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Inserting Peripheral Midline and Central Catheters (PICC)

Purpose: To provide venous access for long-term administration of fluids, electrolytes, blood, medications, or nutrients. Other indications for intravenous (IV) therapy access are administration of diagnostic reagents and monitoring hemodynamic functions.

Preparation
● Examine the package carefully before opening to confirm integrity and identify expiration date.Do not use if package is damaged, opened, or the expiration date has passed.
● Inspect kit for inclusion of all components.
● Flush the catheter with sterile normal saline prior to use.
● Identify the vein and insertion site; select site in region of antecubital fossa.

Special Considerations
Geriatric
• Veins in older adults may be sclerotic and/or very mobile, meaning that the vein has a tendency to be pushed away by the catheter needle rather than pierced by it.Warm compresses can help dilate veins, especially if the patient is cold.
• Tourniquet pressure can damage the vein, especially if the patient is on an anticoagulant or a corticosteroid.Do not tie tourniquet too tightly.
• Avoid overtaping the catheter or dressing; removing the tape can easily tear an elderly patient’s fragile skin.

Pediatric
• Small vessel size makes midline and PICC placement challenging in the pediatric population.
• Palpation of vessels may be difficult, and ultrasound guidance is often not helpful because the child cannot remain still throughout the procedure.
• Risk for piercing nerve bundles or arteries is higher in children due to stages of anatomic development.

Relevant Nursing Diagnoses
● Risk for infection related to placement of invasive IV
● Risk for injury related to placement of invasive IV

Expected Outcomes
● Line is placed atraumatically
● Correct placement is verified

Implementation
1. Verify physician’s order.
Rationale: A physician’s order is needed to initiate therapy.

2. Gather equipment.
Rationale: Enhances efficiency.

3. Wash hands.
Rationale: Reduces microorganisms and chances of cross-contamination.

4. Apply tourniquet above projected insertion site. Assess antecubital veins (basilic, cephalic median cubital veins); basilic vein is preferred.
Rationale: These veins are large and usually straight.

5. Select a vein, and release tourniquet.

6. Measure arm with tape measure from a fingerbreadth below antecubital fossa to shoulder and across the shoulder to midclavicular line for subclavian placement (PICC only). For vena cava placement, continue to the sternal notch and down to the third intercostal space (PICC only).
Rationale: Determines length of catheter needed for insertion.

7. Select a catheter insertion kit with smallest gauge and shortest length that will coincide with therapy.

8. Write down lot number and expiration date from PICC or midline insertion kit.
Rationale: Needed for defects or returns.

9. Wash hands with antibacterial agent for 60 seconds.
Rationale: Decreases chance of contamination.

10. Set up supplies on sterile field.
Rationale: Decreases chance of contamination.

11. Put on mask, and don sterile gloves.
Rationale: Prevents contamination of site and subsequent infection.

12. Flush catheter with 0.9% normal saline.
Rationale: Ensures patency, removes air, and detects leaks.

13. Prepare site with 70% alcohol starting at insertion site cleaning in a circular motion at least 8 to 10 inches in diameter. Repeat three times allow to dry.
Rationale: Decreases transmission of microorganisms.

14. Repeat cleansing using povidone-iodine.
Rationale: Decreases transmission of microorganisms.

15. Remove gloves.
Rationale: Gloves are contaminated; sterile gloves must be worn for insertion.

16. Reapply tourniquet.
Rationale: Promotes venous distention. Tourniquet is no longer sterile, and, therefore, it should be put on before donning sterile garb.

17. Put on second pair of sterile gloves and sterile gown according to agency policies.
Rationale: Decreases chance of contamination.

18. Drape patient’s arm with sterile towels or sheet, making sure a sterile field is created.
Rationale: Provides a sterile field around site.

19. Anesthetize the site using intradermal or topical lidocaine without epinephrine (topical must be done before site prep).* Eliminate this step if local anesthesia is NOT used.Anesthesia should be used in accordance with agency policies and state standards of care.
Rationale: Anesthetic reduces pain.

20. Perform venipuncture with dominant hand while holding the skin taut with other hand.
Rationale: Stabilizes skin and prevents vein rolling.

21. Verify blood return through the introducer/stylet or aspirate with syringe.
Rationale: Ensures cannulation.

22. Decrease the angle, and advance introducer 1/4 to 1/2 inch further into vein.
Rationale: Allows further catheter advancement and prevents contamination.

23. Different manufacturers have different designs. For kit with guidewire, thread wire through needle and remove needle.Then thread catheter over guidewire and remove wire.
Rationale: Wire adds firmness to catheters and enhances advancement.

24. Using sterile gauze to maintain your sterility, remove tourniquet. (Midline catheter may be advanced slowly with tourniquet on while intermittently flushing with normal saline and aspirating for blood).
Rationale: Removal will decrease chance of catheter puncture.

25Remove stylet or needle.

26. Remove breakaway introducer if kit and catheter has this type.

27. Slowly advance catheter about halfway of desired length through the introducer (PICC).
● Have patient turn head toward insertion site with chin placed tucked down toward clavicle or chest (PICC).
Rationale: Position change will facilitate entry into vena cava or subclavian vein.
● Use forceps to stabilize catheter or apply light pressure and then remove the introducer.
Rationale: Ensures that catheter will not be removed with introducer.
● Continue to slowly advance catheter to desired length.

28. If resistance is met, stop advancement.
Rationale: Never force catheter.

29. Attempt to flush or flush while continuing to thread catheter If unsuccessful, you may need to use another vein.
Rationale: May enhance advancement if blood return is still good.

30. Do not force; guidewire could puncture catheter.
Rationale: Avoids puncture of catheter and vein wall.

31. Never withdraw catheter through introducer.
Rationale: May puncture vein or kink catheter.

32. Prime and attach extension tubing and injection cap.
Rationale: Clears air from tubing.

33. Flush with 0.5 mL of normal saline and then aspirate to check blood return; note blood flow, color, and consistency.
Rationale: Helps verify patency and placement.

34. Vigorously flush catheter with remaining normal saline followed by heparinized saline.
Rationale: Clears catheter of blood, preventing clotting.

35. Secure catheter with sterile tape, Steri-Strips, sutures, or stabilization device.
Rationale: Maintains catheter’s position, and prevents catheter migration.

36. Cover site with 2x2 gauze dressing and transparent dressing.
Rationale: Provides pressure on site for 24 hours to control oozing caused by large bore needle.

37. Obtain chest x-ray to assess for catheter tip placement.
Rationale: Verifies correct placement.

38. Document procedure and patient response in the patient record.
Rationale: Communicates information about infusion procedure. Provides patient and caregiver protection and is a part of quality and risk management.

39. After verification of placement, begin IV fluids if ordered.
Rationale: Avoids complications. Do not start IV fluids until placement is verified.

40. Dispose of equipment appropriately.
Rationale: Avoids accidental needle sticks.

Evaluation and follow up activities
● Assess for bleeding, oozing, ecchymosis, or pain around site.May apply pressure or use a pressure dressing for the first 24 hours for oozing. Change dressing if saturated.Notify nurse practitioner or physician if oozing does not stop
● Assess for tenderness,warmth, redness, cord-like feeling of vein.May treat with moist heat and arm elevation. Notify nurse practitioner or physician
● Monitor for infection or sepsis (fever, chills, drainage at site), cellulitis (diffuse redness at site, or thrombophlebitis (pain in arm, shoulder, and neck; edema of arm/shoulder)
● Flush catheter per protocol, and prepare for thrombolytic declotting
● Assess for air embolism (chest pain, confusion, lightheadedness, tachycardia, and hypotension)
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