Assessing the IV site

[CapeCodMermaid, RN]

I am trying to modernize the IV protocols at my facility. Our flow sheet still has a space for hypodermoclysis!

Has the standard changed or is it still sufficient to assess a peripheral IV site q 8 hours?

This is Massachusetts. My pharmacy has not been at all helpful.

Thanks.

[iluvivt, BSN, RN]

I have been writing our infusion policies since 1991 so I can give you some help. How often you assess your site will depend upon your practice setting. I am assuming you are in acute care. Generally speaking,if you are going to state what you want a nurse specifically to do in a policy and procedure you must also expect the nurse to document and have a place to document that. You must state what the minimum standard is,so what I do is pick a time based on the practice area. In medical surgical areas I have them assess q 4 hours and prn and in pediatrics and ICUs they assess q 2 hours and prn. Now, that prn is very important and still holds the nurse accountable. If a patient for any reason needs increased monitoring the prn is stating that the nurse should know that.

Here is what I have on the one I wrote:

RN to assess q______hrs (depends on setting) for the following

a. pain or tenderness at site or along vein pathway

b. redness (you can also use the term erythema)

c. swelling or pt complains of "skin tightness"

d. leaking

e. coolness

f. blanching

g. purulent drainage

h. sluggish infusion

Instead of listing each complication and all of the symptoms I list them this way since they all overlap. It would also get really long. Hypodermoclysis is still used by the way. I usually see it used for MS in the oncology population. I would probably take it off the form too, You can always write that in on the rare occasion you might see it. Let me know if I can help you with anything else.