CVC dressing change - page 2

I'm a student nurse and I'm wondering if my class instructor's practice might be out dated. (She's been an RN for more than 40 years but I don't know when she was last in a clinical setting.) A... Read More

  1. by   sandytoes
    My facility is mask for sure. Clean gloves to remove the old. Sterile gloves for the new one going on.
  2. by   AnnieOaklyRN
    CVC dressings absolutely need to be done in a sterile manner!! I am on an IV team and only we are allowed to change them and we have to wear sterile gloves and a mask, as does the patient and anyone else in the room (Mask only I mean).

    If you instructor is not doing this she may not be following the hospital's policy and is putting patient's at risk for central line infection!!

    Annie
  3. by   vampiregirl
    As other posters suggested, I would begin by looking up the facility policy.

    If the facility policy does not conform to the current evidence based practice recommendations, then I would approach the instructor with a request to meet with her. I would be prepared with the EBP recommendations. From there, it might be case of finding out how to go about getting a policy updated. This can be a great learning experience.

    Evidenced based practice recommendations change frequently. Sometimes policies don't get updated to reflect this.

    I work for a hospital that really does a good job of keeping policies updated and providing education. Several of my co-workers and I have been working to update a policy to reflect the latest recommendations and best practices. Luckily, we also have a policy outlining the steps to update a policy. It did take some effort, but it's been a great learning experience to see what all goes into updating this.
  4. by   kayern
    I manage a M/S Tele & Step-down unit, neither unit has had a CLABs in over 18 months. Gloves to remove the dressing, sterile gloves and mask to change dressing. We have biotin patches for central lines and our patients with central lines receive a clorhexidine bath daily. Ask your professor this.........if there are sterile gloves and a mask in your dressing change kits, then YOU ARE SUPPOSE TO USE THEM!
  5. by   NurseStorm
    We also use clean gloves to remove, then sterile gloves from then on. Mask for nurse and for patient unless they are turning their head completely to the other side it is not required. Be very cautious with central lines. Better to be more cautious if you are unsure of your exact policy. It won't hurt to use sterile gloves and mask. But it could definitely hurt to use neither
  6. by   drdonna
    Here.I.Stand,

    To put my statement of her methods possibly being outdated- She is my Fundamentals professor and has made a number of statements throughout the semester that included outdated language or outdated methods, some have been corrected by students other things have slide by. The school I'm attending apparently made the choice to only provide the instructors with electronic copies of the current books. (I do not know if she purchased her own hard copy.) Some of the mistakes are things she swears are in the textbook but are not in our editions.

    The problem is, as a student, it's hard for me to know if what she's saying is based off of what she remembers/ used to do or older edition textbook versus current, evidence-based practice.

    My question was based off of a test question where her correct answer was using a sterile mask for CVC dressing change (only other viable option was clean gloves). CVC dressing change was not in book and in her lecture she said just a mask and sterile gloves and just expected us to know that there are dressing kits with a sterile mask included-never mentioned in class.

    Thank you to all of you for letting me know what is actually happening in practice. I'm hoping to go into ICU and I know I'll be seeing this on the floor.
  7. by   RescueNinjaKy
    Quote from drdonna
    Here.I.Stand,

    To put my statement of her methods possibly being outdated- She is my Fundamentals professor and has made a number of statements throughout the semester that included outdated language or outdated methods, some have been corrected by students other things have slide by. The school I'm attending apparently made the choice to only provide the instructors with electronic copies of the current books. (I do not know if she purchased her own hard copy.) Some of the mistakes are things she swears are in the textbook but are not in our editions.

    The problem is, as a student, it's hard for me to know if what she's saying is based off of what she remembers/ used to do or older edition textbook versus current, evidence-based practice.

    My question was based off of a test question where her correct answer was using a sterile mask for CVC dressing change (only other viable option was clean gloves). CVC dressing change was not in book and in her lecture she said just a mask and sterile gloves and just expected us to know that there are dressing kits with a sterile mask included-never mentioned in class.

    Thank you to all of you for letting me know what is actually happening in practice. I'm hoping to go into ICU and I know I'll be seeing this on the floor.
    I don't know. Something doesn't add up to me. In your opening post you made no mention of a sterile mask, rather you talked about sterile gloves. Also you don't need a sterile mask. The whole point of the mask is to prevent you or the patient from spitting some bacteria onto the catheter site while changing the dressing. There's a mask in the sterile dressing kit but it's more for convenience rather than necessity.

    It concerns me that you are a nursing student but you claim that your instructor, who's been a nurse for many years, is outdated in her clinical practice. I welcome any desire to learn more but a better way to approach this would have been to ask about the dressing change process rather than make mention of your instructor and your instructors age. It comes off that you have a personal issue against either your instructor or more experienced nurses.

    I like nursing students but saying those kind of derogatory statements irk me. You are not a nurse yet, you do not have experience, a question on patho, pharm, or procedure is entirely appropriate but are you the best person to say whether your instructors knowledge is out of date. There is textbook nursing and real nursing.

    If icu is where you want to go, then you better not have this kind of demeanor when you are with your preceptor. They have better critical thinking skills and they are more knowledgable than you are. In a critical setting, there is less room for error and insubordination can be a dangerous trait there. There are few things worse than an inexperienced nurse who thinks that they know better than an experienced nurse, and if your preceptor, manager, or charge feels that way, it can easily be grounds for dismissal due to their concern for job fit and patient safety.
  8. by   drdonna
    RescueNinjaKy

    One of the challenges of posting online is that attitudes can be misconstrued, making it easy to jump to conclusions and make assumptions.

    I am a non-traditional nursing student in my 40s and have great respect for wisdom gained from experience. I like all of my instructor-some older than me and some younger; they're great.

    In my initial post I referenced 2 instructors-one classroom and one clinical, so maybe that is where some of the confusion lies as well.

    I have absolutely no problem learning from experienced nurses and am friends with 2 OB RNs that have more than 30 years experience each. I've learned and continue to learn a lot from them and they've been incredibly supportive of my learning and going back to school. I'm also consider myself an autodidactic and frequently search out answers from the best sources I can find. I asked my clinical instructor and RNs that I know through volunteering, searched other textbooks, multiple websites and the INS site (couldn't find the guidelines there but they were mentioned on one dressing change protocol online). I asked the question here because I want to get a feel for what's happening in clinical settings compared to what I read online and from CDC guidelines, since our textbook does not included CVC dressing changes and the information available is contradictory.

    But my concern is that she has been out of the clinical setting too long and is teaching from older edition textbooks. Also, she writes her own test questions and on many questions her word choice tends to be, let's say, open to interpretation- which is where the sterile mask reference came in.
    I can't give an exact quote of the entire question and answers but here's my best shot.

    A nurse caring for a patient receiving total parenteral nutrition would do this to reduce the chance of sepsis:
    A. Replace TNP that has been hanging for 36 hours.
    B. Replace lipids that have been hanging for 24 hours.
    C. A sterile mask is worn while changing a CVC dressing.
    D. Clean gloves are worn while changing a CVC dressing.

    I asked because I want to go into the clinical setting with the best available information for keeping my patients safe, while following evidence-based practice. I'm well aware that there is a difference between textbook knowledge and real world experience. I'm also aware that procedures change as evidence is shown that one way is better/safer than another.

    So, to all of the nurses out there, please forgive me if the wording of my post has offended you. It was never my intention.
  9. by   VANurse2010
    Quote from MunoRN
    I don't know where this keeps coming from, but professional practice organizations do not "set the standard of practice". Universal or near universal acceptance and implementation of practices is what defines the "standard of practice". It's pretty common for practice recommendations to reach the level of standard of practice, but just because an organization recommends something does not make it a legal standard of practice.
    Yep, and it almost always seems to come up in the context of INS on this board.
  10. by   Asystole RN
    Quote from MunoRN
    I don't know where this keeps coming from, but professional practice organizations do not "set the standard of practice". Universal or near universal acceptance and implementation of practices is what defines the "standard of practice". It's pretty common for practice recommendations to reach the level of standard of practice, but just because an organization recommends something does not make it a legal standard of practice.
    There is no such thing as a "legal" standard of practice as in there being laws but personally knowing and personally being involved in legal consulting I can assure you that if something happened the determinant of what is "reasonable and prudent" is often determined by what professional organizations determine the standards to be.

    I would invite you to sit in and listen to one of your board's scope of practice committees and see what they say, it can be enlightening.
  11. by   Asystole RN
    Quote from VANurse2010
    Yep, and it almost always seems to come up in the context of INS on this board.
    A little critical thinking here.

    Something happens.

    They call forth expert witnesses to determine if your actions were reasonable and prudent.

    Do you think the expert witness is just going to say, "Well schucks, we used to do this or that on my unit in this facility and this or that at that facility." Or do you think the expert witness will cite the published, and professionally accepted, standards posted by professional organizations that are often cited by board of nursing and government agencies?

    Call your board and see what they say. Call a malpractice attorney and see what they say.

    The problem is when you do something contrary to a standard of practice set forth by a professional organization you are going to get asked why. You better have an amazing rationale as to why your personal opinion on practice is more reasonable than standards supported by studies and KOLs.

    All of this is outside of P&P of which the nurse can hide behind, but the facility obviously cannot.
    Last edit by Asystole RN on Dec 14, '15
  12. by   MunoRN
    Quote from Asystole RN
    There is no such thing as a "legal" standard of practice as in there being laws but personally knowing and personally being involved in legal consulting I can assure you that if something happened the determinant of what is "reasonable and prudent" is often determined by what professional organizations determine the standards to be.

    I would invite you to sit in and listen to one of your board's scope of practice committees and see what they say, it can be enlightening.
    The "standard of practice", aka the "standard of care" is a term for how we establish negligence in a legal sense. Some practice organizations also care their recommendations "standards of practice", although those are actually two different things.

    What determines the standard of care is what you not find any "reasonable or prudent" nurse doing or believing is appropriate, so it represents a very high level of acceptance. Practice recommendations on the other hand are often meant to weigh on issues where there no overwhelmingly established support for a certain practice, thus the need for a recommendation to try and guide practice to an eventual standard of practice.

    This is a generally understood concept except for some reason when it comes to things related to INS, and seems to come from a particular individual's lack of understand of the term. For instance, the INS has recommended using an "antimicrobial ointment" over a CVC puncture site when it is discontinued, although even this particular INS individual points out that it doesn't matter if it's an antimicrobial ointment or not, so would it be considered "negligence" for a nurse to follow Ms. H's advice and use a non-anti-microbial ointment? Or take their recommendation to have a patient valsalva maneuver when discontinuing a PICC, which this same INS person points out isn't based on any evidence, it's just easier than differentiating between centrally inserted lines and PICCs. Or take changing "primary intermittent" tubing every 24 hours, we did a survey of a large number of hospitals and found that less than half believe this is good practice, so again, clearly not a "standard of care" if there is less than 50% support in practice.

    I am a direct care liaison for litigation system wide which often involves our union's retained malpractice firm as well and have worked on many projects in conjunction with our BON's compliance officer and have never heard it suggested, particularly in court or deposition, that the "standard of practice" is decided by practice recommendations. The standard of practice is determined solely by what the standard of practice is, practice recommendations are certainly admissible but their weight is as a recommendation, not an established standard.
  13. by   iluvivt
    Quote from Asystole RN
    There is no such thing as a "legal" standard of practice as in there being laws but personally knowing and personally being involved in legal consulting I can assure you that if something happened the determinant of what is "reasonable and prudent" is often determined by what professional organizations determine the standards to be.

    I would invite you to sit in and listen to one of your board's scope of practice committees and see what they say, it can be enlightening.

    Exactly...Thank you !

close