Registered Nurses' Association of Ontario

Documentation

  • The documentation should include recording in the client’s health record all information reflective of the equipment and supplies being used.
  • Initial VAD insertion documentation should include, but not be limited to, the following:
    • Insertion
    • Site assessment
    • Functionality
  • Insertion documentation includes:
    • The insertion date and time
    • The name of the anatomic location (peripheral or central) to describe the insertion site. Do not identify a device by vein used (e.g., subclavian line).
    • The type of VAD, catheter gauge and length. Use trade names (e.g., Hickman, Angiocath, Insyte) as appropriate to identify the actual catheter in situ. Do not interchange trade names to describe devices. If the trade name is not known, use the generic terms such as peripheral vascular access device (PVAD); implanted vascular access device (IVAD) or implanted port.
    • The number of attempts required to insert VAD and type(s) of VADs used in each attempt.
    • The client’s response using his/her own words. Do not use descriptive statements (e.g. patient tolerated procedure well).
  • Site assessment documentation includes:
    • The assessment of the VAD site. Avoid using the statement “dry and intact” as this is unacceptable and lacks sufficient meaning.
    • Any complication observed. In the event of no complications document “no complications noted”
  • Functionality documentation includes:
    • The function of the VAD including presence of blood return, amount of blood draw and infusion solution.
    • The IV solution and/or medications or flushing solution used.
  • To view a data collection tool for central venous access devices click here.
Clinical Management
Care and Maintenance to Reduce Vascular Access Complications
Sample Tools