Strategies for Preventing/Treating Infection
9. Use Antibiotic Locks
The purpose of antibiotic lock therapy is to sterilize the lumen of the catheter. Most frequently the therapy is over a 2-week period of time.
Antibiotic lock therapy for catheter-related bloodstream infections is often used in conjunction with systemic antibiotic therapy and involves instill-ing in the catheter lumen a high concentration of an antibiotic to which the causative microbe is susceptible. The antibiotic is mixed with 50 to 100 U of heparin or normal saline in sufficient volume to fill the catheter lumen and installed or “locked” into the catheter lumen during periods when the catheter is not being used (Mermel et al., 2001).
NURSING PLAN OF CARE
INFECTION CONTROL
Focus Assessment Subjective
■ History of risk factors: Fever, diarrhea Objective
■ Baseline immunologic studies: T-cell count, WBC count, differ-ential
■ Vital signs, especially temperature
■ Redness, inflammation, purulent drainage, tenderness, and warmth of insertion site
Patient Outcome/Evaluation Criteria Patient will:
■ Be free from nosocomial infection.
■ Maintain adequate oxygenation.
■ Verbalize understanding of precautions for catheter care.
■ Report any need for additional dressing changes.
■ Not contaminate healthcare team, other patients, or family.
Nursing Diagnoses
■ Risk for infection related to immunodeficiency and malnutrition
■ Risk for impaired gas exchange related to alveolar capillary mem-brane changes with infection
■ Risk for altered thought processes related to HIV or opportunistic infection of central nervous system
■ Risk for knowledge deficit related to illness and impact on patient’s future
■ Risk for infection transmission Nursing Management
1. Use standard precautions.
2. Use aseptic technique and follow appropriate protocols when changing catheter dressing, I.V. tubing, and solutions.
3. Use sterile technique when inserting and removing catheter and when maintaining system.
4. Ensure complete skin preparation before insertion.
5. Ensure peripheral catheter removal within 72 and 96 hours.
6. Change insertion site dressing when wet, soiled, or nonocclusive.
7. Secure proximal I.V. connections with a Luer locking set, if possible.
(Continued on following page)
NURSING PLAN OF CARE
INFECTION CONTROL (Continued)
8. Monitor for:
a. Signs and symptoms of sepsis (fever, hypotension, positive blood cultures).
b. Oxygen saturation with oximetry.
9. Observe hand hygiene techniques between patients.
10. Use proper insertion and maintenance of invasive devices.
11. Use sterile equipment and aseptic technique appropriately.
12. Give attention to proper skin care.
13. Use needleless I.V. systems.
Pediatric infection control practices are covered in Chapter 10; infec-tion control issues related to blood products are covered in Chapter 13;
CVC infections are discussed further in Chapter 12; and issues of infection control related to parenteral nutrition are covered in Chapter 15.
In all healthcare environments, patient education is an important component in preventing catheter-related complications. Education regarding vascular access management is crucial. Information regarding catheter management should be individualized to meet the patient’s needs but remain consistent with established policies and procedures for infection control.
Education should include:
■ Instructions on hand hygiene; aseptic technique; and concept of dirty, clean, and sterile
■ Proper methods for handling equipment
■ Judicious use of antibiotics, which is a major nursing role to slow an epi-demic of drug-resistant infections
■ Importance of complying with directions for prescribed antibiotics
■ Written information on steps for dressing changes
■ Assessment of the site and the key signs and symptoms to report to the home care agency, hospital healthcare worker, or physician.
Patient Education
It is generally believed that at-home risk factors for developing a catheter-related infection should be somewhat lower than risk factors in a hospital set-ting. Research and study are needed to describe infection risks in the home setting.
Home Care Issues
■ In the United States, the CDC, a division of the Department of Health and Human Services, is the agency that investigates, develops, recom-mends, and sets standards for infection control practices.
■ The purpose of the immune system is to recognize and destroy invad-ing antigens. Organs include primary (thymus and bone marrow) and secondary (lymph nodes, spleen, liver, Peyer’s patches, appendix, ton-sils and adenoids, and lungs).
■ Impaired host resistance includes:
■ B-cell immunodeficiencies (50 percent of primary immunode-ficiencies)
■ T-cell immunodeficiencies (40 percent of primary immunode-ficiencies)
■ The epidemiologic triangle consists of:
- The host: The living person or animal that provides the atmosphere in which organisms are able to live
The Environmental Protection Agency (EPA) has developed many advi-sory committees regarding infectious waste disposal in the home care setting.
The Medical Waste Tracking Act of 1988 mandated to the EPA the investigation and development of guidelines for handling home-generated medical waste.
The home care provider should establish policies and procedures for handling waste. Prepackaged kits are available from a number of manufacturers and include sharps disposal systems and the CHemBLOC spill kit.
Each home healthcare nurse or aide needs appropriate equipment and supplies related to infection control. OSHA requires that hand hygiene and eyewash stations are available to employees who are exposed to blood and body fluids. The stations may not be available in the home setting; it is impor-tant to provide an alternative until the employee has access to them. It is important to have antiseptic wipes to clean hands, a spill kit in event of a large amount of blood or body fluid is spilled on the floor or a surface, and appro-priate containers for disposal and transport of medical waste and contami-nated sharps.
Rubbermaid® tubs with a sealing lid work well for transporting medical waste from homes to the home healthcare agency. Sharps containers must be used for all contaminated sharps.
Healthcare workers should use an alcohol-based hand rinse or foam, rubbing vigorously to cover all parts of the hands until dry. If hands are visibly soiled, the nurse may have to go out of the way to find a source of run-ning water because alcohol does not remove soil or organic matter (CDC, 2002a).
Key Points
- The agent: The organism that is capable of eliciting a disease process
- The environment: The interacting group of conditions, surround-ings, and influences in which the host and agent coexist
■ A nosocomial infection is one that develops in a patient during or after, but as a result of, his or her stay in a healthcare setting.
■ One of the main complications of infusion therapy is sepsis (sep-ticemia), a pathologic state, usually accompanied by fever, which results from the presence of microorganisms in the bloodstream.
Staphylococci are responsible for the majority of nosocomial I.V.-related infections.
■ Risk factors for infection include:
■ Percutaneously inserted, noncuffed CVCs used for hemodialysis (highest risk)
■ Peripherally inserted CVCs (lower risk)
■ Surgically implanted CVCs (lowest risk)
■ CVCs in all forms pose the greatest risk of septicemia; the skin site is the most common source of organism colonization.
■ Strategies for prevent/treat infection include:
■ Following CDC Standard Precautions guidelines
■ Using the correct hand hygiene procedure
■ Use of appropriate skin antisepsis
■ Catheter site dressing regimens
■ Using catheter securement devices
■ Using antibiotic ointments
■ Using antimicrobial/antiseptic-impregnated catheters and cuffs
■ Using anticoagulants
■ Antibiotic lock therapy.
■■ Critical Thinking: Case Study
A patient is admitted with uncontrolled diabetes mellitus. She has a saline lock in place in her left wrist area. A symptomatic drop in blood sugar to 38 mg/dl requires she receive 50 mL of 50 percent dextrose infused at 3 mL/
min via the peripheral infusion site. She responds well, but the next day needs another dose of dextrose via the same infusion site for a second drop in BS. At discharge, she complains of burning and pain at the site. The nurse documents that the catheter is intact upon discontinuation of the peripheral catheter, but no assessment data or subjective patient complaints are recorded. The patient is admitted three days later with purulent drainage from the left wrist infusion site, temperature of 101, and pulse rate of 100.
What is the probable cause of the second admission? What are con-tributing factors? What breach of standards of practice occurred? What are the legal ramifications of this case?
Media Link: Answers to the case study and more critical thinking activities are located on the CD–ROM.
Post-Test
1. Which of the following constitute the first line of nonspecific defense mechanisms?
a. Phagocytosis, complement cascade b. Leukocytes, proteins
c. Physical and chemical barriers d. Immune system and phagocytes
2. The complement system consists of 17 different:
a. Glucose molecules b. Proteins
c. Fatty acids
d. Immune responses
3. The most common immunodeficiency disorders are:
a. B-cell immunodeficiencies b. T-cell immunodeficiencies c. Induced by drug therapy
d. Caused by poor nutritional status