Skill 16-5

Capping for Intermittent Use and Flushing a Peripheral Venous Access Device

When a continuous intravenous (IV) is no longer necessary, the primary IV line (PIVC or CVAD) can be capped and converted to an intermittent infusion device. A capped line consists of the IV catheter connected to a short length of extension tubing sealed with a cap. Capping of a short peripheral venous catheter is commonly referred to as a medication or saline lock. Capping of a vascular access device provides venous access for intermittent infusions or emergency medications. Capping of a VAD can be accomplished in different ways. Refer to facility policy for the procedure to convert an access for intermittent use.

VADs used for intermittent infusions should be flushed with preservative-free 0.9% sodium chloride solution and aspirated for a blood return prior to each infusion to assess catheter function (Gorski et al., 2021). Flushing of the device is also required after each infusion to clear the infused medication or other solution from the catheter lumen. Vascular access devices are “locked” after completion of the flush solution at each use to decrease the risk of occlusion (Gorski et al., 2021). According to the guidelines from the INS, PIVCs are locked with preservative-free 0.9% sodium chloride (Gorski et al., 2021). If the device is not in use, periodic flushing according to facility policy is required to keep the catheter patent.

It is important to follow the manufacturer's directions for use when flushing, clamping, and disconnecting syringes and IV administration tubing or any other device from needleless connectors. In the absence of manufacturer directions, identify the internal mechanism for fluid displacement reported by the manufacturer for the type of needleless connector being used and use the appropriate sequence for flushing, clamping, and disconnecting based on the type of needleless connector to prevent connection/disconnection reflux (Box 16-4) (Gorski et al, 2021).

Delegation Considerations

Capping and flushing of a peripheral VAC is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, these procedures 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

End cap device, according to facility policy
Gloves
Additional PPE, as indicated
4 × 4 gauze pad
Single-use, commercially prepared, prefilled syringe with sterile normal saline for injection, minimum volume equal to twice the internal volume of the catheter system (Gorski et al., 2021), according to facility policy
Passive disinfection caps (based on facility policy)
Antimicrobial wipes
Nonallergenic tape

Assessment

Assess the insertion site for signs of any complications. Refer to Fundamentals Review 16-3 and Box 16-2 (in Skill 16-2). Assess the appropriateness of discontinuation of the fluid infusion for the patient. Verify the prescribed intervention for discontinuation of IV fluid infusion. Evaluate the patient's history for any allergies or sensitivity to skin antiseptics (Gorski et al., 2021).

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

Outcome Identification and Planning

The expected outcome to achieve when capping a peripheral intravenous infusion is that the peripheral VAD is converted for intermittent use and the patient remains free from injury and signs and symptoms of complications. In addition, the capped VAD remains patent.

Implementation

Action	Rationale
1. Determine the need for conversion to an intermittent access. Verify the prescribed intervention for discontinuation of IV fluid infusion. Check facility policy. Gather the necessary supplies.	This ensures the correct intervention for the correct patient. 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. Assess the peripheral VAD site. Refer to Skill 16-2.	Complications, such as infiltration, phlebitis, or infection, necessitate discontinuation of the IV infusion at that site.
7. If using an electronic infusion device, stop the device. Close the roller clamp on the administration set. If using a gravity/free-flow infusion, close the roller clamp on the administration set.	The action of the infusion device needs to be stopped and the clamp closed to prevent leaking of fluid when the tubing is disconnected.
8. Put on gloves. Close the clamp on the short extension tubing connected to the IV catheter in the patient's arm.	Clamping the tubing on the extension set prevents introduction of air into the extension tubing.
9. Remove the administration set tubing from the needleless connector or end cap on the extension set. Using an antimicrobial swab, disinfect the connection surface and sides of the needleless connector or end cap on the extension tubing and allow them to dry (Figure 1).	Removing the infusion tubing discontinues the infusion. VAD administration set entry points, end caps, and needleless connectors must be disinfected prior to each access to reduce the risk for introduction of microorganisms and prevent VAD-related infection (Frimpong et al., 2015; Gorski et al., 2021; Harper, 2014; Loveday et al., 2014). Friction is needed to physically remove microorganisms from the top, sides, and threads of the needleless connector or end cap. Allow the antiseptic to dry completely, following the manufacturer's directions for use (Gorski et al., 2021).
10. Insert the saline flush syringe into the needleless connector or end cap on the extension tubing. Pull back on the syringe to aspirate the catheter for positive blood return. If positive, instill the solution over 1 minute or flush the line according to facility policy (Figure 2). Prevent connection/disconnection reflux by using the appropriate sequence for flushing, clamping, and disconnecting determined by the type of needleless connector being used (Box 16-4) (Gorski et al., 2021).	The presence of a blood return upon aspiration and lack of resistance when flushing indicate patency of the VAD (Gorski et al., 2021). Flushing maintains patency of the IV line. The action of the positive pressure end cap is maintained with the appropriate sequence for flushing, clamping, and disconnecting determined by the type of needleless connector in use (Gorski et al., 2021). Clamping prevents air from entering the extension set.
11. If necessary, loop the extension tubing near the entry site and anchor it with tape (nonallergenic) close to the site.	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. Using an antimicrobial swab, vigorously disinfect the needleless connector or end cap on the extension tubing and allow it to dry. Attach a passive disinfection cap.	VAD administration set entry points, end caps, and needleless connectors must be vigorously scrubbed and disinfected prior to each access to reduce the risk of introducing microorganisms and to prevent VAD-related infection (Frimpong et al., 2015; Gorski et al., 2021; Harper, 2014; Loveday et al., 2014). Friction is needed to physically remove microorganisms from the top, sides, and threads of the needleless connector or end cap. Allow the antiseptic to dry completely to ensure complete effectiveness. Passive disinfection caps contain an antiseptic-impregnated sponge that dispenses the antiseptic over the connector's top and threads and protects the hub from contamination by touch or airborne sources (Gorski et al., 2021; Stango et al., 2014).
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 gloves properly and 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.	Proper removal of PPE 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 peripheral VAD has been converted for intermittent use, the patient has remained free from injury and signs and symptoms of complications, and the capped VAD has remained patent.

Documentation

Guidelines

Document discontinuation of the IV fluid infusion. Record the condition of the venous access site. Document the flushing of the VAD. This is often done in the eMAR/MAR. Record the patient's reaction to the procedure and any patient teaching that occurred.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Peripheral venous access site leaks fluid when flushed: Check connections. If the site continues to leak, remove it from the site to prevent infection and other complications. Evaluate the need for continued access; if a clinical need is present, restart it in another location.
IV does not flush easily: Assess the insertion site. Infiltration and/or phlebitis may be present. If present, remove the IV. 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). Assess the need for continued venous access. If a clinical need is present, 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 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 does not flush easily: The catheter may be blocked or clotted due to a kinked catheter at the insertion site. Aspirate and attempt to flush again. If resistance remains, do not force. Forceful flushing can dislodge a clot at the end of the catheter. Remove the IV. Assess the need for continued venous access. If a clinical need is present, restart the IV in a new location.
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

Some facilities may use end caps for VADs that are not positive pressure devices. In this case, flush with the recommended volume of saline, ending with 0.5 mL of solution remaining in the syringe. While maintaining pressure on the syringe, clamp the extension tubing. This provides positive pressure, preventing backflow of blood into the catheter, decreasing risk for occlusion.
If the administration tubing was connected directly to the hub of the IV catheter when the access was initiated, short extension tubing should be added when the line is capped.

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Skill 16-5

EVIDENCE FOR PRACTICE