Care and Maintenance to Reduce Vascular Access Complications

Nursing Best Practice GuidelinePost Insertion Complications❏ Early stage mechanical phlebitis:Intervention: _______________________________________________________________________ ______________________________________________________________________________________❏ Phlebitis:0 pain at site, no erythema, swelling, induration or palpable venous cord at or around the site+1 pain at site, no erythema, swelling, induration or palpable venous cord+2 some erythema or swelling or both at site, no induration or palpable venous cord+3 erythema and swelling at site, palpable venous cord < 7.5 cm. above site+4 erythema and swelling at site, induration and palpable venous cord > 7.5 cm. above siteIntervention: _______________________________________________________________________❏ Occlusion: ❏ Thrombotic ❏ Precipitate ❏ LipidsUnblocking procedure performed: ❏ Yes ❏ No # of times _______Occlusion resolved ❏ Yes ❏ No❏ Infection:❏ Insertion site (drainage, erythema, tender) ____________________❏ Catheter sepsis (positive blood culture, positive catheter tip culture,same organism, may be febrile) ______________________________❏ Catheter sepsis suspected (no positive blood culture, fever resolvesafter removal) ______________________________________________❏ Infection resolved __________________________________________❏ Thrombus (validated radiographically)Location: _____________________________❏ Embolus Type: ❏ Air ❏ Catheter ❏ Thrombus❏ Catheter Damage: (describe)Successful repair: (date)❏ Pain: (describe)❏ Leaking at Insertion Site:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________❏ Other: _______________________________________________________________________________Comments:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Source: Hamilton Health Sciences Centre IV Team (2002). Data collection tool for central venous access devices. (Unpublisheddocument). Hamilton: Author. Reprinted with permission.75