DRESSING CHANGE & LABS

Routine Dressing Change, Line Assessment, & Lab Draw (if ordered)

Preparation:

1. Introduce yourself & HHC. Wash/Sanitize hands. (Refer to Hand Hygiene policy.)

2. Check patient ID and verify patient information.

3. Check the date of last dressing change. Confirm / Review orders and check for special instructions for new dressing. Confirm orders for labs.

Note: Ensure that you have either printed out the correct lab req or requested the agency to fax the lab req to the lab of your choice. You MUST have an order for all labs drawn!

4. Prepare for the procedure by having patient don a mask. Nurse is also to wear a mask. Explain procedure to patient/caregiver.

Remove Old Dressing: (refer to Dressing Change policy)

1. Perform hand hygiene and done non-sterile disposable gloves.

2. Remove the old dressing and securement device carefully to avoid dislodging the catheter. May apply tape or adhesive strips to the line to help prevent dislodging. 70% alcohol may be used to assist removal where required.

3. Take care not to touch the insertion site, dislodge, or accidentally withdraw the unsecured catheter. If the catheter migrates out, DO NOT attempt to feed/push the catheter back in. Report the amount of migration to the Agency Supervisor and document the migration. Note: If the external length of the catheter migrates more than 2 cm, report to the agency so that the MD can be notified. If the external length of the catheter is more than 4 cm out, report to the agency so that MD can be notified.

4. Assess insertion site for any visible abnormalities (e.g. redness, tenderness, swelling, or exudate). Gently palpate the insertion site and ask the patient if there is any tenderness or pain. If there are any abnormal signs or symptoms report to agency and document in the clinical record.

5. If sutures have been used, carefully assess their integrity. If loose, other methods of stabilization may be necessary. Do not remove sutures without an order.

6. Remove gloves, discard waste.

Apply Clean Dressing: (refer to Dressing Change policy)

1. This is a sterile procedure. Begin work on a clean work surface. Establish a sterile field.

2. Using aseptic technique open the dressing kit and add sterile items. Don sterile gloves.

3. Disinfect and clean the insertion site. (refer to Dressing Change policy)

a. Note: Care should be taken not to dislodge the unsecured catheter If the catheter has migrated or been dislodged during dressing change, DO NOT attempt to feed catheter back into the insertion site. Continue dressing change and report the amount of migration to the Agency so that it can be reported to the MD. Document the amount of migration in your visit note. Note: If the external length of the catheter migrates more than 2 cm, report to the Clinical Supervisor so that the MD can be notified.

4. Measure the external length of catheter using tape measure in the dressing kit. Measure from the catheter insertion site to the proximal end of the wings. If a tape measure is not available, then count the exposed lines between the insertion site and the wings. Document in centimeters.

5. Measure the arm circumference. Using tape measure, measure 4 cm up from the catheter insertion site, then measure around the arm at the 4 cm mark. Document in centimeters.

6. Use skin preparation if supplied and allow to completely dry. Apply securement device provided by pharmacy as per manufacturer’s instructions.

7. If a CHG sponge is used (e.g., Biopatch) be sure the sponge is right side up (blue side up or smooth foam against skin). Ensure 360-degree contact with the skin. Align the catheter tubing underneath the slit of the CHG sponge for easier removal when changed. The slit sides should touch but not overlap. Note: Not all pharmacies provide a CHG sponge. If patient does not have one in supplies reach out to Agency to see if pharmacy provides.

8. Apply a large semi permeable transparent dressing. The insertion site should be positioned in the center of the dressing. The adhesive securement device must also be completely covered. Use an additional large semipermeable transparent dressing if required.

9. If adhesive tape / strip was used – remove this now.

Change needleless clave connectors:

Note: Needleless clave connectors should be changed every 7 days with the dressing change or PRN (after lab draws).

Finishing:

1. Write the date, time, and your initials on the border of the transparent film dressing.

2. Remove sterile gloves. Dispose of sterile gloves and other waste in waste bin.

3. Perform hand hygiene. (Refer to Hand Hygiene policy.)

4. Document the catheter dressing change, clinical assessment of site, external measurement length, and arm circumference in the clinical record.

Lab Draw from Central Line: (Refer to Blood Draw Practices & Procedures policy)

1. Insert a 10 ml syringe (adults) or 3 ml syringe (neonates) into needleless valve.

2. Open clamp, flush with 10 ml normal saline and then withdraw 10 ml waste blood. Remove and discard.

Note: If unable to draw labs from the central line then attempt to draw labs peripherally. If unable to draw after 2 attempts notify agency.

3. Insert new 10 ml syringe (adults) or 3 ml syringe (neonates) into needleless valve. Withdraw amount of blood needed for all lab studies ordered.

4. Withdraw syringe from needleless valve and attach a blunt needle to the syringe.

5. Transfer blood sample to specimen tube(s).

6. Flush lumen(s) as appropriate to catheter type.

7. Change needleless connectors and flush appropriately.

8. Resume all infusions.

9. Label tubes/vials accordingly, in the presence of the patient, noting site of collection, date/time, initials, and note peripheral or central.

10. Discard used supplies appropriately.

11. Remove gloves and wash hands.

12. Document specimens obtained, any problems encountered, and administration of heparin flush, if applicable, in progress notes.

ADDITIONAL INFORMATION: