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DRESSING CHANGE
PURPOSE
The PICC exit site is an area where microorganisms can enter the body and cause a local or systemic infection. Keeping the area clean, dry and covered is important in preventing catheter-related infections.
STANDARDS
A transparent dressing on a Peripherally Inserted Central Catheter (PICC) is changed every 7-10 days and/or if it is damp, visibly soiled, loosened or if redness/drainage is noted at the site.
The preferred dressing to use on a PICC site is the Tegaderm CHG™ dressing, unless a skin reaction to the dressing occurs. To determine appropriate dressing and exit site care to use if skin reaction occurs, refer to Management of Dressing Related Dermatitis algorithm.
The use of a securement device is recommended to ensure secure stabilization of a PICC. The Tegaderm™ CHG dressing is considered a securement device. If not using the Tegaderm™ CHG dressing, a Statlock™ device must be used to secure the catheter.
If a gauze dressing is used or if gauze is placed under a transparent dressing and obscures the exit site, the dressing must be changed every 48-72 hours, or more often if it becomes damp/soiled/loose.
Aseptic technique is an essential component of all central vascular catheter access procedures to reduce the risk of catheter related blood stream infection.
PICC exit sites are visually examined when changing the dressing and by palpation through an intact dressing every shift. For outpatients, sites are examined at each visit. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or bloodstream infection, the dressing is to be removed to allow thorough examination of the site.
Tegaderm CHG™ dressings are not appropriate for use in patients younger than 2 months of age.
For changing the dressing on a cuffed PICC, follow procedure for dressing change of cuffed central venous catheter.
SITE APPLICABILITY
Applicable to all areas within BCCH and all patients with a non-cuffed PICC.
PRACTICE LEVEL/COMPETENCIES
Changing the dressing on an uncuffed PICC is considered an advanced nursing skill and is performed by a member of the vascular access team (IV therapy).
DEFINITIONS
Aseptic no-touch technique (ANTT): a standardized technique that is used during clinical procedures to identify and prevent microbial contamination of aseptic key parts and key sites by ensuring that they are not touched either directly or indirectly. A ‘key part’ is the part of the equipment that must remain sterile and must only contact other key parts or key sites. Or it is the area on the patient such as a wound, or IV insertion site that must be protected from microorganisms. Aseptic key parts can only contact other aseptic key parts/sites. If it is necessary to touch key parts/sites, sterile gloves are to be worn to ensure asepsis is maintained.
EQUIPMENT
surface disinfectant wipe mask clean gloves dressing tray sterile gloves 2% Chlorhexidine with/without 70% alcohol impregnated swab sticks x
DRESSING CHANGE
sterile cotton tipped applicators (as needed to remove excess drainage/crusting) sterile water if needed to remove excess drainage/crusting ( Do not use normal saline on site as chlorhexidine may be inactivated if in contact with normal saline. ) Cavilon™ no sting barrier Sterile transparent wound dressing (Tegaderm CHG™, Tegaderm™or IV 3000™) or sterile gauze dressing if patient is unable to tolerate a transparent dressing (due to allergy, skin reaction or sensitivity). See Management of Dressing Related Dermatitis algorithm. Securement device (i.e. Statlock™) as needed (securement device not needed if using Tegaderm CHG™)
PROCEDURE Rationale
- IDENTIFY patient and EXPLAIN procedure. Failure to correctly identify patients prior to procedures may result in errors. Reduces child and family’s anxiety. Evaluates and reinforces understanding of previously taught information and confirms consent process.
- CLEAN working surface using disinfectant wipe. Routine infection control practices; reduces
- MASK. SCRUB hands for 1 minute.^ transmission of microorganisms.
- PREPARE equipment using aseptic no-touch technique.
- DON clean gloves. REMOVE Tegederm CHG dressing by wetting the patch with a CHG/etoh swabstick and DISCARD. REMOVE securement device if present.
- ASSESS exit site for redness, swelling, tenderness, or drainage. CULTURE significant drainage and NOTIFY physician. For alternate dressing options for dressing related dermatitis, refer to Management of Dressing Related Dermatitis algorithm.
Assessing the entry site for inflammation will prevent unnecessary delays in providing appropriate interventions in care of the patient.
- NOTE the exit site mark on the catheter and CONFIRM placement has not changed from insertion. If migration inward of the catheter is noted PULL the catheter outward to the mark at insertion. The catheter may NOT be advanced if it has migrated outward. Notify physician if outward migration noted.
To monitor for line migration.
- REMOVE gloves and PERFORM hand hygiene. PLACE sterile drape under arm. DON sterile gloves.
Routine infection control practices; reduces transmission of microorganisms.
- LIFT catheter with sterile gauze. With a chlorhexidine/alcohol swab stick, CLEAN the catheter away from the exit site. Continue to HOLD catheter with a sterile gauze.
- CLEAN exit site immediately around the catheter with a new swab stick using a back-and-forth motion with light friction to area around exit site for 15 seconds.
NOTE: Excess drainage or crusting can be removed with cotton tipped applicator soaked with sterile water if needed.
This action promotes binding of the chlorhexidine to the layers of skin and improves efficacy. Do not use normal saline as chlorhexidine may be inactivated if in contact with normal saline.
DRESSING CHANGE
DOCUMENTATION
LABEL the dressing with the following information: date, time, and initial of the nurse performing the dressing change.
DOCUMENT on Central Line Flowsheet: procedure, date and time dressing used PICC external length (cm mark at exit site) assessment of site and surrounding skin patient's response to procedure unexpected outcomes and related treatment any other actions or observations
REFERENCES
Boyce, J.M. and Pittet, D. (2002). Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Centers of Disease Control and Prevention. MMWR Recommendations Report. 51(RR16):1-44. Retrieved November 4, 2013 from http://www.cdc.gov/mmwr/pdf/rr/rr5116.pdf
Infusion Nurses Society. (2011). Infusion Nursing Standards of Practice. Journal of Infusion Nursing. 34 (1S):S63.
O’Grady, N.P., Alexander, M., Burns, L.A., Dellinger E.P., Garland, J., Heard, S.O., Lipsett, P.A., Masur, H., Mermel, L.A., Pearson, M.L., Raad, I.I., Randolph, A., Rupp, M.E., Saint, S. and the Healthcare Infection Control Practices Advisory Committee (HICPAC). (2011). Guidelines for the prevention of intravascular catheter-related infections, 2011. Centers of Disease Control and Prevention. Retrieved November 4, 2013 from http://www.cdc.gov/hicpac/BSI/BSI-guidelines-2011.html.
Registered Nurses’ Association of Ontario. (2005). Best Practice Guideline: Care and Maintenance to Reduce Vascular Access Complications. Retrieved May 16, 2007 http://rnao.ca/bpg/guidelines/care-and-maintenance-reduce-vascular-access-complications.
Safer Healthcare Now. ( 2012 ). Getting started kit: Prevent Central Line Infections. Retrieved November 4, 2013 from http://www.saferhealthcarenow.ca/EN/Interventions/CLI/Documents/CLI%20Getting%20Started% Kit.pdf
SoluPrep Swabs and Wipes Instructions for Use. (2013). 3M Infection Prevention Solutions.
