Concerning PICCs, what is your current practice of measuring arm circumference? Upon insertion, with every dressing change, only upon suspicion of DVT? If your facility also places midlines, do you follow the same practice? Thanks for any input!
Concerning PICCs, what is your current practice of measuring arm circumference? Upon insertion, with every dressing change, only upon suspicion of DVT? If your facility also places midlines, do you follow the same practice? Thanks for any input!
We do not do routine arm circumferences with PICCs or midlines. I don't believe there is evidence to support this. There's no harm in doing a baseline circumference but we don't do those either. If a patient develops a problem such as mechanical phlebitis which may result in a degree of edema as well as redness, vein firmness and tenderness especially if it has not been caught early, we may measure both arms for a comparison and then just affected arm for improvement. The S&S of DVTs generally are a bit more significant often with edema below the insertion site which you don't often see with mechanical phlebitis. Typically arm circumference is only done on upper or mid upper arm. My practice is in pediatrics.
Angela Lee, RN, BSN, CRNI
Children's of AL
Agreed
Jack diemer
Thank you both for your input. I appreciate it!
The INS standards on documentation state to include a baseline measurement before insertion. The next edition will be more clear on this issue. There is no evidence to support a regular or routine measurement, but a baseline is needed so you can compare if there are any clinical signs and symptoms. This measurement may help convince an LIP to order a color duplex US if you suspect venin thrombosis. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thank you Lynn!
I am not able to find the INS standards mentioning arm measurement in the documentation section. Is it somewhere else?
Thanks Gina
Gina Ward R.N., VA-BC
Sorry Gina. I misspoke, probably because we had so many recent discussions about this. I think it was in the 2006 edition and in 2011 it was left in the glossary but there was no evidence to support it in practice. The current version is now out for review and we will finalize content during July and August, then it goes to publication and will be released in Jan 2016. I don't remember exactly the content but I think baseline measurement and then comparison to measurement when a problem arises will be in the next edition. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
We measure a baseline upper arm and mid forearm circumference on every PICC and midline. We only re-measure if there is a question of DVT.
Same here We measure before & only if there is a problem for all PICC's & Midlines.
Timothy McCrory, RN BSN, CCRN, VA-BC
Columbus Regional Health
The issue of arm circumference has limited evidence to support the practice. The only recent article that I am aware of that supports performing arm circumference is Maneval RE, Clemence BJ. Risk Factors Associated with Catheter Related Upper Extremity Deep Vein Thrombosis in Patients with Peripherally Inserted Central Catheters: A Prospective Observational Cohort Study Part 2. (2014) JIN. 37(4): 260-268. Most teams, such as the one I work on, measure upper arm circumference at the site of insertion and use it as a baseline measure. Additional measurements are taken only if there are complaints of pain or swelling or if there is a reason to perform the assessment. Hope this is helpful to you! [email protected]
Warm regards, Nancy Moureau, BSN, RN, CRNI, CPUI, VA-BC
Chief Executive Officer - PICC Excellence, Inc
Vascular Access Specialist - Greenville Memorial University Medical Center
Adjunct Associate Professor, Alliance for Vascular Access Teaching and Research (AVATAR) Group
Nancy L. Moureau, PhD, RN, CRNI, CPUI, VA-BC
PICC Excellence, Inc.
[email protected]
www.piccexcellence.com
I know this is not well supported but we measure the lower arm circumference (10cm below the insertion site) daily. If there is an increase of 3cm or more, the provider is notified and typically a doppler study is performed. This has been our practice for some time now and we have identified DVTs based on increasing lower arm circumference. We also educate our patients and staff about early signs of clot formation such as tenderness or achiness in the arm/shoulder of the side the picc is in. If a patient c/o of discomfort in the upper extremity with or without swelling, we will inform the provider and again they will often order a doppler study. This has also identified some very significant DVTs.
Vickie Teresinski, RN, CRNI
In the new standards it states to measure 10cm above antecubital area (not what we were doing). To me that eems kind of high for some of our short armed patients. 3 cm is also the measurement increase it mentions for the actions you listed. That was interesting to me since I have not heard that before. We were observing for lower arm edema and going from there but not necessarily monitoring arm measurement as indicated. One reason for that was probably due to our inconsistency in where we measured and our lack of confidence in not only the measurement but our be uncomfortable "waiting" until the edema goes up the arm.
It is interesting how in our practice we are consistently learning from others and fine tuning our skills no matter how long we have been inserting PICC lines. The new standards are more detailed than prior editions. We are growing from the "way we always did it" to true evidence based practice. I continue to learn more about my specialty on a regular basis.
Juline DiSilvestro BSN, RN, CRNI, VA-BC, CPUI
Central Access Team Nurse
Inspira Medical Center- Woodbury,NJ
the 2016 INS Standards have 50 more pages and 350 more references! Yeah! Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Vickie
I would think your way makes more sense. I really don't understand the measurement thing. I know in the new standards it states to measure 10cm above the AC. Unless you you bilateral measurements I'm not quite sure what that number tells you?. If your measuring to have a baseline for future DVT, then inpeded circulation in a limb would cause swelling below the sight. So, are we supposed to do repeated measurements?...I'm sort of lost with this topic.
Jack
When you have a question about anything in the standards document, the very first thing is to check the reference(s) for that statement. This statement about measurement location is from a study. Also look at the ranking of that statement or section and compare to the scale in the front of the document. Nothing is totally black and white thus the ranking scale for the level of evidence. Lynn
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861
Thank you to everyone who has responded--very helpful!