Community Nurse Referral Letter (Hickman Line Care)

Transcription

1 Community Nurse Referral Letter (Hickman Line Care) Name of nurse making the referral: Name Signature.. Date Ward.Tel Ext. Dear Community Nurse The following patient requires care for a Hickman Line: Name.....DOB..... Diagnosis... Address... Tel... GP Please visit as follows.. The Hickman Line was inserted on and has lumens. A Note About Infection A Note About Infection: Most patients on chemotherapy are immunocompromised and infections should be acted on immediately. If the patient experiences a rigor and/or pyrexia following flushing of the line, contact the hospital urgently. Haematology pts: contact Bleep Oncology Pts: contact If the exit site is inflamed or there is purulent exudate, please take a swab. If the patient is pyrexial, contact the hospital urgently as above. If not, this can wait until the next working day. The site should be inspected daily while infection is suspected and use of Biopatch & TegadermTM CHG should be suspended until the infection has resolved. Handwashing and a non-touch technique are vital: please follow attached instructions. Page 1 of 6 continues overleaf UCL Hospitals is an NHS Foundation Trust incorporating the Eastman Dental Hospital, Elizabeth Garrett Anderson & Obstetric Hospital, The Heart Hospital, Hospital for Tropical Diseases, National Hospital for Neurology & Neurosurgery, The Royal London Homoeopathic Hospital and University College Hospital.

2 Please note We have recently stopped using hepsal for locking Hickman Lines We have recently changed our exit site cleaning regime. We are now using Chloraprep for cleaning and a Tegaderm TM CHG dressing. Dressing change is due weekly and flush twice weekly: instructions attached Blood tests: if required patient will be given blood forms with dates for when tests are due. Please take blood from the line and sent to your usual Path lab. Instructions attached. Print off your own copies of the attached information from our website at this internet address: Tick Hickman discharge checklist to be completed by nurse referring patient Patient supplied with items in List A (see below). These should subsequently be supplied by you. Patient supplied with enough items in List B (see below). Patient / carer knows to collect items from List B each time they attend the hospital Copy of this referral to be faxed to you Hard copy of this referral to be given to patient Patient knows who to contact if they have a problem with their Hickman Line Signed..Date List A Dressing pack x 2 10 ml syringes x 10 Green needles x 10 Clinell wipes x 10 1 box 0.9% saline 10mls (IV use) Sharps bin List B Chloraprep 3mls Tegaderm TM CHG dressings Bionectors Large yellow bags x 2 for disposal of chemo (if required) Removal of Stitches (delete as appropriate) Please remove any stitches at venotomy site A (see right) 7 days after insertion which will be on... Please remove the stitches at the exit site B (see right) 21 days after insertion which will be on Page 2 of 6 continues overleaf For advice or to arrange teaching contact Central Venous Access Team Tel: ext centralvenousaccess@uclh.nhs.uk

3 Flushing a Hickman Line Community nurse referral for Hickman Care page 3 / 6 Our Hickman Lines are fitted with Bionectors rather than bungs. These are needle-free access ports. YOU SHOULD NEVER STICK NEEDLES INTO them, and they need to be changed once a week. Please treat each lumen separately, using a different syringe for each lumen. Routine Flushing: weekly for unused lumens. 1. Wash hands. Draw up saline into syringes. 2. Clean end of Bionector with 2% chlorhexidine swab. Rub vigorously for 30 seconds using different parts of the swab. 3. Allow to dry fully without becoming contaminated (OR if Bionector change is due, remove Bionector, clean end of lumen with alcohol swab, allow to dry, apply new Bionector and proceed.) 4. Remove needle from saline syringe. Push the syringe into the Bionector and twist clockwise. The syringe should now stay in place. Equipment Needed per lumen 10 mls 0.9% Saline IV 10 ml syringe (no smaller) Needle 2% Chlorhexidine in alcohol swabs Spare Bionector if change due 5. Flush the Hickman Line using a brisk push-pause technique (ie pause after each ml: this creates turbulence in the line and helps clear any tiny debris). DO NOT FORCE THE FLUSH or you may split the line. If you meet resistance, STOP and contact the hospital for advice. Never use a smaller syringe to try to unblock the line. 6. Create a positive pressure finish by clamping the catheter while you are flushing in the last ml of saline. Leave Bionector in place. Taking blood from a Hickman Line. Equipment Needed As for routine flush (above) but add: two extra empty 10 ml syringes (or one extra syringe plus Vacutainer connector) 2 x 10ml syringes of saline and a spare in case Hickman Line needs flushing before it will bleed back. 1. Access the Hickman Line using aseptic technique as for flushing. 2. Withdraw & discard first 4mls of blood from Hickman Line. (If it won t bleed back try flushing the line first or ask patient to take deep breaths.) 3. Take the blood sample. 4. Flush immediately with 2 x 10mls 0.9% saline: turbulent push-pause flush. Further info: Print off your own copy at Contact Nurse Specialists: Tel: x centralvenousaccess@uclh.nhs.uk Out of hours: Haematology patients contact Bleep Oncology patients contact Updated by Liz Simcock July 2010 If you are flushing off chemotherapy Chemotherapy can damage cells. Avoiding contact with chemotherapy is like avoiding radiation in an X-ray department. Repeated exposure can be harmful. This is why it must be handled with care. Always wear apron and gloves when handling lines, bags and infusion devices containing Chemotherapy Disconnect the giving set from the Hickman Line leaving the Bionector in place. Avoid dripping or splashing of the Chemotherapy. Dispose of contaminated equipment carefully in a double yellow bag including the empty infusion device, the syringe used to flush the line through and your gloves and apron The yellow bag can be brought back to the hospital by the patient at his / her next visit for disposal by the chemotherapy nurses. In the meantime it should always be stored out of the reach of children. Always wash your hands on removing your gloves and apron. In the event of a spillage Chemotherapy can cause irritation if it comes into direct contact with the skin. If for any reason this should happen, flush the affected area with plenty of water and a mild soap. If any burning or rash develops subsequently, seek medical advice.

4 Chloraprep and Tegaderm TM CHG Community nurse referral for Hickman Line Care page 4 / 6 Chloraprep 3mls is a single-use sterile applicator containing a 2% solution of Chlorhexidine Gluconate and 70% Isopropyl Alcohol. It s coverage area is 10cm x 10cm. It works by penetrating the top 5 layers of the skin where most bacteria is found. At UCLH Cancer Services and Adolescent Cancer we are now using Chloraprep for cleaning all our Central Venous Catheter exit sites including Hickman Line. Can it be used for all patients? Patients must be aged 2 months and over. Adverse reactions are very rare but can cause anaphylaxis. Do not use on patients with a history of hypersensitivity to Chlorhexidine. How should it be used? Pinch the wings of the applicator until you feel the inner ampoule break. The antiseptic solution will soak the sponge tip. Use a gentle repeated back-and-forth friction rub for 30 seconds and allow to dry completely. Discard in clinical waste bag. If there is loose blood or exudate around the exit site, clean this away using 0.9% saline before using Chloraprep Tegaderm TM CHG is a transparent dressing with an integrated chlorhexidine gel pad which inhibits bacterial growth. At UCLH we are now using it on all our Central Venous Catheter exit sites including Hickman lines (except for patients under the age of 16). Can it be used for all patients? Patients must be aged 16 or over. Adverse reactions are very rare but can cause anaphylaxis. Do not use on patients with a history of hypersensitivity to Chlorhexidine. How is Tegaderm TM CHG applied and removed? Apply the dressing so that the gel pad is over the exit site. Remove it using low and slow technique. Use alcohol or a few drops of saline if necessary. How often should it be changed? Change the Tegaderm TM CHG every 7 days or sooner if the dressing becomes detached, if there is visible drainage beyond the gel pad or the exit site is obscured. What if the exit site looks infected? If the exit site is visibly infected: STOP using Tegaderm TM CHG. Take a swab and contact the GP or hospital. Switch to a plain transparent or dry dressing daily until the infection is resolved. What if the patient can t tolerate the CHG dressing? Switch to Biopatch with either a transparent or a dry dressing instead (eg Mepore), whichever the patient can tolerate. Do Chloraprep & Biopatch need prescribing & can they be obtained in the Community? They do NOT need to be prescribed. They can be hard to obtain in the Community. Patients should be sent home with a supply and should collect a few more each time they visit the hospital. Further information: Print off your own copy of attached info at Contact Nurse Specialists: Tel: x centralvenousaccess@uclh.nhs.uk. Out of hours: Haematology patients contact Bleep Oncology patients contact Updated by Liz Simcock July 2010

5 Changing a Hickman Line Dressing Community nurse referral for Hickman Line Care page 5 / 6 Changing the dressing Change transparent dressings and Biopatch weekly using aseptic technique. (If using dry dressing change the dressing twice weekly but only change the Biopatch every 7 days unless the Biopatch is more than half discoloured with blood / exudates, or the white edges of the Biopatch become visible around edges of blue disc.) In addition change dressing if it becomes detached or gets wet. 1. Clean hands. Put on non-sterile gloves and remove the existing dressing. 2. Clean exit site with Chloraprep 3mls using gentle repeated back-and-forth friction rub for 30 seconds and allow to dry. 3. If there is loose blood or exudate around the exit site, clean this away using 0.9% saline before using Chloraprep. 4. Apply new Tegaderm TM CHG dressing. Equipment Needed Non-sterile gloves Tegaderm TM CHG Dressing Chloraprep 3mls Tape 5. Always make sure the line is taped to the skin away from the exit site so that if the line is pulled it does not pull on the exit site. Troubleshooting Patient is pyrexial (above 38 o C) and / or experiences a rigor: Contact the hospital urgently for advice. May need IV antibiotics. Exit site looks infected (inflammation / exudate around exit site) If patient is pyrexial see above Take a swab. Contact the hospital or GP. May need oral antibiotics. Stop using Tegaderm TM CHG until infection resolved. Switch to plain transparent or dry dressing (eg Mepore). Inspect daily if patient is in hospital. Increase frequency of dressing if exudate is present. Hickman line is blocked, sluggish, or won t bleed back: Do not force-flush the catheter as this may split the line. Contact the hospital to arrange for the line to be unblocked using a thrombolytic. Pain, swelling, redness or prominent veins around neck, shoulder or arm. Contact the hospital. This might be a thrombosis and should be investigated urgently. Pain / stinging / leaking of fluid when the line if flushed: This may mean the line has become dislodged or may be damaged and may need to be removed. Contact the hospital urgently. NB patients often feel a cold sensation within the skin tunnel when the line is flushed. This is normal and no action needs to be taken. Hickman line has been cut, split or damaged: Take action immediately to ensure air does not enter the catheter. (If possible use the catheter s own clamp, or otherwise just fold the line over on itself and wrap tape around to keep it kinked. Contact the hospital urgently with a view to line removal or repair.) Further information: Print off your own copy of attached info at Contact Nurse Specialists: Tel: x centralvenousaccess@uclh.nhs.uk. Out of hours: Haematology patients contact Bleep Oncology patients contact Updated by Liz Simcock July 2010

6 Central Venous Catheter Care Training for Community Nurses Ever wished you knew more about Hickmans, Portacaths or PICCs? One-off teaching sessions for Community Nurses. Cost: 20 (payable in advance) This is not a substitute for IV training but we do cover: What is a Central Venous Catheter? Hickmans, HICKMAN LINEs and Portacaths Flushing and Dressing techniques Recognising and Preventing Complications DATES FOR th Jan / 22 nd March / 17 th May 12 th July / 6 th Sept / 31st Dec All sessions Obtain application form by: centralvenousaccess@uclh.nhs.uk phone: ext 77491