Pre Insertion Care
1. Provide and document Patient teaching. Include the following: Explanation of the purpose, placement, insertion procedure and post insertion care including what to report to the nurse.
2. The following blood work should be considered: CBC, INR, PTT.
3. Consideration should be given for the type of Picc lines that is most appropriate for the patient. (ie. Power injectable vs non-power injectable, single lumen vs multi-lumen)
PICC’s are inserted by nurses, radiologists and the radiology residents. In some nursing areas, physicians are placing PICC lines in at the bedside with assistance of an RN. The procedure takes less than hour and requires only local anaesthesia. Lines placed at the bedside require x-ray verification of placement prior to use. Insertion is a sterile procedure (a gown, gloves and mask will be worn, the skin at the insertion site will be cleansed with an antiseptic, sterile equipment and drapes will be used). Patients are required to lie still with arm (usually non-dominant) extended at a 90-degree angle. A tourniquet is applied to the upper arm and a needle is inserted into the cephalic or basilic vein at the antecubital fossa. To prevent cannulation of the internal jugular the physician will ask the patient to turn their head and tilt their chin to their chest as the line is threaded into position. Check progress note and health record for insertion information. Documentation of PICC length at insertion is required for comparison at time of removal. The line is saline flushed, capped and stabilized with a securement device. A gauze dressing is placed over the insertion site for the first 24 hours.
Post Insertion Care
Assess the insertion site for bleeding, redness or swelling minimally every 12 hours. Swelling of the upper arm and bleeding at the insertion site are normal for the first 24-48 hours. Assess the arm, shoulder and neck on the side of the PICC for complications (i.e. pain, swelling). If complications are noted, carry out nursing care as outlined in the complications section. All patients should be aware of safety precautions and signs and symptoms to report to the health care professionals. Information for patients on bathing with a PICC line Do not submerge the Catheter under water. Swimming should be avoided. Showering should be permitted if precautions can be taken to reduce the likelihood of introducing organisms into the catheter (e.g., if the catheter and connecting device are protected with an impermeable cover during the shower)
Nursing Approach to Patient Teaching:
-begin teaching home care as early as possible for patients in hospital - involve a family member if able;
-assess patients readiness to learn;
-assess most effective method of learning for patient (i.e., pictures, booklet, demonstration, discussion);
-design a teaching schedule so others may reinforce and add to what has been taught;
-explain procedures in terms appropriate for the individual patient;
-encourage the patient/family member to practice in hospital;
-consistently evaluate effectiveness of teaching.
Care and Maintenance of the PICC Occlusion Prevention:
Regular flushing of the PICC is required to prevent or delay catheter occlusion related to fibrin formation or drug precipitate. This is accomplished by flushing the PICC with 20mLs normal saline following drug administration or blood sampling and every 7 days when not in use. The flushing technique should be a start/stop method, otherwise known as “turbulent flush”. This type of flushing technique helps clear the walls of the PICC line more efficiently then a straight flush. If blood is noted in the catheter or at the hub, flush the PICC with 20mLs normal saline. Always close the clamp of the PICC line after flushing. This will help to prevent backward flow of blood into the catheter during times of changing intrathoracic pressure (e.g. vigorous coughing, vomiting). Scrub the hub of the adaptor with a 15 second juicing technique using an alcohol swab Flush through the adaptor with two 10mLs preservative free pre-filled normal saline syringes using turbulent flushing technique Close the clamp during the last mL Disconnect the syringe
Flushing Your PICC Line
Systemic and local infections are possible complications of a central line. A common source of infection is the catheter hub but other potential causes include migration of skin flora up the catheter tract, hematogenous seeding from another site of infection, catheter related thrombus and rarely, contaminated infusate. To decrease the risk of infection from the catheter, aseptic technique is used at all times. Hand hygiene is critical before performing any aspect of line care. Clean non-sterile gloves are worn to minimize the risk of transferring microorganisms from the caregiver’s hands to the patient as well as for the caregiver’s protection. Catheter hubs/connection sites must be disinfected with 70% alcohol or 2% Chlorhexidine Gluconatewith 70% Isopropyl Alcohol swabs for 15 seconds using a juicing technique before the system is accessed. A mask is to be worn any time the system is open of the dressing is removed.
Venous Air Embolism:
To prevent venous air embolus and decrease the risk of infection, open the system only when it is absolutely necessary. Lines should always be clamped when they are not in use. All lines must be clamped before the system is opened. An open system or cleansed connection site should never be set down.
Removal of the PICC line An RN certified in the removal of PICC lines may complete removal of the PICC line. PICC lines are removed following a physician order when therapy is completed or complications such as line sepsis, thrombosis or phlebitis require removal. The removal of a PICC line is not a sterile procedure. Up to 12% of removal procedures experience some form of complication.
FULL INFORMATION PICC LINE CARE