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James M Joseph
Site selection when skin is not intact

I recently had to go to battle with a resident who insisted that we place a picc line in a patient so he could be discharged to an ecf that he and his family had chosen. The focus of the discharge planner and this resident seemed to be getting this elderly, diabetic, renal failure , patient back to his ecf before he lost his spot. The ecf was prestigeous and .."there are fountains..."!

First of all the man had a permacath on the right so we only had the left to work with. Secondly his plateletts were low so he was getting some through his only iv access..a 22Guage in the thumb. Last but not least, the patients skin was slaughing, red, bloody scabs from an earlier allergic reaction. He had (what the resident described as a rash) one of the worst slaughings of skin i have seen in 22 years of nursing. I would never have called it a rash. Nine days prior to this, when the skin issue was just a rash, the resident had biopsied the skin and confirmed that it was a medication reaction but the patient's skin had deteriorated significantly and was in no shape to have a picc placed.Did I mention the patient was in isolation for VRE? Anyway, the resident gave me the "I am the doctor " speech to which I replied, "I know that but I also know that you would not want me to harm the patient." then the resident called me back and pleaded the "He is going to lose his spot in the ecf if you don't...".Lastly he sent the discharge planners to convince me...they were the ones impressed with the fountains! Finally, the resident called the COE of nursing, interupted her from a meeting,  and wrote a lengthy E-mail about me needing reprimanded. The COE called the Dirrector who high tailed to my office and said," You have to place this picc!" Of course my reply was, "lets go assess the patient together".

After her assessment...10 seconds...the picc was not placed! Where can I find evidence to back up my decision regarding skin integrity? Thanks ahead of time.  Jaime

Many published references on
Many published references on CRBSI discuss the fact that BSI occuring within the first week of dwell are from the skin as the source of organisms. Skin integrity around the insertion site for any IV catheter is in the basic IV nursing literature - the 2 textbooks, etc. Lynn

Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI

Lynn Hadaway Associates, Inc.

PO Box 10

Milner, GA 30257


Office Phone 770-358-7861

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