Which action will the nurse take to minimize the patients risk for injury when applying a dressing to an infusion site?
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Department: upFront: I.V. ROUNDS Arbique, Judy ART (CSMLS), MLT (CSMLS), BHSc; Arbique, Debbie RN, CEN, DABFN, MS-FNPS, BS Judy Arbique is a lab technologist at Capital District Health Authority in Halifax, Nova Scotia, Canada, and a partner in Arbique-Rendell Onsite Training and Consulting of Halifax. Debbie Arbique is a clinical case manager and research nurse/research coordinator at the University
of Texas Southwestern Medical Center, Dallas Campus, and a p.r.n. nurse in the emergency department at St. Paul University Hospital in Dallas. doi: 10.1097/01.NURSE.0000298182.61285.04
Department: upFront: I.V. ROUNDS
Arbique, Judy ART (CSMLS), MLT (CSMLS), BHSc; Arbique, Debbie RN, CEN, DABFN, MS-FNPS, BS
Judy Arbique is a lab technologist at Capital District Health Authority in Halifax, Nova Scotia, Canada, and a partner in Arbique-Rendell Onsite Training and Consulting of Halifax. Debbie Arbique is a clinical case manager and research nurse/research coordinator at the University of Texas Southwestern Medical Center, Dallas Campus, and a p.r.n. nurse in the emergency department at St. Paul University Hospital in Dallas.
Note: This guideline is currently under review.
Definition of terms
Peripheral intravenous catheters (PIVC) are the most commonly used intravenous device in hospitalised patients. They are primarily used for therapeutic purposes such as administration
of medications, fluids and/or blood products as well as blood sampling.
The aim of this guideline is to provide an outline of the ongoing maintenance and management of the PIVC for patients in hospital, outpatient, and home healthcare settings. For information related to insertion of PIVC, please refer to
intravenous access guideline . Nurses who are deemed competent in IV insertion could continue to insert PIVC in consultation with NUM/CSN’s.
Definition of terms
Patient and IV site assessments should be done on a regular basis.
PIVC assessment includes:
Administration of intravenous fluid, drug infusions or blood products
a) Continuous infusion of IV fluids
Infusion Pump Pressure
If pump pressure exceeds the recommended limits, check the patency of the PIVC.
b) Administration of bolus/loading doses:
Drugs administered via PIVC may be
The most appropriate method should be selected depending on volume of diluent required, patient condition, fluid balance and intended rate of delivery.
Drugs administered via:
a completed drug label detailing the drug, dose, diluent, volume of diluent, date, time and signature of the nurse and the staff who double checked.
Access PIVC only after cleaning the access port and scrub the hub.
For intermittent infusions, IV lines which are disconnected are to be discarded between infusions. Ensure the cannula is flushed with normal saline once the giving set is disconnected from the cannula. For Opioid infusion bolus refer to the specific
guidelines: Children’s Pain Management Service (CPMS)(opioid infusion guideline)
Administering blood products:
Flushing of PIVC’s
Change of PIVC dressing and securement of cannula:
Change of Extension sets
IV Fluid Considerations via Peripheral IV line
Which Fluids and how much fluids to use
Fluid bag and infusion changes:
Table 1.Changing IV bags and lines
Removal of PIVCs:
There is no evidence for routine replacement of PIVC unless clinically indicated. PIVC’s should be maintained with regular assessment and documentation of complications.
Management of complications
There are a range of complications that could
occur with the presence of a PIVC in insitu. Some of these complications can be prevented by the correct use of aseptic technique for insertion and maintenance as well as assessing the device as indicated.
The evidence table can be found here.
The development of this nursing guideline was coordinated by Mercy Thomas, Nursing Educator, and approved by the Nursing Clinical Effectiveness Committee. Updated December 2018.
What might the nurse do to minimize the risk of injury in a patient receiving IV therapy?
Regulate the flow rate of the infusion..
Assess the patient frequently for pain at the IV site..
Monitor the IV site frequently for signs of infiltration and phlebitis..
Which action will best minimize the patient's risk for vein injury when removing an IV access device from a patient's arm?
CORRECT. Keeping the hub parallel to the skin minimizes vein trauma during removal of the device.
How will the nurse minimize the risk for infection when changing a patients IV catheter site dressing?
Maintain a clean, dry and intact dressing with Chlorhexidine-impregnated sponge or dressing – Change dressings every seven days and/or when the dressing becomes damp, loosened or soiled – Clean and disinfect the skin and catheter hub at every dressing change.
How can the nurse minimize the risk of dislodging the catheter when removing a dressing quizlet?
Rationale: The old dressing should be removed in the direction of catheter insertion. Positioning the patient with his or her head lower will not reduce the risk of dislodging the catheter during a dressing change.