Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

327

Skill Checklists for Taylor's Clinical Nursing Skills:
A Nursing Process Approach, 3rd edition

Name Date

Unit Position

Instructor/Evaluator: Position

SKILL 15-4

Changing a Peripheral Venous Access Dressing

Goal:The patient exhibits an access site that is clean, dry,

and without evidence of any signs and symptoms of infection,

infiltration, or phlebitis. In addition, the dressing will be clean,

dry, and intact and the patient will not experience injury. Comments

1. Determine the need for a dressing change. Check facility
   policy. Gather all equipment and bring to bedside.


2. Perform hand hygiene and put on PPE, if indicated.


3. Identify the patient.


4. Close curtains around bed and close the door to the room,
   if possible. Explain what you are going to do and why you
   are going to do it to the patient. Ask the patient about
   allergies to tape and skin antiseptics.


5. Put on mask and place a mask on patient, if indicated. Put
   on gloves. Place towel or disposable pad under the arm
   with the venous access. If solution is currently infusing,
   temporarily stop the infusion. Hold the catheter in place
   with your nondominant hand and carefully remove old
   dressing and/or stabilization/securing device.Use adhesive
   remover as necessary. Discard dressing.
   6.Inspect IV site for presence of phlebitis (inflammation),
   infection, or infiltration.Discontinue and relocate IV, if
   noted. Refer to Fundamentals Review 15-3, Box 15-2, and
   Box 15-3.
   7.Cleanse site with an antiseptic solution such as chlorhexi-
   dine or according to facility policy. Press applicator
   against the skin and apply chlorhexidine using a back
   and forth friction scrub for at least 30 seconds. Do not
   wipe or blot. Allow to dry completely.


6. Open the skin protectant wipe. Apply the skin protectant
   to the site, making sure to cover at minimum the area to
   be covered with the dressing. Allow to dry. Place sterile
   transparent dressing or catheter securing/stabilization
   device over venipuncture site.

Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

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