Quick Summary––2000 Infusion
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Nursing Standards of Practice
Recommended
General
■ Wash hands before and after clinical procedures, and
before donning and after removing gloves. (S27)
■ Use aseptic technique, sterile products, and gloves and
consider maximum sterile barrier precautions when
performing infusion procedures. (S25)
Insertion/Site Care
■ Clip hair, do not shave. (S40)
■ Avoid routine use of injectable, local
anesthetics. (S41)
■ Use maximum barrier precautions for the
insertion of midline, arterial, and all tunneled
and non-tunneled central line catheters. (S41)
■ No more than two attempts at cannulation by any
one nurse, only one catheter shall be used per each
attempt. (S43)
■ Use sterile gloves and mask for site care when catheters
have extended dwell times, catheter tip is centrally
located, or patient is immunocompromised. (S55)
Dressing Changes
■ Change tape and gauze dressings q48 hours or
immediately if integrity is compromised. (S44)
■ The integrity of gauze dressing edges should be
maintained with an occlusive material. (S44)
■ Gauze used under a transparent dressing is considered
a tape and gauze dressing and changed q48 hours. (S44)
■ Change transparent dressings at established intervals
or immediately if integrity is compromised (peripheral-
short catheters at time of site rotation). (S44)
Line Changes
■ Change primary and secondary administration sets
q48-72 hours depending on phlebitis and infection
rates. (S48)
■ Change primary intermittent sets and TPN administration
sets q24 hours. (S49)
■ Change lipid administration sets after each unit or q24
hours if units are administered consecutively. (S49)
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Infusion Nursing Standards of Practice. Journal of Intravenous Nursing, November/December 2000; 23 (6S): S1–S88.
■ Minimize exposure to latex. (S31)
■ All add-on devices should be of Luer-Lok design. (S32)
■ All needles should have a safety device with engineered
sharps injury protection. (S29)
■ Cleanse site with an approved antimicrobial solution
before insertion and at every dressing change (2%
tincture of iodine, alcohol, 10% povidone-iodine, or
chlorhexidine), as single agents or in combination. (S42)
■ Air-dry all preps. (S42)
■ Stabilize catheter without interfering with assessment
or monitoring. (S32)
■ Visually inspect site and palpate site for tenderness
on a daily basis. (S44)
■ Any incident of phlebitis, infiltration, or extravasation
should be reported as an unusual occurrence.
(S56, 57, 58)
■ Injection/access ports shall be aseptically cleansed prior
to access. (S45)
■ Use only sterile tape under a transparent dressing,
if required. Tape should be applied to the catheter
adapter, not directly to the catheter-skin junction
site. (S43)
■ Do not use scissors at or near the insertion site
to remove dressing material, tape, or securement
devices. (S29)
■ Change blood administration sets after each unit or
q4 hours, whichever comes first. (S49)
■ Change all add-on devices when changing the
administration set. (S48)
■ Maximum hang time for solutions is 24 hours unless
specific conditions are met (see standard p. S69)
 Peripheral Venous Catheters
■ Short—rotate q72 hours. If institution cannot maintain ■ Midline—optimal dwell time is unknown, 2–4 weeks
a phlebitis rate ≤5%, rotate q48 hours. (S50) recommended. (S51)

Central Venous Catheters

■ Distal tip placement is in the vena cava. X-ray to verify ■ Pump, port needles should be changed at least every
tip placement. (S39) 7 days. (S45)
■ Optimal dwell time is unknown. (S52)

Peripheral Arterial Catheters/Pressure Monitoring Sets

■ Change catheter site q96 hours. (S53) ■ Perform Allen’s test when selecting the radial
■ Change hemodynamic pressure monitoring sets and artery. (S38)
add-on devices q96 hours. (S49)

Epidural/Intrathecal/Ventricular Catheters (Nonvascular Access Devices)

■ Acetone and alcohol are contraindicated for site ■ Wear masks and sterile gloves for access and
preparation or access. (Migration of alcohol may cause maintenance procedures. (S62)
nerve damage). (S44 & 63) ■ Label distinctly to differentiate from venous or
■ Use only preservative-free medications. (S62) arterial catheters. (S62)

Reporting Scales (S56, 57)

Phlebitis
0 No symptoms
1+ Erythema at access site with or without pain
2+ Pain at access site with erythema and/or edema
3+ Pain at access site with erythema and/or edema,
streak formation, palpable venous cord
4+ Pain at access site with erythema and/or edema,
streak formation, palpable venous cord >1" in
length, purulent drainage
Infiltration
0 No symptoms
1 Skin blanched, edema <1" in any direction, cool
to touch, with or without pain
2 Skin blanched, edema 1–6" in any direction, cool
to touch, with or without pain
3 Skin blanched, translucent; gross edema >6" in
any direction; cool to touch; mild to moderate
pain; possible numbness
4 Skin blanched, translucent; skin tight, leaking;
skin discolored, bruised, swollen; gross edema
>6" in any direction; deep pitting tissue edema;
circulatory impairment; moderate to severe pain;
infiltration of any amount of blood product,
irritant, or vesicant

Complication Rate Formulas

Number of phlebitis incidents
x 100 = % Peripheral Phlebitis (S56)
Total number of I.V. peripheral lines
Number of infected I.V. lines
x 1000 = Number of Infected I.V. Lines
Total number of catheter days per 1000 catheter days (S25)

Number of infiltrated incidents

x 100 = % Peripheral Infiltrations (S57)
Total number of I.V. peripheral lines

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