1. Introduction Vascular access cannulation through the use of peripheral venous catheters (PVCs) is a common practice and is considered the most common invasive procedure performed on hospitalized patients [1]. This technique allows quick access to the vascular system, being less invasive and less complex than other techniques [1,2,3]. The type of catheter is chosen based on the estimated duration and type of treatment to be infused, and among the uses of PVCs are fluid therapy, parenteral nutrition, blood products, and diagnostic tests [4]. The most common side effect of PVC is phlebitis [5]. This consists of acute inflammation of the wall of the blood vessels, with irritation of the venous endothelium in the section or segment cannulated by the catheter [6]. Identification of phlebitis requires assessment of possible signs and symptoms present in the insertion area, such as erythema, tumefaction in the vein, pain, heat, and fever [7]. In this sense, the use of rating scales such as the Visual Infusion Phlebitis (VIP) scale, the Phlebitis scale, and the Maddox scale [8,9,10] may be useful. In Spain, up to 30% of the bacteriaemia associated with hospital care is related to the use of intravascular devices, and these produce increased morbidity and hospital expenses, which are estimated at around 18,000 euros per episode [4]. PVC management is an under-recognized issue regarding patient risk within the complexity of care [11]. It was verified through the National Study of Adverse Events (ENEAS, for its acronym in Spanish) that if phlebitis is included as an adverse healthcare event, it would rank first followed by medication errors, infections arising from healthcare-related practices, and surgical techniques [7]. On the other hand, the SENECA Project: Quality of care standards for patient safety in National Health System hospitals, enabled from 1344 revised medical records, from 32 different hospitals, identified approximately 377 patients who developed phlebitis and/or extravasation (25.1%) [7]. Phlebitis prolongs hospitalization and treatment, increases economic expenses, decreases patient satisfaction, and can lead to other complications such as sepsis, pain, discomfort, stress, possibility of clotting, thrombophlebitis, and embolism [5,12,13]. The Infusion Nurses Society (INS) [9] indicates that the accepted phlebitis rate should be 5% or less [14,15]. Currently, a phlebitis incidence of 0.5% to 59.1% [5] is estimated, with a prevalence of between 20 and 80% of patients following intravenous treatment [16]. Nurses’ knowledge on the proper management of PVC and early recognition of risk factors can reduce these complications [14,17]. In Spain, it is a nursing competence, collected in Order CIN/2134/2008, of 3 July [18]. In addition, the North American Nursing Diagnosis Association (NANDA-I) collects a risk diagnosis to prevent risk of (00213) phlebitis, and the Nursing Intervention Classification (NIC) establishes interventions for the prevention and treatment of phlebitis such as (4200) Intravenous therapy (iv); (2314) Medication administration: intravenous (iv); and (4235) Phlebotomy: Cannulated Vessel [19,20]. For this reason, the objective of this review was to identify available evidence on nursing interventions for the prevention and treatment of phlebitis secondary to the insertion of a peripheral venous catheter. 2. Materials and Methods 2.1. Design A systematic scoping review [21] of the literature was carried out, following the standards set out in the PRISMA extension for Scoping Reviews (PRISMA-ScR) [22]. Based on the PICO format (Table 1), the following research question was developed: What are the evidence-based nursing interventions for the prevention and treatment of phlebitis in patients with PVC? 2.2. Search Strategy The search was performed between December 2020 and January 2021 (Table 2). The databases consulted were Scielo, Pubmed, Medline, Scopus, WOS, CINHAL, LILACS, and Dialnet using MeSH and DeCS descriptors (Table 2). 2.3. Selection Criteria The search was limited to full-text documents, in Spanish, English, and/or Portuguese, published in the last 5 years. These included empirical studies and clinical guidelines that focused on phlebitis, its classification, diagnosis, prevention, and treatment from the nursing competence perspective. Those that, during the critical reading, did not meet the expected criteria in the first three questions of the CASPe [23] tool nor of Berra et al.’s instrument [24] for descriptive articles were excluded. Articles not available in full text and published in languages other than Spanish, English, or Portuguese were also excluded. Following the recommendations for improvement for Scoping Reviews by Levac, Colquon, and O’Brien [25], it was decided not to discriminate by type of study in the selection. In the classification and presentation of results, we differentiate according to the design of the selected studies. 2.4. Data Collection and Extraction The search was conducted independently and pooled by the researchers as detailed in the Authors Contributions. The authors performed an evidence synthesis by peer evaluation, analyzing each intervention and evidence individually, following the criteria provided by the Joanna Briggs Institute (JBI). The discrepancies were jointly discussed to reach consensus on the degree of evidence (DE) and the degree of recommendation (DR). 2.5. Evaluation of Methodological Quality Once the titles and summaries of the articles were critically read, data were classified according to the objectives of the study. The included full-text articles were assessed with the CASPe [23] and Berra et al.’s [24] tools. For clinical practice guidelines, AGREE [26] was used for critical reading and the HICPAC system for evidence synthesis [27]. The JBI [28] criteria were used to classify the degree of evidence (DE) and the degree of recommendation (DR) of nursing interventions. 3. Results The number of records identified in the databases was 376, to which five more records were added by referential search to introduce the clinical practice guidelines, for a total of 381 references. Of the 381 identified references, 52 studies were finally selected according to eligibility criteria (Figure 1) [22]. In terms of typology, 9 randomized clinical trials, 17 cohort studies, 8 systematic reviews, 3 case and control studies, 1 qualitative study, 10 descriptive studies, and 4 clinical practice guidelines, out of the total of 52 selected studies were included. Table 3 lists the characteristics of the studies included in the scoping review classified according to the type of article. The articles are classified as nursing interventions for the prevention of phlebitis or for the treatment of phlebitis, both for nurses who apply care independently and for nurses that follow guidelines and protocols. 3.1. Nursing Interventions for the Prevention of Phlebitis Management and maintenance of intravenous therapy
3.2. Asepsis
3.3. Nursing Assessment
3.4. Catheter
3.5. Dressing
3.6. Nursing Interventions for the Treatment of Phlebitis Nurse as a care prescriber
3.7. Nurses Following Protocols and Guidelines
In addition, Table 4 identifies the interventions found in the literature, their evidence synthesis, and their correspondence with NIC nursing interventions. 4. Discussion The objective of this review was to identify available evidence on nursing interventions for the prevention and treatment of phlebitis secondary to the insertion of a peripheral venous catheter. For the prevention of phlebitis, the greatest evidence found regarding asepsis is to use >0.5% chlorhexidine preparation with alcohol or 2% aqueous chlorhexidine, perform hygienic hand washing, and use clean gloves to handle connections and stopcocks (category AI). Regarding the maintenance of PVC, the interventions with the greatest evidence (category IA) are replacing extensions and administration sets between 4 and a maximum of 7 days if they are not loosened or soiled, and using the fewest three-way stopcocks, one of the ports with a bio-connector, and having the others capped [4]. Actions that promote the efficacy and safety of intravenous therapy include maintenance of access, infusion control, verification of signs of phlebitis during saline solution replacement and medication administration, and constant monitoring [53,54]. It is recommended to remove any catheter that is not essential (Category IA) [7]. Once discharged from hospital, it will be necessary to warn the patient about signs of phlebitis after PVC removal [2] (DE 1a). Regarding the dressing, the greatest evidence obtained is the use of “IV House UltraDressing” in pediatric patients to increase dwell time and stabilize the catheter [34] (DE IA). The dressing must be sterile, transparent, and semi-permeable for continuous visual inspection of the catheter site [7] (Category IA). A novel technique is the use of medical grade cyanoacrylate for catheter securement to reduce rates of phlebitis [33] (DE 1c). Vein quality control through palpation and visual inspection can prevent phlebitis as well as the nurse’s duration of hand hygiene and the clinical experience [55]. Regarding the choice of veins, a controversy has been found, as some studies recommend the forearm as it has a larger diameter and this reduces rates of phlebitis in the region, but there are many others that claim that this region should be avoided, in addition to the joints and wrist areas (category IA), for having a higher incidence of mechanical phlebitis related to catheter movement [4,56]. A review of the literature concluded that veins from the antecubital region are associated with lower rates of phlebitis, as compared to veins in the hands. Therefore, although the back of the hand is considered an easily accessible venous place, it is not indicated for prolonged venous therapy, and nurses are believed to need to be trained in carrying out alternatives such as jugular vein venipuncture that has very low rates of prevalence of phlebitis [44]. Although some studies, such as the one conducted by Circolini et al. (cited in Wei et al. [57]), in which Cox’s analysis was used, showed that as the PVC’s dwell time increased by 24 h, the risk of phlebitis also did so with an odds ratio of 1.05. Webster et al.’s [46] team concluded in their clinical trial review that the catheter should be removed only when clinically indicated, evaluating at every new shift to identify signs of phlebitis [46,57,58] early. There are higher rates of phlebitis when larger caliber catheters are used, as they increase attraction to the vessel wall, so the smallest possible length and caliber catheters (Category IB) are recommended [4,56]. The nurse’s clinical judgment regarding the selection of a PVC should also involve assessing comfort, anxiety, and restrictions in the patient’s day-to-day activities. The number of venipuncture attempts is one of the quality indicators and shows patient satisfaction for its sensory impact [59]. For the control and management of intravenous therapy, nurses should carry out a protocol that includes recording all aspects related to the catheter and its maintenance (DE 4a and DR A) [28]. According to the studies consulted, the data show a higher proportion of complications in peripheral venous catheters among women (p = 0.0300), patients 85 years of age or older as compared to those under 65 (p = 0.0500), and when puncturing the forearm region as compared to other regions (p ≤ 0.0001) [60]. Regarding saline flush, the effectiveness and safety of a solution of 0.9% of sodium chloride was compared with heparin saline solution, and it was concluded that both agents are equally effective and safe [14]. However, flushing PVC with normal saline prevents the accumulation of bacteria, proteins, and platelets suspended in plasma; therefore, saline flush prevents and reduces phlebitis [13] (DE 1c). It is necessary to check that the prescription of intravenous medication can be administered peripherally, as many of these drugs are irritating. Regular evaluation is key to the prevention and early detection of intravenous complications (DE 5a) [30,61]. In case the patient has phlebitis, nursing interventions with more evidence in their application are Moist Exposed Burn Ointment (MEBO) for topical treatment of burn injuries, Aloe vera, chamomilla recutita in wet compresses, topical diclofenac, “Essaven” heparin gel, notoginseny, and 5 mg nitroglycerin patch and anti-inflammatory or corticosteroids in a hot or wet compress (DE 1a) [6,36]. On the other hand, the application of marigold ointment, piroxicam, and sesame oil has an evidence level of 1C [36,39]. Some limitations of this bibliographic review are the little available evidence on the use of Burow’s solution as a treatment for phlebitis, despite its usual use in hospitals. This review may contain limitations inherent to the search and selection process. Therefore, we believe that further research and systematic review of the findings is needed. 5. Conclusions In conclusion, this review includes evidence-based interventions for the prevention and treatment of phlebitis associated to the venous catheter. The need for nursing training on the latest available evidence regarding the use and management of venous catheters is highlighted. It is important that hospitals implement projects such as “Flebitis Zero” so that nurses can rely and base their knowledge on them, thus providing quality care to patients. Author Contributions Conceptualization, A.G.-S., M.B.S.-G., M.E.C.-P., J.Á.R.-G., J.G.-S. and G.D.-C.; Data curation, A.G.-S., M.B.S.-G. and G.D.-C.; Formal analysis, A.G.-S., M.B.S.-G., M.E.C.-P., J.Á.R.-G., J.G.-S. and G.D.-C.; Investigation, A.G.-S., M.B.S.-G., M.E.C.-P., J.Á.R.-G., J.G.-S. and G.D.-C.; Methodology, A.G.-S., M.B.S.-G., M.E.C.-P., J.Á.R.-G., J.G.-S. and G.D.-C.; Project administration, A.G.-S., M.B.S.-G. and G.D.-C.; Resources, A.G.-S., M.B.S.-G., M.E.C.-P., J.Á.R.-G., J.G.-S. and G.D.-C.; Software, A.G.-S., M.B.S.-G., M.E.C.-P., J.Á.R.-G., J.G.-S. and G.D.-C.; Supervision, A.G.-S., M.B.S.-G., M.E.C.-P., J.Á.R.-G., J.G.-S. and G.D.-C.; Validation, A.G.-S., M.B.S.-G., M.E.C.-P., J.Á.R.-G., J.G.-S. and G.D.-C.; Visualization, A.G.-S., M.B.S.-G., M.E.C.-P., J.Á.R.-G., J.G.-S. and G.D.-C.; Writing—original draft, A.G.-S., M.B.S.-G., M.E.C.-P., J.Á.R.-G., J.G.-S. and G.D.-C.; Writing—review and editing, A.G.-S., M.B.S.-G., M.E.C.-P., J.Á.R.-G., J.G.-S. and G.D.-C. All authors have read and agreed to the published version of the manuscript. Funding This research received no external funding. Institutional Review Board Statement Not applicable. Informed Consent Statement Not applicable. Data Availability Statement All data is available within this article. Acknowledgments We would like to thank to the School of Nursing Nuestra Señora de Candelaria of Tenerife, Spain, its teachers and board of directors, for their collaboration for the development of this Final Degree Project, as well as for their educational and socializing work. Conflicts of Interest The authors declare no conflict of interest. Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations. Figure and Tables Enlarge this image. Figure 1. Search results (PRISMA flowchart). Table 1PICO.
Search strategy.
Characteristics of the studies included in the scoping review.
* Joanna Briggs Institute (JBI) degree of evidence (DE) and degree of recommendation (DR), ** Category of HICPAC recommendations, *** The Appraisal of Guidelines for Research and Evaluation (AGREE) Instrument, **** Critical Appraisal Skills Programme Español (CASPe), ***** Berra et al. [24]. Table 4Correspondence with NIC interventions and DE and DR analysis with JBI.
* Joanna Briggs Institute (JBI) degree of evidence (DE) and degree of recommendation (DR), ** Category of HICPAC recommendations. Show less You have requested "on-the-fly" machine translation of selected content from our databases. This functionality is provided solely for your convenience and is in no way intended to replace human translation. Show full disclaimer Neither ProQuest nor its licensors make any representations or warranties with respect to the translations. The translations are automatically generated "AS IS" and "AS AVAILABLE" and are not retained in our systems. PROQUEST AND ITS LICENSORS SPECIFICALLY DISCLAIM ANY AND ALL EXPRESS OR IMPLIED WARRANTIES, INCLUDING WITHOUT LIMITATION, ANY WARRANTIES FOR AVAILABILITY, ACCURACY, TIMELINESS, COMPLETENESS, NON-INFRINGMENT, MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. Your use of the translations is subject to all use restrictions contained in your Electronic Products License Agreement and by using the translation functionality you agree to forgo any and all claims against ProQuest or its licensors for your use of the translation functionality and any output derived there from. Hide full disclaimer Longer documents can take a while to translate. Rather than keep you waiting, we have only translated the first few paragraphs. Click the button below if you want to translate the rest of the document. The objective of this work was to identify available evidence on nursing interventions for the prevention and treatment of phlebitis secondary to the insertion of a peripheral venous catheter. For this, a scoping systematic review was carried out following the guidelines in the PRISMA declaration of documents published between January 2015 and December 2020. The search took place between December 2020 and January 2021. Scielo, Pubmed, Medline, Scopus, WOS, CINHAL, LILACS, and Dialnet databases were consulted, and CASPe, AGREE, and HICPAC tools were used for the critical reading. A total of 52 studies were included to analyze nursing interventions for treatment and prevention. Nursing interventions to prevent phlebitis and ensure a proper catheter use included those related to the maintenance of intravenous therapy, asepsis, and choosing the dressing. With regard to the nursing interventions to treat phlebitis, these were focused on vigilance and caring and also on the use of medical treatment protocols. For the prevention of phlebitis, the highest rated evidence regarding asepsis include the topical use of >0.5% chlorhexidine preparation with 70% alcohol or 2% aqueous chlorhexidine, a proper hygienic hand washing, and the use clean gloves to handle connections and devices. Actions that promote the efficacy and safety of intravenous therapy include maintenance of venous access, infusion volume control, verification of signs of phlebitis during saline solution and medication administration, and constant monitoring. It is recommended to remove any catheter that is not essential. Once discharged from hospital, it will be necessary to warn the patient about signs of phlebitis after PVC removal. Longer documents can take a while to translate. Rather than keep you waiting, we have only translated the first few paragraphs. Click the button below if you want to translate the rest of the document. Prevention and Treatment of Phlebitis Secondary to the Insertion of a Peripheral Venous Catheter: A Scoping Review from a Nursing Perspective Guanche-Sicilia, Aitana 1 ; Sánchez-Gómez, María Begoña 2 ; Castro-Peraza, María Elisa 2 ; Rodríguez-Gómez, José Ángel 3 ; Gómez-Salgado, Juan 4 ; Duarte-Clíments, Gonzalo 21 University Hospital Nuestra Señora de Candelaria, Canary Islands Health Service, 38010 Tenerife, Spain; [email protected] 2 University School of Nursing Nuestra Señora de Candelaria, University of La Laguna, 38001 Tenerife, Spain; [email protected] (M.B.S.-G.); [email protected] (M.E.C.-P.); [email protected] (G.D.-C.) 3 Chair of Nursing, Faculty of Health Sciences, University of La Laguna, 38001 Tenerife, Spain; [email protected] 4 Department of Sociology, Social Work and Public Health. Faculty of Labour Sciences, University of Huelva, 21007 Huelva, Spain; Safety and Health Postgraduate Programme, Universidad Espíritu Santo, 092301 Guayaquil, Ecuador https://doi.org/10.3390/healthcare9050611 © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/). Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License. |