How to assess central lines?

SierraBravo · Aug 17, 2014

In our institution, we use Tegaderm dressings for central lines. Those dressings are changed every 7 days or if they fail to become occulsive. Of course, with Tegaderm dressings they are transparent so you can see the catheter insertion site. If a patient has a sensitivity to Tegaderm dressings, we will dress the central line site with gauze and hypafix. Unfortunately, that dressing does not allow you to see the catheter insertion site so the dressing must be changed every 48 hours. For gauze and hypafix dressings, I just document that it is clean, dry, and intact.

Cheyenne RN,BSHS · Aug 17, 2014

We use transparent dressings on central lines after the first 24 hours unless the area would require a gauze dressing. When unable to assess the actual site the dressing can be charted as clean and dry/intact no c/o pain or redness, etc. Assessment should be ongoing and follow facility policy. It is a good idea to check policy and procedure with anything that is new.

FineAgain · Aug 17, 2014

We also measure length of the line from skin to clave and circumference of upper arm...

Here.I.Stand, BSN, RN · Aug 17, 2014

We use transparent dressings but with a CHG patch, so we can't really assess the insertion site except for with dressing changes. But to remove it just for the sake of visualizing the site increases the risk of infection. In fact if we have to change a dressing twice because it has become compromised (e.g., pt very sweaty so dressing now peeling off; NOT routine weekly dressing changes), we require our physicians to replace the line altogether. So yes, we chart "dressing dry and intact."

SoldierNurse22, BSN, RN · Aug 18, 2014

Even with a biopatch in place, you should be able to get some feel for how that site looks under the patch. I used to work oncology and biopatches were the best thing since sliced bread. People used to argue that they were somehow dangerous because you couldn't see the insertion site, but think about it this way: would you rather have chlorhexidine sitting right over the insertion site that's going to protect it for 7 days or would you rather leave the site unprotected but fully visible?

With patients who require gauze dressings due to an allergy, I would palpate the insertion site over the guaze to ensure that there was no pain. Because the dressing changes are so frequent with gauze dressings, you should be able to tell fairly quickly if you've got an infection brewing.

IVRUS, BSN, RN · Aug 18, 2014

What does your policy say as far as assessment of IV sites? Does it say, q 2hours, q 4 hours, q shift? Assessment means checking that site for induration by palpating the site while the dressing is still on, then once it's removed, assessing for the other vital observation points including external length from insertion, or exit site to hub. This needs to be assessed each time you're doing an assessment and each time you're doing a dressing change. What type of Transparent Sterile membrane (TSM) are you using? And I too would use gauze dressings for those allergic to the TSM, or if they have excessive diaphoresis.

iluvivt, BSN, RN · Aug 18, 2014

A tape and gauze dressing needs to be changed every 48 hours. It is not so much so that you can visualize the site as some have indicated rather it is keep the rate of infection low. There are no clinically substantive differences in site colonization rates between a tape and gauze dressing and a TSM dressing such as Tegaderm or Sorbaview as long as they are changed at 48 hours and every 7 days for the TSM dressing and when not clean dry and intact. One of the things that you are trying to prevent by assessing and performing a dressing change (with cap changes and hub cleansing) and site assessment is to avoid an extraluminal source of infection,which would be from the patient's skin.

To answer your question..YES leave it alone as long as it is clean dry and intact and you know for a fact the date is was completed. This is also what you need to assess and document.

1. You need to know what type of CVC is is when it was placed. The date of insertion is very important especially for non-tunneled CVCs which have the highest rate of infection and this may be an issue you need to address if the CVC has been in place for awhile or if another type of long term CVC is a better choice.

2.Verify that there has been a confirmed tip placement. Do you know what the optimal tip location is and why that is important?

3. Gather your flush solutions and alcohol preps and cap covers such as curos if you use them.

4. Perform hand hygiene and don exam gloves (the gloves are for just palpating the site just in case there is some dries blood or something near the site you do not expect)

5. Scrub needleless connectors (NC) for 15 seconds if you do not have alcohol impregnated caps on your NCs

6 Verify a brisk blood return and easy flush. You must treat if you do not have a blood return even of you can still flush (persistent withdrawal occlusion and you suspect it may be a thrombotic cause). Do steps 5 and 6 for all lumens

7. Now palpate the site gently and make sure it is not swollen,or painful to palpation, Keep in mind that there may be slight discomfort if it is a new site (insertion related trauma)or if the sutures are pulling a bit or if patient is hypersensitive . Regardless it needs to be evaluated.

8. Make sure the dressing is clean,dry and intact and that it meets your facilities criteria . For example if your policy states that you need to have a chlorhexidene impregnated patch at the insertion site and it is not in place then you need to re-do the dressing. If you do have to re-do the dressing it is best to scrub the hubs (the point at which the catheter and needless connecter meet) and change the NCs at the same time. It is very difficult to keep track of NCs changes so it is best for the patient to change them with every dressing change. biofilm has been found in cap housing in as little as five days.

9. Next you are going to assess for any local or systemic related complications. The assessment may vary a bit based upon the type of CVC you are assessing. But generally you will be assessing for s/sx of local infection,systemic infection,phlebitis (generally with a PICC and often seen early and if cephalic vein used or if accessed at the ACF) thrombosis, catheter fracture or dysfunction,tip placement (as discussed above),pneumothorax (not PICCS),dislodgement or migration. see this for the highlights of complications....it may help.

Complications of CVCs and their nursing management | Practice | Nursing Times

Remember ..DO NOT just look at the dressing and the site....assess for everything (local and systemic) since you are ultimately responsible. If you want more detaillet me know and I can provide more references!