How to prevent phlebitis

by Angeles, Tess Comments

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PHLEBITIS, A COMMON BUT USUALLY avoidable complication of I.V. therapy, is an inflammation of one or more layers of the vein wall. Irritation of the innermost layer, the tunica intima, causes tenderness-the first symptom of phlebitis. By the time you see skin color changes (redness), the irritation has progressed to include the tunica media, tunica adventitia, dermis, and epidermis. (See illustration.) On palpation, the vein may be hard and cordlike (a late sign). The best way to prevent phlebitis is to change the I.V. site before inflammation occurs. The Intravenous Nurses Society standard of practice is to change peripheral catheters and tubing every 48 hours and intermittent I.V. tubing every 24 hours. The Centers for Disease Control and Prevention (CDC) guidelines are slightly different. In general, the CDC recommends changing catheters every 48 to 72 hours. The I.V. tubing should be changed no more frequently than every 72 hours, unless clinically indicated or the catheter is changed sooner. However, the CDC recommends replacing tubing used to administer blood, blood products, or lipid emulsions within 24 hours of initiating the infusion, and replacing catheters inserted under emergency conditions within 24 hours.

Of course, you should remove a catheter immediately if you suspect infiltration, phlebitis, or contamination. Restart the I.V. infusion at a higher site or in the other arm. Documerit what you saw, what you did, and any comments from the patient. Postinfusion phlebitis can develop up to 96 hours after catheter removal, so continue to assess the I.V. access site for signs of phlebitis after the catheter has been removed. For tips on preventing and treating phlebitis, see the following chart. BY TESS ANGELES, RN, BSN Vice-President Perivascular Nurse Consultants, Inc. - Rockledge, Pa. Copyright Springhouse Corporation Jan 1997 Provided by ProQuest Information and Learning Company. All rights Reserved 1 2 Protect yourself and others from infectious agents by following these updated guidelines. If you've ever been confused by words Universal Precautions, Body Substance, ilosaltion precautions, and similar infection-control terms, fret no more. Recently, the Centers for Disease Control and Prevention (CDC) and the Hospital Infection Control Practices Advisory Committee (HICPAC) revised the isolation precautions for hospitals and other health care facilities. To clarify the confusion and maintain up-to-date isolation precautions nationwide, the CDC and HICPAC have standardized terminology, simplified precautions, and reclassified certain infections. Here's what you need to know.

First up: "Standard" precautions The new term standard precautions incorporates features of universal blood and body fluid precautions and body substance isolation (BSI) precautions. Use standard precautions when performing procedures that may require contact with blood, body fluids, secretions (except sweat), excretions, nonintact skin, and mucous membranes or any item soiled or contaminated with any of these substances. Apply standard precautions to all patients regardless of diagnosis and infection status. To protect yourself and others, follow these guidelines: 1. Wash your hands before and after performing invasive procedures and after touching blood, body fluids, secretions, excretions, and contaminated items, even if you were wearing gloves during the procedure. Also wash your hands between patients and whenever indicated. Use a dry paper towel to turn off the water after washing your hands under a hand-operated faucet. 2. Always wear gloves during procedures that may involve contact with any patient's blood, body fluids, secretions, excretions, nonintact skin, and mucous membranes. Also, wear gloves during all vascular access procedures, including phlebotomy. Remove gloves promptly after use, before touching noncontaminated surfaces and other patients, then wash your hands. Remember, gloves may have unnoticeable defects or get torn or damaged during use, so washing your hands after you remove gloves is important. Change gloves as needed. For example, if you're caring for a patient's infected wound and then need to care for another part of his body, remove

your gloves, wash your hands, and put on a clean pair of gloves. 3. Wear personal protective equipment such as fluidrepellent gowns, protective eyewear, and face masks during procedures that are likely to produce splashes or sprays of blood, body fluids, secretions, and excretions. Use a resuscitation mask or bag to avoid mouth-to-mouth contact. 4. Avoid recapping used needles. But if you must, never recap them with two hands or with any other technique that involves directing the point of a needle toward any part of your body. Instead, use either a one-handed "scoop" technioue or a needle-recannini device that holds the needle sheath. Don't remove used needles from syringes by hand. Place used disposable syringes and needles, scalpel blades, and other sharps such as broken glass, dental wires, and trocars in designated puncture-resistant sharps containers. 5. To clean blood spills, wear *goves (and other personal protective equipment as needed), blot the blood with paper towels, and discard them in a designated medical waste container. Then clean the area with a bleach solution or hos pital-grade disinfectant. 6. Carefully review room assignments and place patients who may contaminate the environment (such as those who are incontinent or have diarrhea) in private rooms. 7. Handle used patient-care equipment and articles soiled with blood, body fluids, secretions, and excretions carefully, preventing skin and mucous membrane exposure, clothing contamination, and the transfer of microorganisms to other patients and environments. Also, clean reusable items appropriately between patients and properly discard

disposable items. Remember to wear appropriate barriers such as gloves when cleaning equipment. Wear a mask and protective eyewear if splashing is likely to occur. Double protection When a patient may be infected with a pathogenic microorganism or communicable disease, or if he may be colonized by a pathogenic microorganism, use transmissionbased precautions along with standard precautions. These precautions revise and combine the old category-specific as well as the old disease-specific isolation precautions (such as respiratory isolation) into three sets of guidelines: 1. Airborne precautions. Use these when caring for patients who have infections that spread through the air, such as tuberculosis (TB), varicella (chickenpox), disseminated zoster, and rubeola (measles). These pathogens, which can remain suspended in the air for long periods, are transmitted when a person inhales small airborne droplets or dust particles containing the pathogen. So place an infected patient in a negative-pressure isolation room with the door closed. Wear respiratory protection (high-efficiency particulate air [HEPA]-filter respirator or N95 respirator) when entering the room of a patient witl suspected or known pulmonary TB. If you're susceptible to the rubeola or varicella virus, wear respiratory protection when entering the room of a patient infected with either virus. Make sure a patient who has an infection that spreads by airborne transmission wears a surgical mask when leaving his room. Note that surgical masks filter expired air. Respirators such as the HEPA-filter respirator and the N95 respirator filter inspired air.

2. Droplet precautions. Apply these precautions when caring for patients who have infections that spread by large particle droplets containing microorganisms. These infections, which include rubella, diphtheria, mumps, pertussis, influenza, and the adenovirus infection in infants and young children, are spread when an infected patient propels droplets through the air (by coughing, sneezing, or talking). The pathogens can infect another person if they land on his conjunctivas, nasal mucosa, or mouth. If a patient has this type of infection, place him in a private room or with another patient who has the same disease. Wear a surgical mask when coming within 3 feet of the patient to protect yourself from contaminated droplets. Make sure the patient wears a surgical mask when leaving his room. Because large-particle droplets generally travel only about 3 feet before falling from the air, special ventilation precautions aren't necessary and you can keep the patient's door open. 3. Contact precautions. Use these precautions when caring for patients who are infected or colonized by a microorganism that spreads by direct contact (skin to skin) with the patient or by indirect contact (touch) with a contaminated object in the infected patient's environment, such as an instrument, needle, dressing, or bed rail. Place a patient who has this type of infection in a private room or with another patient who has the same illness. Wear gloves when entering an infected patient's room and change gloves as needed during care. Before leaving the patient's room, remove your gloves and immediately wash your hands. Wear a gown if you anticipate that your clothing may come into contact with the patient, environmental surfaces, or

items in the patient's room or if the patient is incontinent or has diarrhea, an ileostomy, a colostomy, or wound drainage not contained by a dressing. Remove the gown before leaving the patient's room. Also, consider using dedicated equipment when treating a patient with a multipleresistant microorganism. For example, leave a stethoscope in the patient's room, indicating that staff members use that stethoscope, not their own, when caring for him. Contact precautions are intended to contain pathogenic microorganisms to prevent the spread of infection. Conditions that require using contact precautions include: gastrointestinal, respiratory, skin, or wound infections or colonizations with multiple antimicrobialresistant microorganisms such as vancomycinresistant enterococci and methicillin-resistant Staphylococcus aureus * Clostridium difficile * respiratory syncytial virus * hepatitis A in incontinent patients * highly contagious skin diseases such as impetigo, scabies, and pediculosis * varicella and zoster (disseminated in any patient and localized in immunocompromised patients). When a patient with a virulent microorganism requiring transmission-based precautions is transferred to another unit or is sent to another area for testing, make sure: he's wearing appropriate barriers (such as a mask or impervious dressing) and knows how to help prevent the spread of the microorganism the transporter has taken the necessary precautions and is wearing appropriate barriers staff in the receiving area have been notified and understand

the precautions to take. Keep in mind that under the new guidelines, some infections and conditions fall into two categories because the microorganisms are transmitted in more than one way. For example, varicella (chickenpox) and zoster (disseminated in any patient and localized in immunocompromised patients) can spread through both the airborne and contact routes. And the adenovirus infection in infants and young children can spread through the droplet and contact routes. If a patient has a microorganism with two transmission routes, hang both precaution signs on his room door. SELECTED REFERENCE Garner, J.: "Guideline for Isolation Precautions in Hospitals," Infection Control and Hospital Epidemiology. 17:(1)53-80, January 1996. http:llWWW.splngnet.COm NURSING97, JANUARY BY DOROTHY BORTON, RN, CIC, BSN Infection-Control Practitioner Albert Einstein Medical Center Philadelphia, Pa. Copyright Springhouse Corporation Jan 1997 Provided by ProQuest Information and Learning Company. All rights Reserved