Skill 16-4

Changing a Peripheral Venous Access Device Site Dressing

The intravenous (IV) site is a potential entry point for microorganisms into the bloodstream. Maintenance of an intact and patent dressing at the insertion site is an important means of preventing infection and other complications. Transparent semipermeable membrane (TSM) dressings are commonly used to protect the insertion site. TSM dressings (e.g., Tegaderm™ or OpSite IV™) allow easy inspection of the IV site and permit evaporation of moisture that accumulates under the dressing. Sterile gauze may also be used to cover the catheter site. A gauze dressing is recommended if the patient is diaphoretic, the site is bleeding or oozing, or there is drainage from the exit site; replace it with a TSM once this is resolved (Gorski, 2020; O'Grady et al., 2017).

Facility policy generally determines the type of dressing used and the intervals for dressing change. Perform site care and replace TSM dressings at least every 7 days (except neonatal patients) or immediately if the dressing becomes damp, loosened, visibly soiled, or has a lifted/detached border; blood or drainage is present; or there is compromised skin integrity under the dressing (Gorski et al., 2021). Change sterile gauze dressings at least every 2 days, or if the integrity of the dressing is disrupted (damp, loosened, visibly soiled) (Gorski et al., 2021). Consider the use of sterile adhesive removers and skin barrier film to prevent medical adhesive-related skin injury (MARSI) (Fumarola et al., 2020; Gorski et al., 2021; Zhao et al., 2018). However, dressing changes might be required more often, based on nursing assessment and judgment. Site care and dressing changes are performed using aseptic nontouch technique to minimize the possibility of contamination when changing these dressings (ANTT) (Gorski et al., 2021). In the nontouch technique, the practitioner touches a site or equipment only as absolutely necessary, even when wearing sterile gloves (Taylor et al., 2023).

Delegation Considerations

The changing of a peripheral venous access dressing is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, the changing of a peripheral venous access dressing may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Transparent semipermeable membrane (TSM) dressing
Cleansing swabs (>0.5% chlorhexidine in alcohol solution preferred [Gorski et al., 2021; Sarani et al., 2018]); if there is a contraindication to alcoholic chlorhexidine solution, tincture of iodine, an iodophor (povidone-iodine), or 70% alcohol may also be used (Gorski et al., 2021; Mimoz et al., 2015; O'Grady et al., 2017). Use chlorhexidine with caution in infants up to age 14 days, premature infants, and low-birth-weight infants due to the risk of skin irritation and chemical burns (Gorski et al., 2021).
Adhesive remover
Antimicrobial wipes
Skin protectant wipes (e.g., Skin-Prep™)
IV securement/stabilization device, as appropriate
Nonallergenic tape
Standardized scale for assessing and documenting phlebitis (Box 16-3 in Skill 16-3 provides an example of one scale)
Gloves
Towel or disposable pad
Additional PPE, as indicated

Assessment

Assess the PIVC site. The dressing should be intact, adhering to the skin on all edges. Check for any leaks or fluid under or around the dressing or other indications that the dressing needs to be changed. Inspect the tissue around the IV entry site for swelling, coolness, or pallor. These are signs of fluid infiltration into the tissue around the IV catheter. Also inspect the site for redness, swelling, and warmth. These signs might indicate the development of phlebitis or an inflammation of the blood vessel at the site. Ask the patient if they are experiencing any pain or discomfort related to the IV line. Pain or discomfort can be a sign of infiltration, extravasation, phlebitis, thrombophlebitis, and infection related to IV therapy. Grade phlebitis, if present. Refer to Box 16-2. Refer also to Fundamentals Review 16-3. Note the insertion date and date of last dressing change, if different from the insertion date. Assess the patient's need to maintain venous access. If the patient does not need the access, discuss the possibility of discontinuation with the health care team. Evaluate the patient's history for any allergies or sensitivity to skin antiseptics (Gorski et al., 2021). Assess the patient's knowledge of PIVC therapy.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Infection risk
Injury risk
Altered skin integrity risk

Outcome Identification and Planning

The expected outcomes to achieve when changing a peripheral venous access dressing are that the dressing is changed without adverse effect, and the patient exhibits an access site that is clean, dry, and without evidence of any signs and symptoms of infection, infiltration, or phlebitis.

Implementation

Action	Rationale
1. Assess and discuss with the health care team the need for continued peripheral venous access. Determine the need for a dressing change. Check facility policy. Gather equipment.	The clinical need for the IV catheter should be assessed on a daily basis in acute inpatient settings and during regular assessment visits in community-based care settings (Gorski et al., 2021). The particular facility's policies determine the type of dressing used and when these dressings are changed. Dressing changes might be required more often, based on nursing assessment and judgment. Immediately change any dressing that is damp, loosened, visibly soiled, or has a lifted/detached border; if blood or drainage is present; or if there is compromised skin integrity under the dressing (Gorski et al., 2021). Preparation promotes efficient time management and an organized approach to the task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Assemble equipment on the bedside stand or overbed table or other surface within reach.	Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
5. Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why. Ask the patient about allergies to tape and skin antiseptics.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement. Possible allergies may exist related to the tape or antiseptics.
6. Put on gloves. Place a towel or disposable pad under the patient's arm with the venous access. If the solution is currently infusing, temporarily stop the infusion.	Gloves prevent contact with blood and body fluids. The pad protects the underlying surface.
7. Hold the catheter in place with your nondominant hand and support the patient's skin. Beginning at the device hub, gently lift the edge of the dressing away from the skin, then gently push the skin down and away from the dressing/adhesive (Fumarola et al., 2020). Lift the dressing perpendicular to the skin toward the insertion site, carefully removing the old dressing and/or stabilization/securing device (Figure 1). If the patient is at increased risk for medical adhesive-related skin injury (MARSI), or there is resistance, use an adhesive remover (Barton, 2020; Fumarola et al., 2020; Kelly-O'Flynn et al., 2020). Avoid inadvertently dislodging the catheter, as it may be adhered to the dressing/stabilization device (Gorski et al., 2021). Discard the dressing.	Pushing the skin down and away from the adhesive reduces the risk for medical adhesive-related skin injury (MARSI) (Fumarola et al., 2020). The use of adhesive remover allows for easy, rapid, and painless removal without the associated problems of skin stripping and helps reduce patient discomfort (Barton, 2020; Fumarola et al., 2020; Kelly-O'Flynn et al., 2020). Proper disposal of the dressing prevents transmission of microorganisms.
8. Inspect the IV site for the presence of phlebitis (inflammation), infection, or infiltration. If noted, grade phlebitis and discontinue and relocate PIVC. Refer to Fundamentals Review 16-3 and Box 16-2 (in Skill 16-2). Assess the integrity of the stabilization device if it is separate from the dressing; change the stabilization device according to the manufacturer's directions and/or facility policy.	Inflammation (phlebitis), infection, or infiltration causes trauma to tissues and necessitates removal of the VAD. A standardized scale should be used to assess and document phlebitis (Gorski et al., 2021). The integrity of the stabilization device should be assessed with each dressing change, and the device itself should be changed according to the manufacturer's directions (Gorski et al., 2021).
9. Use a single-use sterile applicator containing sterile antiseptic solution to cleanse the site with >5% chlorhexidine in alcohol solution or the solution identified by facility policy (Figure 2). Follow the manufacturer's directions for use to determine product application process and dry times (Gorski et al., 2021). Allow the antiseptic to dry naturally; do not wipe, fan, or blow on the skin (Gorski et al., 2021).	Cleansing is necessary because organisms on the skin can be introduced into the tissues or the bloodstream with the needle. Use of >0.5% chlorhexidine in an alcohol solution is preferred for skin antisepsis (Gorski et al., 2021; Sarani et al., 2018). If there is a contraindication to alcoholic chlorhexidine solution, tincture of iodine, an iodophor (povidone-iodine), or 70% alcohol may also be used (Gorski et al., 2021; Mimoz et al., 2015; O'Grady et al., 2017).
10. Open the skin protectant wipe. Apply it to the site, making sure to cover, at minimum, the area to be covered with the dressing (Figure 3). Allow it to dry. Place the sterile transparent dressing and/or catheter securing/stabilization device over the venipuncture site (Figure 4).	The skin protectant aids in adhesion of the dressing and decreases the risk for skin trauma when the dressing is removed. A transparent dressing allows easy visualization and protects the site. Stabilization/securing devices preserve the integrity of the access device, minimize catheter movement at the hub, and prevent catheter dislodgement and loss of access (Gorski et al., 2021). Some stabilization devices also act as a site dressing.
11. Label the dressing with the date, time of change, and your initials. Loop the tubing near the entry site, and anchor it with tape (nonallergenic) close to the site (Figure 5). Resume fluid infusion, if indicated. Check that the IV flow is accurate and the system is patent. Refer to Skill 16-2.	Other personnel working with the infusion will know what type of device is being used, the site, and when it was inserted. The weight of the tubing is sufficient to pull it out of the vein if it is not well anchored. Nonallergenic tape is less likely to tear fragile skin.
12. Apply an IV securement/stabilization device if not already in place as part of the dressing, as indicated, based on facility policy. Explain to the patient the purpose of the device and the importance of safeguarding the site when using the extremity.	These systems are recommended for use on all venous access sites, and particularly central venous access sites, to preserve the integrity of the access device, minimize catheter movement at the hub, and prevent catheter dislodgement and loss of access (Gorski et al., 2021). Some devices also act as a site dressing and may already have been applied.
13. Remove equipment. Remove gloves and perform hand hygiene. Ensure the patient's comfort. Lower the bed, if it is not in the lowest position.	Removing PPE properly and performing hand hygiene reduce the risk for infection transmission and contamination of other items. Positioning promotes patient comfort and safety.
14. Remove additional PPE, if used. Perform hand hygiene.	Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents transmission of microorganisms.

Evaluation

The expected outcomes have been met when the dressing has been changed without adverse effect, and the patient has exhibited an access site that is clean, dry, and without evidence of any signs and symptoms of infection, infiltration, or phlebitis.

Documentation

Guidelines

Document the location of the venous access as well as the condition of the site. Include the presence or absence of signs of erythema, redness, swelling, or drainage. Document the clinical criteria for site complications. Refer to Fundamentals Review 16-3 and Box 16-2 (in Skill 16-2). Record the patient's subjective comments regarding the absence or presence of pain at the site. Record the patient's reaction to the procedure and pertinent patient teaching, such as alerting the nurse if the patient experiences any pain from or swelling at the site.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient reports that IV site feels “funny” and hurts: Observe the venous access site for redness, edema, and warmth, and/or swelling, pallor, and coolness. If present, clamp the tubing to stop the IV solution flow, put on gloves, and remove the catheter. Use a skin marker to outline the area with visible signs of infiltration to allow for assessment of changes (Gorski et al., 2021). Secure the gauze with tape over the insertion site without applying pressure. Assess the area distal to the VAD for capillary refill, sensation, and motor function (Gorski et al., 2021). Restart the IV in a new location. Estimate the volume of fluid that escaped into the tissue based on the rate of infusion and length of time since the last assessment. Notify the health care team and use an appropriate method for clinical management of the infiltrate site, based on the infused solution and facility guidelines (Gorski et al., 2021). Record the site assessment and interventions as well as the site for new venous access.
IV catheter is partially pulled out of insertion site (migrates externally): Do not readvance the catheter. Whether the access is salvageable depends on how much of the catheter remains in the vein. Assess for proper placement in the vein before further use and consider the infusion therapy and circumstances to determine viability and secure at the current location (Gorski et al., 2021). Removal and reinsertion at a new site might be the most appropriate intervention if the PIVC is no longer in an appropriate position for the prescribed infusion (Gorski et al., 2021). If the PIVC is not removed, monitor it closely for signs of infiltration and infection.

Special Considerations

General Considerations

Use of >0.5% chlorhexidine in alcohol solution is preferred for skin antisepsis (Gorski et al., 2021; Sarani et al., 2018). If there is a contraindication to alcoholic chlorhexidine solution, tincture of iodine, an iodophor (povidone-iodine), or 70% alcohol may instead be used (Gorski et al., 2021; Mimoz et al., 2015; O'Grady et al., 2017).
Drying time with 70% isopropyl alcohol is 5 seconds; alcohol-based chlorhexidine requires 20 seconds. Povidone iodine requires longer than 6 minutes to be thoroughly dry, making it less favorable to clinical practice (Gorski et al., 2021).
Use of topical antibiotic ointments or creams on insertion sites as part of routine site care is not recommended because of their potential to promote fungal infections and antimicrobial resistance (Gorski et al., 2021; O'Grady et al., 2017).
Do not submerge venous catheters and catheter sites in water (O'Grady et al., 2017). When the patient is showering or bathing, protect the peripheral VAD with clear plastic wrap or a device designed for this purpose. Cover the connections and protect the hub connections from water contamination (Gorski et al., 2021).

Infant and Child Considerations

Use chlorhexidine with caution in infants up to age 14 days, premature infants, and low-birth-weight infants due to the risk of skin irritation and chemical burns (Gorski et al., 2021).

Older Adult Considerations

Avoid using vigorous friction at the insertion site, which can traumatize fragile skin and veins in older adults.

section name header

Skill 16-4

EVIDENCE FOR PRACTICE