4.7 Documentation

Sample Documentation for a CVAD Dressing Change:

11/19/20XX 0900

Double lumen PICC line dressing was changed to the right upper arm using a prepackaged CVAD dressing kit. Old dressing was removed and discarded. Site is without redness, swelling, exudate, or indication of complications. Client denies discomfort at the insertion site or along the vein track. Pre-procedure, catheter measured 4 cm external from insertion site to hub, which corresponds to the initial insertion external measurement. Upper arm circumference 10 cm above insertion site is 23 cm, which corresponds to the previous shift’s measurement of 23 cm. No visible swelling or subcutaneous emphysema is observed. Nurse and client donned sterile masks. Per sterile technique, site area was cleansed with chlorhexidine scrub for 30 seconds and allowed to air dry. Device secured with Statlock followed by chlorhexidine gel impregnated sterile transparent dressing. Line flushed freely with 10mL of sterile, preservative-free 0.9% normal saline after obtaining brisk blood return. Needleless injection ports x2 were replaced and passive caps x2 were changed. Post-procedure, catheter measured 4 cm external from insertion site to hub, which corresponds to the initial insertion external measurement. Dressing dated and labeled. Client tolerated the procedure well without complications. 

Jane Smith, RN