Some more PICC questions

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I am learning a lot about picc lines, but have some questions.

1) When doing dressing changes, is it ok to take old dressing off with clean gloves as long as not touching insertion site?

2) When using statlocks, do you use steri strips also?

3) Do you need to wear sterile gloves to change extension and cap?

4) What do you do for a patient with peeling skin under transparent dressing?

5) regarding removal, do you pull out picc in one steady fashion while pt holds their breath or do it inch by inch? I have read both were correct.:)

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Specializes in Infusion Nursing, Home Health Infusion.

Ok all good questions.....

1. Yes!!!!! use clean gloves to remove the old dressing. I t would be pointless to use sterile gloves b/c the minute you touch anything that is NOT sterile the gloves are no longer sterile either. Remember to perform hand hygiene prior to starting the procedure. I put a mask on change the caps and then remove the dressing bc. if you remove the dressing and securement devices and then change the caps it is much easier to pull out a few cms. If I have any infusions going I also temporarily tape the tails to the upper arm so the weight of the IV tubing(s) does not pull any of the PICC out....it is really important NOT to pull the PICC out.....even a couple of cms matters

2. Yes It is OK to use a stat loc or any other securement device and the use steri strips.....sometimes you will not need steri strips...if there are O cms externally visible for example. We tend to leave anywhere from 5-8 cm externally visible so we do use them b/c if there is moisture under the TSM dressing a PICC can still get pulled out under the dressing. The stat nloc needs to be changed at least every 7 days....horrible skin irritation and infection can occur if this is not done.

3. You do have to change the caps and extension sets if you use them in an aseptic manner but you do not generally have to wear sterile gloves to do so. So the connection from your flush syringe to your sterile new cap will be sterile and then the connection form the sterile end of the cap to the extension tubing. Again.... some policies out there require the nurse to wear a mask for cap and ext set changes

4. Try to determine the reason the pts skin may be peeling...you ma need to change the dressing more frequently and use a skin protectant OR use a different type of TSM dressing..IF any gauze is placed under a TSM dressing such as tegaderm it is essentially a 48 hr dressing.

5 Best to pull the PICC out using a hand over hand technique especially the silicone piccs so you do not snap it..the polyurethane piccs are much stronger ...

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Thanks for the info, much appreciated. I will most likely be back to ask some more questions if thats okay. I love infusion nursing and have been doing home infusion for about 6 months now.

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Specializes in Infusion Nursing, Home Health Infusion.

no problem I do both...I have worked on an IV team since 1986 and I put my first PICC in in 1989. I have also done home infusion nursing for 15 yrs......Yes I still love them both...I work 60-70 hrs per pay period on the IV/PICC team and the then at least 20 hrs for home infusion. I have been writing all of our Infusion related policies and procedures since 1987. I am stil fascinated with all things IV and read extensively on the subject.After literally educating myself with all the theory I needed I advanced myself into more advanced topics of study.

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1) Do you always tell pt to lay down with arm extended out 90 degrees with sterile drape underneath or is it ok to have them sit down, at a table say, and do dressing change?

2) Do you tape tail of lumen to prevent catheter from slipping out from weight of catheter when you change stabilization device. Maybe tape tails down after removing stabile device so you can open your supplies? Sorry, I seem to never have enough hands to open prep packets and hold catheter from slipping out slightly after statlock removed.

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Specializes in Infusion Nursing, Home Health Infusion.

1 Well there is nothing that states the pt has to be in bed to change a PICC dressing...you just need to be mindful during cap changes so you do not introduce air into the pt...YES the risk is lower with a PICC but it still can happen...so make sure if it has a clamp..to clamp..change the cap...then unclamp and flush...if it is valved either in the distal end (groshong) or in the tails (ie.SOLO and PASV) the valve should stay in a neutral postion upon disconnect...if you see blood drippin out.the valve is not working or is up against the wall of the vein and open (as with a Groshong)

2 Yes.. I remove everything and then just tape the tails BEFORE i put on my sterile gloves...you have to really careful not to move the catheter IN or OUT. If you move it in you can drag bacteria from the skin into the pt,IF you pull it out any...you can change its position..the farther away you get from the SVC the greater the risk of thrombosis. So...... if the PICC was in the low SVC and now you pulled it out with the dressing change and it is in the upper SVC..the risk for thrombosis is greater..as a matter of fact the farther you get away from the lower third of the SVC every complication is increased. So see why it is so important to not move that thing

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1 well there is nothing that states the pt has to be in bed to change a picc dressing...you just need to be mindful during cap changes so you do not introduce air into the pt...yes the risk is lower with a picc but it still can happen...so make sure if it has a clamp..to clamp..change the cap...then unclamp and flush...if it is valved either in the distal end (groshong) or in the tails (ie.solo and pasv) the valve should stay in a neutral postion upon disconnect...if you see blood drippin out.the valve is not working or is up against the wall of the vein and open (as with a groshong)

2 yes.. i remove everything and then just tape the tails before i put on my sterile gloves...you have to really careful not to move the catheter in or out. if you move it in you can drag bacteria from the skin into the pt,if you pull it out any...you can change its position..the farther away you get from the svc the greater the risk of thrombosis. so...... if the picc was in the low svc and now you pulled it out with the dressing change and it is in the upper svc..the risk for thrombosis is greater..as a matter of fact the farther you get away from the lower third of the svc every complication is increased. so see why it is so important to not move that thing

okay, now what's the procedure if you feel that it has moved in or out?

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Specializes in Infusion Nursing, Home Health Infusion.

It is important to know how many cms are externally visible so you can keep it that way..IF that number has changed significantly (average length of the SVC is 7 cm long so it does not take much to withdraw out of the SVC) You first need to get a CXR and see where you are at. Once you know where the tip of the PICC is you can move forward with your decision on the next step. Generally speaking,it is best to replace the PICC as soon as possible. If the pt is on TPN and is no longer in the SVC the PICC should not be used. If the PICC is in the BC vein and you have one more dose of abx to administer...give the dose then d/c it. I have given you 2 examples but there are as many scenarios as there are pts.SVC tip placement is the recommeded locations for all CVCs except Dialysis catheter ( RA ok for these ) so you need to do something about it. There are some circumstances, usually pathophysiologic reasons that a CVC can not be advanced into the SVC and in those cases it is crucial that concise documentation takes place and the benefit clearly outweighs the risk. So before you use any CVC..make sure you know where the tip is and that it has been confirmed especially when a pt comes into our facility from anher with an existing CVC

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What is the definition of external catheter length? I would think it means from insertion site to hub of the Picc. Does the length of the catheter from insertion site to the IV connection ever need to get measured? Do all Picc brands have a hub? Is the usage of a stabilization device like Statlock recommended by manufactures? There is some confusion at my workplace because the IV documentation sheets we utilize use the words measure migration in one area and external cath length in another. Wouldn't they be the same thing? Isn't just different terminology to describe both? Thanks for your input.

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Specializes in Infusion Nursing, Home Health Infusion.

1 External amt of the catheter visible is from the catheter skin junction to the hub of the catheter or in reverse the catheter hub to the insertion site at the skin. This measurement needs to be taken with every dressing change or if any change in this amt occurs or is suspected. This also needs to be documented with every dressing change at the minimum. I always state something like this " amt externally visible = 5 cm ,which is no change from original measurement

2. INS does recommend the use of an engineered securement device for PICCs and many manufacturers include this in their insertion kit.

3 I find it odd you have a section for migration in your charting b/c you do not want it to migrate. I would need to see how it is worded exactly b/c ideally you want to chart "0" migration

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