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2011 INS Standards of Practice
38. Catheter Protection
38.1 The use of site protection and/or physical immobilization devices, proper application, and patient monitoring shall be established in organizational policies, procedures, and or practice guidelines.
38.2 The nurse shall be competent in the application, use, and removal of a site protection or immobilization device.
38.3 The use of physical immobilization devices (ie, restraints) to protect the vascular access device (VAD) site shall not be routinely implemented and shall be avoided whenever possible.
A. Site protection methods such as mittens are recommended for patient populations such as pediatric, elderly, those with cognitive limitations, or whenever there is risk of accidental dislodgment. Clear plastic site protectors specifically designed for this purpose are used to prevent accidental dislodgment or vein damage in children.
B. The site protection method selected should be based on a comprehensive assessment of the patient’s physical, behavioral, and psychological status.
C. Immobilization devices or site protection methods should be used in a manner that will preserve circulation and provide visualization of the vascular access site and in accordance with manufacturers’ directions for use. The selected immobilization device or site protection method should not interfere with the prescribed infusion rate, delivery method, ability to assess the vascular access site, or catheter stabilization/securement.
46. Vascular Access Device Site Care and Dressing Changes
46.1 Vascular access device (VAD) site care and dressing changes, including frequency of procedure and type of antiseptic and dressing, shall be established in organizational policies, procedures, and/or practice guidelines.
46.2 The nurse shall be competent in performing VAD site care and dressing changes.
46.3 VAD site care and dressing changes shall be performed at established intervals and immediately if the dressing integrity becomes compromised, if moisture, drainage or blood is present, or if signs and symptoms of site infection are present.
46.4 A sterile dressing shall be applied and maintained on VADs.
J. Gauze, bandages, or any dressing material that may obstruct visualization of the catheter-skin junction and/or constrict the extremity should not be used (see Standard 38, Site Protection).
Source: Infusion Nursing Standards of Practice (2011)