- Considers the type of therapy, which may include infusions (e.g., nutrition solutions, vesicants, irritants) and frequency of blood sampling.
- Once the type of fluid is identified, the osmolality and pH of the solution needs to be determined. The incidence of phlebitis increases as pH and osmolarity of the intravenous solution differs from that of the blood.
- Fluids with higher osmolality and solutions of acidic or alkaline pH cause endothelial damage and subsequent phlebitis and thrombus formation
- The rate of blood flow at the superior vena cava is greater than a peripheral vein – the larger the vessel, the greater the dilution and less irritation to the vein.
- Parenteral nutrition, hyperosmolar solutions, chemotherapy, and vesicants should not be infused through peripheral catheters with tips positioned in the upper arms, subclavian vein or innominate vein.
- Intermediate or long-term infusion of these solutions should be delivered through catheters terminating in the distal superior vena cava
- Catheter tips that are malpositioned into the veins of the arms or small veins of the neck or chest usually result in thrombosis.
- pH outside the range of 5 – 9 and/or osmolarity greater than 500 mOsm/L should be administered through a vascular access device that delivers the infusate into a blood vessel with a high rate of blood flow.
- Use only the number of lumens clinically indicated to deliver the prescribed therapy – additional lumens may impact on care, maintenance and infection rates.
- Chemical structure of the infusate impacts on client outcomes
Duration of therapy
- All clients requiring infusion therapy greater than six days in duration should be assessed for the selection of an intermediate or long-term device.
- A physical assessment should include consideration of the acuity level of the client’s medical condition.
- The existence of a chronic disease state may impact directly on device selection, as the preservation of veins is a critical goal for clients with chronic disease who require long-term vascular access
- Through the physical examination, the nurse should assess the following:
- Circulatory status – impaired circulation, lymphedema, post-operative swelling;
- Vascular status;
- Mobility – use of crutches, walkers or transfer aids;
- Mentation – level of cooperation, mental status;
- Integrity of skin – loss of connective tissue, trauma, open wounds, surgical or radiation damage;
- Activity level – lifestyle factors that may impact on device selection and maintenance;
- Obesity – veins difficult to palpate; and
- Hydration status – dehydration resulting in poor venous filling.
Client Health History
- A comprehensive client history related to vascular access may include:
- Age – older clients may experience diminished renal function and cardiovascular changes;
- Medical diagnosis;
- Current medical condition;
- Medication profile, including over the counter drugs and use of herbal supplements;
- Current coagulation status;
- Past medical history, including complications of diabetes, if applicable;
- Previous history of infusion therapy (peripheral or central) – devices, therapies, outcomes;
- Lifestyle – leisure/recreational activities and occupation;
- Language/cultural barriers;
- History of intravenous drug use;
- Medical and surgical history (e.g., diabetes, mastectomy, renal dialysis, immunocompromised, MRSA positive);
- Allergies (particularly latex); and
- The plan of care for the individual receiving infusion therapy may include collaboration with the client and the client’s family and/or significant others.
- Consideration in the device selection process should be given to the individual’s support system and resources including:
- Home support/resources (caregiver availability);
- Aspects of the home environment;
- Availability of a sanitary water supply;
- Electricity and refrigeration;
- Adequate storage space for supplies; and
- Access to a telephone.
- Ability of the client and family to care for the device and administer the infusion therapy, if needed at discharge from hospital;
- Psychosocial aspects of care;
- Community resources; and
- Financial resources.
- Not all devices are available in all practice settings.
- In some communities, certain devices may not be available as an option for insertion due to supply contracts, lack of resources for insertion, or decreased availability for follow-up care and management in the home
- The involvement of clients and their family caregivers in decisions related to device selection support self-care and self-efficacy
- Individuals need an opportunity to consider their options and reflect on what they can deal with in relation to self-care, particularly in a situation where long-term devices are necessary.
- Self-care can be enhanced through a collaborative approach to device selection, therefore, the client and family caregivers need to be included in the decision-making process
Assessment and Device Selection for Vascular Access
Point of Care Resources