oral, and nasal secretions (Grap, 2009; Siela, 2010; Vollman & Sole, 2011). Historically, evidence shows that mechanically ventilated clients have a decreased incidence of VAP if the client is placed in a 30- to 45-degree semirecumbent position as opposed to a supine position.

• Consider use of kinetic therapy, using a kinetic bed that slowly moves the client with 40-degree turns. Rotational therapy may decrease the incidence of pulmonary complications in high-risk clients with increasing ventilator support requirements, at risk for VAP, and clinical indications for acute lung injury or acute respiratory distress syndrome (ARDS) with worsening PaO₂:FIO₂ ratio, presence of fluffy infiltrates via chest radiograph concomitant with pulmonary edema, and refractory hypoxemia (Johnson, 2011).

• Perform handwashing using both soap and water and alcohol-based solution before and after all mechanically ventilated client contact to prevent VAP (Lacherade et al, 2010).

• Provide routine oral care using toothbrushing and oral rinsing with an antimicrobial agent if needed (Siela, 2010; Vollman & Sole, 2011). EB: Chlorhexidine, but not toothbrushing, reduced early ventilator-associated pneumonia in clients without pneumonia at baseline (Munro et al, 2009). Toothbrushing may be an important intervention in the prevention of VAP (Ames, 2011, Halm, & Armola, 2009). Reducing bacterial colonization of oral cavity includes interventions of daily oral assessment, deep suctioning every 4 hours, toothbrushing twice per day with a plaque reducer, oral tissue cleaning with peroxide every 4 hours. Add these to standard VAP prevention measures and VAP rates can be further reduced (Garcia et al, 2009). Oral care with toothpaste was performed on clients in a neuroscience intensive care unit and did not increase intracranial pressure; thus, oral care may be performed safely (Prendergast et al, 2009).

• Maintain proper cuff inflation for both endotracheal tubes and cuffed tracheostomy tubes with minimal leak volume or minimal occlusion volume to decrease risk of aspiration and reduce incidence of ventilator-associated pneumonia (Siela, 2010; Skillings & Curtis, 2011; Sole et al, 2009; Vollman & Sole, 2011).

• Reposition the client as needed. Use rotational bed or kinetic bed therapy in clients for whom side-to-side turning is contraindicated or difficult. EBN: Changing position frequently decreases the incidence of atelectasis, pooling of secretions, and resultant ventilator-associated pneumonia (Burns, 2011; Johnson, 2011). EB & EBN: Continuous, lateral rotational therapy has been shown to improve oxygenation and decrease the incidence of VAP (Burns, 2011; Johnson, 2011).

 If the client is intubated and is stable, consider getting the client up to sit at the edge of the bed, transfer to a chair, or walk as appropriate, if an effective interdisciplinary team is developed to keep the client safe (Gosselink et al, 2008). For every week of bed rest, muscle strength can decrease 20%; early ambulation helped clients develop a positive outlook (Perme & Chandrashekar, 2009).

• Assess bilateral anterior and posterior breath sounds every 2 to 4 hours and PRN; respond to any relevant changes (Burns, 2011).

• Assess responsiveness to ventilator support; monitor for subjective complaints and sensation of dyspnea (Burns, 2011).

 Collaborate with the interdisciplinary team in treating clients with acute respiratory failure (Grap, 2009). Collaborate with the health care team to meet ventilator care needs and avoid complications (Grossbach, Stanberg, & Chlan, 2011). EB: A collaborative approach to caring for mechanically ventilated clients has been demonstrated to reduce length of time on the ventilator and length of stay in the ICU (Grap, 2009).

Geriatric:

Home Care:

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