PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) Learning Package. Return Test to Educator By:

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PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) Learning Package Return Test to Educator By: Revised June, Table of Content Methods of evaluating competency & Objectives 3 Introduction & Overview
PERIPHERALLY INSERTED CENTRAL CATHETER (PICC) Learning Package Return Test to Educator By: Revised June, Table of Content Methods of evaluating competency & Objectives 3 Introduction & Overview of PICC 4 Anatomy & Physiology 6 Indications & Contraindications of PICC 8 Orders & Guideline for Physician notification 9 Nursing Responsibilities 10 PICC Dressings 11 Documentation Overview 13 PICC Flushing Procedural Guideline 16 Needle-less Connector Changes 19 Blood Sampling 21 Complications 23 Appendix A: Discontinuation & Removal 26 Appendix B: Managing Occlusion 28 Appendix C: CVAD Care sets 30 References 31 Tip Culture 33 Post Test 34 2 Competency Evaluation & Objectives Competency Evaluation This learning package is one component of the peripherally inserted central catheter (PICC) competency. To meet PICC competency, nurses must: 1. Review the self-learning package on Care and Management of PICCs OR Complete the PICC self-learning module on the Learning Management System 2. Successfully achieve 85% or greater on the PICC test 3. Successfully provide a return demo to a Clinical Nurse Educator on each of the following: --dressing change --flushing --changing a needless connector --blood sampling --removal Additional competencies are required for discontinuation/removal and management of an occluded PICC. ONLY nurses who are deemed competent by the Clinical Nurse Educator may discontinue/remove and manage occlusions 4. Successful demonstration on discontinuation and removal 5. Successful demonstration of occlusion management of PICCs OBJECTIVES The following topics will be covered in this learning package: 1. Basic anatomy for peripherally inserted central catheter (PICC) 2. Indications & contraindications for a PICC line insertion 3. Possible complications associated with PICC lines 4. Nursing responsibilities for a) care and maintenance b) dressing & needle-less connector changes c) flushing guidelines d) changing needless connector e) obtaining blood samples Additional competencies are required for discontinuation/removal and management of an occluded PICC. ONLY nurses who are deemed competent by the Clinical Nurse Educator may discontinue/remove and manage occlusions 5. Discontinuation/removal of PICC see Appendix A 6. Occlusion management of PICC see Appendix B 3 INTRODUCTION Peripherally Inserted Central Catheters (PICC) are catheters that are peripherally placed (i.e. the arm) but they are considered a central catheter because the catheter tip sits in the central circulation (i.e. the superior vena cava). Central catheters are commonly used to provide a reliable infusion route for infusion therapy of all types, however they can put patients at risk for complications from catheter related bloodstream infections which can account for significant health care costs and be life threatening. This learning package will empower clinicians caring for patients with these devices with the tools to prevent complications and promote positive outcomes for patients. PERIPHERALLY INSERTED CENTRAL CATHETER PICC lines can differ in size, make & care and maintenance routines. You might encounter different types of catheters when caring for a patient coming from the community or another institution. Therefore, it is important to know what type of PICC your patient has because care and maintenance practices may vary depending on the type. In general, PICC lines are specially formulated cm long catheters and made of polyurethane or silicone. It may be a single, double, or triple lumen. The catheter could be valved (does not have a clamp) or non-valved (have an external clamp). Valved catheters such as the Power PICC Solo (inserted at NYGH) help prevent the passive entry of blood into the catheter. This provides safety for the patient by preventing blood from flowing backwards when the system is open. PICC line catheters are inserted through a peripheral vein (basilic, brachial, or cephalic) so that the tip lies in the distal third of the superior vena cava above the right atrium or at the caval-atrial junction. Pressure Activated Valve Consult with your clinical nurse educator and/or the physician for patients who come from another institution or the community with a PICC line that is not familiar to you. The following diagrams are some examples of PICC lines that you might encounter: 4 Power PICC Solo StatLock Securement Device Non-valved (i.e. clamps) Valved (no clamps ClearClave Needleless Connectors used at NYGH Cook PICC line with Non-Valved Technology, single and double lumen. Groshong Non-Valved PICC Line Double Lumen 5 ANATOMY OF THE VEIN WALL The following information is important for understanding the anatomy of the vein and those used for PICC lines: Tunica Adventitia (Outer Layer) Composed of connective tissue Provides support for the vein and allows the vein to roll Blood vessels in this area provide nutrition to this layer Tunica Media (Middle Layer) Largest layer of the vein, composed of elastic and muscle tissue. Innervated by the SNS (fight or flight response) - promotes venous constriction or dilation in response to anxiety, temperature, mechanical or chemical irritation. Pain can trigger vasoconstriction Tunica intima (Innermost Layer) Composed of one layer of smooth and elastic cells. The cells secrete tissue plasminogen activator and heparin to prevent platelet aggregation. Mechanical injury occurs when the vein wall is injured during insertion or ongoing exposure to the device. Chemical injury occurs when the vein wall is in contact with solutions or medications having hypo-osmolar, hyperosmolar properties, medications with ph 5 or 9, and/or osmolarity 600 (per INS Standards). Beneath the intima is the subendothelial layer. Damage to this layer causes inflammation and adherence of cells and platelets, which may results in phlebitis, thrombosis, extravasation, and/or infiltration. Valves Allow unidirectional flow of blood back to the heart and prevent pooling in the peripheral circulation. Veins dilate where the valve attaches, this creates a sinus that allows blood to become stagnant and lead to thrombus formation. Valves are present in most veins except in the head, vena cava, very small veins. The longer the vein the more valves it will contain. Difficulty is encountered when threading the vein passed the valves. 6 Veins of the Upper Extremities 1. Basilic Vein: The basilic vein is the first choice for insertion due to number of valves. It originates on the ulnar or medial side of the forearm and ascends on the posterior surface of the arm. Just before reaching the elbow, it travels to the front of the arm until it arrives at the antecubital area where it joins the median cubital vein. The basilic vein joins the brachial vein becoming the axillary vein near the armpit. The number of valves located in the basilica vein is four to six. 2. Brachial Veins: The brachial veins are a pair of veins of the brachial artery in the upper arm. Because they are deep to muscle, they are considered deep veins. They begin where the radial veins and ulnar veins (corresponding to the bifurcation of the brachial artery) and they end at the inferior border of the teres major muscle. At this point, the brachial veins join the basilic vein to form the axillary vein. 3. Cephalic Vein: The cephalic vein originates on the radial or lateral side of the forearm near the thumb. It ascends the lateral side of the arm and is joined by the median cephalic vein just below the antecubital fossa. The cephalic vein is smaller than the basilic vein and may be tortuous as it ascends the upper arm. The accessory cephalic vein joins the cephalic vein at the lateral border of the arm. There is a risk of stricture formation at the junction of the accessory cephalic and the main cephalic vein, which makes this a less desirable point of insertion and passage of a catheter difficult. There are a total of six to ten valves. The cephalic vein may also join other veins, such as the external jugular vein. PICC inserted into the cephalic vein have a higher incidence of mechanical phlebitis. 3. Medial Cubital Vein This vein drains the palm of the hand and ascends along the anterior surface of the arm to allow communication between the cephalic and basilic veins. It often forms a Y with one branch going to the basilic vein (called the median cubital basilic) and the branch going to the cephalic vein (called the median cubital cephalic). The median cubital vein is often prominent in the antecubital fossa and is frequently used for obtaining blood specimens by venipuncture. Catheters may be inserted into this vein and threaded into the main vessel. A venous valve may be encountered where the medial cubital vein joins the main vessel. 4. Axillary Vein The axillary vein is a large vein that forms a direct link to the subclavian vein. The axillary vein lies on the medial side of the axillary artery. Nerves are present between the artery and vein. There is only one valve that needs to transverse before entry into the superior vena cava. 7 Indications & Contraindications for a PICC Line Indications Include: 1. Compromised/Inadequate peripheral access 2. Infusion of hyperosmolar solutions or solutions with high acidity or alkalinity (eg. Total Parenteral) Nutrition) 3. Continuous infusion of vesicant or irritant agents (Inotropes, Chemotherapy) 4. Short or long term intravenous therapy (eg. Antibiotics) Contraindications include: 1. Inadequate veins 2. Pre-existing skin surface or subsurface infection at or near the proposed catheter insertion site. 3. Lymphoedema 4. Anatomical distortion from surgery, injury or trauma 5. Anatomical irregularities that may compromise catheter insertion or catheter care procedures. 6. Mastectomy surgery with axillary dissection +/- lymphoedema on affected side 7. Crutch walking as this causes pressure on veins of the arm. Anatomy of PICC placement 8 Orders & Guidelines for Physician Notification A physician order is required for the following: 1) PICC insertion 2) X-ray or fluoroscopy to confirm placement or tip position (see Medical Directive XII-141) note: (PICCS inserted at NYGH in the Angio department are confirmed by fluoroscopy, nurses must review the chart and Angio department notes for details on PICC insertion) 3) Flushing, including solution, volume and frequency (see Medical Directive XII-141) 4) PICC discontinuation and removal see appendix 5) Occlusion management (i.e TPA) see appendix 6) Blood draws from the PICC Guidelines for Physician Notification 1) Excessive bleeding 2) New and/or different cardiac arrhythmias 3) Sudden and unexplained onset of respiratory distress 4) Chest pain 5) Onset of pain and/or edema in the cannulated arm 6) Numbness or tingling in the cannulated limb 7) Swelling or decrease circulation to affected arm Indication for Radiographic Confirmation 1) Evidence of catheter migration 2) Functionality changes (i.e. unable to flush or draw back blood) 3) Signs or symptoms suggestive of complications 4) Confirmation of tip placement may be required when patients are admitted with a PICC Post Insertion Documentation The following information should be included in the documentation by inserter: At NYGH you should be able to find this information in Powerchart in the Patient Care Summary for those PICCs inserted in the organization or in the paper chart in a PICC insertion order set. 1 Date of insertion 2 Insertion vein 3 Tip location (as shown on fluoroscopy report) 4 Location (right or left arm) 5 Internal length 6 Catheter type, gauge, length and number of lumens 7 External catheter length based on catheter marking and measurement **This information should be available and easily accessible to all healthcare providers caring for the patient. 9 Nursing Responsibilities Post PICC Insertion: 1. Verify tip location by reviewing Diagnostic Imaging results in Powerchart (ie. PICC/radiologist report): Upper body insertions: tip is located in the lower half to third of the superior vena cava (SVC) or at the cavoatrial (CA) junction. Review PICC orders, PICC information, and radiologist report 2. The following elements shall be assessed every shift and PRN and documented in accordance with the NYGH documentation guidelines. Insertion site and surrounding tissue: Inspect site through the transparent semi-permeable membrane dressing checking for bleeding,exudate, leakage, kinking, redness and swelling. Gently palpate for pain and temperature. Vein track: Visually inspect the site along the track of the vein to tip location. Note external catheter kinking, external catheter length and the presence of edema in the cannulated limb. Assess for sensory symptoms (tenderness, numbness). If patient verbalizes any pain, gently palpate the vein track checking for pain, induration and or palpable cord. Catheter malposition: Malposition can occur upon PICC insertion or later, due to changes in intrathoracic pressure or catheter migration. A chest x-ray must be ordered if migration is suspected. Malposition can lead to serious complications such as arrhythmia, phlebitis and thrombus formation. Inspect PICC catheter wings are properly secured in securement device. Verify external catheter length to assess if catheter has migrated or moved from the insertion site (any amount of the catheter extending out or beyond the butterfly if not noted in radiologist report can indicate catheter migration). See Section on Complications (i.e catheter migration). Dressing: Inspect the transparent dressing and securement device; they should both be dry & intact. Transparent dressing covering the puncture site and securement device should be adherent to the underlying skin to minimize the risk of catheter migration. The date of most recent dressing change should be visible on the transparent dressing. If patient has a transparent dressing sensitivity or irritation, a sterile gauze may be used and must be changed every 2 days (INS, p.s.63) Infusion tubing: Inspect for precipitate and leakage of fluid. Check that all connections are securely luer-locked. Note: the use of tape around connections has been implicated in the transmission of bacterial contamination and is to be avoided. Tubing should have a label that includes: date that tubing was changed and next due date for tubing change. 10 PICC Dressing Changes Did You Know? Catheter colonization is caused when organisms grow inside a portion of the catheter. A true bloodstream infection related to the central venous catheter occurs when the same organism is not only in the catheter segment but is also obtained from the blood culture with no other identifiable source of infection in the body. Catheters become infected in several different ways. For example: an infection at the exit site may occur when the site becomes colonized by bacteria that migrate along external catheter surface. The site becomes erythmatic and tender with purulent drainage within 2 centimeters of the exit site. Focusing on infection prevention best practices reduces catheter-related bloodstream infections. PICC line dressing changes may need a second nurse to support and assist as needed. 1) Dressing change is a sterile procedure. Mask and sterile non-powered gloves required. Observers should wear masks during procedure. Patients who are actively coughing should also wear a mask. 2) A transparent semi-permeable membrane dressing shall be used except in cases when the patient is known to have allergy to this type of a dressing. 3) The initial gauze and tegaderm dressing should be changed 48 hours after PICC line insertion and every 7 days thereafter and or when the dressing becomes soiled, wet, no longer occlusive, or if the patient complains of unexplained pain at the site; or if moisture, exudates, or bleeding are present or suspected at the site. Daily dressing changes are indicated for suspected or confirmed site infections or if daily treatment/observation of the site is required. Supplies: Gather equipment: mask sterile non-powered gloves clean gloves two sterile towels or dressing tray sterile gauze 2X2 (3) 2% chlorhexidine swab sticks (3-4) alcohol swabs sterile transparent semi-permeable dressing clear clave needle-less connectors (1 or 2 dependent on number of lumens) Securement device (eg. Statlock,) (1-2) 10 ml syringe/s filled with 0.9% normal saline to prime clear clave needle-less connector/s and flush each lumen If discharge or redness is visible, bring a C&S swab for culture of site PROCEDURE: A. Explain procedure to patient and family. B. Position patient supine or upright in sitting position. C. Wash hands, don mask, and clean gloves. D. Offer mask to patient to put on, or ask them to turn face away from PICC site. If patient is actively coughing or on droplet precautions they must wear a mask. E. Prepare a sterile field by placing sterile towel around site and under extremity (may use green towel or drapes from a sterile dressing tray). F. Using sterile technique, place sterile transparent occlusive dressing, securement device, 2% chlorhexidine swabsticks, Steri-strips (available in the StatLock package), clear clave needleless connector/s and sterile gloves onto field. 11 G. To prevent accidental dislodgement of catheter during procedure, anchor catheter extension legs(s) with one steri-strip (provided in the StatLock device package). H. Carefully remove old transparent dressing: Anchor the hub with non-dominant hand and using stretch-technique starting from bottom to top (to prevent dislodgement). Discard dressing. I. Assess catheter insertion site and surrounding tissue. Note external catheter length to verify that the line position has not changed. Obtain a physician order for culture if site is suspicious for an infection (eg. redness, presence of drainage and/or foul smell). J. Stabilize catheter while holding the StatLock stabilization device. K. Use thumb of opposite hand to gently lift retainer door from behind. Reposition hands and repeat process to open second retainer door. NOTE: It is best to grasp the plastic doors from the bottom edge. They are difficult to open if grasped in the middle. L. Carefully remove PICC from securement device. M. Use 3-4 alcohol swabs to lift the corner edge of the anchor pad. Continue to stroke under surface of the pad with generous amounts of alcohol. N. Fold the StatLock device anchor pad under itself and repeat on opposite side. Do NOT pull or use force to remove the pad. The more alcohol used, the easier the removal. O. Remove the remaining portion of the transparent dressing. P. Assess catheter insertion site and surrounding tissue. Note external catheter length to verify that the line position has not changed. Culture site if suspicious for infection: redness, presence of drainage or foul smell. Q. Discard dressing and remove gloves. Wash hands with hand sanitizer. Air dry for 30 sec. R. Don sterile non-powdered gloves S. Cleanse insertion site with 2% chlorhexidine swabsticks. Work in an up, down, side to side friction for seconds. Cleanse from clean to dirty and do not go back over previously cleansed area with the same swab. Repeat process using new swabstick each time. Extend on both sides to an area larger than where the anchor pad will be placed and cleanse portion of catheter that will remain under dressing and ensure you allow complete drying. T. Apply provided skin protectant to stabilization site. Extend to both sides of the stabilization site covering an area larger than where the StatLock device anchor pad will be placed. Allow skin protectant to dry completely (for 10 to 15 seconds) until the skin is smooth to the touch. Protectant should not be applied over the insertion site. U. Orient the StatLock device anchor pad so directional arrows point toward the insertion site. Place one catheter wing hole over one post, then slide the StatLock CV Plus stabilization device to capture second hole in opposite post. Support undersurface of StatLoc
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