Ch 15: Fluid, Electrolyte, and Acid-Base Balance - Removing a Peripherally Inserted Central Catheter

When completing a routine assessment of a client's peripherally inserted central catheter (PICC), the nurse finds no redness, swelling or drainage at the insertion site. The transparent dressing is dry and intact and adheres to the skin around all edges. What is the most appropriate intervention at this time?

Ask the client about any pain or discomfort at the insertion site. Rationale: Assessing for pain and discomfort is part of a routine assessment of the PICC, as these may indicate infection or infiltration. The assessment should be complete before documenting. The dressing is intact and assessment findings do not warrant a dressing change at this time. Flushing the PICC is not part of the routine assessment.

The nurse is assessing the insertion site of a client's peripherally inserted central catheter (PICC). What is a normal finding?

a transparent dressing covering the site Rationale: A PICC is held in place with a transparent dressing. The nurse should assess whether the dressing is intact and adheres to the skin around all the edges. Tape, gauze, or a sterile bandage covering the site should all be unexpected findings. If a gauze pad is used as a dressing on a PICC, it must be changed within 48 hours.

Assessing the insertion site of a client's peripherally inserted central catheter (PICC), the nurse notes redness, swelling, and odor at the site. Which complication does the nurse suspect?

infection Rationale: Redness, swelling, odor, drainage, and discomfort signify an infection at the insertion site. Swelling, pallor, coldness, or pain around the site are symptoms of infiltration. A rash would appear as red, itching bumps. Speed shock is the body's reaction to a substance injected into the circulatory system too rapidly; it manifests as a pounding headache, rapid pulse rate, apprehension, chills, back pains, and dyspnea.

While removing a client's peripherally inserted central catheter (PICC), part of the catheter breaks off. What action is the nurse's priority?

Apply a tourniquet to the client's upper arm. Rationale: In the event that a portion of the catheter breaks off during removal of a PICC, the nurse should immediately apply a tourniquet to the upper arm, close to the axilla, to prevent advancement of the piece of catheter into the right atrium. The other actions should be performed during a routine PICC removal. Use of the Valsalva maneuver by the client during expiration reduces the risk for air embolism. Measurement and inspection of the PICC following removal ensures that the entire catheter was removed. Application of adequate pressure with sterile gauze following PICC removal prevents hematoma formation.

The nurse is caring for a client receiving an antibiotic via a peripherally inserted central catheter (PICC). What two solutions should the nurse use to flush the line and keep it patent?

normal saline and heparin Rationale: When a PICC is being used intermittently, the nurse should flush the PICC after each use with normal saline and heparin to maintain patency. Sterile water is not used for flushing a PICC line. Heparin maintains patency.

The nurse is planning to discontinue a peripherally inserted central catheter (PICC) for a client who is prescribed warfarin therapy. Which intervention will individualize care for this client?

Apply pressure to insertion site for at least 3 minutes. Rationale: The nurse recognizes the client prescribed warfarin is at risk for bleeding and individualizes care by applying pressure to the insertion site for longer than the minimum recommended 1 minute. The remaining interventions are appropriate for all clients when discontinuing a PICC line; they do not individualize care for the client prescribed warfarin.

The nurse is flushing a client's peripherally inserted central catheter (PICC). What action should the nurse perform first?

Cap the infusion line. Rationale: The order in which the nurse should flush a PICC is (1) cap the infusion line, (2) swab the access cap with an alcohol wipe, (3) insert the saline syringe into the catheter port, and (4) flush the catheter using steady pressure.

The nurse is flushing a client's peripherally inserted central catheter (PICC) to maintain patency, because it is being used intermittently. After flushing with normal saline, which action should the nurse perform next?

Flush the line with heparin. Rationale: After flushing the PICC with saline, the nurse should flush the line with heparin to maintain patency. Because the PICC is being used intermittently, the infusion is not restarted. The nurse attempts a blood return prior to flushing the PICC. Documentation should occur following the procedure.

Which is a normal finding upon assessment of a client's peripherally inserted central catheter (PICC)?

an insertion site free of blood and intravenous (IV) solution Rationale: The transparent dressing should allow the nurse to visualize that the catheter inserted into the arm is free of blood or IV solution. A small amount of blood or a crusted appearance at the insertion site would indicate the need for a dressing change. IV solution surrounding the catheter may indicate infiltration and would require further assessment.

The nurse is assessing a client's peripherally inserted central catheter (PICC) insertion site. The nurse measures the length of the catheter that extends out from the insertion site to:

assess if the catheter has migrated inward or moved outward. Rationale: The nurse measures the length of the catheter extending out from the insertion site to compare it to the documented length at time of insertion. This assesses whether the catheter has migrated inward or moved outward. The measurement should not be used to determine the size of the replacement tubing, to ensure patency, or to determine time for catheter removal. Flushing will assist in determining patency. Removal and replacement are dependent on the individual client treatment plan.