Intravenous Tubing and Dressing Change

Definition

Intravenous (IV) infusion is the process whereby fluids, medications, blood products, and nutritional substances are administered into a vein by means of an intravascular device. The most commonly used device is the short peripheral venous catheter, which is usually inserted into the veins of the forearm or hand. IV fluids are supplied in plastic bags and delivered via an administration set, i.e., tubing. The fluid to be infused and the flow rate are prescribed by a physician or nurse practitioner.

Purpose

IV infusion is a method of fluid replacement used most often to maintain fluid and electrolyte balance, or to correct fluid volume deficits after excessive loss of body fluids, or in patients unable to take sufficient volumes by mouth. Many medications are also given by IV infusion and it is used for prolonged nutritional support of patients with gastrointestinal dysfunction.

Precautions

The insertion of an IV access device creates an open wound and the continued presence of the catheter within the wound keeps it "open," which provides easy access for opportunistic bacteria. These bacteria may be present on a patient's skin or may come from touch contamination by a practitioner. Technically, the administration of IV solutions takes place within a "closed-system," but the delivery system usually has a number of connections, which may allow entry of bacteria. Strict adherence to handwashing and aseptic technique must always be followed while obtaining venous access and the equipment must be handled carefully to prevent contamination. Before using any materials, the practitioner must ensure that all packaging is intact prior to opening, that expiration dates have not passed, and that there are no visible signs of contamination. The site at which a catheter is placed has been shown to influence the subsequent risk of catheter-related infections; and in adults, hand vein insertions have a lower risk of problems than do upper arm or wrist vein insertions. Similarly, there is a greater risk with insertions in the legs than the arms, but the choice of a site may be limited by patient factors, e.g., preexisting catheters, anatomic deformity, present illness, or trauma. The practitioner must also be aware of any patient allergies to latex, iodine, or other substances. For selection of catheters, the Centers for Disease Control and Prevention (CDC) recommend the use of a Teflon catheter, a polyurethane catheter, or a steel needle. The choice depends on the intended purpose, duration of use, and known complications. Transparent, semipermeable, polyurethane dressings reliably secure the site, permit continuous visual inspection of it, allow patients to bathe or shower without saturating the dressing, and require less frequent changes than standard gauze and tape dressings. Research has shown no clinically important differences between the two with regard to rate of infection or occurrence of inflammation.

Description

The initial insertion of a catheter with transparent dressing or sterile gauze should be labeled as to the time and date of insertion in an obvious location near the site (e.g. on dressing or on the bed) and the IV administration set should likewise be labeled as to time and date of hanging. CDC recommendations for care and management of peripheral venous catheter sites, IV administration sets, and dressing changes include the following:

• Hands must be washed before and after palpating, inserting, replacing, or changing dressing.
• The catheter site must be visually inspected and palpated for redness, tenderness, or warmth (phlebitis) daily.
• Sites must be replaced and rotated every 48-72 hours to minimize risk of phlebitis. Catheters inserted under emergency conditions must be replaced with new catheters within 24 hours due to possible break-in aseptic technique. Heparin locks must be replaced within 96 hours. Catheters with signs of phlebitis should be removed immediately or as soon as its use is no longer clinically indicated. Do not routinely apply topical antimicrobial ointment to site.
• When the catheter is removed or replaced, the site dressing should be replaced. The dressing should also be replaced when it becomes damp, loosened, or soiled. Dressings are changed more frequently for patients that sweat. Avoid touching the site when dressing is replaced.

• The IV tubing, including piggyback tubing and stopcocks, is replaced no more frequently than at 72-hour intervals, unless clinically indicated. Tubing used to infuse blood, blood products, or lipid emulsions is replaced within 24 hours of initiation.
• Injection ports are cleaned with 70% alcohol or povidone-iodine before accessing the system. Heparin locks require a routine flush with normal saline solution, unless they are used to obtain blood specimens, in which case a dilute heparin (10 units/ml) flush solution should be used.

Preparation

• All needed materials must be assembled prior to approaching the patient for catheter insertion or IV tubing and dressing change.
• Hands must be washed before and after the procedure.
• The procedure is explained to the patient and he/she is encouraged to ask questions.
• If the patient's veins are difficult to access, warm soaks can be applied to the area prior to attempted insertion to increase blood flow to that area and facilitate the process.
• Nonlatex or latex gloves are worn for insertion of the catheter and for changing the dressing.
• The site or dressing should be marked with labels carrying the date, time, and initials of the individual performing the procedure.

Aftercare

Follow-up care includes:

• The site is inspected and palpated daily.
• IV fluids and additives are monitored to ensure that they are those ordered by the physician or nurse practitioner.
• The infusion rate is checked to make sure that it is correct as ordered.

Complications

The use of IV devices is frequently complicated by a variety of local or systemic infectious complications to include:

• bloodstream infection
• inflammation and/or infection of the lining of the cavities of the heart
• inflammation of the vein sometimes associated with a clot
• infections in other areas of the body

The risk of complications in IV therapy is actually higher on the second day of therapy and was believed to increase with time, which made routine restarts after three days a common practice. Recent research has shown, however, that a restarted catheter has a significantly higher risk of complication in its first 24 hours than does an initial catheter. Thus, restarting catheters routinely at 72 hours does not reduce the risk of complication in the next 24 hours when compared to simply continuing therapy with the original catheter, provided the site or the original has no signs of inflammation. Once additional studies confirm these data, the recommendations may change.

Results

The results obtained from IV therapy should primarily serve to improve the condition of the patient. A dehydrated patient's fluid volume and electrolyte balance should improve. Any patient ill from an infection should feel improved with IV antibiotic therapy. The purpose of an IV is to alleviate symptoms and assist with enhancing well-being.

KEY TERMS

Catheter— A hollow tube that is flexible and used for withdraw or introduce fluids into the body.

Dehydration— A condition that results from a loss of water in the body.

Intravascular— Within a vessel, as a blood vessel.

Peripheral— That portion of the body that is outside the main region, as arms or legs.

Povidone— A synthetic polymer used as a dispersing and suspending agent as in povidone-iodine, a topical anti-infective agent.

Semipermeable— Permitting passage of only certain molecules.

Health care team roles

The registered nurse is the primary provider of IV catheter insertion, IV fluids, tubing, and dressings. It is the role of this nurse to ensure that the recommended procedures, protocols, and written orders for IV therapy are followed. It is also the duty of the nurse to maintain her skills for IV therapy and keep updated on any changes in recommendations in providing care. Available data suggest that personnel specially trained or designated with the responsibility for insertion and maintenance of IV devices provide a service that reduces the rate of infections and overall costs.

Resources

BOOKS

Hankins, J., et al., eds. Infusion Therapy in Clinical Practice. Fort Worth, TX: Harcourt Health Sciences Publishers, 2001.

PERIODICALS

Holmes, K. R., and L. D. Homer, "Risks Associated with 72-96-hour Peripheral Intravenous Catheter Dwell Times." Nursing 21 (September/October 1998).

ORGANIZATIONS

Infusion Nurses Society, 220 Norwood Park Rd., Norwood, MA 02062. (781) 440-9408. 〈http://www.ins1.org〉.

League of Intravenous Therapy Education, Empire Building, Suite 3, 3001 Jacks Run Road, White Oak, PA 15131. (412) 678-5025. 〈http://www.lite.org〉.

OTHER

Pearson, Michele L., and the Hospital Infection Control Practices Advisory Committee. "Guidelines for Prevention of Intravascular Device-related Infections." Centers for Disease Control, April 1995. 〈http://www.cdc.gov/ncidod/hip/iv/iv.htm〉.