S28 British Journal of Nursing, 2012 (IV Therapy Supplement), Vol 21, No 21
The strategic role of the nurse
in the selection of IV devices
Use of vascular devices represents one of the most common
procedures used as a complementary measure in the treatment
of patients. An indication algorithm was established to serve as
a guideline for nurses in choosing the best intravenous device,
considering the main variables of drug therapy. A protocol approved
by the Institute of Orthopedics and Traumatology of Hospital
das Clínicas da Faculdade de Medicina da Universidade de São
Paulo (IOT-HCFMUSP), where the authors work, was subsequently
established and the nurse carried out the evaluation for the indication
of both the peripheral device and the central device, whether a
peripherally inserted central catheter (PICC) or other device inserted
by the physician. As a result, there was a decrease in the incidence of
phlebitis from 0.77% in 2010 to 0.17% in 2011, with an annual curve
of negative tendency. The nursing team also appeared more satisfied,
diminishing stress related to puncture failure.
Key words: Intravenous devices n Indication of intravenous device
n Intravenous therapy
Haemodialysis, chemotherapy, prolonged administration of
antibiotics, bone marrow transplants and parenteral nutrition
are all treatments that require long-term venous access. In
addition to these indications, there are blood transfusions,
successive blood collections for the performance of tests and
intravenous therapies. Short peripheral catheters progressively
give way to longer, preferentially central tunnelled or non-
tunnelled catheters, and completely implanted catheters
Health professionals must be familiar with the devices, but
it is also essential that they can act with proficiency, skill and
safety in the analysis of the patient’s condition, in order to
rolonged intravenous therapy requires adequate
venous access and frequent use of the superficial
venous network can lead to its depletion, causing
damage such as sclerosis, phlebitis and leakage.
Thais Queiroz Santolim, Luiz Augusto Ubirajara Santos, Arlete Mazzini
Miranda Giovani and Vanessa Cristina Dias
select the best intravenous device.
The authors consider it the nurse’s responsibility to
establish peripheral venous access, central venous access of
peripheral insertion and to take part in the choice of the
central access together with the physician in charge of the
patient’s care (Mendonça et al, 2011).
There are many catheters available on the market today
and the technological advances of these devices makes
them increasingly inert and biocompatible, yet a series of
complications can still occur.
According to Brannen and Surette (1997), these
complications may be related to physical and chemical
factors. Among the physical factors, we should consider
insertion techniques, the anatomy of the site, the size and
type of device, number of insertions, catheter in situ for more
than 72 hours, the severity of the disease and pre-existing
infections. On the other hand, chemical factors include the
infusion of irritant drugs (such as intravenous vancomycin)
and the concentration of the infusion (hyper or hypotonic).
In this context, as nurses are responsible for the daily
device maintenance procedures and for drug administration,
they play a crucial role in the prevention and reduction
of complications related to venous access. For this reason,
it is essential they are familiar with intravenous devices,
the condition of the patient’s venous network and the
characteristics of the drugs to be infused.
Thais Queiroz Santolim is Nurse and Assistant Director of the Division
of Nursing; Luiz Augusto Ubirajara Santos is Nurse and Dentist; Ariete
Mazzini Miranda Giovani is Nurse and Director of the Division of
Nursing and Vanessa Cristina Dias is Nurse and Coordinator; all at the
Diagnostic Center of the Institute of Orthopedics and Traumatology,
Hospital das Clínicas of the School of Medicine of the University of
Sao Paulo. São Paulo/SP, Brazil.
Accepted for publication: October 2012
Table 1. pH of the antibiotics
standardised by SCIH - IOT
pH 4.5 to 7
pH 4 to 6
pH 5 to 8.5
pH 6.6 to 7
pH 5 to 8
pH 5.5 to 7
pH 3 to 5.5
pH 6 to 8.5
pH 6.5 to 7.5
pH 3.3 to 4.6
pH 7.2 to 7.8
pH 2.4 to 4.5
pH 4.5 to 7
pH 5 to 8
S30 British Journal of Nursing, 2012 (IV Therapy Supplement), Vol 21, No 21
The authors of this article work at the Institute of
Orthopedics and Traumatology of Hospital das Clínicas
da Faculdade de Medicina da Universidade de São Paulo
(IOT-HCFMUSP), which handles complex orthopaedic
trauma. It receives patients on a daily basis who will
need intravenous therapy for a prolonged time. The main
advantage is that upon their arrival at the service, patients’
venous networks are preserved and should be until the end
of the treatment.
After stabilising the patient, it is essential for the nurse to
select the most suitable device to ensure safe and effective
venous access at an early stage, since the drugs commonly
used in the treatment of the Institute’s patients have
strong blood vessel damaging characteristics owing to the
considerable variation of their pH levels (Table 1) and their
high osmotic concentrations.
Depending on the pH and concentration of the drugs, they
may produce damage at the insertion site or on the vascular
route. The pH of a solution or medication determines its
degree of acidity or alkalinity (Ferreira, 2002).
The normal blood pH is between 7.35 and 7.45. When
the drug has an extreme pH level, i.e. is higher than 9 or
lower than 5, these are classified as irritant drugs. This means
that when administered in peripheral veins, they attack
the endothelium, causing pain and a burning sensation,
and producing chemical phlebitis with the appearance of
palpable cord. The cephalosporins, e.g. oxacillin, gentamicin
and clindamycin, are medications with this characteristic
(Giovani, 2006). Tissue necrosis may also occur if there is any
leakage of these medications (Giovani, 2006).
Table 1 presents the pH levels of the most commonly
used antibiotics at IOT-HCFMUSP, according to the
standardisation of antibiotics, proposed by the institution’s
Hospital Infection Control Subcommittee (HICS).
Osmolarity is the concentration of a substance (osmotically
active molecules) dissolved in 1 litre of solution. The
osmolarity of blood is from 280–295 mOsm/litre. Solutions
with an osmolarity very different from that of blood can
cause pain and phlebitis when administered through short
peripheral intravenous devices.
Based on osmolarity, solutions are defined as:
■ Isotonic solutions: when they do not cause changes in
the cell volume. Their osmolarity is between 240 and 340
with the possible occurrence of cell lysis (breaking down
of a cell by an external force). Their osmolarity is below
its volume and reducing its size. Their osmolarity is above
340 mOsm/litre (Giovani, 2006).
The more acid and hypertonic the intravenous solution is,
the greater the risk of chemical phlebitis. The risk of a patient
developing chemical phlebitis based on the osmolarity values
of the solutions and medications is as follows:
■ Moderate risk = 450 - 600 mOsm/litre
■ Hypotonic solutions: makes the cell increase in volume
■ Hypertonic solutions: makes the cell lose water, decreasing
■ Low risk ≤ 450 mOsm/litre
■ High risk ≥ 600 mOsm/litre.
Which vein to puncture
and which device to select
The choice of which vein to puncture should be based on:
■ Characteristics of the drugs
Prolonged intravenous therapies need reliable access. In
these cases, the best selection is the central venous access,
even when the patient has the entire peripheral venous
network preserved. Options for central catheters include the
peripherally inserted central catheter (PICC), tunnelled and
totally implanted catheters. At the IOT-HCFMUSP, when
the patient has a preserved venous network, the first option
is the valved PICC, which allows intermittent use with a
greatly reduced risk of obstruction, and that facilitates the
patient’s de-hospitalisation for treatment continuity. The vein
(Figure 1) of first choice should be the basilic, as it is a vein of
thick caliber, of medial location and with a smaller number
of valves, favouring catheter progression. The second option
should be the cephalic vein, where insertion is also facilitated
owing to its caliber, keeping in mind that puncturing the
vein above the antecubital fossa is preferred.
With regards to the characteristics of the drugs, we
should always know their pH and osmolarity, since as
mentioned, acid, alkaline, hypotonic and hypertonic drugs
can cause irreversible histological alterations to the vessel
endothelium, as well as complications in cases of leakage.
Therefore, drugs with these characteristics should also be
Peripheral veins are only selected in short therapies and
when the solution to be administered is not harmful to the
blood vessels. Nevertheless, puncturing the vein near the
joints should always be avoided because of the greater risk of
mechanical phlebitis caused by the movement of the limb, and
the catheter with the smallest caliber is preferred. The arm
veins are the most appropriate because they produce a lower
incidence of this complication and afford more freedom of
movement to the patient, which is very important when
considering the orthopaedic patient who frequently makes
use of crutches and other aids to get around.
Based on this knowledge, the nurses from the intravenous
■ Duration of the intravenous therapy
■ State of the patient’s peripheral venous network.
Superior vena cava
Median cubital vein
Figure 1. The basilic vein should be the first vein of choice, followed by the cephalic vein
British Journal of Nursing, 2012 (IV Therapy Supplement), Vol 21, No 21
(IV) therapy group of the Institute of Orthopedics and
Traumatology (IOT) use an intravenous device algorithm in
order to help them in their daily practice for the choosing
the best device for the infusion of solutions.
The algorithm facilitates the professional’s reasoning
when indicating the device, besides producing important
considerations for the success of therapy continuity.
Intravenous therapy group
The IV therapy group at the Institution was created in
1999 after the first nurses completed the PICC insertion
certification course. Since then this group, which is formed
of nurses representing all medical care areas, has had the
important role of guiding the team with regards to the best
practice in IV therapy through the preparation of protocols
and training programmes based on the evidence in literature.
The work of the group together with the medical team
was essential for nurses to gain visibility and autonomy in
the selection of the IV device (Figure 2). As the professional
who handles and assists patients with venous access most
often, the nurse is the most qualified to analyse and select
the device. It is also the role of this group to keep track of
the indicator of phlebitis, bloodstream infection and central
catheter losses, as well as to develop any improvement actions
After the publication of the protocols in 2010 and the
training of the entire team of nurses in the selection of
the most appropriate IV device with the lowest risk of
complications, using the proposed algorithm, the authors
observed a decrease in phlebitis incidence, as shown in
Figure3 showing 2010, Figure 4 showing 2011 and Figure 5
showing January to June of 2012.
As the correct device is inserted early on at the beginning
of the therapy, the patient is submitted to fewer painful
procedures for the insertion of catheters.
> Strong securement reduces the risk of
dislodgement, compared to an alternative
peripheral I.V dressing1
> Non-touch handles facilitates Aseptic Non Touch
Technique Key-Part and Key-Site Protection2
> Excellent moisture management provided by
the diamond pattern adhesive technology3
> Tegaderm fi lm protects the I.V. site providing
a waterproof, sterile barrier to external
3M and Tegaderm are trademarks of the 3M Company.
© 3M Health Care Limited 2012.
1. Jackson A; Retrospective
comparative audit of two peripheral
IV securement dressings, British
Journal of Nursing, Jan 2012,
2. 3M data on file, Association for
Safe Aseptic Practice, Product
Evaluation Programme, Feb 2012.
3. 3M data on file, Study-05-011226,
4. 3M data on file, 2009.
3M™ Tegaderm™ I.V. Advanced Securement Dressings
1681 Peripheral Dressing
Size: 7 x 8cm
1685 Central Line Dressing
Size: 8.5 x 11.5cm
for Comfort and
The duration of the IV therapy is > 1 month
Define the duration of the therapy
and need for the device
Define the period of the therapy
0 to 5 days 7 to 30 days 1 month to 1 year> 1 year
Choose the PICC, tunneled
CVADs or Port
Choose the Port
or tunneled CVADs
Is this solution appropriate for
Choose the PICC or catheter
inserted inthe subclavian or
Appropriate infusions for peripheral venous
access – Short peripheral catheters:
• < 600 mOsm/l
• pH = 5 to 9
• Non-vesicant or irritant
• Consider the need for one or more lumens. Prefer fewer lumens
• Consider the need to continue the IV therapy outside hospital or in the outpatient clinic
• Choose the device with less risk to insertion and maintenance and that remains until the end of the therapy
• Consider the level of understanding and collaboration of the patient and family in the maintenance of the device
Figure 2. Selection of the IV device for performance of the venipuncture
S32 British Journal of Nursing, 2012 (IV Therapy Supplement), Vol 21, No 21 Download full-text
The nursing team also manifests greater satisfaction and
less stress since they feel confident they are administering the
medications at the correct times and have safe and reliable
Nurses with concrete knowledge, trained in intravenous
therapy are crucial for quality nursing care.
In preparing the care plan, the nurse should monitor the
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Figure 3. Incidence of phlebitis - 2010
Figure 4. Incidence of phlebitis – 2011
Figure 5. Incidence of Phlebitis – January to June 2012
Incidence of phlebitis - 2010
Incidence of phlebitis - 2011
Incidence of phlebitis - 2012
n Prolonged intravenous therapies need reliable access
n Peripheral veins are only selected in short therapies and when the solution to be administered is not harmful to the blood
n It is essential for the nurse to select the most suitable device to ensure safe and effective venous access at an early stage
n The choice of which vein to puncture should be based on duration of the intravenous therapy, characteristics of the drugs
and state of the patient’s peripheral venous network
evolution and the effectiveness of the prescribed therapy,
documenting the patient’s response and the interventions
necessary to achieve the expected result (Alexander, 2011).
Studies show that the rate of local complications such as
phlebitis was lower in patients who received care from nurses
trained in intravenous therapy (Soifer et al, 1998; Karadag
and Görgülü, 2000), making it clear that this professional
is important in care provision and in the follow-up of
protocols that aim to reduce the risks and the complications
of intravenous therapy, acting directly in the choice of the
insertion site and of the device.
In recent years incidence of phlebitis at the Institute
has decreased from 0.77% in 2010 to 0.17% in 2011, with
annual curve of negative tendency. However, the goal is
always to be as close as possible to zero, since the institute
has nurses trained in indicating and maintaining intravenous
devices besides prescribing the correct dilution for each
type of catheter.
The low incidence of phlebitis and other complications
arising from intravenous therapy is only possible with the
involvement and commitment of the entire nursing team.
The confidence of the medical team in delegating the
indication of the device to the nurse was an achievement
resulting mainly from the work of the intravenous therapy
group that plays the important role of bringing the latest,
safest procedures into medical practice, ensuring drug therapy
without complications and damage to the patient.
Conflict of interest: none.
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Ferreira AO (2002) Guia Prático da Farmácia Magistral. 2nd edn.
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