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PICC dressing change nurses notes

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lindygirl lindygirl (New) New

I need to chart that I changed a PICC dressing. But I am terrible at wording nurses notes, and I have never charted/ done this before. Can someone give me an example?

melizerd, ASN, RN

Specializes in Med/surg, Onc.

Maybe I'm no help because we don't write notes for it.

Under invasive lines you chart that you changed the dressing by clicking the options. It is assumed you used proper technique per policy.

I'd find out what you are required to put in your note. Mask, hand hygiene, scrub used, dressing type applied, bio patch etc.

A note could be as short as this:

Performed PICC dressing change per policy.

I would keep it simple and just document what you do and see...

PICC dressing changed per facility policy. sterile technique maintained. site appears normal with no swelling, redness, or signs of infection noted. new dressing dry and intact. pt tolerated well. no complications. will continue to monitor site.

Also, be sure to fill out any facility related forms that may be required after changing a PICC dressing.

jj224

Specializes in Critical Care. Has 4 years experience.

PICC line dressing changed using aseptic technique. Keep it simple.

Edited by jj224
misspelled word

IVRUS, BSN, RN

Specializes in Vascular Access. Has 32 years experience.

Performed PICC dressing change per policy.

Writing per policy, or Per protocol, can be problematic. Whose protocol did you follow? Was it the employing institution's protocol, or perhaps a protocol of a previous employer. Maybe it was my own, person protocol because I really liked that one!.

I personally would spell it out:

0900: PICC line dressing changed. Old dressing removed and discarded. Site without redness, swelling or exudate, or any other s/s complications. Patient denies discomfort at site, or along vein track. Catheter has 2cm external which corresponds to previous external measurements. Per sterile technique, area cleansed with XYZ and allowed to air dry. Secured with statlock/wingguard or tape, steristrips, followed by transparent sterile membrane (Opsite/tegraderm etc). Needleless cap also changed and line flushed with 10cc NSS after obtaining brisk blood return.

anewsns

Specializes in Neurosciences, stepdown, acute rehab, LTC. Has 8 years experience.

PICC drsg changed per protocol, no s/s infection or complications at insertion site. External catheter length maintained at Xcm. Flushed without difficulty .

PsychNurseWannaBe, BSN, RN

Specializes in Psych, LTC, Nursing Management, WCC. Has 7 years experience.

I guess it depends. Our changes are put on the MAR, so we sign it off plus the other info we fill out on the MAR. Measure the length from point of insertion to the hub and measuring three inches about the site and then the circumference of the arm. And changing the caps. Also changing the caps after pulling blood off the PICC. Flushes are also on the MAR Also every shift we have to monitor the site. But if I had to chart it, I agree with others. Keep it simple.

Edited by PsychNurseWannaBe
typo

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 40 years experience.

Lindy...the members have been nice to you....is this a homework assignment?

If it is....ask yourself what does your textbook say about central line dressings?'

What type of technique this?

One you know the technique how would you put that into words on paper?

What does the site look like?

Is there a blood return?

Give us an example of what you think and we will help you.

I put, "PICC dressing changed, site of insertion is unremarkable, patient tolerated procedure well, PICC remains patent, will continue to monitor"

KatieMI, BSN, MSN, RN

Specializes in ICU, LTACH, Internal Medicine. Has 7 years experience.

"PICC line dressing (optional - loose, soiled), changed according to orders using standard aseptic technique (optional if your place's policy requires any of them: CGH dressing applied, stockinette applied, caps #... changed). No signs of infection or inflammation noted. Lumen(s) #1,2,3 draw/no drawback blood, flush(es) easily. Patient tolerated well.

Separate charting for total flushes volume if patient is on strict I/O.

FlyingScot, RN

Specializes in Peds/Neo CCT,Flight, ER, Hem/Onc. Has 28 years experience.

Please, please always document the external catheter length and check it when changing the dressing. I cannot tell you how many times I have found mal-positioned catheters just based on changes in the external length. One patient of mine suddenly started having arrhythmias and nobody could figure out why until I checked her PICC and found someone had PUSHED IT IN almost 10 centimeters (don't get me started on that fiasco).

KelRN215, BSN, RN

Specializes in Pedi. Has 10 years experience.

I don't see why this needs to go in a nurse's note. There must be a section for lines/tubes on the flow sheet. Under PICC line where it says "dressing" check "changed". The end.

annie.rn

Has 21 years experience.

FlyingScot said:
Please, please always document the external catheter length and check it when changing the dressing. I cannot tell you how many times I have found mal-positioned catheters just based on changes in the external length. One patient of mine suddenly started having arrhythmias and nobody could figure out why until I checked her PICC and found someone had PUSHED IT IN almost 10 centimeters (don't get me started on that fiasco).

^^Yes!^^ I dealt with a similar situation. When documenting the external length, you need to compare it to the length at time of insertion. If it is different (shorter or longer), you need to get an x-ray to confirm proper location of the tip. Do not use the PICC until placement is confirmed.

scuffles, RN

Has 33 years experience.

I document, sterile technique maintained throughout procedure. Picc line measured as per local policy = . Vip score = . IV dressing, statlock or griplock, bionector renewed.