When clinicians start an IV, the first instinct is often to look for the best vein. Chris Cavanaugh,
MSN, RN, CRNI, VA-BC, suggests clinicians first take a step back — from the vein to the skin.
Cavanaugh, a vascular access nurse with extensive experience in geriatric and long-term care
populations, presented on this topic at INS 2026 in her session, “Beneath the Dressing:
Managing Skin Conditions and Optimizing Vascular Access Outcomes.” Her message was
clear: skin problems can be just as challenging as vein problems, and skin assessment should
be part of every vascular access decision.
The Overlooked Foundation of Vascular Access
In older adults and patients with chronic illness, skin may already be fragile before a catheter is
placed. Aging reduces collagen and elasticity, making skin more susceptible to injury during
catheter securement and dressing removal. Diabetes can leave skin drier, less supple and
slower to heal. Long-term steroid use can produce “paper-thin” skin that bruises easily and tears when adhesive dressings are removed.
Cavanaugh explains that in patients with fragile skin, the bond between the adhesive and the
skin can be stronger than the skin’s own structural integrity. That observation should change
how clinicians approach vascular access. A catheter cannot remain stable if the dressing cannot adhere to intact skin. Once skin begins to break down, the dressing may lift, shift or fail.
Catheter movement can then contribute to phlebitis, infiltration and infection risk.
The Skin-to-Catheter ‘Death Spiral’
Cavanaugh describes this as a “vascular access death spiral”: skin breakdown leads to dressing failure; dressing failure leads to catheter movement; catheter movement creates a pathway for bacteria; and bacteria can contribute to catheter-related bloodstream infection (CABSI).
That is why medical adhesive-related skin injury, or MARSI, deserves more attention in vascular
access. MARSI is not just a painful skin problem. It can compromise the dressing, the catheter
and the entire access plan.
Cavanaugh believes MARSI remains under-recognized in everyday practice. Although INS
Standards of Practice address vascular access-associated skin injury 1 , she said many facilities do not focus on it.
Clinicians are often “so hyper focused on the vein” that they overlook the body’s largest organ
— the skin — and forget that vessel health and preservation must include skin health.
MARSI Risk Begins Before Dressing Removal
MARSI risk also does not begin only when a dressing is pulled off. Skin breakdown may already
be present before insertion, or it may be triggered by moisture, edema, inadequate barrier
protection, antiseptics that have not fully dried, chronic dermatologic disease, aging skin or
medication-related fragility. Once the skin breaks down, Cavanaugh explained, “there’s nothing
for the dressing left to adhere to.”
The practical takeaway: skin assessment should happen before access, not after problems
appear.
Let the Skin Assessment Guide the Access Plan
For patients with fragile or dermatologic skin conditions, Cavanaugh recommends a deliberate
pre-access assessment. Clinicians should look for skin tears, redness, scarring, plaques from
psoriasis or eczema, keloid scars, edema, moisture, bruising and areas where skin integrity is
already compromised. In patients with darker skin, redness may not be obvious, so clinicians
may need to rely on touch, texture, swelling, warmth and other visual cues.
The assessment may change the access plan. If a patient has psoriasis, eczema or skin
breakdown across the lower arm, a short peripheral IV may not be best. Clearer skin in the
upper arm may support a midline. In some patients, a tunneled central venous catheter may be
more appropriate if the chest offers the only stable skin surface. The goal is to match the device
and dressing strategy to the patient, rather than forcing a planned device into compromised
skin.
Before inserting a vascular access device, take a closer look at the skin. This pre-insertion assessment tool helps clinicians identify allergies, existing skin conditions and other risk factors that could affect site selection, antisepsis, dressing adhesion and securement. Its green-yellow-red grading system also provides practical guidance for adapting the care plan to protect skin integrity and reduce the risk of complications, including medical adhesive-related skin injury (MARSI).
Click to download
Treat Dressing Removal as a Procedure
Skin protection also matters at every dressing change. Cavanaugh says removal should be
treated as a procedure, not an afterthought. Her advice is “low and slow”: remove the dressing
carefully, keep the pull parallel to the skin, and avoid lifting upward. Transparent dressings may
release more easily when stretched outward rather than pulled away from the skin.
Cavanaugh also says clinicians need to use “some type of adhesive remover,” particularly when
a dressing is well-adhered or a patient is at risk for skin injury. A dressing that has remained
intact for several days has done so because the adhesive bond is strong. “If you’ve got a
beautiful intact dressing, there’s a reason for that and that adhesive needs something to
release,” she said.
That point matters in vascular access, where dressings must adhere securely enough to protect
the site and stabilize the catheter, but also come off without stripping fragile skin. Cavanaugh
described this as a “double-edged sword”: the stronger the adhesive must be to last several
days, the greater the need for a tool to remove it safely.
She also cautions against relying on alcohol to loosen dressings. While alcohol may release
some adhesives, it can dry and irritate skin and may worsen damage in patients with paper-thin skin, psoriasis, eczema or other vulnerabilities. Barrier film can help protect the skin before
adhesive application, while adhesive remover can help reduce trauma during removal.
Ultimately, Cavanaugh’s message is simple: nurses need to take ownership of the skin. Before
the IV, look at the skin. Before applying a dressing , protect it. Before removing a dressing, plan
the removal as carefully as the insertion. And when skin is fragile, compromised or difficult to
assess, use a structured skin assessment tool to guide site selection, device choice, barrier
protection, adhesive remover and dressing removal technique.
For vascular access clinicians, a consistent skin assessment process can turn “skin first” from a good idea into repeatable bedside practice — one that protects fragile skin, supports dressing
integrity and helps preserve the vascular access device patients depend on.
References
- Nickel B, KleidonTM, Alexander M, et al. Infusion therapy standards of practice, 9th edition. J Infus Nurs. 2024;47(suppl 1):S1-S285. doi:10.1097/NAN.0000000000000532
