Nurses Understanding of the Care and Management of Short Peripheral Intravenous Catheters - Essay Example

Nurses' Understanding of the Care and Management of Short Peripheral Intravenous Catheters (Adult Patients) Introduction: More than 80% of hospitalized patients receive some form of intravenous therapy. Many nurses are called on for insertion of intravenous lines, which are accomplished though intravenous catheter of shorter length that are inserted into the peripheral veins. By shorter length, it is meant that that are longer intravenous or intravascular catheters that are inserted through peripheral vessels deep into the circulatory system. In adult patients where the veins are developed enough to offer a reasonable lumen, this process is technically easier, and many nurses perform these in their day to day clinical practice. The nurse is responsible for maintaining the lines and preventing complications throughout therapy. Therefore, practically, the nurses need to know the administration methods and primary uses of intravenous therapy. As far as the peripherally inserted short intravenous catheters are concerned, the nurses need to know how to maintain, manage, and offer care to these lines and devices, since a default in such knowledge may lead to several aberrations culminating into complications that may increase the sufferings of the patients (Dougherty, 2002, 45-52). Therefore, to ensure quality and standards of care, it would be worthwhile to examine the knowledge of the nurses and their understanding about the care and management short peripheral catheters in actual practice. The intent of this study from the literature can help this researcher identifying gaps, if there be any, in the understanding of this process, and then steps to address these deviations in care can be employed to improve case based on evidence. Background: The factors that are involved in choosing an intravenous delivery method would be dictated by the therapy's purpose and duration; the patient's diagnosis, age, and health history; and the condition of his veins. In peripheral intravenous therapy, the nurse is required to administer intravenous solutions through a vein in the arm, hand, leg, or foot for short-term or intermittent therapy. The nurse in this regard is required to know how to prepare the intravenous catheter insertion site, how to insert, maintain, and remove specific intravenous lines and devices; how to control infection and maintain flow rates; and how to monitor the patient's response to therapy. The nurse has also patient-teaching responsibilities in relation to the intravenous therapy issues (HICPAC, 2002). Although applicable to surgical intensive care practice nursing, the statement made by Chesnutt and Everhart holds good for management and care of short intravenous catheters for intravenous therapy. It has been observed that graduate nurses function as advanced beginners. These nurses mainly rely on rules and at the same time lack the clinical ability to adapt to rapidly changing situations. However, they are task oriented. In addition, a focus on completing tasks rather than using advanced planning and prevention strategies may hinder the nurses from preventing urgent situations among patients. Thus, there is a need for nurses to have the skills to anticipate and prevent complications. It is to be noted that this holds good for all clinical techniques and skills, not just intravenous catheter related complications. However, this article also does not mention about the clinical guidelines and competency requirement of registered nurses that they require to be both accountable and responsible in terms of introducing a peripheral venous catheter and prevention of complications associated with it (Chesnutt and Everhart, 2007, 36-51). Karadeniz and coworkers in their article, "Nurses' knowledge regarding patients with intravenous catheters and phlebitis interventions" explore these responsibilities in terms of prevention of complications associated with catheter during intravenous therapy. In the first stage of this study, the authors examined the views of knowledge of the nurses on intravenous catheter application, intravenous fluid treatment, and phlebitis diagnosis, and procedures to be performed when phlebitis develops (Karadeniz et al., 2003, 44-47). The study group comprised nurses in the hospital across all the departments where intravenous fluid therapy could be required for the inpatients. In the second phase of this study, an observer observed the patients for a 5-day period of intravenous therapy for selection of veins, diagnoses of phlebitis, and the procedures performed by nurses on patients who had developed phlebitis. This indicates that this study not only evaluated knowledge and perception of the nurses, but also studied the outcomes on the patients whom they inserted and maintained the catheter. This study group comprised of a mix of nurses of different age groups and different experience durations across all possible departments. Intentionally, the sample was restricted to comparatively less experienced nurses. The focus area of the study was correlation between the nurses' knowledge on prevention of phlebitis. Category wise, 90% of the nurses knew that hand washing was the simplest and the most important measure to prevent hospital infections. About 75% of the nurses selected the appropriate vein for insertion of the catheter, some were partially correct. However, despite this knowledge, the nurses were observed to wash their hands before applying intravenous catheters to each patient only 53.3% of the time, indicating a gap between the theory and practice. As per the nurses statements, most never touched the aseptically cleaned area, many touched the area accidentally, and 7% touched the area to find the vein. However, a nominal proportion of the nurses has no understanding about the aseptic procedures apparent from their statement that touching the clean area was not harmful because of the usage of antiseptic solution. It is important to note that regarding catheter size determination, most of the participating nurses knew the proper catheter number to be used for an adult patient, and they also know the maximum permissible duration of the catheter within the vein. Regarding checking the expiry date of the catheter mention on the packet, the knowledge was poor, since this study revealed that only 35% of them checked the date before catheter use; many have tendency to forget this important step, but they could check if they had remembered to check, and 16% of the sample never bothered to check the date. Only 55% of the nurses could answer the questions correctly about phlebitis diagnosis. The knowledge was partial in a sizable proportion of the nurses, and similar results were evident regarding their knowledge about management of phlebitis in case it occurs. In phase 2 of this study, the patient population was likewise a mix of different clinical diagnoses from different age groups and sexes, where different venous access sites were selected for introduction of the catheter. The symptomatic criteria for diagnosis of phlebitis were decided to be pain, red spots, sensitivity near the catheter area, hardness along the vein, and swelling, and all the patients exhibiting one or more of these symptoms and signs were considered to have developed phlebitis (Erdem et al., 1998, 31-34). A 67.24% of the patients developed phlebitis in this study, but once it developed, the nurses' knowledge about the care was demonstrated to be limited. Only 28.20% of the nurses removed the catheter, similar number of nurses removed the catheter and applied alcohol, 25.64% of the nurses removed the catheter and elevated the arm, and 15.40% of the nurses removed the catheter and applied nitrofurazone. It is to be noted that there are some natural predispositions associated with development of phlebitis that are not related to the nurses; knowledge about short peripheral catheters in the vein, although knowledge about the natural predisposition could help prevention of the complications in these patients (Gallagher, 1995, 62-65). There is evidence that age of the patient has a statistically significant relationship with development of phlebitis. Moreover, the area of the vein selected has some contribution, indicating if the nurse would have understood these differences; the episodes phlebitis in those cases could be prevented. There is indeed a higher percentage of phlebitis development on the back of the hand and the forearm (Julia, 1993, 31-34). The authors have presented concise literature evidence in support of these findings. The main reason for catheter infections has been recognised to be gaps in the hand washing practices of the care personnel, and it has been observed and proved that hands are contaminated (Tagalakis et al, 2002, 131-151),. Moreover, studies show that hand washing is most forgotten step when it is most needed. In preventing phlebitis specifically, 53% of the nurses used hand washing, and this percentage is inadequate and reflects lack of knowledge about this important step, and 67.24% of phlebitis develops due to a failure to wash hands while handling the procedure. This study also revealed that selection of vein in correlation with the type of fluid and treatment requirement should guide this, but the other parameters should be patient choice and allowance for his mobility (Maki and Mermel, 1998, 689-724). The nurses should have knowledge as to what areas give rise to more phlebitis and which areas are comparatively safe. Thus study aptly discloses the fact that despite having satisfactory knowledge, nurses do not apply it to their practice satisfactorily. Although studies have revealed other factors that needed to be incorporated in the management and care of such catheters, such as, removal of the catheter, elevating the arm, avoiding the use of the same vein, hot-cold application, or pomade treatment, this study fails to elucidate the reasons for this gap between knowledge and application of knowledge in practice (Maki, Kluger, Crnich, 2006, 159-171). To understand these factors, the seminal study, "Factors influencing nurses' handling and control of peripheral intravenous lines-an interview study" by Lundgren and Ek, could be cited. In this study, thrombophlebitis associated with peripheral intravenous catheter has been studied. The authors have presented their findings from literature about the pain, distress, and suffering of the patients in relation to thrombophlebitis, and its direct correlation with the duration of the intravenous catheters. Insertion, maintenance, and removal of peripheral intravenous catheters remains the responsibility of the nurses across the world, and the care should be guided by knowledge about how to plan, insert, care and handle the peripheral intravenous infusions. The patients who have the catheter in situ for less than 24 hours have a considerable drop in the incidence of thrombophlebitis. Previous studies indicate that the care was unsatisfactory in about 52% of cases with worsening of the symptoms after a period over 24 hours or more. Although the type of fluid used in intravenous therapy has an aetiological role to play, it must be acknowledged that in many cases, the care was suboptimal due to nurses' failure to check, remove, or change the catheter when necessary (Lundgren and Ek, 1996, 131-142).. This was an interview study with structured questions where the nurses could add comments to elaborate the point if they wished to. The areas of the study included questions about how the nurses plan a catheter insertion in terms of insertion area, cannula size, method of fixation, and cannula time in situ; how they care the catheter and catheter site through care and handling information and the use of peripheral catheters; how they document indicated by insertion, removal, drugs and solutions; how they act depending on education in the area, laws, experience and knowledge; and most importantly what are the governing factors in their care principles and policies. This study provides an appropriate framework for the analysis of the lapse on the part of the nurses in the sense that the authors classified the lapses in terms of bad routines and lack of responsibility (Keenlyside, 1992, 226-232). The first category included "no check, no control, no documentation, changing the peripheral cannula too seldom, left in place as long as the cannula works, the cannula should have been changed but the staff did not want to, and great variations in the care of the cannula." They demonstrated lack of responsibility when they commented, "no one to take the responsibility, carelessness, forgetfulness, mistake, it felt troublesome, inconvenience, and laziness. Not going into the statistical details and its analysis, it can be stated that this study revealed the very important factors as to why lapse of care and management happens. It appears that nurses prefer the forearm as the catheter insertion site due to the facts that the cannula would not be close to a joint, it could ensure patients' freedom and comfort. It was also acknowledged to be a good place for insertion since the veins were visible with cannula being safe, easy to protect, use, take care of, and observe on a steady, solid base (O'Grady et al., 2002, 1-29). The most concerning reason perhaps was routine and habit cited as the reason for selection of a vein. Important to note that only 14 persons in this group preferred to choose a vein on the forearm and the bend of the arm in relation to the type of the solution infused since these sites offer bigger veins that take a lot of fluid, with better flow of solutions and less pain associated with the insertion place. The choice of the catheter size in prevention of catheter associated complications is very important (Amoore and Adamson, 2003, 45-52).. It was interesting to find that rather than choosing a cannula size based on science, the nurses chose any particular size based on the reasons such as "there was no need for thicker ones on the ward; the cannula size was appropriate, thin and narrow; the cannula did not chafe, sizes were suitable for both medication and solutions as well as being easier to insert, work with, and take care of than bigger sizes." Although smaller sizes were known to be associated with fewer cases of thrombophlebitis and were less "painful, injurious or irritating", only eight nurses in this study preferred a 1 mm catheter for reasons such as " good flow around the vein catheter; the size is more useful for glucose, intralipid and blood; it is also easy to fix and flush" and for longer use. Regarding the site of insertion literature is not in an opinion of consensus, and therefore the nurses' knowledge could be limited in those areas. Although the veins were classified according to the diameter, recommendation would be difficult, but a superficial vein may be preferable since it is more difficult to diagnose in deeper veins and more easy to miss the diagnosis there. Current academic training should be able to incorporate research findings in the academic training (Idvall and Gunningberg, 2006, 31-34).. When irritating drugs or solutions are used, there is a higher chance of complications, which the nurses have no control over. Despite different beliefs about the choice of the cannula size, it has also been evidenced in the literature that it would be an advantage to use a small cannula size with a good infusion fluid with a very quick mixture of the solutions with the venous blood so the intima can be protected from the harmful effects of the infused drug or solution (White, 2001, 19-24). Literature has repeatedly highlighted the fact that a well secured cannula is important in reducing the risks of complications associated with trauma to the vascular endothelium. The preferences of the nurses in this regard were inappropriate in light of the fact that woven cotton dressing may allow the catheter to be stuck and glided under the dressing in comparison to the tapes (Turnidge 1984, 37-40). The nurses' report about the duration of the cannula in situ was concerning since rather than following the science, they are following a ward routine where depending on the patient responses, they leave the catheter in situ for over a period of 2 to 7 days or nights. Many nurses consider this practice as a bad routine or irresponsible work despite the fact being that only three nurses intended it to be inserted for only up to 24 hours. For removal of the cannula, the nurses cited many reasons, and all of them seem plausible except a few who even wanted to wait till the signs of infections had developed. However, most of them know the signs of complications such as redness, induration, and hardness with or without fever. The intravenous route allows rapid and effective drug administration, when the drugs are prescribed to be parenterally administered. Many drugs fall into this category including antibiotics, analgesics, and others. However, most common uses of intravenous therapy are maintaining and restoring fluid and electrolyte balance, administering drugs, transfusing blood, and delivering parenteral nutrition. Selection and preparation of appropriate equipment are essential for accurate delivery of an intravenous solution. Peripheral intravenous line insertion involves selection of a venipuncture device and an insertion site, application of a tourniquet, preparation of the site, and venipuncture. Selection of a venipuncture device and site depends on the type of solution to be used; frequency and duration of infusion; patency and location of accessible veins; the patient's age, size, and condition; and, when possible, the patient's preference (Tagalakis et al, 2002, 146-151). If possible, a vein is chosen in the nondominant arm or hand. Preferred venipuncture sites are the cephalic and basilic veins in the lower arm and the veins in the dorsum of the hand. On the other hand, the least favorable sites are the leg and foot veins because of the increased risk of thrombophlebitis, which may complicate the clinical condition of the patient. Also, in some cases, antecubital veins can be used when no other venous access is available. It is also used when for therapeutic purposes, a large-bore catheter needs to be introduced, such as to administer drugs that require large-volume dilution (Martinez et al., 1994, 83-93) A peripheral line is intended to allow administration of fluids, medication, blood, and blood components as has been mentioned earlier, but perhaps the more important use is to maintain intravenous access to the patient that can be utilized to intervene in case the patient's condition is critical. A peripheral line can be maintained for a prolonged duration, such as, throughout the course of an antibiotic regimen. Prolonged peripheral intravenous catheters induce an inflammatory response, and thus utmost care is necessary to prevent that inflammation. Moreover, since a peripheral catheter can serve as an entry point of infection, meticulous care and aseptic handling are necessary to prevent systemic infection from a catheter portal or entry point. If any such sort of complicating conditions are suspected, the nurse is required to identify them and take appropriate preventive measures so complications cannot occur. Insertion is contraindicated in a sclerotic vein, an edematous or impaired arm or hand, or a postmastectomy arm and in patients with a mastectomy, burns, or an arteriovenous fistula. Subsequent venipunctures should be performed proximal to a previously used or injured vein. Practically, the puncture of peripheral veins to set up an intravenous line needs preparation on the part of the nurse. In the clinical area, the equipment is usually available in a tray where several different categories of these devices are available, where depending on the patient's condition, the nurse has the option to choose a particular set of venous access device. This discourse is on short peripheral catheters, so this discussion would be limited to short venous access devices in the adult patients. Irrespective of the type of the patient, few components of this tray are common to all. These are alcohol pads or other approved antimicrobial solution, such as tincture of iodine 2% or 10% povidone-iodine, gloves, tourniquet, intravenous access devices, intravenous solution with attached and primed administration set, sterile gauze pads or a transparent semipermeable dressing, hypoallergenic tape, and other accessories (Couzigou et al., 2004, 197-204). Most intravenous infusions are delivered through one of three basic types of venous access devices, an over-the-needle cannula, a through-the-needle cannula, or a winged infusion set. To improve intravenous therapy and guard against accidental needle sticks, one can use a needle-free system and shielded or retracting peripheral intravenous catheters. These sets make accidental puncture of the vein less likely than with a needle; more comfortable for the patient when it is in place; contains radiopaque thread for easy location. Some units, however, come with a syringe that permits easy check of blood return; some units include wings. The preparation of the site is very important from the point of view of care and management of such catheters (Barker, Anderson, MacFie, 2004, 281-283). The nurse should wear gloves and clip the hair around the intended insertion site if needed. The site needs to be cleaned with alcohol pads or another approved antimicrobial solution, according to the facility's policy. It is important to note that the nurse must know not to apply alcohol after applying 10% povidone-iodine because the alcohol negates the beneficial effect of the povidone-iodine. The technique of aseptically prepare the site in a circular motion outward from the site to a diameter of 5 to 10 cm. to remove flora that would otherwise be introduced into the vascular system with the venipuncture. The antimicrobial solution must be allowed to dry. After the venous access device has been inserted, the skin is cleaned completely. If necessary, the stylet needs to be disposed in a sharps container. The flow rate is regulated followed by this (Curran et al., 1998) The objective of this paper is to examine the nurses' understanding about the care and management of short peripheral venous catheters. The care and management are all about preventing complications out of this short peripheral venous catheter. The complications that may result from the catheter are infection, phlebitis, and embolism. To be able to analyze those, it is important to understand what is meant by this understanding. Phlebitis is manifested by tenderness at tip of and proximal to venous access device, redness at tip of catheter and along the vein, and puffy area over the affected vein. The patient has an elevated temperature, and the affected vein feels hard. The nurse needs to know these. This happens due to several reasons. These are poor blood flow around venous access device, friction from catheter movement in vein, the venous access device left in the vein too long for prolonged intravenous therapy, clotting at the catheter tip, or with drug or solution with high or low pH or high osmolarity that is administered through the intravenous route (Tripepi-Bova, Woods, and Loach, 1997, 377-381). The nursing care would include removal of the venous access catheter, application of warm soaks, notification of the physician if patient has a fever, and documentation of the patient's condition and nursing interventions. However, this can be prevented if there is appropriate understanding about the use of these catheters, where the nurse can anticipate such situations and can take the following measures before this happens to a patient. The nurse can restart infusion using a larger vein for irrigating solution or restart with a smaller-gauge catheter to ensure adequate blood flow. Optionally, a filter can be used to reduce the risk of phlebitis. The catheter must be securely taped to prevent motion between the catheter and the vein (Darouiche, 2001, 1567-1572). While inserting or post-insertion, there may be extravasation of fluid into the subcutaneous tissue. The nurse should know and understand the implications of extravasation to the patient. This most commonly appear as a swelling at and above the intravenous site and it may extend along the entire limb. The patient starts suffering from discomfort, burning, or pain at the insertion site. However, some cases may be entirely painless. The patient has a tight feeling at the site with decreased skin temperature around that site with apparent blanching. Sometimes this occurs when the fluid infusion is continued despite occlusion at the tip of the catheter. When this happens, the rate of infusion may decrease, and the nurse should be able to recognise the condition, since otherwise, if there is any drug in the infusion, this may be even lead to toxic reactions in the subcutaneous tissue. This can be easily recognised by absent back flow of blood through the catheter. This occurs due to dislodgement of catheter from the vein or due to accidental perforation of the vein (Maki and Ringer, 1991, 845-854). Immediately following the recognition, the nurse needs to stop infusion. The extravasation site needs to be infiltrated with an antidote, if appropriate and if indicated. In case of early detection, ice needs to be applied or if late, warm soaks are applied to aid absorption of extravasated fluid. The limb should be elevated to facilitate absorption. The circulation needs to be assessed periodically by repeated checks of pulse and capillary refill. The infusion should be restarted above this site of extravasation or in another limb. The patient's condition and the interventions are documented. The care should comprise of frequent checks of the intravenous site, and the patient may be taught to observe the intravenous site for swelling and report inordinate pain if there is any (Cornely et al., 2002, 249-253) Catheter dislodgement is a known complication, where the tape may be loose resulting into partially backed out cannula off the vein with the infusion solution infiltrating. This frequently occurs due to loosened tape or tubing snagged in bed linens. Consequently, being short, the catheter retracts partially, and in some other cases, the patient in a state of confusion would pull it out. If no infiltration occurs, the catheter would need to be pushed back into the vein followed by retaping (Homer and Holmes, 1998, 301-305). While retaping, it should be borne in mind that a sterile dressing could be used to apply pressure on the entry site. The management would necessitate taping of the venipuncture site securely at insertion itself. The other common complications that need care are occlusion, venous irritation or pain at the intravenous site, hematoma, severed cannula, venous spasm, thrombosis, vasovegal reaction, thrombophlebitis, and/or nerve, tendon, or ligament damage. These complications are largely preventable, and appropriate nursing management may prevent this, where adequate and appropriate care is taken of the catheter and the catheter entry site. Short peripheral venous catheters are most commonly inserted into the forearm or hand veins. They are usually used for a short-term basis, and hence they are rarely associated with blood stream infections, but they are frequently associated with a non-infective complication, phlebitis (Bregenzer et al., 1998, 151-156). As per NHS guidelines, ongoing care actions for such catheters are important. They are divided into various categories. These include hand hygiene involving decontamination of hands before and after each patient contact using correct hand hygiene procedure. It is the nurse's responsibility to examine and reassess the continuity of the clinical indication for which the intravenous therapy was initiated. Therefore a relook into whether all intravenous cannula and associated devices are still indicated and if there is no indication then the intravenous cannula should be removed (Karadag et al, 2000, 158-166). The access site must be inspected for regular observation for signs of infection, at least daily. This would include dressing that ideally would be an intact, dry, adherent transparent dressing. As mentioned earlier, the catheter access must be appropriate with the use of 2% chlorhexidine gluconate in 70% isopropyl alcohol with allowance to dry prior to accessing the cannula for administering fluid or injections. Immediately after administration of blood, blood products, and all other fluid sets must be replaced after 72 hours. The cannula should be replaced routinely in a new site after 72-96 hours or earlier if indicated clinically, although if venous access is limited, the cannula can remain in situ if there are no signs of infection. These could serve as an acceptable guideline for care and management of the intravenous catheter (Department of Health, 2006, The Health Act 2006). Taking care of the site also included exchange of information with the patients, and most of the nurses were complaint with this, and few also asked the patients to report "redness, swelling, pain, or if the solution went subcutaneously." While caring, the nurses were observed to palpate the outside of the area, and they noted tenderness, redness, swelling, subcutaneous solutions, possible leakage, and the skin round the insertion site. In exploring these findings, despite there being a considerable body of knowledge, the nurses were found to have considerable lack of academic knowledge in this area, and most of them actually did not know why their management and care of the catheter and catheter site were so. The awareness of the regulations and conformity to existing guidelines were questionable since many did not know about an existing guideline. The most decisive factor in the care and management of catheter site was knowledge followed by experience and routine irrespective of years of experiences in handling these catheters (Barker, Anderson, MacFie, 2004, 281-283). Conclusion: Given the fact that there is a great paucity of current literature in this specific area, it obviously demands more research encompassing this topic. This study can throw important and significant insight into this very frequently nurse-administered care management in the clinical area so areas less highlighted and less well known are identified. Given the knowledge backup in this area, there is no reason why nurses may not follow guidelines that may prevent even life-threatening complications associated with peripheral short venous catheters, apart from reducing distress of the patient. Moreover this study also demonstrated what are the areas that are needed to be looked for and to be worked upon while intending to address this issue in the clinical area. Reference List Amoore J, Adamson L (2003). Infusion devices: characteristics, limitations and risk management. Nursing Standard. 17, 28, 45-52. Barker P, Anderson AD,MacFie J., (2004) Randomised clinical trial of re-siting of intravenous cannulae. Ann R Coll Surg Engl;86:281-3. Bregenzer T, ConenD, Sakmann P,Widmer AF.(1998). 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