Oct 21, 2012

Dressing Changes

Last week, I did a post about TPN and the supplies and what goes into connecting and disconnecting Manny daily. 

Well another activity I do is Dressing Changes.  This is done weekly typically unless it's needed to be done more frequently. 

First thing you need to know is ... this is considered a "Sterile Procedure".  We are exposing Manny's central line to the air and the elements so it's critical this is done carefully and quickly, exposing him to as few germs as possible.  You'll all remember how horrible a line infection was! 

Before I even bring Manny into the room, I lay out all the supplies.  I am careful not to touch anything that will be used for the sterile procedure, laying all the supplies out on the sterile cloth.
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Above, what you can see are the supplies I need for this procedure.  Upper right is a mask.  Manny and I both get one.  Right center is a blue cap.  Bottom right are sterile gloves.  Bottom left Iodine (3).  Upper left is alcohol.  Small circle silver disk in middle (it's upside down but it's white on one side and silver on the other).  Two semi circles in the middle are tape like IV 3000. 

Once all the supplies are set out, I go get Manny and lay him down on a changing table.  I take off his shirt.  We both put on our masks.  He calls, "We going to be the doctor?"  (Every time he says it the same way.  These are our "doctor masks".) 

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Take off his old dressings.  This picture shows it half way on and half way off. 

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This skin is completely covered 24 hours a day, 7 days a week and the only exposure it gets is during the dressing changes.  He says the skin itches.  I can imagine it does!  So the picture above is showing me holding an Iodine swab.  I make sure I do a bit of "scrubbing".  Not because it's dirty, but because it itches.  He usually says, "Ooooo, that feels SOOO good!" So I scrub longer than is necessary. 

There are three iodine swabs in the pack and I use all three.  Start from the center and then work outwards from there.  The idea is to sterilize the area to kill off any bacteria.  Now Iodine is what was used for decades and was the go to product forever!  But recently, a new product has made its way into circulation that is more effective.  It last longer and kills better.  That is ChloroHexadine Gluconate or CHG. 

Turns out Manny is very allergic to CHG.  How do I know?  First, remember all the horrible skin issues he had?  We didn't know what was causing them?  I did a systematic approach to find out the culprit and voila! CHG.  Again, how do I know?  I drew a straight line with the different products and there was a bright red line of bumps where I had placed the CHG.  Since we stopped using it, not one skin allergy! 

Oh, and I was put in contact with a group.  I find this fascinating.  They manufacture broviacs and are starting to "lace" them with CHG.  Why? Because at the time of the insertion is when there is the highest risk of infection.  So the CHG would help prevent infections for up to 30 days upon insertion.  (That would have helped a lot as Manny's first Broviac had to be removed after 3 weeks!)  But a friend worked for this company and she knew of Manny's allergy and asked what do they do for the kids with a CHG allergy? Well, turns out they're rare.  They would like to develop a bedside test to see if a kid is CHG allergic before inserting the broviac.  But since the allergies are rare, how do they obtain blood samples? 

So ... last week, I got blood samples and overnighted them to this company!  They are going to do testing and send the results.  And Manny's blood could actually help other kids. 

Anyway ... back to to the procedure. 

After doing three swabs of iodine and pausing to let them dry in between because "Dry time is kill time" I was taught", we then remove the iodine with alcohol swabs.  This stings for a second Manny says but it's not that bad. 

Next is the little circle.  Normally it's a white circle that's laced with CHG.  But because of his allergy, we use Silver Disks instead. 

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They have a slit on one side so it's easy to slip right over the line. 

Next comes the dressing.  It's like a clear bandage.  We use something called IV 3000 which is a bit breathable.  It's also clear that way we can see if there are any issues going on below the bandage.  (Leaking, blood, discharge, redness, etc.) 

View photo.JPG in slide show

There are a million ways to do the dressing.  In this one, I was being creative.  Every time I try to adjust the pressure of the line as well as the placement of the dressing to give the skin some time to breathe.  Last time I put them north and south so this time it's more east and west.  And because there are now two repairs the line is a tiny bit longer and it doesn't bend in every direction, I sometimes have to get creative in the way it's looped.  If you see the silver disk, the area right around that is what's critical and must be completely closed up.  So that's all under one solid bandage.  The "tape" at the top of that is because I've discovered Manny likes to pick at the dressing so I have learned to secure it there. 

The little loopy thing on the right chest is a tension loop.  That is so in case his line gets pulled, the tension loop will first move and the part that is in the chest won't budge. And more "tape" on his right chest ... again, that's for wandering fingers. Then in the center of the chest is more "tape" to anchor the whole thing so it won't get tugged.  And as you can see, Manny no longer has the mask on in this picture because we were done and he likes that off ASAP. 

Now other people do this differently based on what allergies/needs the kids have.  Some kids get skin prep or might be allergic to the dressings, etc.  But so far, this is what is keeping Manny's skin looking healthy and clear. 

Finally, we have to change out the cap.  In the picture above, you can see a little orange tip. That's a swap cap.  It's laced with alcohol and goes on daily for the 4 hours Manny is not hooked up to his TPN.  There is a white cap right above that which gets changed weekly during the dressing changes.  (Sometimes it's blue like the one in the very first picture ... still in the package.  There are just different types.)  The white cap is connected to the next part up called the Hub.  These are cleaned thoroughly and a new cap is put on. 

The whole process?  Even with us taking extra time to scratch a lot and to let things dry, the whole process takes less than 10 minutes.  I've got it down to a science! Practice.  Lots of practice. 

So there you have it.  Now you're all certified in Dressing Changes.  Like I said, this is typically only done once a week unless it gets pulled or wet or starts to come off.  But for Manny, it's rare to need it more than once a week.  (Well, back in the days before we knew about the CHG allergy, he needed daily changes.) 

What mundane thing from my life should I share with you next? Oh, I know, I should show you the charts and tables I have of record keeping for Manny's medical related things.  :)

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