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It’s the first step that’s crucial
Any reduction in severe phlebitis would make your patients’ lives much easier, as it would the lives of your staff members. While avoiding phlebitis altogether may be impossible, it is well within your reach to reduce the incidence of severe phlebitis dramatically by educating your patients and staff to use one simple assessment.
Marie Meredith, RN, BN, unit manager of the IV team at the Winnipeg Health Sciences Center in Manitoba, Canada, says she has added one stage to the Intravenous Nurses Society’s phlebitis scale with great results.
"The rating scale we use is different from INS’ rating scale because we add the most important component of phlebitis identification, which is the first stage," she says. "The first stage is not the true complication. The first stage identifies irritation of the vein so the device can be removed before you have a true complication."
The staff at Winnipeg Health Sciences Center, as well as their IV program staff and patients, are trained to evaluate an IV regularly for that first stage of irritation.
"Assessment includes palpation of the vessel containing the device and along the pathway," says Meredith, who explains that such a simple step followed by careful evaluation usually can head off phlebitis at the pass. "Palpation identifies the tender-to-the-touch’ symptom.
"When you have damage at the insertion site from insertion of the device, you have tissue damage and sometimes you have vessel damage," she explains. "When you have vessel damage, the damage at the insertion site continues to progress into phlebitis."
Such damage will exhibit itself as irritation, such as chemical or mechanical irritation from a peripheral IV, central line, midline, or PICC.
"The first stage of irritation shows up as discomfort," notes Meredith. "When you palpate over the site and along the vessel, you have tenderness. That is basically the first sign. That will show up before you have redness, pain, swelling, or any of the other symptoms of phlebitis. This tenderness to touch over the site and along the vessel is the first sign of phlebitis."
However, it can be tricky telling the difference between tissue damage from the venipuncture — which is normal — and vessel damage.
"If you have bruising or tenderness from insertion damage, you have to try to establish whether it is insertion damage that will clear up within 24 hours or vessel irritation which will develop into phlebitis," she says.
When in doubt, if the site is less than 24 hours old, a simple follow-up the next day is all that’s required. If the site is still tender the day after insertion, Meredith says the device should be removed. Otherwise, the progression of phlebitis will cause scarring in the vessel and lead to long-term complications.
Patient education is key
In the hospital, the IV team members monitor IV sites each day for the first stage of phlebitis. For home infusion patients who aren’t visited every day, patient education is the difference between catching phlebitis at the first stage or having to treat a full-blown case of phlebitis later on.
"Educating patients is important because patients want to leave the device in so they don’t have to get poked again," says Meredith. "I tell them, If we catch this at the first sign of irritation and take it out, then it will clear up in 24 hours and you won’t have any discomfort. If I leave it in for one more dose of antibiotic, then it may take six weeks for this to heal. So you have a choice of six weeks of a sore spot on your arm or 30 seconds of grief when I insert the new needle.’"
Meredith adds that patients with their first IV are those who need the education and reinforcement.
"The people who have had IVs know what that hard spot in the vein feels like in phlebitis," she says. "The people who are hard to convince are those with their first IV and they don’t want another one."
Educating patients is more than telling them to feel for a sore spot along the vessel; there’s a specific sensation inside the vein, as well.
"I explain [that] it like a sunburn inside your vein," says Meredith. "The drug is irritating and it may burn the inside of your vein wall, and people will say, Yeah, that’s what it feels like.’"
Benefits of first-stage identification
Meredith implemented the tool in 1993 when her hospital began requiring outcomes related to new IV catheters.
"I did independent study for my nursing degree on phlebitis, and in my research, I found a lot of work done in the early ’80s on phlebitis and identifying in animals what caused phlebitis and what the disease process was," she recalls. "The first stage was an irritation of the intima, and if you could identify it in the first stage then the phlebitis wouldn’t progress to the full inflammatory process with damage."
Once she became the unit manager, Meredith decided to put this research to good use by creating a phlebitis rating tool. (See sample rating tool, p. 88.)
Since the implementation of the phlebitis rating tool, Meredith says there is a marked decrease in phlebitis that progresses to the third and fourth stages. When she compiles monthly data on the tool each year, she says she looks for more IVs changed at the first sign of phlebitis and a lower rate of second- and third-degree phlebitis.
Since the tool’s implementation, Meredith says there has been a significant increase in the identification at Stage 1 and a decrease at the later stages. In 1992, the rate of second-degree phlebitis was 25%, with 40% first- degree, 1% third-degree, and less than 1% fourth-degree. In 1998, the third- and fourth-degree remained the same but the second-degree decreased to 17%, and the first-degree increased to 48%.
"Because we identify it at the earliest stage and the IVs are changed, the more severe complication of phlebitis is decreased," she says. "The more advanced the phlebitis, the greater the potential for thrombus."