Oncology Nursing

Oncology nurse and cancer patients management

Anita Zeneli

THEORETICAL AND PRACTICAL

COURSE IN ONCOLOGY

for Nurses, Medical Doctors and

Pharmaceutical Technicians

9-11 June 2014

Oncology Conference Room

Bugando Medical Center - Mwanza

Learning program

Some nursing considerations in cancer care: what is specific

in cancer patients?

Chemotherapy adverse events management:

Toxicity evaluation: nursing triage

Mielotoxicity (thrombocytopenia, neutropenia, anemia)

Nausea, vomit, diarrhea

Mucositis

Access device s management:

Complications related to access devices: extravasation

Nursing interventions to prevent complications

Supportive care: pain management

Infection prevention measures

Learning questionnaire

Nurses have key roles not only as caregivers but in patient and family education and clinical

cancer research

They are involved in the enhancement of nursing practice

through research, continuing education, and advanced

education.

what is specific in cancer patients?

- Some nursing considerations -

Oncology Nurse: key role in

multidisciplinary team care

Some significant International Nursing

Associations for the Oncology Nurses:

– ONS (Oncology Nursing Society) https://www.ons.org/practice-resources/chemotherapy-administration-safety-standards

– EONS (European Oncology Nursing Society) http://www.cancernurse.eu/about_eons/index.html

They develop Standards and Guidelines for Nurses involved in cancer care

what is specific in cancer patients? - Some nursing considerations -

what is specific in cancer patients? Some nursing considerations: Oncology Nurses Role by ONS

Standards of Care (nursing process) Standards of Professional Performance

I. Assessment: The oncology nurse systematically and continually collects data regarding the health status of the patient.

I. Quality of Care: The oncology nurse systematically evaluates the quality of care and effectiveness of oncology nursing practice.

II. Diagnosis:The oncology nurse analyzes assessment data in determining nursing diagnosis.

II. Performance Appraisal: The oncology nurse evaluates his/her own nursing practice in relation to professional practice standards and relevant statutes and regulations.

III. Outcome Identification:The oncology nurse identifies expected outcomes individualized to the patient

III. Education: The oncology nurse acquires and maintains current knowledge in oncology nursing practice.

IV. Planning: The oncology nurse develops an individualized and holistic plan of care that prescribes interventions to attain expected outcomes.

IV. Collegiality: The oncology nurse contributes to the professional development of peers, colleagues, and others.

V. Ethics: The oncology nurse’s decisions and actions on behalf of clients are determined in an ethical manner.

V. Implementation: The oncology nurses implements the plan of care to achieve the identified expected outcomes for the patient

VI. Collaboration: The oncology nurse collaborates with the client, significant others, and multi-disciplinary cancer care team in providing client care.

VI. Evaluation: The oncology nurse systematically and regularly evaluates the patient’s responses to interventions in order to determine progress toward achievement of expected outcomes

VII. Research: The oncology nurse contributes to the scientific base of nursing practice and the field of oncology through the review and application of research.

VIII. Resource Utilization: The oncology nurse considers factors related to safety, effectiveness, and cost in planning and delivering client care.

What is the common to all nurses of the world ?

The steps in the patient-centered, outcome-oriented nursing process are dynamic and

inter-related. Each of the five steps depends on the accuracy of the preceding steps.

Termination of

nursing care

OR

Revision of plan of

care

Nursing process

the

steps

of

nursing

Process

Are

always

the

same

Nursing process what is specific in cancer patients ?

- Specific Patients Needs – Specific Nursing Assessment tools -

Cancer Patient Needs

Physical needs:

Treatments management

Symptoms control

Treatment toxicity management

Nutrition

Fatigue management

Devices management

To manage the comorbidity

Information needs

To know the treatment and their

implications

To know the adverse event

to comply with treatment

how to copy with disease

Supportive care needs

Psycological

Social

the use of nursing assessment tools provides a good starting point for planning

targeted assistance

Name Surname : ____Pinco Pallino Date of Birth: /01/01/1960/ Tumor site: oropharynx Date: /08/06/2014/

Cognitive status: Allert Verbal Pain Unresponsive

ADL (ACTIVITIES OF DAILY LIVING): Independent Needs help Bedridden

Bowel: physiological Incontinent Constipation Particular conditions:__No__

Feeding: Normal diet Liquid diet

Urine elimination: Physiological Incontinent Bladder catheter Insertion date:__________

Access devices and vein status: Peripheral access device Insertion date: _________________ PICC Last medication date: ______________

Allergies: No Drug name: _______ Hyper­sensitivity reactions ___________

Medical devices presence : No Thoracic drainage Hepatic drainage Ureterocutaneostomy Tracheostomy Nasogastric tube

Comorbidity: No HIV TBC Skin lesions: Yes No Site: ___________________ Other: ________________

Other: _____________________________________________________________________________

Nu

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)

the nursing assessment must be performed at the time of taking charge of the

patient

The vital signs measurments

Nursing

Assessment

at

patient

Admission

is the first

step of

Nursing care

planning

The Edmonton Symptom Assessment Scale (ESAS)

What the ESAS is?

•Assists in assessment of 9 common symptoms experienced by cancer patients: Pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, wellbeing, shortness of breath, and “other problem”

Severity of symptom at time of assessment • 0 –10 numerical scale • “0”= symptom absent • “10”= worse possible symptom severity • ESAS is one part of holistic clinical assessment

A specific and useful instrument for the evaluation of symptoms control

ESAS Benefits

Used internationally Provides clinical profile of symptom severity over time Quick identification of priority concerns

WHY ?

Who may Complete the ESAS?

•patients (self-reported symptoms)

• caregivers • health professionals

BODY DIAGRAM

Cancer patients problems/nursing diagnosis

The oncology nurse must formulate

nursing intervention to manage these problems:

Bone marrow dysfunction

Nutritional Alterations

Pain

Fatigue

Alopecia

Dyspnea

Bowel dysfunctions

Patohological fractures

Ascites

Odors

Not all the cancer patients problems are

nursing diagnosis

That does not mean

The Nurse is not involved in their assessment,

evaluation, recording and management

Patients problems and

oncology nurse’s role

Diagnosis:The oncology nurse analyzes assessment data in determining

nursing diagnosis and collaborative problems

Which kind of Nursing Diagnosis in cancer

patients?

Constipation related opioid use

Fungating cancer wounds*

Fall risk

Urine Incontinence

Educational need for self-manage the stoma

Infection risk related mucositis and

neutropenia

Extravasation risk related drugs infusion

Which kind of collaborative problems?

Dehydration risk vomiting/diarrhea related

Bleeding risk thrombocytopenia related

Febrile neutropenia (risk of septic shock)

Uncontrolled pain

NURSING OUTCOME:

What they mean?

The Nursing Outcomes are changes on patients

health status that depend on how the nurses

work

Outcome Identification and planning:

The oncology nurse identifies expected outcomes individualized to the patient and develops an holistic plan of care

Outcome Identification and planning

Shortlist of Nursing Outcome domains

in cancer patients:

Fall prevention

Skin pressure lesions prevention

Controlled symptoms (pain, nausea, vomiting

ecct)

Extravasation prevention

Blood stream catheter related infection prevention

Diarrhea control

Education and communication

Fatigue

Nutrition

Oral Mucositis

Pain control

Safe medication administration

Septicaemia

Wellbeing and function

The oncology nurses

can make the

difference on the

patient outcomes

Implementation

Which kind of intervention?

Develop

procedures, guidelines

Form the staff

Implement procedures

Promote the procedures adherence of

singles professionals

Monitor adherence

The oncology nurse implements the plan of care to achieve the identified expected

outcomes for the patient

Evaluation

Nurses evaluate the patient’s

responses to interventions in order to

determine progress toward

achievement of expected outcomes

1. Patient reports Pain 7 NRS baseline;

evaluated 30 minutes after

administering the analgesic prescribed

therapy, Pain 3 NRS. (Positive

outcome evaluation).

2. Patient reported three episodes of

vomiting, evaluated after antiemetic

therapy, vomit persists. (Negative

outcome evaluation)

How cancer is treated?

Cancer treatment depends on the type of cancer, the stage, age, health

status and additional personal characteristics.

There is no single treatment for cancer and patients often receive a

combination of therapies

surgery

radiation

chemo therapy

immuno therapy

hormone therapy

gene therapy

recombinant DNA approach

A Cancer patient’s Goal:

Quality of life, not quantity of life, is the ultimate goal for patients living

with cancer

Some Nursing considerations about cancer treatments - Chemotherapy -

The goals of cancer

treatments:

1. Preventive

2. Curative

3. Palliative

4. Adjuvant therapy

Most of drugs currently used in cancer treatment either

damage DNA (or) inhibit DNA replication

Consequently,

these drugs are toxic not only to cancerous cells but allso to

normal cells

Toxicities (antineoplastic agents side effects)

24

1. Bone marrow myelosuppression

Leucopenia, thrombocitopenia and

anemia

Nadir: tipically 7-14 days after

chemotherapy treatment. Caused by all

chemotherapeutic agents expect for the

hormonal, antibody and receptor

inhibitor agents.

2. Mucosa of the gastro-intestinal tract

Nausea, vomiting, diarrhea and

mucositis

3. hair loss

Alopecia

These side effects are generally temporal and reversible

Side effects of chemotherapy

Classification of Chemotherapy Side Effects

Designed to Facilitate Patient Education by ONS and ASCO

HSR

Nausea/vomiting

Phlebitis

Extravasation

Skin rash

Vomiting

Nephrotoxicity

General approach to manage Adverse events

• Staff Information

– Provide detailed information about AEs of medication

• Adherence

– Provide calendar with medical visit and laboratory

monitoring before the administration and dates of

treatment regimen to improve adherence

• Inform patient and caregiver of symptoms

– Nausea, vomiting, mucositis, neutropenia, infection,

bleeding, and peripheral neuropathy

• Reinforce precautions

Remember

Information needs remain high

for cancer patients regardless

of length of time from diagnosis

Information on adverse

effects and diagnosis

are the most important

for cancer patients

General approach to manage Adverse events

Use plain language in all written

patient education

Encourage patient to come to all

APPOINTMENTS planned by the

oncologist for therapy, exams or

follow-up visits.

Chemotherapic agents Adverse events

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METHOTREXAT

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HYDROSSIUREA

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FLUDARABINE X X X X X X

5-FU X X X X X X X X

CISPLATIN X X X X X X

OXALIPLATINO

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CHLORAMBUCIL

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IDARUBICIN X X X X X X

PROCARBAZINE

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EPIRUBICIN X X X X X X

ACTINOMYCIN X X X X X

Patient monitoring and assessment

Why monitor and assess?

To administer the drug safely

To evaluate the disease response to treatment

To evaluate and document treatment-related toxicities

To modify dose or schema, to discontinuate treatment in

case of toxicities life threatening

To evaluate the adherence with the treatment regimen

When and how to do these evaluations ?

Disease response

When? (eg,.. every 3 , 5, 6 cycles of therapy)

How? (eg., laboratory results, or scans/imaging)

Treatment-related toxicities evaluation

When?

Before chemotherapy prescription

During chemotherapy administration

During intercicle follow-up

How?

PS evaluation

Physical examination, psycosocial concerns,……..

Laboratory

Who are Acute Oncology Patients?

Two Patient Groups:

1.Patients with potentially acute complications of their

cancer treatment.

2.Patients potentially suffering from certain

emergencies caused by the disease process itself

whether the primary site is know unknown or

presumed

What kind of acuties caused by the cancer threatments? - Chemotherapy -

The following, as caused by the systemic treatment of cancer: Neutropenic sepsis. Uncontrolled nausea and vomiting. Uncontrolled diarrhoea. Complications associated with venous access devices. Uncontrolled mucositis. Hypomagnesaemia. Extravasation injury. Acute hypersensitivity reactions including anaphylactic

shock.

The following, as caused by radiotherapy:

Acute skin reactions.

Uncontrolled nausea and vomiting.

Uncontrolled diarrhoea.

Uncontrolled mucositis.

Acute radiation pneumonitis.

Acute cerebral/other CNS, oedema.

The following, as caused directly by malignant disease and presenting as an urgent acute problem.

Pleural effusion

Pericardial effusion

Lymphangitis carcinomatosa

Superior vena cava obstruction

Abdominal ascites

Hypercalcaemia

Spinal cord compression including MSCC

Cerebral space occupying lesion(s)

Provide a reliable guide to toxicity/problem grading

Prioritise the level of urgency indicated by the presenting symptoms and will aid in identifying potential emergency situations

Nursing TRIAGE

TO

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com

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Hem

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Remember

Always:

IF YOU

HAVEN’T

DOCUMENT

IT,

YOU

HAVEN’T

ASKED IT!

Record Triage

A triage Schedula should be completed for all evaluated

patients.

The Triage boxes MUST all be marked accordingly.

IF YOU HAVEN’T TICKED IT,YOU HAVEN’T ASKED IT!

38

How the side effects are evaluated?

NCI Common Terminology Criteria for Adverse Events v3.0

How to manage?

• Establish underlying cause: therapy induced bone marrow suppression, bleeding, nutritional, inherited, renal insufficiency,

• Assess Risks for complications and Consider risks/benefits of treatment approach:

• Transfusion (possible risks viral transmission, TRALI, TACO, fatal hemolysis, febrile nonhemolytic reactions)

• Erythropoiesis-stimulating agent (ESA) (possible risks: thrombotic events, potential decreased survival, potential reduced TTP)

– If Hb rises > 1 g/dL in any 2-wk period, dose reductions are required

– Program Mitigation Strategy

Bone marrow suppression

- Anemia - fatigue

Blood safety: crucial steps for hand hygiene action

NOTE: Cancer patients often require transfusion of blood: red blood cells,

platelets, fresh frozen plasma

REMEMBER

Bone marrow suppression

-Thrombocitopenia - bleeding risk

How to manage?

Monitor carefully in patients with platelet count below 20,000/mm3 for

bleeding:

Stool urine, nose, vagina, rectum, mouth and venipuncture sites

Skin should be inspected daily for bruises or petechiae

Avoid invasive maneuvers: rectal tube, catheterization, …..

Use soft toothbrush

Soft foods and stool softeners

Platelet transfusions may be required

Bone marrow suppression

- Neutropenia - infection risk

How to manage?

Monitor the patient for Fever is the

most important sign (38,3)

Administer prescribed antimicrobics

Maintain aseptic technique

Avoid exposure to crowds

Avoid giving fresh fruits and veggie

Handwashing

Avoid frequent invasive procedures

Educate the patient correct behaviors

MANAGE COMPLICATION:

Septic Shock

Monitor VS, BP, Temp

Administer IV antibiotics

Administer supplemental O2

How to evaluate?

Slight( neutrophils count 1000-

1500 per microlitro)

Moderate (neutrophils count 500-

1000 per microlitro)

Severe (neutrophils count lower

than 500 per microlitro)

Mild Symptoms might include:

Feeling generally unwell with or without a

temperature

Temp 38°c and hypotension or slight

tachycardia

Symptoms of infection

Shivering, hot and cold, spontaneous

rigor

Diarrhoea

At the early stage the patient will be

warm and alert and not look unwell

Apyrexial patients may also be at risk

However, they can deteriorate rapidly

and death can follow

Severe Symptoms:

Cold and clammy

Restless, anxious or confused

Hyperthermic , Hypothermic

Hypotensive, tachycardic

Patients at risk: (Both Oral and Intravenous

Chemotherapy and post Radiotherapy)

Post chemotherapy: 7- 21 days is a classic time for

neutropenia following chemotherapy, however delayed

neutropenia can occur with some regimes:

Haematology patients

Immuno-supressed patients

Elderly patients

Heavily pre-treated for chemotherapy

Any indwelling line

Co-morbid conditions e.g. advanced cancer

General poor health

Patients with a history of spinal or pelvic radiotherapy

Neutropenia

- Neutropenic Sepsis - Neutropenic Deaths Risk -

Post Chemotherapy? – Act Fast to Prevent Death

REMEMBER: Symptoms may be vague and often there is no obvious focus of infection !

What to do?

History – Are they on chemotherapy? When did they last have

treatment? How have they been feeling? Are there any specific

symptoms of infection?

Examine- Temperature, pulse, blood pressure and respiration.

Action – Urgent full blood count is required, swabs of potentially

infected sites

Treatment - On a suspected diagnosis of neutropenic sepsis,

urgent intravenous antibiotics must be administered within one

hour of admission time, don’ t wait for the blood count.

Neutropenia

- Neutropenic Sepsis - Neutropenic Deaths Risk -

Post Chemotherapy? – Act Fast to Prevent Death

NOTE : Neutropenic Sepsis is a clinical life-threatining emergency

Nutritional Alterations

Cachexia a state of malnutrition and

protein (muscle) wasting.

In some cases, untreated cachexia is

the cause of death.

Causes of Nutritional Alterations:

Anorexia

Nausea and vomiting

Alterated taste sensation

Dysfagia

Mucosal inflammation

Mucosa of the gastro-intestinal tract NAUSEA-VOMIT-DIARRHEA (dehydration and cachexia risk)

Manifestation by symptoms:

Nausea/vomit – most common, 24 hrs (delayed 48 to72 hrs)

prevention and treatment with antiemetics:

Serotonin blockers – ondasentron, granisetron, dolasetron

Dopaminergic blockers (metoclopramide)

Sedatives

Corticosteroids

Anti-histamines

Diarrhea

Stomatitis and anorexia

AE Monitoring and Management

Nausea and vomiting

Ensure baseline and ongoing renal and hepatic function assays Premedicate for anticipated nausea/vomiting Monitor the daily number of the AEs Encourage adequate hydration

Diarrhea Monitor the daily number of the AEs Adequate hydration Antidiarrheal medications Dietary measures/consult

Oral mucositis typically occurs 7 to 14 days after chemotherapy or radiotherapy and may last for 2-3 weeks after the completion of treatment. It may result in pain, discomfort and difficulty eating.

Mucosa of the gastro-intestinal tract - MUCOSITIS -

Mucositis: is defined as the damage that occurs to the oral mucosa and gastrointestinal tract following chemotherapy or radiotherapy, leaving the tissue exposed to infection.

Stomatitis refers to the diffuse inflammatory, ulcerative condition affecting the mucous membranes lining the mouth.

It is important to take preventative measures against mucositis and to recognise and treat it promptly and effectively if it occurs.

Assessment

Patients presenting with acute oncological

problems, during and immediately after

their treatment, should be assessed for

the presence of oral mucositis.

• Clinical examination of oral mucosa

• Functional status - ability to eat

Mucosa of the gastro-intestinal tract - MUCOSITIS -

Management :

- mouthcare,

- management of oral pain

- consideration of nutritional

support in severe cases.

What nurses can do?

Inform and Advise patient about: 1. Mucositis as possible adverse event of chemotherapy

2. Mouth hygiene with a soft toothbrush after each meal, and at

bedtime. 3. Rinse the mouth after each meal and at bed- time using

bicarbonate solution 4. Adequate oral fluid and nutrition intake

5. Avoid alcohol , tobaco, spicy or crunchy foods 6. Assess pain level and administer antalgic drugs if prescribed

before meals

The information should be given to all patients before starting the relevant cancer

treatment

Mucosa of the gastro-intestinal tract - MUCOSITIS -

Drug induced Nephrotoxicity

How to recognise it

Hypertension

Fluid imbalance (positive);

Urine out put dicrease;

Weight increase;

Oedema

Lab test: BUN,Cr

How to manage it

Diuretic administration

Adequate hydration

Vital signs monitoring (BP, Weight, diuresis, fluid balance..etc)

How to prevent it

Adequate hydration associated to the nephrotoxic drug administration

Extravasation - What it is?

In a general sense, extravasation refers to the process by which

one substance (e.g., fluid, drug) leaks into the surrounding

tissue.

In terms of cancer therapy, extravasation is defined as the

accidental leakage from its intended compartment (the vein)

into the surrounding tissue.

Depending on the substance that extravasates into the tissue, the

degree of injury can range from a very mild skin reaction to severe

necrosis

Depending on their pH and the oncotic pressure (compared with that of the plasma), the solutions are classified into:

-HYPOTONIC; - ISOTONIC;

-HYPERTONIC Hypotonic and hypertonic solutions may harm blood cells and

intimate vein

Different solutions

What kind of harms? - Some definitions -

• Infiltration: Inadvertent administration of a non-vesicant solution or medication into surrounding tissue

• Phlebitis: Inflammation of a vein; may be accompanied by pain, erythema, edema, streak formation, palpable cord

• Extravasation: Inadvertent infiltration of vesicant solution or medication into surrounding tissue

Hypotonic and hypertonic solutions may harm cells

what nurses have to do?

So these solutions may cause phlebitis

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Antineoplastic agents classification

Non-vesicants (do not cause ulceration or inflammation)

Irritants (do tend to cause pain at, and around the injection

site, and along the vein, tissues inflammation)

Vesicants are drugs that have the potential to cause tissue

destruction and necrosis

Antiblastics drug classification

IRRITANTS

1 Any agent extravasated in high enough concentration may be an irritant.

2 There have been few reports of these agents acting as irritants, but there is no clear evidence

What are the implications of extravasation?

Extravasation should be avoided because:

Physical consequences (pain and discomfort)

Other consequences

• longer hospital stay,

• hightreatment costs;

• psychological consequences (e.g., distress,

anxiety).

How to recognise?

Patient reporting

Visual assessment

Checking the infusion line

Signs and symptoms:

Discomfort or pain,

Erythema,

Oedema

Discolouration

Slowing of the infusion rate

Lack of blood return from

cannula

of the skin near the site near the

injection site.

How to prevent?

Adequate IV site selection

Know your medications

(neutral, irritant, vesicant)

Secure your IV device

Inform the patient to report

immediately signs and

symptoms

Blood return on before

flushing

The IV site must be visible

at all times during administration

Check IV site at least hourly or

more often if there is any

concern during an infusion

Extravasation – the inadvertent infiltration of

vesicant/irritant solution or medication into surrounding

tissue.

Patient reporting

Visual assessment

Checking the infusion line

How is extravasation recognised?

How to recognise? - Patient reporting -

Patient-reported symptoms for assessing

extravasation relate to the sensation around the site

of injection

Typically these complaints include:

Pain

Swelling

Redness

Discomfort

Burning

Stinging

Other acute changes at the site of extravasation

Visual assessment

Early symptoms: - Swelling/oedema

- Redness/erythema

Later symptoms: - Inflammation

- Induration

- Blistering

Careful monitoring of the site should continue during the infusion time and for some time following an infusion

Signs related to the cannula - Checking the infusion line -

Signs of extravasation, in relation to the cannula, include:

Increased resistance when administering IV drugs

Change in infusion flow (Slow/sluggish)

Lack or loss of blood return from the cannula

Look for blood return (flashback) upon insertion of the

needle!

THE EXTRAVASATION SHOULD BE AVOIDED

HOW?

Adequate IV site selection

Know your medications (neutral, irritant, vesicant)

Secure your IV device

Inform the patient to report immediately signs and

symptoms

Blood return on before flushing

The IV site must be visible at all times during

administration

Check IV site at least hourly or more often if there is

any concern during an infusion

Extravasation

- Prevention -

PREVENT – PREVENT – PREVENT – PREVENT

Equipment selection

Important considerations include:

- The size and type of cannula or catheter,

- The size and type of vein (whether to use a

subcutaneous device or a central line).

As a rule, it is advisable to use the smallest gauge

cannula in the largest vein possible

Equipment selection

Specific recommendations include:

Use of a small bore plastic cannula (1.2–1.5 cm long)

For peripheral access, short, flexible polyethylene or

Teflon

Use a clear dressing to secure the cannula – to allow

for constant inspection

Secure the infusion line, but never cover the line

with a bandage (the insertion point must always be

visible)

Whenever possible, always give vesicant drugs into a

recently inserted cannula

Vein selection in peripheral administration

Try to use the forearm, not the back of the hand

Avoid:

small and fragile veins, next to joints, tendons, nerves or arteries , the antecubital fossa, and limbs with lymphoedema or with neurological weakness, insertion site below a previous venepuncture site

If a first attempt to insert a cannula failed, the second insertion should be made above (closer to the heart) the original site if possible.

Extravasation Management – initial steps

No matter what the nature of the drug, if extravasation is suspected the initial response remains the same.

1. The most important thing initially is to limit the amount of drug extravasating into the surrounding tissue, the first course of action is to STOP the infusion,

2. Aspirate as much of the infusate as possible,

3. Mark the site and then

4. Remove the cannula (while continuing to aspirate from the extravasation site).

5. Call the doctor

6. Elevate the affected limb

7. Administer analgesia if required.

7. Depending on the drug being infused, the correct protocol should be followed to determine the next steps.

8. Decide the appropriate treatment: if vesicant drug apply warm compresses; if irritant cold compresses

9. Complete required documentation.

10. Arrange follow-up for the patient

Drug Hyper - sensitivity reaction:

What Nurses Need to Know ?

What is a hypersensitivity reaction (HSR)?

HSR is an exaggerated immune response to an antigen which results in local

tissue injury and may include life-threatening systemic effects.

HSRs are more likely to occur with intravenous administration.

The HSR is a life-threatening emergency

How to recognise? signs and symptoms

fever bronchospasm hemolysis

rash, hives, pruritis dyspnea, feelings of impending doom

vomiting back pain chills

nausea angioedema rigors

flushing circulatory collapse diaphoresis (sweating)

Why the HSRs may occur during antiblastic drug administration?

1. Complex, protein-based molecules are more likely to elicit the

immune-mediated response of an acute HSR, which accounts for the

increased incidence of acute HSRs with infusions of biological agents

such as monoclonal antibodies. These agents are often administered in

ambulatory settings to patients with cancers (eg. Rituximab).

2. The smaller molecules, bind to circulating serum proteins, resulting in

increased size and antigenic potential in susceptible individuals. Some

diluents used in medication admixture contribute to the risk for HSR.

Cremophor, for example, is a diluent for paclitaxel, cyclosporin, and

tenoposide.

Drug Hyper - sensitivity reaction:

What Nurses Need to Know ?

Drug Hyper - sensitivity reaction:

What Nurses Need to Know ?

How to manage?

Stop, Call, Assess, Prepare !!!

If you suspect your patient is experiencing early symptoms of an acute HSR,

don’t hesitate to implement your emergency interventions:

1. STOP the infusion but maintain IV access.

2. CALL the doctor.

3. ASSESS your patient further: collect vital signs, use a pulse oximeter to obtain

oxygen saturation, listen to breath sounds, and check for symptom progression.

4. PREPARE for emergency treatment, including the potential need to administer IV

fluids, oxygen, and resuscitative medications.

How to prevent ?

1. Assess and document the patient related risk factors1.

2. Premedicate with antihistamines and corticosteroids before the high-risk

drug administration

3. Begin slowly and then gradually increase the dose every 15 to 30 minutes to

induce tolerance.

4. Monitor closely the patient during the drug administration

What is specific in cancer patients?

Palliative care

“The goal of palliative care is:

to prevent and relieve suffering and to support the best possible

quality of life for patients and their families, regardless of the stage of

the disease or the need for other therapies”

Cancer Pain Management

"an unpleasant sensory and emotional experience in association with actual or potential tissue damage, or described in terms of such damage."

Cancer Pain can be caused by:

• the disease itself or

• by treatments

WHO scale for Analgesic therapy

Major opioid (Morphine, Phentanil)

+/- non opioid +/- Adjuvants

Minor opioid (codeina)

+/- non opiods +/- Adjuvants

Non oppioyd therapy

+/- Adjuvants , FANS, Corticosteroid

Pain can be acute or chronic:

• Acute pain usually starts suddenly, may be sharp, and often triggers visible bodily reactions such as sweating, an elevated blood pressure, and more.

• Chronic pain lasts, and pain is considered chronic when it lasts beyond the normal time expected for an injury to heal or an illness to resolve. Chronic pain, sometimes called persistent pain, can be very stressful for both the

body and the soul, and requires careful, ongoing attention to be appropriately treated.

Cancer Pain Management

Remember, CANCER PAIN CAN BE MANAGED. No one should have to suffer from

unrelieved pain.

What nurses can do

• Assess cancer pain: site/location, time (when), duration (how long),

intensity (NRS Scale), description, What makes the pain worse?

What eases the pain?

• Assess, document, and administer prescribed Analgesic

Medications

• Inform the patient about the Side effects of pain medications and

about correct assumption.

THE PAIN SHOULD BE CONSIDERED AS VITAL SIGN

what is specific in cancer patients? Some nursing considerations ……. frailty

the term “frailty” is defined as

characterizing

“the group of patients that presents the most complex and challenging problems

to the physician and all health care professionals,” because these are The

individuals who have a higher susceptibility to adverse outcomes, such

as … mortality

CANCER

PATIENTS

ARE

FRAIL

Frail - Why ?

Due to:

Polypharmacy,

Immunosuppression,

Malnutrition,

Multiple co-morbidities with signs of

impairments in day to day

functioning;

Deteriorating functional score eg

ECOG/ Karnofsky

Combination of at least 3 symptoms

of: weakness, weight loss, self

reported exhaustion

Cancer illness trajectory

Depression, psychological

distress,

Mobility impairment (the

presence of severe neuropathy,

bone metastases)

Social- economic context

Cancer patients are frail and immunocompromised

Due to the cancer disease nature and to the

toxic effects of cancer treatments

from this patients specificity it follows that the infection prevention is a priority in the care of these patients

Asymptomatic or sub-clinical infection is an infectious process

running a course similar to that of clinical disease but below the

threshold of clinical symptoms.

Symptomatic or clinical infection is one resulting in clinical

signs and symptoms (disease).

Infection

The entry and multiplication of an infectious

agent in the tissues of the host.

Infection Transmission involves:

• presence of an infectious agent (e.g. bacterium, virus,

fungus) on equipment, objects and surfaces in the health

care environment

• a means for the infectious agent to transfer from

patient-to-patient, patient-to-staff, staff-to-patient or staff-

to-staff

• presence of susceptible patients , staff and visitors.

Agent

Reservoir

Portal of exit

Modes of Trasmission

Portal of entry

Susceptible host

A model used to understand the infection process

Routine Practices and

Additional Precautions

In All Health Care Settings

Provincial Infectious Diseases Advisory

Committee (PIDAC)

Factors affecting risk of transmission of microorganisms in a healthcare setting

Microorganism/Infectious Agent related factors:

Presence of a large amount of the infectious agent

Low infective dose required for infection (i.e., high infectivity)

High pathogenicity/virulence

Airborne-spread

Able to survive in the environment

Able to colonize invasive devices

Able to exist in an asymptomatic/carrier state

INFECTIOUS AGENT:

A microorganism, i.e., a

bacterium, fungus, parasite, virus

or prion, which is capable of

invading body tissues and

multiplying

Factors affecting risk of transmission of microorganisms in a health care setting

RESERVOIR:

An animate or inanimate source where

microorganisms can survive and multiply (e.g.,

water, food, SURFACES, EQUIPMENTS,

DEVICES, PEOPLE).

Environment related factors:

Inadequate cleaning

Shared care equipment without cleaning between patients

Crowded facilities

Shared facilities, such as multi-bed rooms (e.g., toilets, sinks, baths)

High patient-nurse ratio

PORTAL OF ENTRY:

The anatomic site at which microorganisms get into

the body, i.e., mucous membranes of nose, mouth and

broken skin, access devices, mucositis, urine catheter

Factors affecting risk of transmission of microorganisms in a health care setting

SUSCEPTIBLE HOST:

An individual who is at risk for infection.

Susceptible Host related factors:

Patient in intensive care unit or requiring extensive hands-on care

Patient has invasive procedures or devices

Non-intact skin ( patient or staff)

Debilitated, severe underlying disease

Extremes of age

Recent antibiotic therapy

Immunosuppression

Lack of appropriate immunization

Inadequately educated, trained or non-compliant staff

Factors affecting risk of transmission of microorganisms in a health care setting

RESERVOIR:

An animate or inanimate source where

microorganisms can survive and multiply (e.g.,

water, food, SURFACES, EQUIPMENTS, DEVICES,

PEOPLE).

PORTAL OF EXIT:

The anatomic site at which microorganisms leave

the body, ( i.e., secretions and excretions that exit

the respiratory tract, GI tract or broken skin).

Source Patient related factors:

Incontinent of stool and stool not contained by incontinence products

Draining skin lesions or wounds not contained by dressings

Copious uncontrolled respiratory secretions

Inability to comply with hygienic practices and IPAC precautions

Patient in intensive care unit or requiring extensive hands-on care

HOW the transmission may be interrupted ?

1. The AGENT is eliminated or inacivated or cannot exit

the RESERVOIR (ANTIMICROBIC USE, CLEANING, SANITIZATION)

2. PORTAL OF ENTRY/EXIT are protected/contained through “SAFE

PRACTICES”

3. TRANSMISSION between objects or people does not occur due to

barriers and/or safe practices ( HAND CLEANING, PROTECTIVE

EQUIPMENTS, DISINFECTION,…..)

4. HOSTS are not suscetible (IMMUNIZATION)

The responsibility to prevent the infection risk is to all health care professionals

Staff training

Procedures

Patients/caregivers education

Audit

HOW ?

Routine Practices and

Additional Precautions

In All Health Care Settings

Provincial Infectious Diseases

Advisory Committee (PIDAC)

THE INFECTION TRANSMISSION MODES

Mode of Transmission: The method by which

infectious agents spread from one person to another

Routine Practices and

Additional Precautions

In All Health Care Settings

Provincial Infectious Diseases

Advisory Committee (PIDAC)

What can we do to avoid infection trasmissione?

All we have to comply with correct behaviours:

medical devices, equipments, surfaces, people

Environment related factors:

Inadequate surfaces cleaning

Shared care equipment without cleaning between

patients

ENVIRONMENTAL CLEANING

WHY?

Because :

it reduces the number and

amount of infectious agents that

may be present

eliminate routes of transfer of

microorganisms from one

person/object to another

reducing the risk of infection.

Provision of a ‘Hospital Clean’ care environment is important for both

patient safety and staff safety.

THREE TYPES OF AREAS

HOTEL

+

HEALTH CARE

+

PATIENT ZONE

Environment related factors: Inadequate cleaning

ENVIRONMENT: HOSPITAL CARE SETTING AREAS

Maintaining a clean and safe health care environment

HOSPITAL ENVIRONMENT AREAS

HOTEL AREAS:

THESE AREAS ARE NOT INVOLVED IN THE PATIENT CARE:

HOSPITAL/ HEALTHCARE AREA

ALL THE AREAS ARE INVOLVED IN PATIENT CARE outside the

immediate environment of the patient:

THE PATIENT ZONE

IS DEFINED AS

THE PATIENT’S INTACT SKIN AND HIS/HER IMMEDIATE

SURROUNDINGS COLONIZED BY THE PATIENT FLORA

eg of critical sites with infectious risk for the patient and critical

sites with body fluid exposure risk (for staff and environment

contamination )

1. intact skin and his/her immediate

surroundings colonized by the patient

flora

2. All other surfaces in the room

3. ALL OTHER SURFACES OUT OF THE HEALTH-CARE AREA

= HOTEL AREA

HAND HYGIENE is considered the most important and effective measure to prevent the spread of health care-associated infections

Patient room

corridor

WHAT ARE THE DIFFERENCES BETWEEN THE AREAS/SURFACES ?

These THREE TYPES OF areas differ for:

amount of microorganisms which may

be present

infections transmission probability

cleaning procedures required

cleaning products required

cleaning frequency required

Areas to receive Areas to receive

‘Hotel Clean’ ‘Hospital Clean’

regimen regimen

Areas where care is Areas where care

not provided is provided

Type of Cleaning Regimen to Apply Based on Population Served

The key to effective cleaning and disinfection of environmental surfaces is the use of

friction (‘elbow grease’) to remove microorganisms and debris. Surfaces must be

cleaned of visible soil before being disinfected, as organic material may inactivate a

disinfectant.

Let’s try to reason together about

the different types of areas and

surfaces !

WHY?

HEALTHCARE AREA: high touch surfaces

PATIENT ROOM

high-touch (i.e., frequently touched) surfaces in the immediate vicinity of a patient

may be a reservoir for pathogens and that these pathogens are transmitted

directly or indirectly by the hands of health care workers.

NURSING STATION

HEALTHCARE AREA: high touch surfaces

HEALTHCARE AREA: high touch surfaces

PATIENT BATTHROOM

EQUIPMENTS

INFECTION VEHICLES

HANDS,

SURFACES,

WATER,

ALIMENTS,

LINEN,

CLOTHES,

MEDICAL EQUIPMENTS

WHAT WE CAN DO TO REDUCE THE INFECTION TRANSMISSION POSSIBILITY ?

SOME KEY PROCEDURES FOR INFECTION PREVENTION

ALL NURSES MUST KNOW AND APPLY

HAND CLEANING

ENVIRONMENT SURFACES CLEANING AND

SANITIZATION

REUSABLE EQUIPMENT CLEANING AND SANITIZATION

PROTECTIVE EQUIPMENTS

LINEN AND WASTE

SHARP INJURY PREVENTION

ROUTINE PRACTICES

ADDITIONAL PRECAUTION PRACTICES

INVASIVE DEVICES MANAGEMENT

ELEMENTS OF ROUTINE PRACTICES :

Risk Assessment + Hand Hygiene + Personal Protective

Equipment

+

Control of the Environment (Placement, Cleaning, Controls)

+

Administrative Controls

(Policies and Procedures, Staff Education, Healthy Workplace Policies, Respiratory

Etiquette, Monitoring of Compliance with Feedback)

The consistent and appropriate use of Routine Practices by all health care

providers with all patient encounters will lessen microbial transmission in the

health care setting and reduce the need for Additional Precautions.

Health care providers must assess the risk of exposure to blood, body fluids and non-

intact skin and identify the strategies that will decrease exposure risk and prevent the

transmission of microorganisms.

Routine Practices and

Additional Precautions

In All Health Care Settings

Provincial Infectious Diseases Advisory

Committee (PIDAC)

ROUTINE PRACTICES - goals

Infe

ctio

n P

reve

nti

on

Me

asu

res

ADDITIONAL PRECAUTIONS are used in addition to Routine Practices for clients/patients/residents known or suspected to be infected or colonized with certain microorganisms to interrupt transmission.

Routine Practices and

Additional Precautions

In All Health Care Settings

Provincial Infectious Diseases Advisory

Committee (PIDAC)

Routine Practices

+ Specialized Accommodation and Signage

+ Personal Protective Equipment

+ Dedicated Equipment and Additional Cleaning Measures

+ Limited Transport

+ Communication

Elements of Additional Precautions:

INFECTION VEHICLES

HANDS,

SURFACES,

WATTER,

ALIMENTS,

LINEN,

CLOTHES,

MEDICAL EQUIPMENTS

WHAT WE CAN DO TO REDUCE THE INFECTION TRANSMISSION POSSIBILITY ?

INFECTION VEHICLES: SURFACES, HANDS, WATTER, ALIMENTS, LINEN,

CLOTHES, MEDICAL EQUIPMENTS

HAND CLEANING

1. Organisms present on patient skin or the immediate environment

2. Organism transfer from patient to HCWs’ hands

3. Organism survive and multiply on HCWs’ hands

4. The HCW is now going to have direct contact with patient B without cleansing his

hands in between. Cross-transmission of microorganisms from patient A to patient

B through the HCW’s hands is likely to occur.

Clean your hands! Why?

The patient zone, health-care area, and critical sites with inserted time-space

representation of “My five moments for hand hygiene”

When?

Clean your

hands!

WHO Guidelines 2009

on Hand Hygiene in Health

Care

Gloves must be worn according to STANDARD and CONTACT PRECAUTIONS

Correct gloves uses

Hand hygiene should be performed when

appropriate regardless

indications for glove use.

Sterile gloves:

Surgical procedures,

IV Drug preparation

Clean not steril gloves:

Direct or indirect exposure to biologic material, additional precautions

Gloves not indicated

All the other situations

INFECTION VEHICLES

HANDS,

SURFACES,

WATTER,

ALIMENTS,

LINEN,

CLOTHES,

MEDICAL EQUIPMENTS

WHAT WE CAN DO TO REDUCE THE INFECTION TRANSMISSION POSSIBILITY ?

Hospital Environment

- SURFACES -

should be sanitized

to make them sanitary or hygenic for people

Sanitization: Destruction of most microorganisms (whether or not pathogenic) on

wounds, clothing, or hard surfaces, through the use of chemicals or heat.

SANITATION DEFINED

The process of making a surface

sanitary and safe by

Cleaning

Disinfection

Sterilization

Cleaning: Process of removing soil (food residue, microbes, etc.)

Sanitizing: Process that destroys microorganisms after cleaning

To reduce the number of pathogens on a surface

Medical Equipment/Devices Classification and Required Level of Processing/Reprocessing

Classification Definition Level of processing /reprocessing

Examples

Critical equipment/ device

Equipment/device that enters sterile tissues, including vascular system

Cleaning followed by sterilization

Surgical instruments, Biopsy instruments

Semicritical equipment/ device

Equipment/device that comes in contact with non-intact skin or mucous membranes but does not penetrate them

Cleaning followed by High-level disinfection (as minimum

Respiratory equipment, Anaesthesia equipment

Non critical equipment/ device

Equipment/device that touches only intact skin and not mucous memebranes , or does not directly touch the patient

Cleaning followed by low-level disinfection (in some cases cleaning alone is acceptable

Oximeters ECG machines

Unless the item to be sanitized is effectively cleaned, it is impossible to obtain

close contact between the sanitizer and the surface to the sanitized.

Why the cleaning is needed before?

Because some chemical sanitizers, such as chlorine and iodine, react with organic

matter and so will be less effective when the surface is not properly cleaned

Definitions for Sanitizing Terms

WHAT IT MEANS?

the removal of foreign material (e.g., dust, soil, organic material such as blood,

secretions, excretions and microorganisms) from a surface or object.

WHY?

Cleaning physically removes rather than kills microorganisms, reducing the organism

load on a surface.

HOW?

It is accomplished with water, detergents and mechanical action.

The KEY to cleaning is the use of FRICTION TO REMOVE microorganisms and

DEBRIS

CLEANING

THOROUGH CLEANING IS REQUIRED FOR ANY EQUIPMENT/DEVICE TO BE

DISINFECTED/STERILIZED,

AS ORGANIC MATERIAL MAY INACTIVATE A DISINFECTANT.

WHAT THEY MEAN?

DISINFECTION is a process used on inanimate objects and surfaces to kill

microorganisms. Disinfection will kill most disease-causing microorganisms but

may not kill all bacterial spores.

STERILIZATION used on inanimate objects and surfaces to kill all forms of

microbial life

ASEPSIS: Antisepsis reduces microorganisms on the skin or mucous membranes – Living Tissue .

Practices used to promote or induce infection prevention by protecting the sterile part of

human body from all biological contaminants. The goal of asepsis is elimination of

infection not the sterility (it is no possible on the human body because there is no

current method to safely eliminate all of the patients' contaminants without causing

significant tissue damage)

DISINFECTION - STERILIZATION - ASEPSIS

Detergents remove organic material and suspend grease or oil.

Equipment and surfaces in the health care setting must be

cleaned with approved hospital-grade cleaners and disinfectants.

Equipment cleaning/disinfection should be done as soon as

possible after items have been used.

Detergents and Cleaning Agents

Most disinfectants lose their effectiveness rapidly in the presence of organic

matter.

A hospital-grade disinfectant may be used for equipment that only touches intact

skin. Examples include intravenous pumps and poles, hydraulic lifts, blood

pressure cuffs, apnoea monitors and sensor pads, electrocardiogram (ECG)

machine/cables and crutches.

It is important that the disinfectant be used according to the manufacturer’s

instructions for dilution and contact time.

When using a disinfectant:

1. Assemble materials required for dealing with the spill prior to putting on

PPE.

2. Inspect the area around the spill thoroughly for splatters or splashes.

3. Restrict the activity around the spill until the area has been cleaned and

disinfected and is completely dry.

4. Put on gloves; if there is a possibility of splashing, wear a gown and facial

protection (mask and eye protection or face shield).

5. Confine and contain the spill; wipe up any blood or body fluid spills

immediately using either disposable towels or a product designed for this

purpose. Dispose of materials by placing them into regular waste receptacle,

unless the soiled materials are so wet that blood can be squeezed out of

them, in which case they must be segregated into the biomedical waste

container (i.e., yellow bag).

6. Disinfect the entire spill area with a hospital-grade disinfectant and allow it to

stand for the amount of time recommended by the manufacturer.

7. Wipe up the area again using disposable towels and discard into regular

waste.

8. Care must be taken to avoid splashing or generating aerosols during the

clean up.

9. Remove gloves and perform hand hygiene.

Sample Procedure for Cleaning a Biological Spill

Reprocessing Decision Chart

Cleaning Physical removal of soil, dust or foreign material. Chemical, thermal or mechanical aids may be used. Cleaning usually involves soap and water, detergents or enzymatic cleaners. Thorough cleaning is required before disinfection or sterilization may take place.

• All reusable equipment/devices

• Oxygen tanks and cylinders

All reusable equipment/devices

•**concentration and contact time are dependant on manufacturer’s instructions Quaternary ammonium compounds (QUATs) Enzymatic cleaners Soap and water Detergents 0.5% Enhanced action formulation hydrogen peroxide

Reprocessing Decision Chart

Low-Level Disinfection Level of disinfection required when processing noncritical equipment/devices or some environmental surfaces. Low-level disinfectants kill most vegetative bacteria and some fungi as well as enveloped (lipid) viruses. Low-level disinfectants do not kill mycobacteria or bacterial spores.

Environmental surfaces touched by staff during procedures involving parenteral or mucous membrane contact (e.g. dental lamps, dialysis machines) Bedpans, urinals, commodes Stethoscopes Blood pressure cuffs Oximeters Glucose meters Electronic thermometers Hydrotherapy tanks Client/patient/resident lift slings ECG machines/leads/cups etc. Sonography (ultrasound) equipment/probes that only contact intact skin Environmental surfaces (e.g. IV poles, wheelchairs, beds, call bells) Fingernail care equipment that is single-client/patient/resident use

Noncritical equipment/devices

** concentration and contact time are dependant on manufacturer’s instructions

3% Hydrogen peroxide (30 minutes) 60-95% Alcohol (10 minutes) Sodium hypochlorite (bleach) (1000 ppm) 0.5% Enhanced action formulation hydrogen peroxide (5 minutes) Quaternary ammonium compounds (QUATs) (10 minutes) Iodophors Phenolics ** (should not be used in nurseries)

Reprocessing Decision Chart

Flexible endoscopes that do not enter sterile cavities or tissues

Laryngoscopes Bronchosopes, cystoscopes

(sterilization is preferred) Nebulizer cups Endotrachial tubes Specula (nasal, anal, vaginal –

disposable equipment is strongly recommended)

Sonography (ultrasound) equipment/probes that come into contact with mucous membranes or non-intact skin (e.g. transrectal probes)

Cervical caps Glass thermometers CPR face masks

Semicritical equipment/devices

concentration and contact time are dependant on manufacturer’s instructions : ≥ 2% Glutaraldehyde (20 minutes at 20°C) ≥ 6% Hydrogen peroxide (30 minutes) 0.55% Ortho-phthalaldehyde (OPA) (10 minutes at 20°C) Pasteurization (30 minutes at 71°C) 2% Enhanced action formulation hydrogen peroxide (8 minutes at 20°C)

High-Level Disinfection The level of disinfection required when processing semicritical equipment/devices. High-level disinfection processes destroy vegetative bacteria, mycobacteria, fungi and enveloped (lipid) and non-enveloped (non-lipid) viruses, but not necessarily bacterial spores.

Reprocessing Decision Chart

Sterilization The level of reprocessing required when processing critical equipment/devices. Sterilization results in the destruction of all forms of microbial life including bacteria, viruses, spores and fungi.

Surgical instruments : Implantable equipment/devices Endoscopes that enter sterile cavities and spaces Bronchosopes , cystoscopes (sterilization preferred) Biopsy forceps, brushes and biopsy equipment associated with endoscopy (disposable equipment is strongly recommended) Colposcopy equipment Electrocautery tips Endocervical curettes Transfer forceps

Critical equipment/devices

**concentration and contact time are dependant on manufacturer’s instructions : Steam autoclave 100% Ethylene oxide Dry heat Hydrogen peroxide gas plasma (75 minutes at 50°C) Vapourized hydrogen peroxide (55 minutes) Ozone (4 hours) Hydrogen peroxide/ozone combination ≥2% Glutaraldehyde (10 hours at 20°C) 0.2% Peracetic acid (12 minutes at 50-56 C) 6-25% hydrogen peroxide liquid (6 hours) 2% Enhanced action formulation hydrogen peroxide (6 hours at 20 C) 7% Enhanced action formulation hydrogen peroxide (20 minutes at 20°C)

Access Device: Parts of the IV Set

Possible contamination ways of infusion lines

Drip defects

INTRINSEC CONTAMINATION (DURING FABRIQUE)

CONTAMINATION OF DRUG SOLUTION 1) DURING PREPARETION PHASE;

2) DURING INFUSION SET CONNECTION

CONNECTION POINT CONTAMINATION

VeIn

Fibrina

air (Filter absence or malfunction)

CONTAMINATED DISINFECTANTS

DIRTY HANDS OF HEALTH CARE PROFESIONALS

AUTOINFECTION ( BS CATHETER COLONIZATION FROM PATIENT SKIN)

During management of infusion lines we have to comply with (ANTT)

• Aseptic Non-Touch Technique (ANTT) aims to prevent micro-organisms on hands, surfaces or equipment from being introduced to a susceptible site such as a surgical wound, catheter or central venous line.

3. Prepare the sterile field

1. Clean your hands

2. Choose Gloves Sterile/or not

4. Perform Non-Touch Technique

5. Clean your hands

Components of an asseptic procedure

“Not key” elements: If you touch them the asepsi is not

compromised

Examples of “not key” elements of the infusional line:

The external part of the infusion set, the cover of the

cannula, the covers of infusion line extremities end so on

The main rule

“The key elements shouldn’t be in contact with other not key elements, but they can be touched by other key elements “

Key elements: if touched the asepsy is compromised

Examples: cannula, IV drug, the entry of infusion, discovered point connection of siringe

“Key” element

“Not Key” element

Thank you for the attention!