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

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

SKILL 15-7

Changing the Dressing and Flushing

Central Venous Access Devices (Continued)

Comments

10. Put on sterile gloves. Starting at insertion site and continu-
    ing in a circle, wipe off any old blood or drainage with a
    sterile antimicrobial wipe. Using the chlorhexidine swab,
    cleanse the site. Cleanse directly over the insertion site by
    pressing applicator against the skin.Apply chlorhexidine
    using a back and forth friction scrub for at least 30
    seconds.Moving outward from the site, use a scrubbing
    motion to continue to clean, covering at least a 2- to 3-
    inch area. Do not wipe or blot. Allow to dry completely.
    Apply the skin protectant to the same area, avoiding direct
    application to insertion site and allow to dry.


11. Stabilize catheter hub by holding it in place with nondomi-
    nant hand. Use an alcohol wipe to clean each lumen of the
    catheter, starting at the insertion site and move outward.


12. Apply transparent site dressing or securement/stabilization
    device, centering over insertion site. If patient has PICC in
    place, measure the length of the catheter that extends out
    from the insertion site.


13. Working with one lumen at a time, remove end cap. Cleanse
    the end of the lumen with an alcohol swab and apply new
    end cap. Repeat for each lumen. Secure catheter lumens
    and/or tubing that extend outside dressing with tape.
    If required, flush each lumen of the CVAD. Amount of
    saline and heparin flushes varies depending on specific
    CVAD and facility policy.


14. Cleanse end cap with an antimicrobial swab.


15. Insert the saline flush syringe into the cap on the extension
    tubing. Pull back on the syringe to aspirate the catheter for
    positive blood return. If positive, instill the solution over
    1 minute or flush the line according to facility policy.
    Remove syringe. Insert heparin syringe and instill the vol-
    ume of solution designated by facility policy over 1 minute
    or according to facility policy. Remove syringe and
    reclamp the lumen. Remove gloves.


16. Label dressing with date, time of change, and initials.
    Resume fluid infusion, if indicated. Check that IV flow is
    accurate and system is patent. (Refer to Skill 15-3.)


17. Remove equipment. Ensure patient’s comfort. Lower bed,
    if not in lowest position.


18. Remove additional PPE, if used. Perform hand hygiene.

ExcellentSatisfactoryNeeds Practice