CVAD assessment

Section Recommendation statement Grading of recommendations
1.

The nurse must systematically assess the CVAD each shift covering the following elements:

  1. dressing
  2. securement
  3. integrity of CVAD
  4. labelling of administration sets and infusion therapies.

The findings must be documented in the clinical record.

Consensus
The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that change these recommendations.

Patient assessment

Staff should undertake regular assessment and monitoring of these devices for signs of inflammation and infection. Catheter patency should also be evaluated to assess thrombotic risk. How to assess a CVAD provides guidelines for performing a CVAD assessment with the goal and suggested strategies for when there are abnormal findings.

How to assess a CVAD

Goal/elements

Abnormal findings

Potential actions

CVAD site

Clean site free from abnormalities.

Pain, induration, redness, swelling, tenderness, fever, chills, leakage or exudate are evident.

Abnormal findings must be reported to medical staff and documented in the patient’s clinical record.

Integrity of CVAD device

Catheter integrity maintained.

Leakage from catheter or around site is detected.

Assess catheter for damage and check connections for tightness and fit.

Optimum catheter tip placement.

Ensure tip position has been confirmed.

Measurement of external portion of catheter is monitored for change or migration.

Change in external catheter measurement must be reported to medical officer and documented in patients clinical notes.

All lumens of the catheter are patent and located within the vessel.

The catheter has migrated from the initial documented position.

Blood is unable to be gently aspirated from unused lumen.

Infusions are unable to be administered through the lumen. There are occlusion alarms unrelated to the administration set or it cannot be flushed.

Discuss options to restore lumen patency with a medical officer.

Dressing

Clean and intact.

Dressing is not intact or the dressing is soiled.

Redress site.

Covers insertion point and catheter to securement junction.

Dressing does not cover sufficient area.

Securement

Catheter sutures are intact or sutureless fixation device is well secured to skin.

Non-intact sutures and/or sutureless fixation device is not well adhered to skin.

Replace with sutureless fixation device and redress.

IV administration sets are secured to patient to prevent tension on catheter.

Presence of strain or tension on catheter or administration sets.

Catheter has migrated from documented position.

Apply additional fixation to anchor IV administration sets to patient.

Practice point 1: How to perform an assessment

  • The frequency of the assessment will be determined by the patient’s condition and individual institutional policy.
  • Always attend to hand hygiene and wear clean gloves.
  • Check flasks, medicines, connections to administration set and all Luer connections to the CVAD .
  • Check for labelling as per National Recommendations for User-applied Labelling of Injectable Medicines, Fluids and Lines 2012 (1).
  • Visually inspect and palpate the insertion site and surrounding area.
  • Assess for swelling, heat, pain, tenderness or exudate.
  • Observe CVAD site for redness, induration, integrity of sutures or sutureless securement device and dressing.
  • Ensure all lumen of the CVAD are in working order. Assess patency including aspiration of blood and 0.9% saline flush of unused lumens. When an anticoagulant lock is in place the lumen should be appropriately labelled.
  • Measure the external portion of the CVAD from insertion at skin to the last visible marking on catheter and check against insertion documentation. Document in the clinical record and notify the medical officer if there has been a change from original measurement.

Grading of Recommendations

Grade of recommendation Description
A Body of evidence can be trusted to guide evidence
B Body of evidence can be trusted to guide practice in most situations
C Body of evidence provides some support for recommendation/s but care should be taken in its application
D Body of evidence is weak and recommendation must be applied with caution
Consensus Consensus was set as a median of ≥ 7
Grades A–D are based on NHMRC grades (2)

References

  1. Care ACoSaQiH. National Recommendations for User-applied Labelling of Injectable Medicines, Fluids and Lines. Sydney: ACSQHC; 2012.
  2. Hillier S, Grimmer-Somers K, Merlin T, Middleton P, Salisbury J, Tooher R, et al. FORM: an Australian method for formulating and grading recommendations in evidence-based clinical guidelines. BMC Medical Research Methodology. 2011;11:23. PubMed PMID: 21356039.

Disclaimer

The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.