Infection Control and IV Therapy Notes

Infection

• Venipuncture punctures the skin, the body's first line of defense, creating a portal for microbes to enter the circulatory system. Proper skin antisepsis is crucial to minimize this risk.

• Types of infections:

  • Local: Limited to one specific area (e.g., IV site infection). Manifests as redness, swelling, pain, and potentially purulent drainage at the insertion site. Meticulous site care is required to prevent progression.

  • Systemic: Affecting the entire body (e.g., central line infection leading to bloodstream infection). Can cause fever, chills, altered mental status, hypotension, and organ dysfunction. Requires immediate intervention with antibiotics and supportive care.

• Preventing infections during IV starts:

  • Clean hands and gloves: Adhering to strict hand hygiene protocols before and after any contact with the patient or IV equipment.

  • Appropriate cleansing of the site: Using chlorhexidine-based antiseptic solutions and allowing adequate drying time per hospital protocol.

  • Choosing an appropriate IV site: Selecting a site in the upper extremities, avoiding areas of flexion, and assessing for signs of previous trauma or infection.

IV Site Selection Considerations

• Avoid areas near bends or previous puncture sites with bruises or hematomas: These areas can impede blood flow and increase the risk of phlebitis or infiltration.

• Consider the patient's mental status (e.g., confusion may lead to them tampering with the IV): Confused patients may require additional measures to secure the IV site and prevent dislodgement or contamination.

• Avoid the groin area due to a higher risk of infection: The groin area is prone to contamination due to its proximity to the perineum and higher moisture levels.

Impaired Host Resistance

• Individuals with weakened immune systems are at higher risk of infection. Implementing stringent infection control measures is vital, along with monitoring for early signs of infection.

• Factors contributing to impaired host resistance:

  • Age: Older adults and children have less robust immune responses, making them more susceptible to infections. Premature neonates are at highest risk.

  • Steroid use: Corticosteroids suppress the immune system, increasing the risk of opportunistic infections. The higher the dose and longer the duration, the greater the risk.

  • HIV/AIDS: HIV destroys CD4 T-cells, crippling the immune system and predisposing individuals to a range of opportunistic infections. Prophylactic antibiotics and vaccinations may be necessary.

  • Bone marrow or organ transplant recipients: Immunosuppressant drugs are required to prevent rejection, but these dramatically increase the risk of infection. Close monitoring for infection and prompt treatment are essential.

Infections in Immunocompromised Patients

• Increased risk and severity of infections: Subtle signs of infection should be promptly evaluated and treated due to blunted immune responses.

• Potential for secondary infections related to IV therapy or environmental exposure: Immunocompromised patients are more vulnerable to nosocomial infections from indwelling devices, contaminated equipment, or healthcare personnel.

• Unusual or opportunistic infections may occur: Infections by organisms that are normally harmless in immunocompetent individuals (e.g., Pneumocystis jirovecii, Candida albicans) can cause severe disease in immunocompromised patients.

• Some immunosuppressants have side effects that increase infection risk: Some medications can impair wound healing, cause neutropenia, or disrupt the mucosal barrier, further increasing infection risk.

Immune Deficiencies

• Primary Immune Deficiency:

  • Inborn defects in immune cells: Genetic mutations affecting the development or function of immune cells lead to increased susceptibility to infections.

  • Congenital, acquired, or inherited.

  • Examples: hereditary conditions, infections from parents

• Secondary Immune Deficiency:

  • Arises from disease processes or therapies that weaken the immune system.

  • Examples: leukemia, HIV/AIDS, chemotherapy (potentially leading to other cancers).

Healthcare-Acquired Infections (HAIs)

• Infections that develop in a healthcare setting: Often preventable with stringent infection control practices.

• Common HAIs associated with tubes inserted into the body:

  • UTIs (catheters): Catheter-associated urinary tract infections are the most common type of HAI, often caused by E. coli or other bacteria entering the urinary tract. Limiting catheter duration and adhering to sterile insertion techniques are key prevention strategies.

  • Central line infections: Central line-associated bloodstream infections (CLABSIs) are serious infections that can lead to sepsis and death. Using a standardized insertion checklist, chlorhexidine skin antisepsis, and maximal barrier precautions are crucial for prevention.

  • IV infections: Infections related to peripheral IVs can range from local site infections to bloodstream infections. Regular site assessment, proper insertion technique, and timely removal of unnecessary IVs are vital.

  • ET tube infections: Ventilator-associated pneumonia (VAP) is a lung infection that develops in patients on mechanical ventilation. Elevating the head of the bed, providing oral care with chlorhexidine, and minimizing ventilator days can reduce the risk of VAP.

Factors Contributing to HAIs

• Location of insertion site (groin increases risk): The groin area is more likely to be colonized with bacteria and has higher moisture levels, increasing infection risk.

• Length of time the device is in place: The longer an indwelling device remains, the greater the risk of bacterial colonization and biofilm formation, leading to infection.

• Common devices associated with HAIs:

  • Central lines.

  • Inhaling catheters.

  • Ventilators.

• Examples of HAIs:

  • Viral infections.

  • Pneumonia.

  • C. difficile (C. diff).

Infections in Long-Term Care

• Common infections:

  • Influenza: Annual vaccination is recommended for residents and staff.

  • COVID-19: Stringent infection control practices and vaccination are crucial.

  • Lice: Common in crowded conditions; treat with topical medications and thorough cleaning of linens.

Infection Prevention: Standard Precautions (Tier 1)

• Hand hygiene:

  • Soap and water for visibly soiled hands or C. diff infections (spores require physical removal).

  • Alcohol-based hand sanitizer otherwise.

• PPE (Personal Protective Equipment):

  • Gloves, mask, eye protection, gown, face shield.

  • Prevents bacteria from entering the body or contaminating clothing.

Safe Injection Practices

• Use single-dose vials whenever possible. Avoiding multi-dose vials reduces the risk of contamination and transmission of bloodborne pathogens.

• Multi-dose vials should be used for a single patient only. If multi-dose vials are necessary, strict aseptic technique must be followed, and the vial should be discarded after use on a single patient.

• Avoid re-utilizing equipment to prevent contamination. Never reuse syringes or needles, even on the same patient. This prevents the transmission of bloodborne pathogens and other infectious agents.

Isolation Precautions

• Contact:

  • Gloves and gown.

  • For infections spread by physical contact (e.g., C. diff, MRSA, staph).

  • Pathogens present in feces, urine, or on the skin.

• Airborne:

  • N95 respirator.

  • Gloves, gown may be needed.

  • Private room with negative pressure (air is vented outside the facility).

  • Common airborne infections: TB, measles, chickenpox.

• Droplet:

  • Mask, face shield, gown, gloves.

  • For infections spread by wetness (droplets) contacting eyes, nose, or mouth.

  • Patients should wear a mask when transferring or traveling within the facility.

General Infection Control Practices

• Avoid long nails, nail polish, and jewelry, as they can harbor bacteria and puncture gloves. Short, clean nails reduce the risk of bacterial contamination and glove puncture. Remove jewelry from hands and wrists before patient care.

• Avoid touching fluids that the body did not produce (urine, feces, blood) without protection. Use appropriate PPE (gloves, gown, face shield) when handling bodily fluids to prevent exposure to pathogens.

• Never fan or blow on a central line dressing change area. Fanning or blowing can introduce airborne microorganisms into the sterile field, increasing infection risk.

Cleansing Methods

• Chlorhexidine is the preferred cleansing method (stays on the skin for up to 48 hours). Chlorhexidine has broad-spectrum antimicrobial activity and provides persistent protection against bacteria. Solutions with >0.5% Chlorhexidine are most effective.

• Iodine is an alternative if the patient is allergic to chlorhexidine. Iodine-based solutions are effective, but can cause skin irritation and staining. If using iodine, allow adequate drying time.

• Allow to dry completely to kill bacteria. This allows the antiseptic to penetrate and kill microorganisms on the skin surface. Follow manufacturer's recommendations for drying time (usually 30 seconds to 2 minutes).

Central Lines

• Tip terminates in or close to the superior vena cava (larger vein, increasing infection risk). The proximity to the heart and large blood flow make central lines prone to bloodstream infections.

• Requires sterile field during insertion and dressing changes. Strict aseptic technique is essential to prevent the introduction of microorganisms into the bloodstream.

• RN role: Ensure hand hygiene, prepare equipment, assist with sterile field setup. Nurses play a critical role in maintaining the sterility of the procedure and monitoring the patient for signs of complications, including infection.

• Assess the ongoing need for the central line to reduce infection risk. Remove the central line as soon as it is no longer necessary to minimize the risk of CLABSI.

Central Line Example

• Patient admitted to ICU after a heart attack, central line placed for fluids, medications, and antibiotics.

• After three days, the patient is stable with minimal requirements.

• Advocate for removal of the central line to decrease the potential for infection (similar to unnecessary catheter use).

• If purulent drainage is coming from the insertion site, do not remove it; notify the doctor or nurse. Purulent drainage indicates a possible infection, and the physician needs to assess the situation.

Central Line Dressing Changes

• Transparent dressings allow visualization of the insertion site. Allows for ongoing assessment of the site without removing the dressing.

• Dressings changed every seven days unless soiled or contaminated. Reduces the risk of infection by removing moisture and bacteria from the site.

• If gauze is present, the dressing must be changed every 48 hours (gauze can soak up blood, promoting bacterial growth). Gauze dressings absorb moisture and blood, creating a breeding ground for bacteria, necessitating more frequent changes.

• Avoid using tape if the patient is diaphoretic or has fragile skin. Tape can cause skin irritation and breakdown in diaphoretic patients or those with fragile skin. Use alternative securement methods.

Infection Related to IV Therapy

• Systemic vs. Local infections.

• Phlebitis: Inflammation of the vein (major complication).

  • Mechanical: Movement of the canula. Irritation caused by the physical motion of the catheter within the vein. Prevent with proper stabilization.

  • Chemical: Irritation from cleaning agents (e.g., chlorhexidine not allowed to dry) or medications (e.g., dextrose). Certain IV solutions and medications can irritate the vein lining, leading to inflammation.

  • Bacterial: Bacteria introduced into the vein. Introduction of bacteria during insertion or through contaminated equipment. Always use strict sterile technique.

  • Post-infusion: Inflammation or infection develops after IV removal. Can occur up to 48 hours after IV removal. Monitor site for redness, swelling, or pain after removal.

Phlebitis Scale (0-4)

• 0: Nothing (normal).

• 1: Redness with or without pain.

• 2: Redness, swelling, and pain.

• 3: Redness, pain, edema, palpable cord or streak.

• 4: All of the above plus purulence (pus).

Phlebitis Treatment

• Stop the infusion and remove the IV. Prevents further irritation and reduces risk of infection.

• Apply a warm compress and elevate the arm. Warm compresses promote vasodilation, increasing blood flow and reducing inflammation.

• Administer pain medication (Tylenol or Advil). Relieves pain and discomfort associated with phlebitis.

• Identify and address the cause. Determine the underlying cause of phlebitis to prevent recurrence.

• Warm compress: Vasodilator, opens everything up. It helps fluid dissipate, and then it would help with the blood flow as well. Help that reabsorb that area.

Causes of Phlebitis

• Mechanical: Movement or instability of the cannula inside the vein. Secure the catheter properly to prevent movement and irritation.

• Chemical: Irritating solutions (e.g., dextrose) or antiseptics that haven't dried. Allow antiseptics to dry completely before insertion. Dilute irritating solutions when possible.

• Bacterial: Poor aseptic technique during insertion. Use strict sterile technique during insertion and dressing changes.

• Post-infusion: Can occur up to 48 hours after IV removal. Monitor the site after removal for signs of phlebitis.

Inflammatory Response

• Infection triggers an inflammatory response: White blood cells, red blood cells, and platelets rush to the area. The body's defense mechanism to combat infection and promote healing.

• Excessive inflammation can cause organ damage and failure. Uncontrolled inflammation can lead to systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS).

• Kidneys are particularly vulnerable. The kidneys are highly susceptible to damage from inflammation and toxins.

Sepsis: Signs and Symptoms

• Sepsis can start with flu-like symptoms: Fever, chills, body aches, fatigue, nausea. Early recognition is crucial for improving patient outcomes.

• Progression:

  • Hypotension (low blood pressure) and tachycardia (rapid heart rate) due to fluid volume deficit. Systemic vasodilation and increased capillary permeability lead to hypotension.

  • Tachypnea (rapid breathing) and hypoxemia (low blood oxygen). Respiratory rate increases to compensate for metabolic acidosis and hypoxemia.

  • Profuse cold sweating (insensible loss contributing to dehydration). Vasodilation and increased metabolic rate cause sweating.

• Elevated lactic acid level: Byproduct of muscle breakdown due to poor perfusion. Indicates anaerobic metabolism due to inadequate tissue oxygenation.

• Elevated white blood cell count: Body's response to infection. Indicates the body's attempt to fight off the infection.

• Diminished urine output: Less than 30 \, \text{mL/hour}.

Sepsis: Signs and Symptoms Continued

• Diminished Pulses: diminished blood flow.- body shunts blood to vital organs (heart, brain, lungs).

  • arms and legs are disposable.

  • mottling (bluish, grayish, purplish discoloration).

  • decreased bowel sounds.

• Treatment for Sepsis.

• Mean Arterial Pressure (MAP) should be between 60 to 65 to maintain perfusion to organs. If hypotensive, MAP will be around 50.

Sepsis: Treatment & Prevention

• Early Recognition: Identifying the signs and symptoms early. Prompt recognition and intervention are crucial for improving patient outcomes.

• Blood Cultures: Aerobic and anaerobic to identify the causative organism. Obtain blood cultures before initiating antibiotics, if possible.

• Remove or replace potential sources of infection (central lines, catheters). Removing or replacing infected devices can help control the source of infection.

• Broad-spectrum antibiotics (e.g., vancomycin). Administer broad-spectrum antibiotics within one hour of sepsis recognition.

• IV Fluids: Fluid Resuscitation for dehydration. Aggressive fluid resuscitation is essential to restore blood pressure and tissue perfusion.

• ICU Monitoring: For close observation and intervention. Patients with sepsis require close monitoring and support in the ICU.

LPN Scope of Practice: Infection Control & IV Therapy

• Central Line Dressing Changes: Every 7 days, unless gauze is present (then every 48 hours)

• IV Solutions Verification: Verify name of solution. Ensuring the correct solution is administered to the patient.

• Peripheral IV Solutions: Check the rate of flow, insertion site. Regularly assessing the IV site for complications and ensuring proper flow rate.

• Peripheral IV Insertion: For Little Timmy and Adults.

LPN Scope of Practice: Infection Control Procedures

• Peripheral IV Infiltration: Fluid is escaping from the vein to surrounding tissue. Recognizing and managing IV infiltration promptly.

• When an IV is infiltrated, turn off the pump, fluid will go into your skin. Immediately stopping the infusion to prevent further fluid extravasation.

• Vesicant: Medication or solution that can cause tissue death or necrosis.

  • Vancomycin.

• Extravasation: Tissue Death.

• You leave it in place.

• Specific Protocol: Call the pharmacist and see if there's the antidote.

How to Prevent IV Complications

• Always visually inspect IV sites for redness, swelling, or other abnormalities. Regular assessments help detect complications early.

• Be aware of potential complications like infiltration and extravasation. Understanding potential complications enables timely intervention.

• Ensure proper catheter stabilization to prevent movement. Use appropriate securement devices to minimize the risk of phlebitis and dislodgement.

Skills Check

• Avoid flexion to reduce risk of phlebitis. Prevents mechanical irritation of the vein.

• Stabilize the catheter well to prevent movement of the catheter in the vein. Minimizes the risk of phlebitis and dislodgement.

• Performing thorough hygiene before and after IV insertion. Reduces the risk of bacterial contamination.

Medications and Labs

• Warfarin: Prevents and treats blood clots.

  • Lab: INR (therapeutic range 2-3).

  • If INR is less than two, give warfarin, contact physician.

  • If INR is more than three, hold warfarin contact physician.

• Antidote: Vitamin K.

• Heparin: Prevents and treats blood clots, DVTs, pulmonary embolisms.

  • Lab: PTT (reference range 25-35).

  • Antidote: Protamine sulfate.

Medications to Treat Anxiety

• Lorazepam (Ativan): Benzodiazepine, habit-forming, CNS depressant.

  • Decreases heart rate, blood pressure, and respiratory rate.

  • Do not give with alcohol, alcohol, another benzodiazepine.

  • Given for anxiety, alcohol withdrawal, mild sedation, seizure activity, and can be used for sleep.

  • Can be given IV, orally, drip push.

  • Stroke of practice for adult patient, can get oral medications and sub q, IM, rectal.

LPN Scope of Practice: IV Responsibilities

• Start IV from the antecubital fossa down, as long as it is less than three inches.

• Peripheral Inserted Central Catheter (PICC): Central line, LPNs do not insert or remove.

• LPN can flush with normal saline and heparin.

• LPN can change a dressing.

• Everything up to Antibiotics and fluids.

• Stop Medication that causes harm.

• LPN can hang all of her approved fluids and antibiotics.

• LPN can verify solutions on any patient, but cannot spike or prime them.

Solutions and Electrolytes

• RN has to hang the first bag of fluids with electrolytes or multivitamins. Rapid infusion of electrolytes can cause cardiac instability.

• It can cause cardiac resonance.

• LPN can complete hanging all other bags.

• Fluids for Little Tinny, can get oral Medications and I'm rectal.

• Verify solutions on patient. Already Has IV, Bag of Fluid Hanging.

• For ABG the pH is seven point three five seven point four five, BCO two, thirty five to 45, and BCO three is twenty two twenty six.

• Basic: In Partial Compensation, Everything is Messed Up.

• Full compensation: PH is Normal.

IV Calculation

• Primary Tubing is changed every ninety six hours.

• Secondary Tubing is changed every 24 hours.

• Blood Tubing is changed every four hours.

• Central line dressing is every seven days unless GOD was present and then twenty four.

• Always label Everything.