Care and Maintenance for Patients

• Dressing Changes
• Flushing the Catheter
• Changing the Injection Cap
• PICC Removal

Dressing Change Frequency

There are two types of dressings:

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 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 needed.
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 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" ©)
    2. Practices may vary based on hospital or home care provider protocols.
17. Note date, time and initials on dressing.
18. Notify MD/designee of any signs of infection or dislodgement at catheter exit site.

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 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.
  4. isopropyl alcohol 70%
  5. povidone iodine 10%.
  6. chlorhexidine gluconate 2%-isopropyl alcohol 70%
  7. Allow antiseptic to air dry on site.
  8. 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.
  9. 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.
  10. 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. You can check with your home health agency to determine what types of caps they utilize.
  11. If you have a double lumen catheter, both lumens must be flushed per protocol.
  12. If resistance is encountered when flushing the catheter, do not use force. Call your doctor or home care nurse. It is important to flush the catheter twice per day and after medications to keep the line open and functioning properly.

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) -Three (3) 70% isopropyl alcohol swabstiks and three (3) 10% povidone iodine swabstiks may be used if patient has Chlorhexidine allergy.
   2. Two (2) sterile gauze pads or two (2) alcohol prep pads
   3. Clean gloves
   4. CVC port/cap-one cap for each lumen of the catheter
4. Perform hand hygiene with 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 waterless alcohol gel or foam cleaning solution or, if visibly soiled, wash hands with soap and water for 15 seconds.

PICC Removal
 

• PICC removals may be removed by trained personnel in various settings including the home and physician's office. The physician managing the medications being given through the PICC should arrange for removal of the PICC.
• Notify your physician immediately for accidental dislodgement (partial or complete) at catheter exit site.