PROCEDURE Peripherally Inserted Central Catheter

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PROCEDURE

87

Peripherally Inserted Central Catheter Debra L. Wiegand

PURPOSE: Peripherally inserted central catheters are used to deliver central venous therapy to provide venous access for patients who require infusates that are not peripherally compatible (e.g., vesicants, irritants). Peripherally inserted central catheters can be used for all types of infusion therapy including chemotherapy, total parenteral nutrition, analgesia, blood products, intermittent inotropic medications, and long-term antibiotics.

PREREQUISITE NURSING KNOWLEDGE

• Successful completion of specialized education in ultrasound-guided peripherally inserted central catheter (PICC) insertion utilizing a modifi ed Seldinger technique and demonstrated competency are necessary. 3,4 In addi-tion, opportunities to demonstrate clinical competency on a regular basis (e.g., yearly) may be needed.

• Knowledge of the principles of sterile technique is essen-tial.

• Knowledge is necessary of the anatomy and physiology of the vasculature and adjacent structures in the upper extremity, neck, and chest.

• Knowledge is necessary of assessment of upper-extremity venous access using ultrasound.

• A patient receiving a PICC should have a peripheral vein that can accommodate a 22-gauge microintroducer needle to perform the modifi ed Seldinger technique. The smallest device in the largest vein allows for maximal hemodilu-tion of the infusate and minimizes the risk of phlebitis and thrombosis. 1 The catheter-vein ratio should be 45% or less. 5

• The basilic, medial cubital, cephalic, and brachial veins should be considered for cannulation with a PICC ( Fig. 87-1 ). The basilic vein is the larger vessel and is the vein of choice for insertion of a PICC. Brachial veins are a second choice due to close proximity to the brachial artery and nerve structures. The cephalic vein has been associ-ated with an increased risk of thrombosis. Patient prefer-ence for arm selection (e.g., nondominant hand, lifestyle, activity restrictions, ability to care for the catheter) should be considered with selection of the insertion site. 2 Once inserted, the PICC is advanced to the lower segment of the superior vena cava at or near the cavoatrial junction. 4,5

• Patient indications for the insertion of a PICC are not limited to inpatient therapies. A PICC is also placed for patients who require intravenous (IV) therapy in the home setting for chronic heart failure, cancer treat-ment, chronic pain management, nutritional support, fl uid replacement (e.g., hyperemesis gravidarum) and long-term antibiotics.

• PICCs may be preferred over percutaneously inserted central venous catheters for patients with trauma of the chest (e.g., burns) or certain pulmonary disorders (e.g., chronic obstructive pulmonary disease, cystic fi brosis). 7 PICCs eliminate the risks associated with insertion of percutaneously inserted central venous catheters in the neck or chest (e.g., pneumothorax). 1

• PICCs are contraindicated in patients with sclerotic veins, chronic kidney disease stages 4 and 5, lymphedema, mas-tectomy with lymph node dissection, arteriovenous graft, fi stula, radial artery surgery, or extremities affected by cerebral vascular accident. Other access devices may be a better choice in patients with altered upper extremity skin integrity, or upper extremity fractures where PICC complications could compromise wound healing.

• The most common complications associated with PICCs are phlebitis, thrombosis, and catheter occlusion. 5,9

• A variety of PICCs are available for use. PICCs are fl ex-ible catheters that are made of silicone or polyurethane. Catheter diameters range from 2 Fr to 6 Fr, and the cath-eter length ranges from 40 cm to 65 cm. For adults, 4 Fr to 5 Fr catheters that are 60 cm in length are typical.

• PICCs are available as single-lumen, double-lumen, and triple-lumen catheters, with and without valves. Some PICCs are designed to handle power injections (e.g., con-trast media for computed tomographic scans).

• A PICC can be inserted with or without the use of a modi-fi ed Seldinger technique. When a modifi ed Seldinger tech-nique is used, venous access is achieved with a small-gauge (20- or 22-gauge) peripheral IV catheter. Once the IV catheter is inserted, the stylet is removed and the guide-wire is threaded through the IV catheter. The IV catheter is then removed, and the dilator/introducer is inserted over

This procedure should be performed only by physicians, advanced practice nurses, and other healthcare professionals (including critical care nurses) with additional knowledge, skills, and demonstrated competence per professional licensure or institutional standard.

87 Peripherally Inserted Central Catheter 767

technology using ECG and Doppler can be utilized to further assist the clinician in confi rming tip location in the superior vena cava. This technology can be used in lieu of chest x-ray for verifi cation of tip location.

• Longitudinal or transverse views can be used when placing the PICC with ultrasound. The needle tip should remain in view at all times. If the tip of the needle cannot be visualized, the probe, not the needle, should be moved to reestablish visibility. 4

EQUIPMENT

• Catheter-insertion kit • PICC catheter of choice • Single-use tourniquet • Sterile and nonsterile measuring tape • Waterproof underpad/linen saver • Sterile gown • Head cover • Mask • Goggles or eye protection • Two pairs of nonpowdered sterile gloves

the guidewire. The dilator and guidewire are removed, leaving the introducer in the vein to allow for passage of the PICC into the vein. Once the PICC is in place, the introducer is removed. Care must be taken with the use of a guidewire. Although advancement of the introducer is enhanced by the fi rmness provided by the guidewire, the guidewire can inadvertently traumatize the vessel. 5

• There are alternate PICC placement techniques and the manufacturer ’ s guidelines should be followed.

• A variety of safety-engineered introducers are available and should be used to reduce the risk for blood exposure and needlestick injury. 4,5,7

• PICCs can be placed at the patient ’ s bedside, in interven-tional radiology, or in specialized rooms dedicated for PICC insertions.

• Ultrasound guidance is recommended to place PICCs if the technology is available and it is associated with improvement in insertion success rates, reduced number of needle punctures, and decreased insertion complication rates. 4

• Ultrasound scan technology can be used to assist with vein assessment and PICC insertion ( Fig. 87-2 ). Tip-locating

Figure 87-1 Location of the veins of the right shoulder and upper arm. (From Jacob SW, Fran-cone CA: Elements of anatomy and physiology , ed 2. Philadelphia, 1989, Saunders.)

768 Unit II Cardiovascular System

decreases patient anxiety, enhances cooperation, provides an opportunity for the patient to voice concerns, and pre-vents accidental contamination of the sterile fi eld and equipment.

• Instruct the patient and family to refuse injections, veni-puncture, and blood pressure measurements on the arm with the PICC. Rationale: The risk for catheter-related complications and catheter damage is minimized.

• Provide appropriate patient and family discharge educa-tion regarding the care and maintenance of the PICC if the patient will be discharged with the PICC in place. Rationale: Education reduces the risk for catheter-related complications from lack of knowledge and skills needed to care for the PICC after discharge.

PATIENT ASSESSMENT AND PREPARATION Patient Assessment • Assess the patient ’ s medical history for mastectomy,

fi stula, shunt, CVA, or radial artery surgery. Rationale: PICC insertion should be avoided in extremities affected by these conditions to preserve veins for future needs and because the risk for complications is increased.

• Obtain the patient ’ s baseline vital signs and cardiac rhythm. Rationale: Cardiac dysrhythmias can occur if the catheter is advanced into the heart. Baseline data facilitate the identifi cation of clinical problems and the effi cacy of interventions.

• Assess the vasculature of the proposed extremity for appro-priate vessel size, round shape, normal path, and compress-ibility. These assessments should be performed without a tourniquet to establish the appropriate vein-to-catheter ratio

• Sterile drapes and towels, including one fenestrated full bar-rier drape

• Antiseptic solution (e.g., 2% chlorhexidine–based prepa-ration)

• 10-mL vial of heparin (concentration and use per institu-tional standard)

• 30-mL vial of normal saline (NS) solution • Needleless connector with/without short extension tubing • One to three 10-mL, 20-gauge, 1-inch needle syringes (blunt

needles recommended), depending on the number of lumens • Sterile 4 × 4 gauze pads or sponges • Sterile 2 × 2 gauze pads or sponges • Sterile, transparent, semipermeable dressing • Bedside ultrasound machine with vascular probe • Sterile ultrasound probe cover • Sterile ultrasound gel • Catheter securement device Additional equipment, to have available as needed, includes the following: • One 1-mL, 25-gauge, 58 -inch needle syringe (if intrader-

mal lidocaine is used) • 1% lidocaine without epinephrine or 1 to 2 mL of eutectic

mixture of local anesthetics (EMLA) cream (optional)

PATIENT AND FAMILY EDUCATION

• Explain the reason for the PICC, the benefi ts and risks associated with the catheter, and the alternatives to PICC placement. Rationale: Clarifi cation of information is an expressed patient need and helps to diminish anxiety, enhance acceptance, and encourage questions.

• Describe the major steps of the procedure, including the patient ’ s role in the procedure. Rationale: Explanation

A B

Figure 87-2 Use of ultrasound scan technology to assist with vein location. A, Ultrasound scan probe is positioned over the insertion site. B, Depiction of ultrasound scan–assisted catheter inser-tion. (Courtesy of Bard Access Systems, Salt Lake City.)


the selected insertion site to the shoulder ( Fig. 87-3, A ) and from the shoulder to the sternal notch ( Fig. 87-3, B ). Add 3 inches (7.5 cm, or the measured distance from the sternal notch to the third intercostal space) to this number for catheter placement in the superior vena cava. Ratio-nale: Accurate measurement ensures proper tip position in the distal portion of the superior vena cava at the cavoatrial junction and determines the length of the cath-eter to be inserted.

• Measure the mid–upper arm circumference of the selected extremity. Rationale: Measurement provides a baseline for evaluation of suspected thrombosis after PICC inser-tion. Increases of greater than 2 cm over baseline may be indicative of venous thrombosis. A diagnostic ultrasound should be obtained.

• Stabilize the position of the arm with a towel or pillow. Rationale: Stabilization increases patient comfort, secures the work area, and facilitates access to the selected vein.

• Instruct the patient on proper head positioning. The head is positioned to the contralateral side (away from the insertion site) throughout the procedure, except when the catheter is advanced from the axillary vein to the superior vena cava. At this point, the patient is instructed to posi-tion his or her head toward the ipsilateral side (toward the insertion site) with the chin dropped to the shoulder. Rationale: Proper positioning limits the risk for the cath-eter being inadvertently directed into the jugular vein.

and to ensure there is adequate blood fl ow around the cath-eter in situ. Rationale: Placing a catheter in a healthy vein with adequate blood fl ow around the catheter will optimize catheter function and decrease the risk of thrombosis.

• Determine the patient ’ s allergy history (e.g., lidocaine, heparin, EMLA cream, antiseptic solutions, tape, latex). Rationale: Assessment decreases the risk for allergic reactions with avoidance of known allergenic products.

Patient Preparation • Verify that the patient is the correct patient using two

identifi ers. Rationale: Before performing a procedure, the nurse should ensure the correct identifi cation of the patient for the intended intervention.

• Ensure that the patient and family understand preprocedural teaching. Answer questions as they arise, and reinforce information as needed. Rationale: Understanding of previ-ously taught information is evaluated and reinforced.

• Ensure that informed consent has been obtained. Ratio-nale: Informed consent protects the rights of the patient and allows the patient to make a competent decision.

• Perform a preprocedure verifi cation and timeout. Ratio-nale: Ensures patient safety.

• Assist the patient to a supine position with the head of bed elevated. Rationale: Ensures patient comfort.

• For catheter placement in the superior vena cava, use the nonsterile measuring tape to measure the distance from

Figure 87-3 Measurement of the catheter length for placement in the superior vena cava. A, First, measure the distance from the selected insertion site to the shoulder. B, Continue measuring from the shoulder to the sternal notch and add 3 inches (7.5 cm) to this number.

A B


* Level E: Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations.

Steps Rationale Special Considerations

1. Obtain ultrasound equipment. Prepares equipment. Assistance may be needed from radiology.

2. HH 3. PE 4. Place a waterproof pad under the

selected arm. Avoids soiling of bed linens.

5. Determine the anatomy of the access site. (Level E * )

Helps ensure proper placement of the PICC and guides the area to be prepped. 4,5

6. Wash the insertion area with soap and water.

Prepares insertion site.

7. Discard used supplies and remove gloves.

Removes and safely discards used supplies.

8. HH 9. With the measuring tape, perform

the preinsertion anatomical measurements (see Fig. 87-3 ).

Catheters are provided at various lengths.

This can be guided by ultrasound. Make a note of the required catheter

length. 10. Position the tourniquet high on

the upper extremity, near the axilla, but do not constrict venous blood fl ow at this time.

Placement high on the extremity avoids contamination of the sterile fi eld.

11. Open the PICC insertion tray and drop the remaining sterile items onto the sterile fi eld.

Maintains aseptic technique; prepares the work area, including procurement of all necessary equipment; avoids interruption of the procedure and contamination of the work area.

12. HH 13. Apply sterile gown and sterile

gloves. PICC insertion is a sterile procedure. Personnel protective equipment (e.g.,

head cover, mask, goggles) is needed as well as sterile equipment.

Blood splashing may occur with the use of guidewires, stylets, and breakaway or peel-away introducers.

14. Prepare the catheter according to manufacturer ’ s recommendations.

Each manufacturer recommends a specifi c preparation protocol for each type of catheter.

15. Fill the 10-mL syringe with normal saline. Add the needleless connector to the short extension tubing and prime it with normal saline. Leave the syringe attached.

Prepares the system. If inserting a double-lumen or triple-lumen catheter, prime the additional lumen(s) of the catheter with normal saline.

Procedure for Peripherally Inserted Central Catheter


Procedure continues on following page


16. Prepare the site with a 2% chlorhexidine–based antiseptic solution. 4,5,9 A. Cleanse the site with a

back-and-forth motion while applying friction for 30 seconds.

B. Allow the antiseptic to remain on the insertion site and to air-dry completely before catheter insertion. 4,5,9 (Level D * )

Limits the introduction of potentially infectious skin fl ora into the vessel during the puncture.

17. Discard gloves in the appropriate receptacle.

Removes and safely discards used supplies.

18. HH 19. Apply the tourniquet snugly,

approximately 6 inches (15 cm) near the axilla well outside of the sterile fi eld.

Provides vasodilation of the vein for venipuncture.

Constriction should effectively cause venous distention without arterial occlusion.

21. HH 20. Apply a new pair of sterile

gloves. PICC insertion is a sterile procedure.

22. Instruct the patient to lift his or her arm; place a sterile drape underneath and the fenestrated drape over the entire patient, leaving the venipuncture site exposed. Place a sterile 4 × 4 gauze pad over the tourniquet.

Maintains the sterile fi eld and facilitates aseptic technique.

Ultrasound scan technology can be used to assist with catheter insertion (see Fig. 87-2 ).

23. Instruct the patient to turn his or her head away from the insertion site.

Prevents contamination of the fi eld by organisms from the patient ’ s respiratory tract.

If the patient is not intubated ensure the patient has on a mask.

24. Inject a skin weal of approximately 0.5 mL of 1% lidocaine without epinephrine at or adjacent to the venipuncture site. (Level B * )

Provides local anesthesia for venipuncture with large-gauge needles and introducers.

Local anesthesia should be administered with insertion of a PICC. 2–6,8

Patients report less pain when a local anesthetic agent is used before venipuncture. 2,3

Lidocaine may produce stinging, burning, obscuring of the vein, or venospasm.

The use of EMLA (a topical anesthetic cream) before venipuncture has been researched. 2,6,8

If it is used, manufacturer ’ s recommendations should be followed.

25. Perform the venipuncture according to catheter design and manufacturer ’ s instructions.

Catheters vary according to design and introducing techniques.

Relocate the intended vein with the ultrasound probe and use the ultrasound images to guide the insertion process. 4,5

Procedure for Peripherally Inserted Central Catheter—Continued

* Level B: Well-designed, controlled studies with results that consistently support a specifi c action, intervention, or treatment. * Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.



26. Perform the modifi ed Seldinger technique ( Fig. 87-4 ): A. Insert a microintroducer

needle or cannula and observe for blood return in the fl ashback chamber (see Fig. 87-4, 1 ).

B. Advance the fl oppy tipped guidewire 2 to 4 inches (5–10 cm) through the needle or cannula (see Fig. 87-4, 2 ) . 5

C. Remove the needle or cannula back over the guidewire and insert the dilator/introducer over the guidewire (see Fig. 87-4, 4 ).

Use of a guidewire enhances the advancement of the dilator/introducer.

Place a fi nger over the opening of the catheter to limit blood loss and risk for air embolism (see Fig. 87-4, 2 ).

If unable to access the vein, the procedure should be terminated and an alternate access site selected.

A small dermatotomy or nick in the skin using a sterile scalpel adjacent to the guidewire may facilitate the advancement of the dilator/introducer (see Fig. 87-4, 3 ).

If a scalpel is not provided in the PICC insertion kit, a No. 11 blade should be used.

D. Gently advance the dilator/introducer until the tip is well within the lumen of the vein (see Fig. 87-4, 5 ).

E. Remove the guidewire and then the dilator leaving the introducer in place (see Fig. 87-4, 6 ).

Place a fi nger over the opening of the introducer to limit blood loss and the risk for air embolism (see Fig. 87-4, 6 ).

F. Insert the catheter approximately 6–8 inches (15–20 cm).

Establishes venous access. Sterile forceps may be used to insert the catheter into the introducer and advance the catheter into the vein (see Fig. 87-4, 7 ).

27. Release the tourniquet with sterile technique (e.g., with a sterile 4 × 4 gauze pad).

The tourniquet may inhibit catheter advancement.

28. Instruct the patient to turn his or her head toward the cannulated arm and to drop his or her chin to the chest.

Changes the angle of the jugular vein and decreases the potential for malpositioning of the catheter in the jugular vein.

29. Advance the remainder of the catheter until approximately 4 inches (10 cm) remain while observing the heart rate and rhythm.

Cardiac dysrhythmias may occur if the catheter is advanced into the heart.

Never advance the catheter if resistance is felt.

Excessive pushing could lead to perforation of the vein, catheter malposition, or pericardial perforation.

30. Instruct the patient to return his or her head to the contralateral side (away from the insertion site).

Prevents contamination of the fi eld by organisms from the patient ’ s respiratory tract.

31. Pull the introducer out of the vein and away from the insertion site and remove (see Fig. 87-4, 8 and 9 ).

The introducer sheath should remain in place until the catheter is properly positioned.

Methods of removing the introducer vary according to the manufacturer.

32. Measure the length of the catheter remaining outside the skin and reposition, if necessary, to the predetermined length. Approximately 1 inch (2.5 cm) of the catheter should remain externally.

Ensures proper catheter tip position. The catheter should be advanced to the zero mark.

Optimally, no more than 2 cm should remain external to the insertion site.



Figure 87-4 Modifi ed Seldinger technique. 1, Insertion of the peripheral intravenous catheter. 2, Advancement of the guidewire through the catheter. 3, Small skin nick to facilitate the advance-ment of the dilator/introducer. 4, Insertion of the dilator/introducer over the guidewire. 5, Advance-ment of the dilator/introducer. 6, Removal of the dilator and guidewire. 7, Insertion of the catheter using sterile forceps. 8, Removal of the introducer. 9, Introducer peeled apart and removed. (Courtesy Bard Access Systems, Salt Lake City, UT.)


Figure 87-5 PICC Statlock device. 1, Insertion of the wings of the PICC onto the device. 2, Placement of the device on the forearm. 3, Application of the sterile, transparent, semipermeable dressing over the device. 4, Device properly secured. (Courtesy Bard Access Systems, Salt Lake City UT.)


33. Attach the primed extension tubing (with injection port) to the catheter; aspirate for evidence of blood, and fl ush with normal saline with use of a push/pause technique.

Use of extension tubing provides easier access to the catheter and reduces local trauma at the insertion site.

Aspiration affi rms patency of the catheter.

The push/pause technique during fl ushing optimizes catheter long-term patency. 4,5

Most PICCs have their own extension sets and only require a needleless connector.

34. Inject the recommended amount and concentration of heparin as prescribed into the catheter, clamp the extension tubing, and remove the syringe. Repeat the procedure with use of a double-lumen or triple-lumen catheter.

Maintains catheter patency and prevents backfl ow of blood in the catheter.

Recommendations vary regarding the use, amount, and concentration of heparin to maintain catheter patency. 1,9

Contraindicated in persons with known allergies to heparin.

Institutional standards should be followed.

35. Secure the catheter at the insertion site by applying a catheter securement device ( Fig. 87-5 ).

Prevents inward or outward migration of the catheter.

Follow institutional standards.



Procedure continues on following page


36. Apply a dressing: A. If bleeding is noted, cover the

insertion site with a sterile, 2 × 2 gauze pad and then cover the site with a sterile, transparent, semipermeable dressing. 4

B. If there is no bleeding, omit the gauze and apply a chlorhexidine impregnated gel dressing or sponge to the site and then cover it with a sterile transparent semipermeable membrane dressing. 4

Decreases catheter-related infections. A 2 × 2 gauze can be folded and placed immediately below the insertion site to act as a “wick” for any drainage in the fi rst 24 hours.

If the chlorhexidine impregnated sponge or gel dressing is applied at the insertion site, the dressing can remain for 7 days before changing.

37. Remove PE and sterile equipment and discard used supplies in appropriate receptacles.

Reduces the transmission of microorganisms; Standard Precautions.

Ensure that sharp objects are safely removed.

38. HH 39. Prepare the patient for a chest

radiograph to determine tip location if a tip-locating technology was not used.

Confi rms placement of the catheter tip and detects any complications.

Some PICCs require contrast media for good visualization.

Infusions should not be initiated until the catheter tip placement is confi rmed.


Expected Outcomes • The PICC tip is positioned in the distal portion of the

superior vena cava at the cavoatrial junction. • The PICC remains patent • The insertion site and upper extremity remain free of

phlebitis and thrombophlebitis • The insertion site, catheter, and systemic circulation

remain free of infection

Unexpected Outcomes • Pain or discomfort during the procedure • Complications on insertion, such as cardiac

dysrhythmias, pericardial tamponade, air embolism, catheter embolism, arterial puncture, and nerve (brachial plexus) injury

• Complications after insertion, such as phlebitis, thrombophlebitis, thrombosis, infection (e.g., insertion site, catheter, systemic), and infi ltration

Patient Monitoring and Care Steps Rationale Reportable Conditions

These conditions should be reported if they persist despite nursing interventions.

1. Observe the patient for signs or symptoms of cardiac dysrhythmias and pericardial tamponade during the procedure. If cardiac dysrhythmias occur, pull the catheter back and reassess the patient.

Cardiac dysrhythmias may occur if the catheter is advanced into the heart.

Pericardial tamponade may occur if the catheter penetrates the atrium.

• Cardiac dysrhythmias • Hemodynamic instability (changes

in vital signs, level of consciousness, peripheral pulses, narrow pulse pressure, jugular venous distention)

2. Assess the patient and obtain the chest radiographic report confi rming proper catheter tip placement before initiating any intravenous solutions.

Ensures accurate catheter tip placement and aids in identifi cation of potentially life-threatening complications.

• Abnormal chest radiographic report

• Change in lung sounds • Chest pain • Respiratory distress


* Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.


3. Observe the dressing and insertion site every 30 minutes for the fi rst 4 hours after insertion.

Postinsertion bleeding may occur in patients with coagulopathies or with arterial punctures, multiple attempts at venipuncture, or use of the through-the-needle introducer design for insertion.

• Excessive bleeding • Hematoma

4. Assess the insertion site and upper extremity every shift for signs and symptoms of phlebitis, thrombophlebitis, or infi ltration.

Mechanical phlebitis is the most common complication within the fi rst 72 hours after insertion.

Thrombophlebitis may occur at any time after catheter insertion.

• Pain along the vein • Edema at the puncture site • Erythema • Ipsilateral swelling of the arm,

neck, or face • Venous occlusion (changes in arm

circumference > 2 cm from baseline)

• Infi ltration 5. Assess the catheter for venous

blood return and patency before initiating infusions. A. Connect a 10-mL syringe

fi lled with 10 mL of NS to the extension tubing.

B. Release the clamp and aspirate slowly to verify blood return.

C. Flush with 10 mL of NS (with a push/pause technique) and then administer the infusion.

Verifi es position of the catheter in the vascular space and patency before initiation of infusions.

• Catheter occlusion (failure to obtain blood return on aspiration or resistance to irrigation)

6. Assess the catheter for dislodgment or migration by measuring the length of the external catheter.

The catheter may no longer be properly positioned if the length of the external catheter is longer or shorter than the length measured at the time of insertion.

• Change in external catheter length • Catheter occlusion • Cardiac dysrhythmias • Pain or burning during infusions • Palpation of the catheter in the

internal jugular vein • Palpation of a coiled catheter • Infi ltration

7. If there was insertional bleeding, the initial dressing should be left in place for 24 hours. 4 After this: A. Assess the insertion site and

upper forearm while performing a sterile dressing change.

B. Transparent, semipermeable dressings should be changed at least weekly. 9

C. Sterile gauze dressings should be changed every 48 hours. 4,5

D. Dressings should be changed if they become damp, loosened, or visibly soiled. 9 (Level D * )

Policies may vary regarding the type of dressing and frequency of dressing changes after the initial dressing change.

• Redness, warmth, hardness, tenderness, pain, or swelling at the insertion site

• Presence of purulent drainage from the insertion site

• Local rash or pustules

—Continued



8. Monitor the insertion site and patient for signs and symptoms of local or systemic infection.

The incidence of infection related to the catheter may result from failure to maintain asepsis during insertion, failure to comply with dressing change protocols, immunosuppression, frequent access to the catheter, and long-term use of a single IV access site.

• Redness, warmth, hardness, tenderness, pain, or swelling at the insertion site

• Presence of purulent drainage from the insertion site

• Local rash or pustules • Fever, chills, or elevated white

blood cell count • Nausea and vomiting

9. Avoid measuring blood pressure, performing venipuncture, or administering injections in the extremity with a PICC. Follow institutional standards regarding placing a sign at the patient bedside regarding avoiding use of the extremity with the PICC.

Minimizes the risk for catheter-related complications and catheter damage.

10. Follow institutional standards for assessing pain. Administer analgesia as prescribed.

Identifi es need for pain interventions. • Continued pain despite pain interventions

—Continued

Documentation Documentation should include the following: • Patient and family education • Completion of informed consent • Preprocedure verifi cation and timeout • Known allergies • Mid–upper arm circumference • Date and time of the procedure • Catheter type, size, and length, including the length of

catheter remaining outside the insertion site • Type and amount of local anesthetic (if used)

• The location of the PICC insertion site and the vein accessed

• The method of securing the catheter • Confi rmation of the catheter tip placement • Problems encountered during or after the procedure

or nursing interventions • Patient tolerance of the procedure • Pain assessment, interventions, and effectiveness • Vital signs and cardiac rhythm • Assessment of the insertion site

References and Additional Readings For a complete list of references and additional readings for this procedure, scan this QR code with any freely available smartphone code reader app, or visit http://booksite.elsevier.com/9780323376624 .

Documents

PROCEDURE Peripherally Inserted Central Catheter