Vascular Access Device Site Selection and Placement



Vascular Access Device Site Selection and Placement






Vascular Access Device (VAD) Selection


Policy

The appropriate type of VAD (peripheral or central) is selected in collaboration with the nurse, the licensed independent practitioner (LIP), and the patient/caregiver based upon the following factors:



  • Patient’s condition, age, and diagnosis


  • Vein integrity, size, and location


  • Type and duration of prescribed therapy


  • Patient’s infusion history


  • Patient’s preference for location, as appropriate


  • Ability and resources to care for the device

A central vascular access device (CVAD) should be considered for anticipated infusion therapy if the medication or solution has a pH of less than 5 or greater than 9, osmolarity greater than 600mOsm/L, a final dextrose concentration above 10%, or for continuous vesicant therapy.

For patients with chronic kidney disease, consideration is made for preservation of peripheral veins for a potential arteriovenous fistula; the nurse should collaborate with the LIP in developing an appropriate plan for vascular access.

Procedure



  • Follow these guidelines when selecting a short peripheral catheter:



    • Infusion therapy duration is less than 7 days


    • The catheter can be maintained in the patient’s health care setting by health care provider or patient and/or caregiver


    • Use the smallest-size catheter to accommodate the prescribed therapy



      • 14- to 16-gauge catheters are recommended for trauma patients and those who require large volumes of fluid at a rapid rate


      • 18-gauge catheters are recommended for surgical patients and for rapid administration of blood (blood can be administered through smaller-gauge catheters, but the flow will be slower)


      • 20- to 24-gauge catheters are recommended for most medicalsurgical patients


      • 22- to 24-gauge catheters are recommended for older adults


    • Limit use of steel winged devices to single-dose administration


  • Follow these guidelines when selecting a midline catheter:



    • Infusion therapy duration anticipated 1 to 4 weeks


    • Infusion therapies administered include hydration solutions, pain medications, and nonirritating antibiotics



    • Infusâtes with pH less than 5 or greater than 9, or with an osmolarity greater than 600 mOsm/L, or a final dextrose concentration above 10%, should not be administered through a midline catheter


    • The catheter can be maintained in the patient’s health care setting by health care provider or patient and/or caregiver


    • Use the smallest-size catheter to accommodate the prescribed therapy.


  • Follow these guidelines when selecting a CVAD:



    • Infusion therapy duration anticipated to be greater than 4 weeks


    • Infusion therapies administered include short- or long-term continuous or intermittent solutions such as antineoplastic medications, vesicants or known irritants, parenteral nutrition, a variety of antibiotics, and infusâtes with a pH less than 5 or greater than 9 and osmolarity greater than 600 mOsm/L


    • The catheter can be maintained in the patient’s health care setting by health care provider or patient and/or caregiver


    • Use the smallest-size catheter to accommodate the prescribed therapy


    • Anti-infective CVADs are considered for nontunneled CVADs in patients at high risk for catheter-associated bloodstream infection and/or in organizations that have a high rate of catheter-associated bloodstream infections despite other infection prevention strategies


    • CVADs that can withstand high-pressure injections (eg, powerinjectable infusion devices) are considered for patients who require ongoing imaging testing



Bibliography

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 September 1, 2010.

Bullock-Corkhill M. Central vascular access devices: access and insertion. 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.

Cook, Lynda. Choosing the right intravenous catheter. Home Healthcare Nurse. 2007; 25(8):523-531.

Joanna Briggs Institute. Management of peripheral intravascular devices: best practice information sheet. Aust Nurs J. 2008;16(3):25-28.

Perucca, R. Peripheral vascular 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.

Phillips LD. Manual of I.V. Therapeutics: Evidence-Based Practice for Infusion Therapy. 5th ed. Philadelphia, PA: FA Davis; 2010:303-345;458-475.



Site Assessment and Selection


Policy

The vein selected for cannulation shall accommodate the size and length of the catheter.

Site selection is based upon the following factors:



  • Patient’s condition, age, and diagnosis


  • Vein integrity, size, and location


  • Type and duration of prescribed therapy


  • Patient’s infusion history


  • Patient’s preference for location, as appropriate

Procedure


Patient Education and Assessment



  • Obtain and review licensed independent practitioner’s (LIP’s) order.


  • Verify patient’s identity using 2 independent identifiers, not including patient’s room number or bed number.


  • Provide patient with information on site assessment and selection, including vascular access device (VAD) benefits, management, and potential complications.


  • Obtain patient consent.


  • Place patient in recumbent position, as tolerated.


  • Assess patient.


Site Selection for Short Peripheral Catheter



  • Perform hand hygiene.


  • Explain procedure to patient.


  • Assess patient’s upper extremities.



    • Avoid using lower-extremity veins in adults


    • Initiate the site selection process in nondominant arm


    • Use vein visualization technologies as appropriate


  • Use the following principles to guide vein selection:



    • Assess appropriate veins on both dorsal and ventral surfaces including the metacarpal, cephalic, and basilic veins of the hand and forearm


    • Avoid the following:



      • Areas of flexion


      • Areas of pain upon palpation



      • Compromised veins (eg, bruised, phlebitic, infiltrated, sclerosed, corded)


      • Areas near valves


      • Areas where there are planned procedures


      • Extremity on the side of breast surgery with axillary node dissection, after radiation therapy to that side, presence of lymphedema; affected side after a stroke


    • For patients with chronic kidney disease, avoid forearm and upper arm veins


  • Assess veins by applying tourniquet (see Tourniquets).



    • Palpate extremity distal to tourniquet to assess vein condition and visually inspect skin integrity


    • Palpate intended venipuncture site to differentiate arteries from veins


    • If unable to palpate vein:



      • Instruct patient to open and close fist several times


      • Position extremity lower than the heart for several minutes


      • Lightly stroke vein downward


      • Apply heat to extremity for approximately 10-15 minutes to promote vein relaxation and dilation. Do not leave patient unattended during heat applications


  • Select the most distal site for short peripheral catheter placement.



    • Select sites that are proximal to any previous cannulation sites


  • Remove tourniquet.


  • Perform hand hygiene.


Site Selection for Midline Catheter and Peripherally Inserted Central Catheter (PICC)



  • Perform hand hygiene.


  • Explain procedure to patient.


  • Assess patient’s upper extremities.



    • Initiate the site selection process in nondominant arm


    • Use vein visualization technologies as appropriate


  • Use the following principles to guide vein selection:



    • Assess veins of upper extremity appropriate for midline catheter and PICC placement including the cephalic, basilic, median cubital, and brachial


    • Avoid the following:



      • Areas of pain upon palpation


      • Compromised veins (eg, bruised, phlebitic, infiltrated, sclerosed, corded)



      • Areas where there are planned procedures


      • Extremity on the side of breast surgery with axillary node dissection, after radiation therapy to that side, presence of lymphedema; affected side after a stroke


    • Do not place a midline catheter or PICC in a patient with chronic kidney disease


  • Assess veins by applying tourniquet proximal to intended insertion site and use vein visualization technology as available.



    • Palpate extremity distal to tourniquet to assess vein condition and visually inspect skin integrity


    • Palpate the intended venipuncture site to differentiate arteries from veins


    • If unable to palpate vein:



      • instruct patient to open and close fist several times


      • position extremity lower than the heart for several minutes


      • lightly stroke vein downward


      • apply heat to extremity for approximately 10-15 minutes to promote vein relaxation and dilation. Do not leave patient unattended during heat applications


  • Select catheter insertion site.


  • Remove tourniquet.


  • Perform hand hygiene.


Site Selection for Arterial Catheter Placement



  • Perform hand hygiene.


  • Explain procedure to patient.


  • Use the following principles to guide vein selection:



    • The radial artery is the most appropriate choice for cannulation


    • Alternative arteries include the ulnar, brachial, and dorsalis pedis


  • Assess circulation.



    • Perform Allen test



      • Occlude the radial artery and compare the hand color to the other hand. Adequacy of collateral circulation through the ulnar artery is present if there is no change in color


      • Occlude the ulnar artery and compare the hand color to the other hand. Adequacy of collateral circulation through the radial artery is present if there is no change in color. If there is a change in hand color, this is considered a negative Allen test. Radial artery access is contraindicated


    • Consult with LIP for a negative Allen test



  • Select catheter insertion site.


  • Perform hand hygiene.



Bibliography

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 September 1, 2010.

Bullock-Corkhill M. Central vascular access devices: access and insertion. 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.

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. St Louis, MO: Saunders/Elsevier; 2010:139-177.

Perucca, R. Peripheral vascular 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.

Phillips LD. Manual of I.V. Therapeutics: Evidence-Based Practice for Infusion Therapy. 5th ed. Philadelphia, PA: FA Davis; 2010:303-345;458-475.

Weinstein S. Plumer’s Principles & Practice of Intravenous Therapy. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:242-259.



Local Anesthesia


Policy

Consider the use of local anesthesia based upon nursing assessment of patient condition, needs, risks, and benefits to minimize the pain associated with vascular access cannulation or implanted port access.

The local anesthetic agent and method that is least invasive and carries the least risk for allergic reaction or infection will be selected.

Types of local anesthesia administered may include:



  • Transdermal analgesic cream or patch


  • Intradermal injection of lidocaine hydrochloride 1% solution


  • Iontophoresis technology

Supplies



  • Transdermal (topical) analgesic cream with following supplies:



    • Transparent semipermeable membrane (TSM) dressing


    • Gauze pads


    • Gloves, nonsterile


  • Anesthetic dermal patch


  • Lidocaine hydrochloride 1% solution with following supplies:



    • Antiseptic solution


    • Gauze pads


    • Gloves, nonsterile


    • 1-mL (tuberculin) syringe


  • Iontophoresis equipment

Procedure


Note: Numbers 1-6 apply to all following phlebotomy procedures.

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Aug 18, 2016 | Posted by in NURSING | Comments Off on Vascular Access Device Site Selection and Placement

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