TestifyToLove

How much PICC migration is acceptable and at what point do you need to be concerned and consider it's no longer SVC? Recent patient was extremely active. PICC team (we outsource PICC insertion to the hospital system PICC team, which we are not) failed to write how much tubing was external at insertion. However, I was able to document 1.5cm weekly migration with dressing changes. Antibiotic and CRP levels remained in good ranges, but we discussed as a team that any further migration would need to be reported to the prescribing MD after the second week. Patient d/c'd and it was no longer a concern for *this* case, but am interested in learning for future reference. He was our first PICC that was migrating at all. Most of our patients are very careful and protective of their PICCs and we never see little to no migration at all.

You can actually take that a step further. You can tap the air bubbles out of the syringe (or even just tap them to the plunger side of the syringe) and simply put the fluids you drew out back into the line, depending upon how much fluid you pulled out to get the air out. I can do the whole step without disconnecting so it remains a closed system and just throw the syringe with air bubble away when I'm done.

Another option, as we say "go for the gusto." If you need access and the arms and hands don't look good, just head for the ac. I occasionally have a few patients that have skin that tough. Are you advancing the needle and catheter 1-2mm after hitting flashback before trying to thread the catheter? Are threading with the turniquet on or off? While most literature I've seen says to thread with the tourniquet applied, we always release it for hard to thread patients, as it makes it easier to thread once we've hit the vein. You can also float the catheter in if you've got good flashback but not threading well. However, in the ED you would probably just opt for bigger veins in the ac than trying to do an intricate manuver to float a catheter into the vein. Inside of the forearm will have less tough skin, although ime you can't always tell from looking at skin if it's going to be tough. We're an infusion center. We don't have u/s. We do have a vein light which does wonders for visualizing veins when we're struggling to see good options though.

I realize my situation is abnormal. For starters, while I was out of paycheck nursing for 14 years, I was still using my nursing skills as a medical foster and adoptive mother. When I decided to revive my licensure, I had to submit a TON of CEs for my original licensure state plus fingerprints and a $150 fee. I got lucky. My state did not require a refresher course and counted college courses to the tune of 14 CEs per credit hour. I was able to count my Biology and my Sociology of Medicine courses to fulfill my entire CE requirement to reinstate my licensure. I had moved long ago from my state of original licensure. However, to transfer to my current state, I needed only to have an active license elsewhere. My previous state had a work hour requirement or required a refresher course. I was prepared to take a refresher course but we moved and I didn't need to do so. Took me several months, 2 more specific CE courses and another licensure fee to get licensure in my current state of residence. At that point, I worked my contacts. I knew that a recruiter looking at my resume was going to throw it out and never give it a second look. I used references all in the medical field, all who had personally observed me using my nursing skills with the foster and adoptive children. One of them was a physician of my child, a second was one of my children's primary nurse in the hospital setting. Then, I looked for job listings that fit my experience and background to match what areas I worked without a paycheck all those years. I got *very* lucky. The Nursing Manager for one of my children's speciality clinics listed a position specifically looking for a nurse with in-depth knowledge of the very medical condition my child has. Before I even applied for the job, I called her personally. It was a part-time job and the hours were not clear on the listing. I needed her to see *me* and not the weak resume. I also needed to be assured I could work part-time, not just for the permenant position but in the orientation process as well. Because the manager knew me, had observed me utilizing my nursing skills, spoke with me directly before I submitted my resume, I had a HUGE advantage. She strictly informed me on the phone that the personal connection would ONLY guarantee me the interview and a quick pass from the screening process. However, as luck would have it the morning after I interviewed, my child had a medical crisis and she observed me in full nursing mode. I strongly suspect that it was that coincidental encounter where she could see me in my element that landed me the job. All that said, I am now a part-time Infusion Nurse for an outpatient infusion center. I did not have to return to Med/Surg. I didn't not have to sink into LTC facilities (where I would rather never return to nursing than enter). There was a LOT I was out of practice on. There was a lot that fit like a glove too. You don't lose your nursing as much as you THINK you do. For years, I tried to hide was a nurse. Everytime I encountered the medical professions, I attempted to be percieved as a knowledgable advocate and mother and NOT a nurse. It never worked. It never took more than one encounter for both doctors and nurses to immediately recognize I was a nurse. It is true that nursing has changed and progressed in the years I was home, but it's also true that it is easy to adapt and catch onto the changes. In my general nursing orientation (prior to my unit orientation), I was one of THREE nurses returning after significant absences from the profession. All three of us utilized the same basic concept to secure jobs. We used existing contacts with people who knew us to network for a job position. With a special needs son and having worked as a home health aide now, you HAVE those contacts. Have you asked your Nursing Manager if your current company would hire you as a nurse instead of an aide if you pursued renewing your licensure? I interviewed for a home health aide job two years ago, before I found a way to salvage my nursing license, and the hiring manager made it VERY clear that he would hire me as an aide but he would personally push and encourage me to restore my licensure and would hire me as a nurse if I was able to accomplish that feat. He stated all of that before I even worked for him. I suspect your current employer would support allowing you to advance back to nursing if you sought reinstatement. With a special needs child, I suspect you have other personal connections you could network as well. I had to come back to the concept of restoring my licensure four times before I saw how to accomplish it and had the confidence to believe I could not only do it but secure a job that fit the needs of my family when I did it. Now, I have a job that fits my needs perfectly--both professionally and for my family. I am starting my BSN this week and am contemplating if I want to remain in nursing and seek advanced practice, or enter academia. The first two times I came to this puzzle, the ONLY answer I could see was an emphatic NO, that the task was impossible. The third time, I realized it might be possible but believed I could NEVER find employment even if I accomplished it. I now realize why people kept telling me "once a nurse, always a nurse" in the years I tried to conceal my background. There are a LOT of medications I don't know at this point. There are new practice techniques I never saw when I worked as a nurse or went to school years ago. However, I found my footing quickly. My department AND my hospital embraced me as a seasoned nurse. It felt ackward to hear myself refered to in that manner given how non-traditional my trajectory was all those years. However, we had a new graduate intern in our clinic this last week and I realized immediately WHY everyone considered me seasoned. She may have just graduated and her skills are up to date, her pharmacology is grilled into her brain from taking the NCLEX. However, her skills in seeing a whole picture, and responding appropriately and calmly didn't exist....not yet. I came back with those skills neve gone, even if it took me nearly a month to convert the butterfly push skills I have done for a decade into consistently successful saline locs to run longer IVs.

Protocal in our center is to measure the line from insertion site external length at every dressing change to be aware if the line is migrating. The original length is supposed to be documented when the PICC is placed. However, we have a very strange set-up and the home health team is the PICC team for the entire hospital system (multiple hospitals and outpatient facilities in the system around the city). If it migrates too far, our protocal is to immediately inform the ordering physician and allow them to make the judgment call on how to proceed. We have several options, including as mentioned making it a midline placement or sending them back for a re-insertion. We don't have authority to do or order any of the options without physician orders, however.