So here is the back story. I'm a new nurse, and have been working on a med-surg floor of a fairly large teaching hospital for 9 months. I just got a per diem home infusion job. I was a little surprised at how quickly I was hired given how little experience I have. With that said, I was even more shocked to only get one day of orientation (one day, one visit!) before I was thrown out there on my own. Being as I've only been in the hospital, some of the dressing change kits (among other things) in home care are foreign to me and I find myself questioning if I've done the right thing. So on to my question....
Yesterday I saw a guy with a Hickman catheter. After I stopped his infusion, I noticed his dressing was coming loose. The dressing was dated 1/2/13 and he had a Biopatch on the site, which I know is good for 7 days. It was clean and intact. His therapy will be done on the 9th. The kit including a sterile gauze with a slit in it, a larger piece of gauze, an occlusive dressing, a chloraprep applicator, and 2 alcohol pads. I would rather see him with the Biopatch than a piece of gauze under the dressing, so rather than take the Biopatch off I left it and just replaced the occlusive dressing. Did I do the wrong thing? Should I have changed everything?
Jan 7, '13
If you dated the entire dressing for 1/6/12, which was yesterday, it would be assumed that the Biopatch was also changed on this date. I get that he only has till the 9th and therapy is done,
but legalistically speaking, its deceptive. Dating it for the 6th, means that the area was cleansed, and the biopatch placed on that date. You can rectify this situation by writing on the label: TSM (transparent sterile membrane) changed only on the label, with asterix and attn: see NN. then address what was done in your notes.
Now, did you not have another Biopatch to replace the old one with?
If you didn't have one, I would have assessed the benefit versus risk of removing just the dressing and not cleaning, nor addressing the biopatch. The Biopatch is designed to stay under a TSM and to be changed every 7days, as long as the dressing remains occlusive. If the dressing is loose, as in this case, then I have to assume that the biopatch integrity too was comprimised and I would have removed it all, cleansed the area at the site as well as anything that would be under the dressing and then once dry, replaced a Sterile TSM. Three days without the Biopatch which, because the drsg was loose, is now comprimised, is not that big of a deal.
You are right not to cover the site with gauze and then place a TSM as this is then considered a gauze dressing and should be changed as such.
Does this help?
Jan 7, '13
Yes it does help. Unfortunately I did not have another Biopatch (never seen one in home care to date, his dressing was from the hospital) and the only other thing to work with was the occlusive dressing and the piece of slitted gauze.... I hate the kits in home care. I guess next time I don't even have to use the gauze, I can just cleanse and replace with the TSM only. Like I said, the kits are ridiculous and don't give me much to work with sometimes. After I left the house I kept thinking about what I had done and that I probably should have chosen another route.
Jan 15, '13
Most of the pharm companies I deal with in home health won't automatically send the Biopatch. But when I call them and tell them the patient came home from the hospital with one - and no replacements are in with their supplies --- the company will send them with the next weekly shipment. I completely agree with you on the kits....they ARE ridiculous!!
Jan 16, '13
Agree with IVRUS as we usually do. Also do not forget to change whatever needless connector (NC) that you have on the line as well and remember to scrub that connection for at least 15 sec with IPA...time yourself it is longer that you think. I too just change everything at once including the caps so everything is theoretically good for 7 days or until it is no longer CDI.
OK I see your concern to be functioning in an area that is specialized BUT you can do it safely if you practice prudently. I am concerned that you only had one day of orientation. What type of cases does your agency take? I can suggest some resources for you. I works on a busy IV/PICC team but my PD job is for a home infusion company..been a doing this a long long time. DO NOT go into anything unprepared for example if you need to set up and instruct on a 3 in 1 TPN you must be prepared to not only set it up you have to know it well enough to teach the pt and or caregiver, You also need to instruct and document all this teaching including all the potential complications and potential side effects such as electrolyte imbalance. Patient and caregiver teaching is a huge part of home infusion and you need to make sure that they are independent if they are self administering the prescribed IV therapies.
I can tell you care about the quality of care you are delivering b/c you are seeking help. This is a great resource for you as well and I can direct you towards more as needed. Please read your policy and procedure manual.