This presentation is part of the theoretical and practical training course for oncology nurses of Bugando Medical Centre (Tanzania) that our institute organized in collaboration with Dr Nestory Masalu, Prof Dino Amadori, Dr Patrizia Serra, Dr Carla Masini, Dr Marina Bragagni and Dr Ivana Barlati. It was for all of us an amazing experience sharing with Tanzanian Colleagues these information.

1. 1
Principles of ICH-GCP and Ethical Aspects
Oncology nurse: caring patients living with cancer
Day 1° -June 9th 2014
Bugando Medical Center - Mwanza
Dr.ssa Anita Zeneli
Nursing and Technical Directory IRST - Italy

2. Learning program
 Some nursing considerations in cancer care: what is specific
in patients suffering from cancer?
 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

3. 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 patients living with cancer?
- Some nursing considerations -
Oncology Nurse: key role in
multidisciplinary team care

4. 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
 UKONS (United Kingdom Oncology Nursing Society)
http://www.ukons.org/
They develop Standards and Guidelines for Nurses
involved in cancer care
what is specific in patients living with cancer?
- Some nursing considerations -

5. what is specific in cancer care?
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.

6. 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

7. Note please how similar we are

9. Nursing process: what is specific in cancer care ?
- 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

10. Cancer treatment access process
Outpatient Setting
Inpatient setting
Oncology Ward
Clinic
Day
Unit
In choosing the right assessment tool nurses should consider the care setting and the
time at nurses disposal for the assessments
Nursing assessment's goal is the same: To know
the patient’s health status in order to establish
care priorities, objectives and interventions

11. Day Unit process map
Please note the patient assessment moments during treatment process

12. Assessment tool: outpatient regimen
What the Triage Interview is?
Triage interview consists of a systematically and continually
data collecting aimed to assess patients’ health status.
Nursing assessment is done before chemotherapy
prescription in order to screen patients that need a medical
evaluation to modify dose or schema, to discontinuate
treatment in case of life threatening toxicities.

13. How to make the Triage interview?
Initial Toxicity Assessment.
 It is important to ask always about the occurrence of all common
chemotherapy toxicities
 In addition to the initial complaint, as several toxicities occurring together
needs closer management. During the assessment a standard tool should
be used.
 The assessment should include as standard the following questions:
 The chemotherapy drugs : name and last date of chemotherapy (IV
infusions or oral)
 Ask the general condition and ability to carry out normal function at
home, has this changed recently?
Cont….

14. Does the patient have any of the following situations?
 Fever: - if yes, inform the doctor immediately and initiate the neutropenic sepsis
protocol
 Chest pain: if yes admit urgently to hospital, patient will need cardiology unit ( with
on – site cardiology).
 Nausea Vomiting, Diarrhoea, Sore mouth, Breathlessness, Rash, Bleeding or
bruising, Neurosensory/motor loss Sore/red hands and feet, Signs of dehydration
e.g., decreased urine output, fever, thirst, dry mucous membranes, weakness,
dizziness, confusion.
 Perform a rapid initial assessment of the situation
 Is this an emergency ? Activate immediately with the doctor!
 Ask questions in a logical sequence. Follow the log sheet and the assessment tool.
 Speak to the patient directly whenever possible
 Provide information slowly and thoughtfully assessing the patients comprehension,
anxiety and distress throughout the process
 Adopt a calm and sensitive approach.

15. Step 1.
Explain that you have a number of
questions to ask and information that
you will need to collect to make sure
that you give the correct advice.
Step 2.
Move methodically step by step down the
triage assessment tool.
For each single toxicity evaluation e.g. do you
have any nausea?
If NO, tick grade 0 and move on,
If YES, use the questions provided to help you
grade the problem and determine the
patient level of risk.
Prioritise the level of urgency indicated by the
presenting symptoms and identify
potential emergency situations.
Remember always that chemotherapy
toxicities are reversible, but need
aggressive management. Patient rapid
deterioration is possible.

16. Name Surname : _______________ Date of Birth:__/___/______/
Tumor site: _____________ Setting: ________________________
Treatment Schema: ____________________________ Admission Date: __/___/______/
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
 PEG
NPT
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: _______
 Hyper-sensitivity
reactions ___________
Medical devices presence :
 No
 Thoracic drainage
 Hepatic drainage
 Ureterocutaneostomy
 Tracheostomy
 Nasogastric tube
Comorbidity:
 No
 HIV
 TBC
Skin lesions:  Yes  No
Site: _______________
 Other: _______________
Note: _________________________________________________________
INPATIENT: the nursing assessment must be performed at the time of taking
charge of the patient
Nursing
Assessment
is the first
step of
Nursing
care
planning
INPATIENT

17. Assessment: The vital signs measurments
In all care settings
Objective data should be collected in order to evaluate changes on patients outcome

18. Nursing notes
are a very
important
source of
information for
other
professionals
and nurses

19. 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

20.  Used internationally
 Provides clinical profile of symptom severity over time
 Quick identification of priority concerns
WHY ?
Who may Complete the ESAS?
 patients (self-reported)
 caregivers
 health professionals
How to Complete the
ESAS
0 1 2 3 4 5 6 7 8 9 10
0 1 2 3 4 5 6 7 8 9 10
No pain
No
tired
Worst
posible pain
Worst
possible
tiredness
Number is transcripted onto the ESAS flow sheet
Indicate who completed the ESAS (patint,
caregiver, nurse)

21. BODY DIAGRAM

22. The most frequent problems/nursing diagnosis in oncology
 Bone marrow dysfunction
 Nutritional Alterations
 Pain
 Fatigue
 Alopecia
 Dyspnea
 Bowel dysfunctions
 Patohological fractures
 Ascites
 Odors
 Psychological issues

23. 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

24. 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

25. 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

26. Outcome Identification and planning
Shortlist of Nursing Outcome domains in
patients living with cancer:
 Education and communication
 Controlled symptoms (pain, nausea, vomiting,
fatigue ecct)
 Extravasation prevention
 Blood stream catheter related infection prevention
 Diarrhea control
 Nutrition
 Safe medication administration
 Oral Mucositis
 Septicaemia
 Wellbeing and function
 Fall prevention
 Skin pressure lesions prevention
The oncology nurses
can make the
difference on the patient
outcomes

27. 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

28. 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)

29. 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

30. 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”
Life-Prolonging Therapy
Palliative Care
Medicare
Hospice
Benefit

31. 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

32. 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.

33. 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

34. 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

35. Toxicities (antineoplastic agents side effects)
36
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 e 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

36. Classification of Chemotherapy Side Effects
Designed to Facilitate Patient Education by ONS and ASCO

37. 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

38. 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.

39. Chemotherapic agents Adverse events
DRUG NAME
BONEMARROW
SUPPRESSION*
NAUSEA
VOMITING
DIARRHEA
MUCOSITIS
RENALTOXICITY
HEPATOXICITY
CARDIACTOXICITY
HYPERSENSITIVITY
REACTIONS
NEUROPATHIES
CYSTITIS
GONADALSUPPRESSION
ALOPECIA
BRADYCARDIA
ANOREXIA
HAND-FOOTSYNDROME
ILEOPARALITTIC
NEUTRAL
IRRITANT
VESICANT
FLU-LIKESYMPTOMS
INFECTIONS
DIZZINESS
METHOTREXAT
E X X X X X X X X X
HYDROSSIUREA
X X X
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
X X X X X X X X
CHLORAMBUCIL
X X X X X X X
IDARUBICIN
X X X X X X
PROCARBAZINE
X X X X X
EPIRUBICIN
X X X X X X
ACTINOMYCIN
X X X X X

40. 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

41. 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)
When?
 Before chemotherapy
prescription
 During chemotherapy
administration
 During intercicle follow-up
How?
 PS evaluation
 Physical examination,
psycosocial concerns,……..
 Laboratory
Treatment-related toxicities evaluation

42. 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

43. 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

44. 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

45. 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)

46.  A tool that will determine “the patient’s level of risk”
 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
 Prioritise the level of urgency indicated by the
presenting symptoms and will aid in identifying
potential emergency situations
Nursing TRIAGE
http://www.ukons.org/

47. 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!

48. 49
How the side effects are evaluated?
NCI Common Terminology Criteria for Adverse Events v3.0

49. http://www.ukons.org/
Assessment Tool

50. 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

51. Blood safety: crucial steps for hand hygiene action
NOTE: Cancer patients often require transfusion of blood: red blood cells, platelets,
fresh frozen plasma
REMEMBER

52. 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

53. 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)

54. 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 !
http://www.ukons.org/

55. 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

56. 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

57. 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

58. 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.

59. Initial Assessment: Who to assess: (Identify!) , History
Principle rules: Involve the patient on the assessment by asking him, then do your assessment!
 The assessment should be done by trained personnel by using the same instrument e.g. WHO Toxicity
Criteria Stomatitis
Grade 0 none
Grade 1 Soreness +/- erythema
Grade 2 Erythema, ulcers; Patients can swallow solid diet
Grade 3 Ulcers, extensive erythema; Patients cannot swallow solid diet
Grade 4 Mucositis to the extent that alimentation is not possible;
 assess on a regular basis previous a baseline assessment,
 know the patient-specific circumstances and risk factors: treatment, prior problems of the oral cavity;
current constitution of the oral cavity;
 document the assessment on the patient records.

60. Most important questions for the patient:
Does the patient have any difficulties on swallowing, dry mouth, taste changes?
Does the patient have any pain or bleeding from the mouth?
Are they able to eat and/or drink?
Does eating or swallowing make the pain worse?
Are they using any mouthwashes, pain killers or other treatments within the mouth?
Does the patient have any blisters, ulcers or white patches on tongue, lips or mouth?
Do they also have diarrhoea?
Are they passing usual amounts of urine?
Careful examination of mucous membranes – erythema, ulceration, signs of secondary
infection (bacterial or fungal), signs of dehydration.
Rules of oral cavity inspection: Material: good light (flash light), gloves (latex-free), spatula,
dry gauze; Know the normal constitution of oral cavity; Patient at ease / in convenient
position; Own attitude.

61. The most common localizations of ulcerations:
 lateral and ventral tongue;
 left and right inner side of the cheek;
 sublingual area,
 lower inner side of the cheek,
 soft palet,
 upper inner side of the lip.
Assess Oral intake of food:
 Ability of oral food intake important
 Solid food: food that one has to chew, e.g. soup
with pieces, meet, grain, pasta, hole fruits /
vegetables
 Fluid food: food, that one does not need to chew,
e.g. creamy soup, pudding, yoghurt, mashed
potatoes
 No oral food intake (e.g. tube feeding): impossible
to tolerate solid or fluid food in the mouth except
some oral medication with water
Management :
 mouthcare,
 management of oral pain
 consideration of nutritional
 support in severe cases.
Mucosa of the gastro-intestinal tract
- MUCOSITIS -

62. 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 -

63. 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)

64. 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 ?

65. 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 oxymeter 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

66. 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

67. 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

68. 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

69. 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

70. Hypotonic and hypertonic solutions may harm cells
what nurses have to do?
So these solutions may cause phlebitis
E
V
A
L
U
A
T
I
O
N
I
N
T
E
R
V
E
N
T
I
O
N
S

71. 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

72. Classification
of
chemotherap
y drugs
according to
their ability to
cause local
damage after
extravasation
Management of
chemotherapy
extravasation: ESMO–
EONS Clinical Practice
Guidelines
Annals of Oncology 23 (Supplement 7): vii167–vii173,
2012 doi:10.1093/annonc/mds294
Any agent
extravasated in high
enough
concentration may
be an irritant

73. Chemotherapy drugs possibly causing local reactions
Management of chemotherapy extravasation: ESMO–EONS Clinical Practice
Guidelines
Annals of Oncology 23 (Supplement 7): vii167–vii173, 2012 doi:10.1093/annonc/mds294

74. 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).

75. 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.

76. 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

77. 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

78. 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!

79. 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

80. 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

81. Equipment selection
Specific recommendations include:
 Use of a small bore plastic cannula
 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

82. 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.

83. 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

84. PREVENTION OF DEVICE RELATED INFECTIONS
SOME NURSING KEY PROCEDURES REQIURING ASSEPTIC TECHNIQUE
1. PREVENTION OF BLOODSTREAM CATHETER RELATED INFECTIONS: IV
infusions procedures have been associated with increased bloodstream
infections
 Drug preparation
 Access device insertion
 IV line management
2. Indwelling urinary catheterization
3. Wound care
ASSEPTIC TECHNIQUE

85. 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

88. Components of an asseptic procedure
“Not key”/”NOT CRITICAL”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

89. 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

90. Access Device: Parts of the IV Set

91. Sites of possible contamination of intravascular infusions
CONTAMINATION OF DRUG SOLUTION
1) DURING PREPARETION PHASE;
2) DURING INFUSION SET CONNECTION
INTRINSEC CONTAMINATION
(DURING FABRIQUE)
Drip defects
CRITICAL/KEY
ELEMENTS

92. The four main sites through which bacteria may reach the bladder of
a patient with an indwelling urethral catheter

102. Section 2
Infections:
Prevention and Control

103. 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

104. 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

105. 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

106.  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.

107. 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.

108. 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)

109. 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

110. 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

111. 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

112. 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

113. 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)

114. 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)

115. 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)

116. 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

117. 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.

118. THREE TYPES OF AREAS
HOTEL
+
HEALTH CARE
+
Environment related factors: Inadequate cleaning
ENVIRONMENT: HOSPITAL CARE SETTING AREAS
Maintaining a clean and safe health care environment

119. 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

120. 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 AREAHAND
HYGIENE
is considered
the most
important
and
effective
measure
to prevent
the spread
of health
care-
associated
infections
Patient room
corridor

121. 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

122. 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.

123. Let’s try to reason together about
the different types of areas and
surfaces !
WHY?

124. 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.

125. NURSING STATION
HEALTHCARE AREA: high touch surfaces

126. HEALTHCARE AREA: high touch surfaces
PATIENT BATTHROOM
EQUIPMENTS

127. INFECTION VEHICLES
HANDS,
SURFACES,
WATER,
ALIMENTS,
LINEN,
CLOTHES,
MEDICAL EQUIPMENTS
WHAT WE CAN DO TO REDUCE THE INFECTION TRANSMISSION POSSIBILITY ?

128. 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
The responsibility to prevent the infection risk is to all
health care professionals

129. 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)

130. InfectionPreventionMeasures
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 - goals
Routine Practices and
Additional Precautions
In All Health Care Settings
Provincial Infectious Diseases Advisory
Committee (PIDAC)

131. Routine Practices
+
Specialized Accommodation and Signage
+
Personal Protective Equipment
+
Dedicated Equipment and Additional Cleaning Measures
+
Limited Transport
+
Communication
Elements of Additional Precautions:

132. INFECTION VEHICLES
HANDS,
SURFACES,
WATTER,
ALIMENTS,
LINEN,
CLOTHES,
MEDICAL EQUIPMENTS
WHAT WE CAN DO TO REDUCE THE INFECTION TRANSMISSION POSSIBILITY ?

133. INFECTION VEHICLES: SURFACES, HANDS, WATTER, ALIMENTS, LINEN,
CLOTHES, MEDICAL EQUIPMENTS
HAND CLEANING

134. 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?

135. 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

136. 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

137. INFECTION VEHICLES
HANDS,
SURFACES,
WATTER,
ALIMENTS,
LINEN,
CLOTHES,
MEDICAL EQUIPMENTS
WHAT WE CAN DO TO REDUCE THE INFECTION TRANSMISSION POSSIBILITY ?

138. 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.

139. 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

140. 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

141. 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

142. 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.

143. 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

144. 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

145. 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:

146. 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

147. 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

148. 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)


149. 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.

150. 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)

151. Thank you for the attention!