Radiology

Care and Maintenance for Health Care Providers

Dressing Changes

  • Dressing Change Frequency
    1. Transparent dressings are changed every 7 days.
    2. Dressings containing gauze are changed every 48 hours.

(If StatLock© present, please change with every dressing change)

  1. Gather supplies:
    1. Clean gloves
    2. Sterile dressing change kit or
    3. Sterile gloves
    4. Mask (2)
    5. 2% Chlorhexidine-70% alcohol applicator
    6. Alcohol/povidone iodine swabstiks - 3 each, if chlorhexidine is contraindicated for the patient.
    7. Sterile transparent dressing or sterile gauze
    8. Tape
    9. Sutureless securement device ("StatLock" ©) as needed for PICC line
  2. Obtain assistance of second caregiver if patient cooperation cannot be assured due to age or altered mental status.
  3. Perform hand hygiene with hospital approved waterless alcohol gel or foam cleaning solution or, if visibly soiled, wash hands with soap and water for 15 seconds.
  4. Clear and clean work surface. Wipe down work surface with disinfectant cloth and allow to dry.
  5. Don clean gloves.
    1. If already wearing gloves related to isolation or other procedure, remove them, perform hand hygiene and don new gloves.
  6. Apply mask to patient or ask patient to turn head away from catheter site.
  7. Don mask
    1. Don additional personal protective equipment such as gown and cap if part of nursing unit protocol.
  8. Open supplies on clean, stable work surface maintaining their sterility. If dressing kit is not available, may use sterile glove wrapper as sterile field.
  9. Remove dressing and dispose in waste container.
  10. Remove gloves and dispose in waste container.
  11. Perform hand hygiene with hospital approved waterless alcohol gel or foam cleaning solution or, if visibly soiled, wash hands with soap and water for 15 seconds.
  12. Don sterile gloves.
  13. Pinch the wings on the Chlorhexidine-70% alcohol applicator to break the ampule and release the antiseptic onto the sponge pad.
  14. Clean area approximately 2 inches around the catheter exit site with the chlorhexidine applicator. Use a back and forth motion for 30 seconds to clean site.
    1. If using alcohol and povidone iodine, clean in a circular motion from the CVC exit site outwards approximately 2" in diameter.
    2. Use 3 alcohol swabstiks followed by 3 povidone iodine swabstiks.
  15. Allow the area to air dry for 30 seconds. Do not blot, fan or wipe away solution.
    1. Let povidone iodine dry completely prior to applying dressing.
  16. Secure catheter as appropriate:
    1. Securement dressing and or sutureless securement device ("Stat-Lock" ©)
  17. Note date, time and initials on dressing.
  18. Document the date and time of the procedure and assessment of the site in the patient's medical record.
  19. Notify MD/designee of any signs of infection or dislodgement at catheter exit site.

**For UCLA staff, please refer to UCLA Department of Nursing Policies and Procedures-Sterile CVC Dressing Change (Nur-HS 104)

Flushing the Catheter

  • No flush is recommended for continuous infusions
  • Variations in practice for a specific population may be guided by unit based protocols.
  • All CVC lumens are flushed with 10 ml 0.9% sodium chloride or per unit protocol
    1. After intermittent IV medications and infusions.
    2. After CVC blood draws or
    3. Every 12 hours if lumen is not in use
  • Flush should ensure no visible blood is left in cap.
    1. Perform hand hygiene with hospital approved waterless alcohol gel or foam cleaning solution or, if visibly soiled, wash hands with soap and water for 15 seconds.
    2. Don clean gloves. If already wearing gloves, remove them, perform hand hygiene and don new gloves.
    3. Scrub external surface of the cap or port vigorously with approved antiseptic for fifteen (15) seconds.
      1. isopropyl alcohol 70% (RR-UCLA preferred agent)
      2. povidone iodine 10%.
      3. chlorhexidine gluconate 2%-isopropyl alcohol 70% (SM-UCLA preferred agent)
    4. Allow antiseptic to air dry on site.
    5. You must always use a 10 cc syringe or larger. Smaller syringes put too much pressure on the PICC line and may cause damage to the catheter.
    6. Flushing should be done using the "PUSH-PAUSE" method. Simply push a small amount of saline into catheter, pause, and then push some more in. Repeat as needed until total flush is given. Clamp the PICC then remove the syringe after the last bit of saline is flushed in.
    7. When a neutral pressure cap is attached to the end of the catheter (this is the blue cap currently used by UCLA) it is crucial to clamp the catheter BEFORE disconnecting the flush syringe. This prevents the backflow of blood into the catheter tip and prevents catheter occlusions.
    8. If you have a double lumen catheter, both lumens must be flushed per protocol.
    9. Document intervention in patient's medical record.
    10. If resistance is encountered when flushing the catheter, do not use force. Initiate the declotting protocol utilizing t-PA (ALTEPLASE). It is important to flush the catheter twice per day and after medications to keep the line open and functioning properly.

**For UCLA staff, please refer to UCLA Department of Nursing Policies and Procedures-Sterile CVC Dressing Change (Nur-HS 104)

Changing the Injection Cap

This is required once every seven days.

  1. PICC caps are changed every 7 days or as needed.
  2. Hub care refers to any CVC cap/tubing change or tubing discontinuation which requires opening the CVC line at the hub.
  3. Gather supplies on a clean, stable work surface: \
    1. Chlorhexidine-70% alcohol applicator (1)
    2. Three (3) 70% isopropyl alcohol swabstiks and three (3) 10% povidone iodine swabstiks may be used if patient has Chlorhexidine allergy.
    3. Two (2) sterile gauze pads or two (2) alcohol prep pads
    4. Clean gloves
    5. CVC port/cap-one cap for each lumen of the catheter
  4. Perform hand hygiene with hospital approved waterless alcohol gel or foam cleaning solution or, if visibly soiled, wash hands with soap and water for 15 seconds.
  5. Don clean gloves. If already wearing gloves, remove them, perform hand hygiene (Step 4 above) and don new gloves.
  6. Flush each new cap with 1-2ml of Normal Saline.
  7. Scrub from the connection between catheter and cap (or IV tubing) outward in a circular fashion using Chlorhexidine-70% alcohol applicator (or three (3) 70 % isopropyl alcohol saturated swab sticks, followed by three (3)10% povidone-iodine saturated swabsticks).
    1. Extend cleansed area approximately 1 inch on either side of the junction.
  8. Clamp PICC.
  9. With alcohol preps or sterile gauze wrapped around both sides of the junction, remove the CVC access port/cap or IV tubing from hub.
  10. Connect hub to new primed caps. Perform cap changes to each connection port. For example, if you have a double lumen, both caps must be changed.
  11. Remove gloves.
  12. Perform hand hygiene with hospital approved waterless alcohol gel or foam cleaning solution or, if visibly soiled, wash hands with soap and water for 15 seconds.
  13. Document intervention in patient's medical record.

**For UCLA staff, please refer to UCLA Department of Nursing Policies and Procedures-Sterile CVC Dressing Change (Nur-HS 104)

Declotting the Catheter

  • Rationale: Fibrin accumulation can cause partial or complete blockage or indwelling CVCs. Administration of a small volume of a thrombolytic agent, IV push into the CVC may clear blockage of the internal lumen of the CVC without causing a systemic change in clotting times
  • Indications:
    1. Partial or complete occlusion of the PICC
    2. Difficulty flushing the PICC
    3. Inability to withdraw 3mls of blood from the PICC.
  • Contraindications: If additional symptoms such as swelling of the PICC arm, leaking from the insertion site, or pain along the PICC tract with infusion exist, IV push t-PA (ALTEPLASE) should not be administered until a radiopaque dye study or ultrasound can be performed to rule out vascular thrombosis.
    1. Midlines terminate in a peripheral vein. Due to the tip location, blood aspiration from a midline may not be possible.
    2. If a malposition is suspected, a chest x-ray should be ordered to confirm tip location prior to administration of t-PA (Alteplase).
  • Procedure:
    1. Obtain order for t-PA (Alteplase). See CVC Care Grid for specific dose recommendations.
    2. Clean PICC cap/hub per CVC Cap Change/Hub Care Procedure.
    3. Gather supplies on a clean, stable work surface:
      1. 2% Chlorhexidine-70% alcohol applicator
      2. 70% isopropyl alcohol/povidone iodine swabstiks - 3 each, if chlorhexidine is contraindicated for the patient.
      3. Two (2) sterile gauze pads or two (2) alcohol prep pads
      4. Clean gloves.
    4. Perform hand hygiene with hospital approved waterless alcohol gel or foam cleaning solution or, if visibly soiled, wash hands with soap and water for 15 seconds.
    5. Don clean gloves. If already wearing gloves, remove them, perform hand hygiene and don new gloves.
    6. Scrub from the connection between catheter and cap outward in a circular fashion using Chlorhexidine-70% alcohol applicator (or three (3) 70 % isopropyl alcohol saturated swab sticks, followed by three (3)10% povidone-iodine saturated swabsticks).
      1. Extend cleansed area approximately 1 inch on either side of the junction.
    7. Stop infusions and clamp lumen of the PICC to be declotted.
    8. With alcohol preps or sterile gauze wrapped around both sides of the junction, remove the cap from hub.
    9. Attach t-PA (Alteplase) syringe to the hub. Slowly instill using a gentle push-pull motion on the plunger of the syringe.
    10. Clamp PICC and connect hub to a new primed cap.
    11. Leave t-PA in place for 120 minutes.
    12. After wait period, unclamp PICC and attempt to aspirate drug and 5ml of blood.
    13. If unable to aspirate, clamp PICC for another 30-60 minutes and attempt to repeat step 12. If still unsuccessful, consult with MD/designee re: order for repeat administration of t-PA
    14. If successful, irrigate CVC with 5-10 mls of 0.9% sodium chloride. Replace cap(s) or tubing to resume IV

**For UCLA staff, please refer to UCLA Department of Nursing Policies and Procedures-Sterile CVC Dressing Change (Nur-HS 104)

Pre-existing PICC

  • Please take the following steps for patients who present to the UCLA Health System with an existing PICC line:
    1. Contact the primary medical team to initiate a PA chest x-ray order to confirm catheter tip placement.
    2. Perform a sterile dressing change if due or the dressing is not secure.
    3. Note the length of catheter external to the body.
    4. Contact the PICC Service so that we may identify the line and evaluate it for use.
    5. Do not use the line until a physician or PICC Service NP has provided an order "OK to use PICC" or "OK to use MIDLINE".

PICC Removal

  • To remove PICC lines within the UCLA Hospital System you exhibit competency performing this function. Competency is reviewed annually
  • There are designated personnel that have been trained and have exhibited competency in PICC removal. If there is no RN who has completed competency for PICC removal please contact a resident, fellow, or physician to perform this function.
  • If PICC line removal is met with resistance. Please do not "pull" against resistance. If a PICC is not retracting with ease during removal it could be related to a venous spasm, fibrin build up, an infectious process, possible thrombus, or catheter entrapment. Please refer to "Difficult PICC Removal" in the "Problem Solving" section or contact the PICC Service for assistance.
  • Document intervention in patient's medical record.