clean devices prior to access are unresolved. The access port should be accessed only with sterile devices.6,7(V)
F. The nurse should change the add-on device with the catheter, with each administration set replace-ment, or as defined by the organization, and whenever the integrity of the product is compro-mised or suspected of being comprocompro-mised.1(V)
G. The use of stopcocks is not recommended due to the increased risk of infection. When a stopcock is attached as an add-on device, the nurse should attach sterile caps to the ports of the stopcock to provide a closed system when not in use and access sites that will allow cleaning prior to accessing.1(V)
REFERENCES
1. H adaway L. Infusion therapy equipment. In: Alexander M , Corrigan A, Gorski L, H ankins J, Perucca R. eds. Infusion
Nursing: An Evidence-Based Approach. 3rd ed. St Louis, M O :
Saunders/Elsevier; 2010:391-436.
2. The Joint Commission. Tubing misconnections: a persistent and potentially deadly occurrence. Joint Commission Sentinel Event
Alert. http://w w w.jointcommission.org/SentinelEvents/Sentinel
EventAlert/sea_36.htm. Accessed December 5, 2009.
3. US Food and Drug Administration. 2009 medical device safety calendar on luer misconnections. http://www.fda.gov/medicalde-vices/Safety/Alertsand N otices/ucm134863.htm. Accessed July 8, 2009.
4. Institute for Safe M edication Practices (ISMP). Problems persist with life-threatening tubing misconnections. Medication Saf
Alert! June 17, 2004.
5. American Nurses Association [position paper]. Safety Issues Related
to Tubing & Catheter Misconnections. http://www.nursingworld.org/
position/practice/tube.aspx. Accessed February 13, 2010.
6. Kaler W, Chinn R. Successful disinfection of needleless mechani-cal valve access ports: a matter of time and friction. J Assoc
Vascular Access. 2007;12(3):140-142.
7. Marschall J, Mermel L, Classen D, et al. Compendium of strategies to prevent central line-associated bloodstream infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008;29(S1):S22-S30.
26. ADD-ON DEVICES
Standard
26.1 The use of add-on devices shall be established in organizational policies, procedures, and/or practice guidelines and according to manufacturers’ directions for use.
26.2 The nurse shall be competent in the use of the add-on device and shall be knowledgeable about the risk of misconnection and potential disconnections. 26.3 All add-on devices shall be of luer-lock design to ensure a secure junction.
Practice Criteria
A. Add-on devices may include, but are not limited to, stopcocks, single- and multilumen extension sets, manifold sets, extension loops, solid cannula caps, needleless systems, in-line filters, and manual flow-control devices.1(V)
B. All add-on devices should be compatible with the administration system to prevent the risk of leaks, disconnections, or misconnections.2,3(V)
C. The nurse should be aware that the potential for contamination exists with all add-on devices. In an effort to decrease the risk of contamination, the number of manipulation episodes, accidental disconnections or misconnections, and costs, there should be limited use of these devices.1(V)
D. To determine the appropriate placement of the selected add-on device, the nurse should trace the administration set from the patient to the point of origin before attaching the device.2,4,5(IV)
E. The nurse should disinfect the ports of the add-on device using friction, with an appropriate disin-fectant such as 70% alcohol before accessing. Specific guidelines directing the appropriate tech-nique, disinfectant, or amount of time required to
Infusion Equipment
27. NEEDLELESS CONNECTORS
Standard
27.1 The use of needleless connectors shall be established in organizational policies, procedures, and/or practice guide-lines and according to manufacturers’ directions for use. 27.2 N eedleless connectors attached to a catheter hub or access site shall be of luer-lock design to ensure a secure junction.
27.3 The nurse shall be competent in the use of needle-less connector devices.
27.4 The nurse shall disinfect the needleless connector prior to each access.
27.5 Needles shall not be used to access catheters, admin-istration sets, access sites, or needleless connectors.
Practice Criteria
A. The nurse should be aware that needleless con-nectors are identified by design (simple and com-plex) and function. The simple needleless connec-tor group includes the split-septum design with no internal mechanisms, a straight fluid pathway, and can be blunt cannula or luer-lock design. The complex needleless connector group includes a variety of luer-lock mechanical valve needleless connector with various internal mechanism designs and fluid pathways.1-5(IV)
B. The nurse should be knowledgeable about the function of the needleless connector and the man-ufacturer’s directions for use for each needleless connector to reduce the risk of blood reflux into the catheter tip upon disconnection. Currently, there are 3 categories of needleless connector function: negative fluid displacement, positive fluid displacement, and neutral design.2-11(II)
C. The nurse should be aware that the catheter hub is a known source for the development of catheter-related bloodstream infection (C R-BSI) and that needleless connectors are recognized sites for microbial contamination.5,10,12-26(II)
D. The nurse should be aware of and implement manufacturers’ directions for use, implement appropriate infection prevention practices, and review the research and published literature relat-ed to this issue to promote and provide quality patient outcomes.2,4-8,10,14-18,20,21,27-36(II)
E. The needleless connector should be consistently and thoroughly disinfected using alcohol, tincture of iodine, or chlorhexidine gluconate/alcohol combination prior to each access. The optimal technique or disinfection time frame has not been identified.3,5,9,12,13,15-17,19,22-25,27,29,31,32,37-41(III)
F. The nurse should change the needleless connector in the following circumstances: if the needleless
connector is removed for any reason; if there is blood or debris within the needleless connector; prior to drawing a blood culture sample from the catheter; upon contamination; per organizational policies, procedures, and/or practice guidelines; or per the manufacturer’s directions for use. The nurse should be knowledgeable about the manu-facturer’s directions for use and other device per-formance criteria to assist in the development of policies and procedures for needleless connector change frequency. The optimal time frame for changing the needleless connector has not been determined (see Standard 49, Infection).7,8,22,37,42-46
(IV)
REFERENCES
1. Gorski L, Perucca R, H unter M . Central venous access devices: care, maintenance, and potential complications. In: Alexander M , Corrigan A, Gorski L, H ankins J, Perucca R, eds. Infusion Nursing:
An Evidence-Based Approach. 3rd ed. St Louis, M O : Saunders/
Elsevier; 2010:495-515.
2. H adaway L, Richardson D. N eedleless connectors: a primer on terminology. J Infus Nurs. 2010;33(1):1-11.
3. Yebenes J, Delgado M , Sauca G, et al. Efficacy of three different valve systems of needle-free closed connectors in avoiding access of microorganisms to endovascular catheters after incorrect han-dling. Crit Care Med. 2008;36(9):2558-2561.
4. Rupp M , Sholtz L, Jourdan D, et al. O utbreak of bloodstream infection temporally associated with the use of an intravascular needleless valve. Clin Infect Dis. 2007;44:1408-1414.
5. Safdar N , M aki D. Lost in translation [editorial]. Infect Control
Hosp Epidemiol. 2006;27(1):3-7.
6. Jasinsky L, Wurster J. O cclusion reduction and heparin elimina-tion trial using an antireflux device on peripheral and central venous catheters. J Infus Nurs. 2009;32(1):33-39.
7. Khalidi N , Kovacevich D, Papke-O ’Donnell L, Btaiche I. Impact of the positive pressure valve on vascular access device occlusions and bloodstream infections. J Assoc Vascular Access. 2009;14(2): 84-91.
8. Association for Professionals in Infection C ontrol and Epidemiology (APIC). Guide to the Elimination of Catheter-related
Bloodstream Infections. Washington, D C: APIC; 2009.
9. E C RI Institute. N eedleless connectors. Health Devices. 2008;37(9): 261-283.
10. Blake M . Update: catheter-related bloodstream infection rates in relation to clinical practice and needleless device type. Can J
Infect Control. 2008;23(3):156-160, 162.
11. Jacobs BR, Schilling S, Doellman D, et al. Central venous catheter occlusion: a prospective, controlled trial examining the impact of a positive pressure valve device. J Parenter Enteral Nutr. 2004;28: 113-118.
12. Ivy D, Calderbank M , Wagner B, et al. Closed-hub systems with protected connections and the reduction of risk of catheter-relat-ed bloodstream infection in pcatheter-relat-ediatric patients receiving intra-venous prostanoid therapy for pulmonary hypertension. Infect
Control Hosp Epidemiol. 2009;30(9):823-829.
13. Buchman A L, Spapperi J, Leopold P. A new central venous catheter cap: decreased microbial growth and risk for catheter-related bloodstream infection. J Vascular Access. 2009; 10(1):11-21.
14. Jarvis W, M urphy C, H all K, et al. H ealth-care associated blood-stream infections with negative- or positive-pressure or displace-ment mechanical valve needleless connectors. Clin Infect Dis. 2009;49:1821-1827.
15. Soothill J, Braver K, H o A, et al. A fall in bloodstream infections followed a change to 2% chlorhexidine in 70% isopropanol for catheter connection antisepsis: a pediatric single center before/after study on a hematopoietic stem cell transplant ward. Am J Infect
Control. 2009;37(8):626-630.
16. Field K, M cFarlane C, Cheng A, et al. Incidence of catheter-related bloodstream infection among patients with a needleless, mechanical valve-based intravenous connector in an Australian/hematology-oncology unit. Infect Control Hosp Epidemiol. 2007;28(5):610-613. 17. M enyhay S, M aki D. Disinfection of needleless catheter connec-tions and access ports with alcohol may not prevent microbial entry: the promise of a novel antiseptic-barrier cap. Infect Control
Hosp Epidemiol. 2006;27(1):23-27.
18. Adams D, Karpanen T, Worthington T, et al. Infection risk asso-ciated with a closed leur access device J Hosp Infect. 2006;62(3): 353-357.
19. Leon C, Alvarez-Lerma F, Ruiz-Santana S, et al. Antiseptic chamber-containing hub reduces central venous catheter-related infection: a prospective, randomized study. Crit Care Med. 2003;31(5): 1318-1324.
20. Seymour V M , Dhallu TS, M oss H A, et al. A prospective clinical study to investigate the microbial contamination of a needleless connector. J Hosp Infect. 2000;45(2):165-168.
21. Donlan R M , M urga R, Bell M , et al. Protocol for detection of biofilms on needleless connectors attached to central venous catheters. J Clin Microbiol. 2001;39(2):750-753.
22. Do A, Ray B, Banerjee S, et al. Bloodstream infection associated with needleless device use and the importance of infection-control prac-tices in the home health care setting. J Infect Dis. 1999;179:442-448. 23. Arduino M , Bland L, Danzig L, et al. M icrobiologic evaluation of needleless and needle-access devices. Am J Infect Control. 1997; 25(5):377-380.
24. Segura M , Alvarez-Lerma F, Tellado J, et al. A clinical trial on the prevention of catheter-related sepsis using a new hub model. Ann
Surg. 1996;223(4):363-369.
25. Randolph A, Cook, D. Antiseptic hub connectors reduce central venous catheter-related sepsis. Crit Care Med. 1999;27(1)(suppl): 141A.
26. M urga R, M iller JM , Donlan R M . Biofilm formation by gram negative bacteria on central venous catheter connectors: effect of conditioning films in a laboratory model. J Clin Microbiol. 2001; 39(6):2294-2297.
27. M ermel L, Allon M , Bouza E, et al. Clinical practice guidelines for the diagnosis and management of intravascular catheter-relat-ed infection: 2009 update. Clin Infect Dis. 2009;49:1-45. 28. Hadaway L. Infusion therapy equipment. In: Alexander M, Corrigan
A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: An
Evidence-Based Approach. 3rd ed. St Louis, M O: Saunders/Elsevier;
2010:391-436.
29. M arschall J, M ermel L, Classen D, et al. Compendium of strate-gies to prevent central line-associated bloodstream infections in acute care hospitals: SH E A/IDSA practice recommendations.
Infect Control Hosp Epidemiol. 2008;29(1):522-530.
30. Cherneck C, M acklin D, Casella L, Jarvis E. Caring for patients with cancer through nursing knowledge of IV connectors. Clin J
Oncol Nurs. 2009;13(6):630-633.
31. C asey A L, W orthington T , Lambert PA , et al. A randomized, prospective clinical trial to assess the potential risk associated
with the PosiFlow needleless connector. J Hosp Infect. 2003; 54(4):288-293.
32. Casey A L, Burnell S, Whinn H , et al. A prospective clinical trial to evaluate the microbial barrier of a needleless connector. J Hosp
Infect. 2007;65(3):212-218.
33. Salgado C, Chinnes L, Paczesny T, Cantey, R. Increased rate of catheter-related bloodstream infection associated with use of a needleless mechanical valve device at a long-term acute care hos-pital. Infect Control Hosp Epidemiol. 2007;8(6):684-688. 34. Jarvis W R. Choosing the best design for intravenous needleless
connectors to prevent bloodstream infections. Infect Control
Today. http://www.infectioncontroltoday.com. Published July
2010. Accessed August 5, 2010.
35. US Food and Drug Administration. Letter to infection control prac-titioners regarding positive displacement needleless connectors. http://w w w.fda.gov/ M edical D evices/Safety/A lertsand N otices/ ucm220459.htm. Accessed August 5, 2010.
36. Guerin K, Wagner J, Rains K, Bessesen M . Reduction in central line-associated bloodstream infections by implementation of a postinsertion care bundle. Am J Infect Control. 2010;28(6):430-433. 37. M athew A, Gaslin T, Dunning K, Ying, J. Central catheter blood sampling: the impact of changing the needleless caps prior to col-lection. J Infus Nurs. 2009;32(4):212-218.
38. Kaler W, Chinn R. Successful disinfection of needleless access ports: a matter of time and friction. J Assoc Vascular Access. 2007; 12(3):140-142.
39. H orvath B, N orville R, Lee D, et al. Reducing central venous catheter-related bloodstream infections in children with cancer.
Oncol Nurs Forum. 2009;36(2):232-238.
40. Z ack J. Z eroing in on zero tolerance for central line-associated bacteremia. Am J Infect Control. 2008;36(10):s176.e1-s176.e2. 41. Doellman D, Pettit J, Catudal P, Buckner J, Burns D, Frey A M . Association for Vascular Access. Best Practice Guidelines in the
Care and Maintenance of Pediatric Central Venous Catheters.
PE DIV A N ; 2010.
42. M cGoldrick M . Infection prevention and control. In: Alexander M , Corrigan A, Gorski L, H ankins J, Perucca R, eds. Infusion
Nursing: An Evidence-Based Approach. 3rd ed. St Louis, M O :
Saunders/Elsevier; 2010:204-228.
43. Toscano C, Bell M , Z ukerman C, et al. Gram-negative blood-stream infections in hematopoietic stem cell transplant patients: the roles of needleless device use, bathing practices, and catheter care. Am J Infect Control. 2009;37(4):327-334.
44. Yebenes JC, Serra-Prat M . Clinical use of disinfectable needle-free connectors. Am J Infect Control. 2008;36(10):S175e1-S175e4. 45. Sharp M K, M ohammed SF. H emolysis in needleless connectors
for phlebotomy. J Am Soc Artif Intern Organs (ASAIO). 2003;49(1): 128-130.
46. Sheretz R, Karchmer T, O hl C, Palavecino E, Bischoff W. Blood cultures (BC) drawn through valved catheter hubs have a 10-20% positivity rate with the majority being false positives. Paper pre-sented at: Fifth Decennial International Conference on Healthcare-Associated Infections; M arch 18-22, 2010; Atlanta, G A.
28. FILTERS
Standard
shall be established in organizational policies, proce-dures, and/or practice guidelines.
28.2 For nonlipid-containing solutions that require fil-tration, a 0.2-micron filter containing a membrane that is particulate-retentive and air-eliminating shall be used. 28.3 For lipid infusions or total nutrient admixtures that require filtration, a 1.2-micron filter containing a membrane that is particulate-retentive and air-eliminating shall be used. 28.4 Blood and blood component filters appropriate to the therapy shall be used to reduce particulate matter, microaggregates, or leukocytes in infusions of blood or blood components.
28.5 For intraspinal infusions, a 0.2-micron filter that is surfactant-free, particulate-retentive, and air-elimi-nating shall be used.
28.6 A blunted filter needle or filter straw shall be used when drawing medications from glass ampoules.
Practice Criteria
A. Use of all filters should adhere to manufacturers’ directions for use and filtration requirements of the therapy.1(V)
B. Bacteria- and particulate-retentive and air-elimi-nating membrane filter changes should coincide with administration set changes.2(V)
C. Blood and blood component filters should be changed every 4 hours or coincide with blood administration set changes.3(V)
D. Add-on bacteria- and particulate-retentive and air-eliminating membrane filters should be located as close to the catheter insertion site as possible.2(V)
E. When an electronic infusion device is used, con-sideration should be given to the pounds per square inch (psi) rating of the filter.1,2,4(V)
REFERENCES
1. H adaway L. Infusion therapy equipment. In: Alexander M , Corrigan A, Gorski L, H ankins J, Perucca R, eds. Infusion
Nursing: An Evidence-Based Approach. 3rd ed. St Louis, M O :
Saunders/Elsevier; 2010:418-421.
2. Principles and use of intravenous equipment for infusion therapy. In: Weinstein S, ed. Plumer’s Principles & Practice of Intravenous
Therapy. 8th ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2007;45:193-230, 563.
3. A ABB. Technical Manual. 16th ed. Bethesda, M D: A ABB; 2008: 618-621.
4. Phillips L D. Manual of I.V. Therapeutics. 5th ed. Philadelphia, PA: F A Davis; 2010:253.
29. FLOW-CONTROL DEVICES
Standard
29.1 T he type of flow-control device selected shall be based on patient age, condition, prescribed
infu-sion therapy, type of vascular access device, and care setting.
29.2 O nly electronic infusion devices with administra-tion-set–based anti–free-flow mechanisms shall be used.
29.3 Dose-error reduction systems shall be considered in the selection and use of electronic infusion devices. 29.4 The use of flow-control devices shall be estab-lished in organizational policies, procedures, and/or practice guidelines.
29.5 The nurse shall be competent in the use of flow-control devices, including manual devices, mechanical devices, and electronic infusion devices.
Practice Criteria
A. Flow-control devices should be monitored during the administration of infusion therapy to ensure accurate delivery of the prescribed infusion rate.1-6
(III)
B. The nurse should not rely on the electronic infu-sion device alarms to detect IV infiltration or extravasation as these alarms are not intended to detect disruption of the fluid flow pathway.6-8(V)
C. Safety features and dose-error reduction systems should be considered in the selection of all electronic flow-control devices. The nurse should be involved in the evaluation and selection of flow-control devices.9-15(V)
D. Systematic methods, such as failure mode and effects analysis (F M E A) or Six Sigma, should be incorporated into the evaluation of flow-control device selection and used to reduce errors and enhance safety. In addition, adverse event reports (such as those from the US Food and Drug Administration’s M anufacturer and User Facility Device Experience site) should be consulted when considering mechanical and electronic flow-con-trol devices for purchase.12-14,16 (V)
E. The frequency of inspection, cleaning, testing, and maintenance of electronic flow-control devices should adhere to manufacturers’ direction(s) for use and directions and guidelines established by regulato-ry agencies.10,11,17,18(V)
F. The choice of a flow-control device (manual flow regulators, pressure bags, mechanical pumps, elas-tomeric balloon pumps, spring-based pumps, negative-pressure pumps, electronic infusion pumps) for a given clinical application should take into account such factors as age and mobility of the patient, severity of illness, type of therapy, and health care setting. Features should be consistent with recom-mendations for safe and effective use. Additional features are recommended for patient-controlled analgesia (PC A) pumps (eg, patient ease of use, accuracy) and systems that require a higher pump-ing pressure (eg, arterial and epidural lines).11,17(V)
G. Patient education for those using electronic flow-control devices in the home care setting should include written instructions, troubleshooting guides, whom/how to contact for assistance, signs of under-or over-infusion, and pump malfunction. Education should include demonstration and explanation of infusion pump functions followed by observation of the patient/caregiver performance.19,20(V)
REFERENCES
1. Rosenthal K. Smart pumps help crack the safety code. Nurs
Manag. 2004;35(5):49-51.
2. H ertzel C, Sousa V D. Use of smart pumps for preventing medica-tion errors. J Infus Nurs. 2009;32(5):257-267.
3. M urdoch LJ, Cameron V L. Smart infusion technology: a mini-mum safety standard for intensive care? Br J Surg. 2008;17(10):630-636.
4. Rothschild JM , Keohane C A, Cook EF, et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Crit Care Med. 2005;33(3):679-680.
5. Institute for H ealthcare Improvement. Reduce adverse drug events (A D Es) involving intravenous medications: implement smart infusion pumps. www.I H I.org. Accessed M arch 26, 2010. 6. Ilan R, Fowler F A, Ferguson N D, et al. Prolonged time to alarm
in infusion devices operated at low flow rates. Crit Care Med. 2008;36(10):2763-2765.
7. Pennsylvania Patient Safety Reporting System. IV infiltration: be alarmed even when your infusion pump isn’t. Patient Saf
Advisory. 2007;4(3):1-4.
8. H uber C. IV infusion alarms: don’t wait for the beep. Am J Nurs. 2009;109(4):32-33.
9. Bowcutt M , Rosenkoetter M M , Chernecky C C, Wall J, Wynn D, Serrano C. Implementation of an intravenous medication infusion pump system: implications for nursing. J Nurs Manage. 2008;16: 188-197.
10. E C RI Institute. Large volume infusion pumps. Health Devices. http//www.ecri.org. Published December 2009. Accessed M arch 15, 2010.
11. E C RI Institute. E C RI Institute’s infusion pump criteria. Health
Devices. http//www.ecri.org. Published February 2008. Accessed
M arch 15, 2010.
12. N emeth C, N unnally M , Bitan Y, N unnally S, Cook RI. Between choice and chance: the role of human factors in acute care equip-ment decisions. Patient Saf. 2009;5(2):114-121.
13. Adachi W, Lodolce A E. Use of failure mode and effects analysis in improving the safety of I.V. drug administration. Am J
Health-Syst Pharm. 2005;62(9):917-920.
14. Christopher D A, Campbell A, Dateshidze J. Working smarter with intelligent pumps. Pharm Solutions. http//www.nursingmanagement. com. Published N ovember 2008. Accessed February 22, 2010. 15. Rothschild JM , Keohane C A, Cook EF, et al. A controlled trial of
smart infusion pumps to improve medication safety in critically ill patients. Crit Care Med. 2005;33(3):533-540.
16. US Food and Drug Administration. M anufacturer and user facility device experience (M A U D E). http://www.accessdata.fda.gov/scripts/ cdrh/cfdocs/cf M A U D E/search.C F M . Accessed December 30, 2009. 17. Perucca R. Infusion therapy equipment: types of infusion therapy equipment. In: Alexander M , Corrigan A, Gorski L, H ankins J, Perucca R, eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed. St Louis, M O : Saunders/Elsevier, 2010:411-418.
18. Rutala W, Weber D. H ealthcare Infection Control Practice Advisory Committee (H ICPA C). Guideline for Disinfection and
Sterilization in Healthcare Facilities, 2008. http://w w w.
cdc.gov/ncidod/dhqp/pdf/guidelines/Disinfection_N ov_2008.pdf. Accessed December 5, 2009.
19. US Food and Drug Administration. Infusion pump risk reduction strategies for home health nurses. http://www.fda.gov/M edical Devices/Productsand M edicalProcedures/General H ospitalDevices andSupplies/InfusionPumps/ucm205411.htm. Published April 22, 2010. Accessed June 1, 2010.
20. Gorski L A. Pocket Guide to Home Infusion Therapy. Boston, M A: Jones & Bartlett, 2005.
30. BLOOD AND FLUID WARMERS
Standard
30.1 The use of blood and fluid warmers shall be estab-lished in organizational policies, procedures, and/or prac-tice guidelines and in accordance with A ABB standards for administration of blood.
30.2 Blood and fluid warming shall be performed only with devices specifically designed for that purpose. 30.3 Blood shall be warmed in a manner to avoid hemolysis.
Practice Criteria
A. Blood and fluid warmers should be used when warranted by patient history, clinical condition, and prescribed therapy, including, but not limited to, avoiding or treating hypothermia, during car-diopulmonary bypass, when the patient is known to have cold agglutinins, or during replacement of large blood volumes.1-5(III)
B. The frequency of cleaning and preventive mainte-nance of blood and fluid warming devices should adhere to the manufacturer’s directions for use and guidelines established by regulatory agencies.1,4,5
(V)
C. N urses should use blood and fluid warmers equipped with warning systems, including an audi-ble alarm and visual temperature gauges.6-8(V)
D. O ther warming methods, including, but not lim-ited to, microwave ovens, hot water baths, and devices not expressly designed for blood and fluid warming, should not be used because tem-peratures and infection risks cannot be con-trolled.9-11(V)
REFERENCES
1. A ABB. Standards for Blood Banks and Transfusion Services. 26th edition. Bethesda, M D: A ABB; 2009.
3. H asankhani H , M ohammadi E, M oazzami F, M okhtari M , N aghgizadh M M . The effects of intravenous fluids temperature on perioperative hemodynamic situation, post-operative shiver-ing, and recovery in orthopaedic surgery. Can Oper Room Nurs
J. 2007;25(1):20-27.
4. Stainsby D, M acLennan S, H amilton PJ. M anagement of massive blood loss: a template guideline. Br J Anaesth. 2000;85:487-491. 5. US Food and Drug Administration. C FR Title 21. H ematology and Pathology Devices. Blood and plasma warming devices (864.9205). http://w w w.accessdata.fda.gov/scripts/cdrh/cfdocs/ cf C F R/C F RSearch.cfm?F R=864.9205. A ccessed January 11, 2010.
6. Stammers A H , M urdock JD, Klayman M H , et al. Utilization of rapid-infuser devices for massive blood loss. Perfusion. 2005;2: 65-69.
7. AST M Standard F217-02 (2009), “Standard Specification for Blood/Intravenous Fluid/Irrigation Fluid W armers, ” AST M International, West Conshohocken, PA, 2009. www.astm.org. Accessed January 22, 2010.
8. Avula RR, Kramer R, Smith C E. Air detection performance of the Level 1 H-1200 fluid and blood warmer. Anesth Analog. 2005; 101:1413-1416.
9. McEwen MP, Roxby D. Can latent heat safely warm blood? In vitro testing of a portable prototype blood warmer. BMC Emerg Med. 2007;7(8). http://www.ncbi.nlm.nih.gov/pmc/articles/PM C1988795/. Accessed April 5, 2010.
10. Riley W. BelmontT Mhyperthermia pump in the conduct of
intra-operative heated chemotherapy. Perfusion. 2009;24:115-118. 11. Trick N . Blood component therapy. In: Alexander M , Corrigan
A, Gorski L, H ankins J, Perucca R, eds. Infusion Nursing: An
Evidence-Based Approach. 3rd ed. St Louis, M O : Saunders/
Elsevier; 2010:249-253.
31. TOURNIQUETS
Standard
31.1 A tourniquet shall be properly applied to promote vascular distension in preparation for peripheral venipuncture.
31.2 The use of tourniquets shall be established in orga-nizational policies, procedures, and/or practice guidelines.
Practice Criteria
A. The tourniquet should be single-patient use.1-8(IV)
B. The nurse should assess the patient for latex aller-gy when considering tourniquet material (see Standard 25, Latex Sensitivity or Allergy).9,10(V)
C. The tourniquet should be applied at an appropriate location above the selected venipuncture site.8,11,12(V)
D. An arterial pulse should be easily palpable distal to the tourniquet location.8,11,12 (I A/P)
E. The tourniquet should be applied in such a man-ner as to prevent circulatory impairment. 8,11,12
(I A/P)
F. The nurse should assess for factors indicating that a tourniquet should be loosely applied or its use avoided in patients who bruise easily, are at risk for bleeding, have compromised circulation, and/or have fragile skin or veins.11-13(V)
REFERENCES
1. Franklin G F, Bal A M , M cKenzie H . Phlebotomy tourniquets and M RSA. J Hosp Infect. 2007;65:173-184.
2. Fellowes C, Kerstein R, Azadian B. Breaking the cycle. J Hosp
Infect. 2007;65:279-280.
3. Leitch A, M cCormick I, Gunn I, Gillespie T. Reducing the poten-tial for phlebotomy tourniquets to act as a reservoir for methicillin-resistant Staphylococcus aureus. J Hosp Infection. 2006;63(4):428-431.
4. Sacar S, Turgut H , Kaleli I, et al. Poor hospital infection control practice in hand hygiene, glove utilization, and usage of tourni-quets. Am J Infect Control. 2006;34(9):606-609.
5. Fellowes C, Kerstein R, Clark J, Azadian BS. M RSA on tourni-quets and keyboards. J Hosp Infect. 2006;64(1):86-88. 6. Rourke C, Bates C, Read R C. Poor infection control practice in
venipuncture and use of tourniquets. J Hosp Infect. 2001;49(1): 59-61.
7. Golder M , Chan C L H , O ’Shea S, Corbett K, Chrystie IL. Potential risk of cross-infection during peripheral-venous access by contamination of tourniquets. Lancet. 2000;355:44. 8. H adaway L C, M illam D A. O n the road to successful IV starts.
Nursing. 2005;35(suppl 1):1-14.
9. Society of Gastroenterology N urses and Associates. Guideline for preventing sensitivity and allergic reactions to natural rubber latex in the workplace. Gastroenterol Nurs. 2008;31(3):239-246. 10. Gavin M , Patti PJ. Issues in latex allergy in children and adults receiving home healthcare. Home Healthc Nurse. 2009;27(4): 231-239.
11. Perucca R. Peripheral venous access devices. In: Alexander M , Corrigan A, Gorski L, H ankins J, Perucca R, eds. Infusion
Nursing: An Evidence-Based Approach. 3rd ed. St Louis, M O :
Saunders/Elsevier; 2010:456-479.
12. Elkin, M K, Perry, A G, Potter, PA. Nursing Interventions and
Clinical Skills. 4th ed. St Louis, M O : M osby/Elsevier, 2007:598.
13. M oureau N . Tips for inserting an IV in an older patient. Nursing. 2004;34(7):18.
D. The use of steel winged devices should be limited to short-term or single-dose administration.13,14(V)
E. Therapies not appropriate for short peripheral catheters include continuous vesicant therapy, parenteral nutrition, infusates with pH less than 5 or greater than 9, and infusates with an osmolal-ity greater than 600 mOsm/L. The nurse should collaborate with the pharmacist and the licensed independent practitioner (LIP) to assist in selec-tion of the most appropriate vascular access device based on a projected treatment plan.5,6,13,14,18-24
(IV)
F. Peripheral administration of parenteral nutrition via a short peripheral catheter should be used with caution in adults.21,22(IV)
G. The nurse should be aware that a short peripher-al catheter of 14-24 gauge for adults and 22-24 gauge for pediatric or neonates can generally be used for administration of blood or blood products.11,12,16
(V)
Practice Criteria II. Midline Catheters
A. The nurse should consider selection of midline catheters for therapies anticipated to last 1-4 weeks. Reported dwell time for midline catheters in neonates is 6-10 days.9,10,16,25,26(V)
B. A midline catheter should be used for hydration, intravenous solutions, pain medications, and some antibiotics. Therapies not appropriate for midline catheters include continuous vesicant therapy, par-enteral nutrition, infusates with pH less than 5 or greater than 9, and infusates with an osmolality greater than 600 mOsm/L.9,13,14(V)
C. Midline catheters are peripheral infusion devices with the tips terminating in either the basilic, cephalic, or brachial vein, distal to the shoulder. The basilic vein is preferred due to vein diameter. The tip does not enter the central vasculature.
32. VASCULAR ACCESS DEVICE
SELECTION
Standard
32.1 Indications and protocols for vascular access devices (VADs) shall be established in organizational policies, procedures, and/or practice guidelines and according to manufacturers’ directions for use.
32.2 The nurse shall select the appropriate type of catheter (peripheral or central) to accommodate the patient’s vas-cular access needs based on the prescribed therapy or treat-ment regimen, length of treattreat-ment, duration of dwell, vas-cular integrity, patient preference, and ability and resources available to care for the device.
32.3 The catheter selected shall be of the smallest gauge and length with the fewest number of lumens and shall be the least invasive device needed to accommodate and manage the prescribed therapy.
32.4 The nurse shall not alter the vascular access device outside the manufacturer’s directions for use.
Practice Criteria
I. Short Peripheral Catheters
A. The nurse should select a short peripheral catheter based on prescribed therapies, duration of treatment (usually for treatments of less than 1 week), availability of peripheral vascular access sites, diagnosis, known complications of the device, and the inserter’s experience.1-9(V)
B. A short peripheral catheter comes in a variety of gauge sizes (ie, 14-27); winged or nonwinged; sin-gle or double lumen; or over-the-needle catheters. The tip of a short peripheral catheter terminates in a peripheral vein.2,3,5,6,10-16(V)
C. The nurse should use short peripheral catheters equipped with a passive or active safety mechanism to provide sharps injury protection.12,16,17(V)
Vascular Access Device Selection
and Placement
Midline catheters inserted via a scalp vein in neonates and pediatric patients should have the tip terminating in the external jugular vein (EJV).5,16,20,27(V)
D. Midline catheters are available as single- or double-lumen (1.9 Fr-5 Fr) polyurethane or silicone devices. Midline catheters for pediatric patients are available in gauge sizes of 22-24.3,9,10,12-14,16,25,28(V)
Practice Criteria
III. Central Vascular Access Devices
(CVADs) (Nontunneled, PICC, Tunneled, Implanted Port)
A. The nurse should use CVADs to administer short- or long-term continuous or intermittent infusion solu-tions such as antineoplastic medicasolu-tions, vesicants or known irritants, parenteral nutrition, a variety of antibiotics, and any medications with a pH of less than 5 or greater than 9 and osmolarity of greater than 600mOsm/L.5,6,13,29(V)
B. The nurse should be aware that in order to minimize thrombotic complications, the tip of a CVAD should terminate in the central vasculature, such as the supe-rior vena cava (SVC) or infesupe-rior vena cava (IVC). Dialysis catheter tips may terminate in the right atrium.6,20,30(V)
C. CVADs can be manufactured as single or multilumen, silicone, or polyurethane, along with various gauge sizes and lengths; open- or closed-ended; power-injectable; and/or as anti-infective devices.6,10,13,16,31-34
(V)
D. The nurse should collaborate with the multidiscipli-nary team to consider anti-infective CVADs in the following circumstances: expected dwell of more than 5 days; catheter-related bloodstream infection (CR-BSI) rate remains high even after employing other preventive strategies; neutropenic, transplant, burn, hemodialysis, or critically ill patients; catheter insertion or exchange in patients with infection or bacteremia; or for emergency insertions. Anti-infec-tive CVADs have shown a decrease in colonization and/or CR-BSIs. These types of CVADs include devices coated or impregnated with chlorhexidine and silver sulfadiazine, minocycline and rifampin, and silver ion. The nurse should be aware that anti-infective CVADs should not be used in patients with allergies to silver, chlorhexidine, silver sulfadiazine, rifampin, or tetracyclines.1,29,32,35-51(I)
E. CVADs designed to withstand high-pressure injec-tions (up to 300 pounds per square inch [psi]) have been found to be feasible and effective and with published reports of safe use.6,10,52-57(II)
F. The nurse should be knowledgeable about whether the CVAD may be trimmed (considering factors
such as open- versus closed-ended; staggered lumen exits) and should follow the manufacturer’s direc-tions for use for altering the device length, should the device require trimming. The use of scissors should be avoided in trimming catheter length. Use of scissors to adjust the length of peripherally insert-ed central catheters (PICCs) was found to result in rough, irregular surfaces as observed with scanning electron microscopy. If the catheter length is modi-fied, the nurse should document the length in the patient’s permanent medical record.34,58-60(IV)
G. The nurse should be aware that there are specific catheter selection and placement recommendations for patients with chronic kidney disease (CKD). Catheters with high flow rates should be used (see Standard 40, Hemodialysis Vascular Access Devices).30(V)
H. CVAD tip location and dwell time for CKD patients vary based on type of catheter selected and the specific patient condition. Short-term CVAD tips should be located in the SVC; long-term (tun-neled) CVAD tips should be located in the right atrium; femoral CVAD tip locations should be in the IVC. Uncuffed hemodialysis CVADs should be used in hospitalized CKD patients only and dwell up to 1 week. If an uncuffed hemodialysis CVAD is selected for femoral placement, it should be used in bed-bound CKD patients and dwell for only 5 days (see Standard 40, Hemodialysis Vascular Access Devices).30(V)
Practice Criteria IV. Arterial Catheters
A. Peripheral or pulmonary arterial catheters should be considered for short-term use for hemodynamic monitoring, obtaining blood samples, and analyz-ing blood gas in critically ill patients.28(V)
B. The nurse should be aware that the radial artery is the most common insertion site because of easier access and a lower complication rate. Other possi-ble sites are the femoral, axillary, brachial, and tib-ial posterior arteries.61-64(I)
C. If the radial artery site is selected, a 20-gauge arte-rial catheter is preferred to decrease the risk of thrombosis.62(I)
D. The nurse should be aware of the potential complica-tions associated with arterial catheters and that rates of complications, such as thrombosis and infection, appear to increase with extended dwell time.61-65(I)
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34. Pettit J. Trimming of peripherally inserted central catheters: the end result. J Assoc Vascular Access. 2006;11(4):209-214. 35. Raad I, Hanna H. Intravascular catheter related infections: new
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38. Raad I, Darouiche R, Dupuis J, et al. Central venous catheters coat-ed with minocycline and rifampin for the prevention of catheter related colonization and bloodstream infections: a randomized dou-ble-blind trial. Ann Intern Med. 1997;127(4):267-274.
39. Hanna H, Benjamin R, Chatzinikolaou I, et al. Long-term silicone central venous catheters impregnated with minocycline and rifampin decrease rates of catheter-related bloodstream infection in cancer patients: a prospective, randomized clinical trial. J Clin
40. Bassetti S, Hu J, D’Agostin R, et al. Prolonged antimicrobial activ-ity of a catheter containing chlorhexidine and silver sulfadiazine extends protection against catheter infection in vivo. Antimicrob
Agents Chemother. 2001;45:1535-1538.
41. Logghe C, Vanossel C, Dhoore W, et al. Evaluation of chlorhex-idine and silver sulfadiazine-impregnated central venous catheters for the prevention of bloodstream infection in leukaemic patients: a randomized controlled trial. J Hosp Infect.1997;37:145-156. 42. Bach A, Eberhardt H, Frick A, et al. Efficacy of silver-coating
cen-tral venous catheters in decreasing bacterial colonization. Crit
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43. Bong JJ, Kite P, Wilco M, et al. Prevention of catheter related blood-stream infections by silver iontophoretic central venous catheters: a randomized controlled trial. J Clin Pathol. 2003;56:731-735. 44. Fraenkel D, Rickard C, Thomas P, et al. A prospective randomized trial
of rifampin-minocycline coated and silver-platinum-carbon impregnat-ed central venous catheters. Crit Care Mimpregnat-ed. 2006;34:668-675. 45. Ranucci M, Guiseppi I, Gromarelli P, et al. Impact of oligon
cen-tral venous catheters on catheter colonization and catheter-relat-ed bloodstream infections. Crit Care Mcatheter-relat-ed. 2003;31:52-59. 46. Crnick JC, Maki DG. Are antimicrobial-impregnated catheters
effective? When does repetition reach the point of exhaustion?
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49. Rupp M, Lesco S, Lipsett P, et al. Effect of second generation venous catheters impregnated with chlorhexidine and silver sulfa-diazine (CHSS) on central catheter-related infections: a random-ized controlled trial. Ann Intern Med. 2005;143:570-580. 50. Darouiche R, Raad I, Heard S, et al. A comparison of two
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Care. 2002;6(3):198-204.
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Prospective study with peripheral arterial catheter infection and com-parison with concurrently sited central venous catheters. Crit Care
Med. 2008;36(2):397-402.
64. Blot F, Estphan G, Boughaba A, Soltani D, et al. Is routine chang-ing of peripheral arterial catheters justified? Clin Microbiol Infect. 2008;14(9):813-815.
65. Khalifa R, Dahyot-Fizelier C, Laksiri L, et al. Indwelling time and risk of colonization of peripheral arterial catheters in critically ill patients. Intensive Care Med. 2008;34(10):1820-1826.
33. SITE SELECTION
Standard
33.1 Site selection for all vascular access devices (VADs) shall be established in organizational policies, proce-dures, and/or practice guidelines.
33.2 The vasculature shall accommodate the gauge and length of the catheter required for the prescribed therapy. 33.3 Site selection for vascular access shall include assess-ment of the patient’s condition; age; diagnosis; comorbidi-ties; condition of the vasculature at the insertion site and proximal to the intended insertion site; condition of skin at intended insertion site; history of previous venipunctures and access devices; type and duration of infusion therapy; and patient preference.
33.4 Prior to insertion of a peripherally inserted central catheter (PICC), anatomical measurements shall be taken to determine the length of the catheter required to ensure full advancement of the catheter to the lower third of the superior vena cava and the junction of the superior vena cava and right atrium.
33.5 Placement of central vascular access devices (CVADs) by nurses shall be established in organizational policies, procedures, and/or practice guidelines and in accordance with rules and regulations promulgated by the state’s Board of Nursing.
Practice Criteria
I. Peripheral Venous Access via Short Peripheral Catheters
A. For adult patients, veins that should be consid-ered for peripheral cannulation are those found on the dorsal and ventral surfaces of the upper extremi-ties, including the metacarpal, cephalic, basilic, and
median veins. Avoid the lateral surface of the wrist for approximately 4-5 inches because of the poten-tial risk for nerve damage. For pediatric patients, similar veins to consider are in the hand, forearm, antecubital area, and upper arm below the axilla, as well as the veins of the scalp, foot, and fingers in infants and toddlers. For adult and pediatric patients: avoid the ventral surface of the wrist due to the pain on insertion and possible damage to the radial nerve.1-5(V)
B. Site selection should be initiated routinely in the dis-tal areas of the upper extremities; subsequent cannu-lation should be made proximal to the previously cannulated site.3(V)
C. Site selection should be initiated routinely in the nondominant arm. VAD sites should avoid areas of flexion; areas of pain on palpation; veins that are compromised (eg, bruised, infiltrated, phlebitic, scle-rosed, or corded); location of valves; and areas of planned procedures. In infants and children, avoid the hand or fingers, or the thumb/finger used for sucking.2,3,6,7(V)
D. Veins of the lower extremities should not be used routinely in the adult population due to risk of tissue damage, thrombophlebitis, and ulceration.2
(I A/P)
E. Veins in an upper extremity should be avoided on the side of breast surgery with axillary node dissec-tion, after radiation therapy to that side, or with lym-phedema, or the affected extremity from a cere-brovascular accident. For patients with chronic kid-ney disease stage 4 or 5, avoid forearm and upper-arm veins “suitable for placement of vascular access.” A collaborative discussion with the patient and the licensed independent practitioner (LIP) should take place related to the benefits and risks of using a vein in an affected extremity.3,6,8-12 (V)
F. Veins in the right arm of infants and children should be avoided after procedures treating congen-ital cardiac defects that may have decreased blood flow to the subclavian artery.13(V)
G. Cannulation of hemodialysis fistulas and grafts for infusion therapy requires the order of a nephrologist or LIP.3(V)
H. The nurse should consider using visualization technologies that aid in vein identification and selection.3,14(V)
Practice Criteria
II. Peripheral Venous Access via Midline Catheters
A. Site selection should be routinely initiated in the region of the antecubital fossa. Veins that should be considered for midline catheter cannulation are the basilic, cephalic, and brachial veins. For neonate and
pediatric patients, additional site selections include veins in the leg with the tip below the groin and in the scalp with the tip in the neck, above the thorax.1,3(V)
B. Site selection should avoid areas of pain on palpa-tion, veins that are compromised (eg, bruised, infil-trated, phlebitic, sclerosed, or corded), and for patients with chronic kidney disease stage 4 or 5, avoid forearm and upper-arm veins “suitable for placement of vascular access.”2,3,8,12(V)
C. Veins in an upper extremity should be avoided on the side of breast surgery with axillary node dissection, after radiation therapy to that side, or with lymphedema, or the affected extremity from a cerebrovascular acci-dent. For patients with chronic kidney disease stage 4 or 5, avoid upper-arm veins “suitable for placement of vascular access.” A collaborative discussion with the patient and the licensed independent practitioner (LIP) should take place related to the benefits and risks of using a vein in an affected extremity.3,8,9,11(V)
D. Veins in the right arm of infants and children should be avoided after procedures treating specif-ic congenital cardiac defects that may have decreased blood flow to the subclavian artery.13(V)
E. The nurse should consider using visualization technologies that aid in vein identification and selection.14(V)
Practice Criteria
III. Central Venous Access via Peripherally Inserted Central Catheters (PICCs)
A. Veins that should be considered for PICC cannula-tion are the basilic, median cubital, cephalic, and brachial veins. For neonate and pediatric patients, additional site selections include the temporal vein and posterior auricular vein in the head and the saphenous vein in the lower extremities.13,15(V)
B. Site selection should avoid areas of pain on palpa-tion; veins that are compromised (eg, bruised, infil-trated, phlebitic, sclerosed, or corded); and for patients with chronic kidney disease stage 4 or 5, avoid forearm and upper-arm veins “suitable for placement of vascular access.”2,8,12(V)
C. Veins in an upper extremity should be avoided on the side of breast surgery with axillary node dissection, after radiation therapy to that side, or with lymphedema, or the affected extremity from a cerebrovascular acci-dent. For patients with chronic kidney disease stage 4 or 5, avoid upper-arm veins “suitable for placement of vascular access.” A collaborative discussion with the patient and the licensed independent practitioner (LIP) should take place related to the benefits and risks of using a vein in an affected extremity.8,9,11(V)
Practice Criteria
IV. Central Venous Access via Nontunneled Central Vascular Access Devices (CVADs) A. To minimize the risk of catheter-related infection with a nontunneled CVAD, the subclavian vein is recommended in adult patients, rather than the jugu-lar or femoral veins, although benefits and risks accompany each access site. For patients with chron-ic kidney disease, the subclavian vein is not recom-mended in order to preserve the vein.8,12,17,18(I)
B. To minimize the risk of catheter-related thrombotic complications with a nontunneled CVAD, the sub-clavian vein is recommended in adult patients, rather than the femoral vein, although benefits and risks accompany each access site.17(I)
C. There is no preferred venous insertion site for a nontunneled CVAD in infants and children to minimize the risk of infection.19(V)
Practice Criteria
V. Central Venous Access via Tunneled Central Vascular Access Devices and Implanted Ports
A. The nurse should collaborate with the health care team and patient in assessment and site selection for place-ment of tunneled catheters and implanted ports.11(V)
Practice Criteria
VI. Peripheral Arterial Access
A. Criteria for selection should include the presence of a pulse and assessment of distal circulation. An Allen test should be performed when selecting the appro-priate artery for cannulation, prior to device inser-tion, and for assessment of distal arterial perfusion.2
(I A/P)
B. The radial artery should be considered the most appropriate access for percutaneous cannulation in adults for its advantages and to prevent infection. Alternative arteries include ulnar, brachial, and dor-salis pedis in adults, with each having advantages and disadvantages. These sites are preferred over the femoral or axillary to reduce the risk of infection. For pediatric patients, site selections include radial, posterior tibial, and dorsalis pedis arteries and are preferred over the femoral or axillary sites to reduce the risk of infection. The brachial artery should not be used in pediatric patients due to the absence of collateral blood flow.2,20(I A/P)
C. Infusion therapy is not administered in peripheral arteries via peripheral arterial catheters; these catheters are used for hemodynamic monitoring, blood gas analysis, and obtaining blood samples.2,14(V)
D. The nurse should consider using visualization technologies that aid in arterial identification and selection.14(V)
Practice Criteria
VII. External Jugular Vein Access
A. Nurses who are competent in infusion therapy may insert short peripheral intravenous (IV) catheters and PICCs, using the external jugular vein in patients in acute care settings and in emergency sit-uations when other veins cannot be accessed.2,21(V)
B. A short peripheral catheter in the external jugular vein should not be used for contrast media or with power injectors.21(V)
C. Central venous pressure monitoring may be performed through PICCs in the external jugular vein.21(V)
D. When a short peripheral catheter is inserted into the external jugular vein and infusion therapy is expected to exceed 72 to 96 hours, the nurse should collaborate with the LIP for an alternative vascular access site as soon as possible.3,21(V)
REFERENCES
1. Frey AM, Pettit J. Infusion therapy in children. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:
An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/
Elsevier; 2010:550-570.
2. Hadaway L. Anatomy and physiology related to infusion thera-py: In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing: An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/Elsevier; 2010:139-177.
3. Perucca R. Peripheral venous access devices. In: Alexander M, Corrigan A, Gorski L, Hankins J, Perucca R, eds. Infusion Nursing:
An Evidence-Based Approach. 3rd ed. St Louis, MO: Saunders/
Elsevier; 2010:456-479.
4. Laskowski-Jones L, Falkowski A. Infusion therapy. In: Ignatiavicius DD, Workman ML. Medical-Surgical Nursing: Patient-Centered
Collaborative Care. 6th ed. St Louis, MO: Mosby/Elsevier; 2010:
213-240.
5. Peripheral infusion therapy techniques. In: Weinstein S, ed.
Plumer’s Principles & Practice of Intravenous Therapy. 8th ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2007:242-259. 6. Ostendorf W. Fluid, electrolyte, and acid-base balance. In: Potter P, Perry A. Fundamentals of Nursing. 7th ed. St Louis, MO: Mosby/Elsevier; 2009:966-1027.
7. Taylor E. Infant perioperative patients. AORN J. 2007;86:843-848. 8. American Nephrology Nurses’ Association Board of Directors [position statement]. Vascular access for hemodialysis. http:// www.annanurse.org/cgibin/WebObjects/ANNANurse.woa/wa/view Section?s_id/1073744052&ss_id/536873322&tName/vascAccess. Published 2010. Accessed March 17, 2010.
9. Felty CL, Rooke TW. Lymphedema. In: Fahey V.Vascular Nursing. 4th ed. St Louis, MO: Saunders; 2004:33-46.
10. Hayden BK, Goodman M. Chemotherapy: principles of administra-tion. In: Yarbro CH, Frogge MH, Goodman M. Cancer Nursing:
Principles and Practice. 6th ed. Boston, MA: Jones and Bartlett;
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