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PENCEGAHAN DAN PENGENDALIAN

PLEBITIS

Oleh
Himpunan Perawat Pencegah dan Pengendali Infeksi Indonesia
( HIPPII)

Pelatihan Dasar Pencegahan & Pengendalian Infeksi RS


RS.TELOGOREJO
SEMARANG 14-16 JANUARI 2014
POKOK BAHASAN
 Pendahuluan

 Pengertian

 Faktor –faktor yang mempengaruhi


plebitis

 Pencegahan dan pengendalian


plebitis
PENDAHULUAN
Pemasangan infus melalui vena perifer dapat
berisiko terjadinya plebitis

The incidence of infusion phlebitis is estimated to


be as high as 62% of patients with an intravenous
access device in place (Lundgren, Jordfeldt & Ek
1993).
Insioden Rate Plebitis Perseribu Hari Pemakaian Alat ( ‰ )
di RS Jantung Harapan Kita
Periode Tahun 2005 s/d 2012
PENGERTIAN
 Peradangan pada vena perifer

 Plebitis sering dihubungkan dengan

pembentukan bekuan darah (trombosis) 


Tromboflebitis

 Secara klinis adanya keluhan nyeri, nyeri tekan,


bengkak, pengerasan, eritema dan hangat pada vena
oleh karena peradangan, infeksi dan/atau trombosis
TANDA –TANDA PLEBITIS
 Secara klinis :
Ada nyeri, nyeri tekan,bengkak,pengerasan,
eritema dan hangat pada vena

 Jika infeksi :
Kemerahan, demam, sakit, bengkak,
adanya pus atau kerusakan pada kulit
Patofisiologi
Faktor etiologi plebitis
(spontan, komplikasi , p’sangan infus) Tidak diatasi

Pengaruh
penurun Terbentuknya Inflammatory
histamine, Menyebabkan faktor continued
bradikinin, dan Kerusakan dan procoagulan di
serotonin iritasi PB endothelial

Mengaktifasi A thrombus
Permeabilitas ‘ll form in
proacugulan
Nyeri kapiler me ↑ vein

Penumpukan cairan & protein di Collect


intertitial space leukosit

Edema dan
tenderness Hipertermia
FAKTOR –FAKTOR YANG MEMPENGARUHI PLEBITIS

 Usia
 Jenis kelamin
 Kondisi dasar ( diabetes melitus,
infeksi, luka bakar )
 Faktor kimia seperti obat atau cairan yang
iritan
 Faktor mekanis seperti bahan, ukuran kateter,
lokasi dan lama kanulasi
 Agent infeksius
Catheter Related Infection Risk

Contaminated
Infusate

Fibrin sheath, HEMATOGENOUS,


Thrombus From distant local Infection
INS Visual Infusion Phlebitis (V.I.P.) Score, 2006
IV site appears healthy
No pain at IV site, no erythema,
No swelling 0 No signs of phlebitis
OBSERVE CANNULA
No palpable venous cord (all ages)
• Stop infusion if possible
• Erythema at access site
• With or without pain 1 • Identify additional resources
for management
• Remove IV if symptoms persist

• Stop infusion if possible


• Erythema
• Pain at access site
• With or without edema
2 • Identify additional resources
for management
• Remove IV if symptoms persist

• Erythema • Stop infusion if possible


• Pain at access site • Identify additional resources
• With or without edema
• Streak formation
3 for management
• Remove IV
• Notify primary service
• Palpable venous cord
• Erythema
• Pain at access site • Stop infusion and establish alternate

4
IV site
• With or without edema
• Remove IV and culture site and catheter
• Streak formation tip
• Palpable venous cord > 1 inch • Notify primary service
• Purulent drainage
Infiltration Scale (INS 2006)
No symptoms 0
• Skin blanched
• Edema < 1 inch in any direction
• Cool to touch 1
• With or without pain

• Skin blanched
• Edema 1 – 6 inches in any direction
• Cool to touch 2
• With or without pain

• Skin blanched, translucent


• Gross edema > 6 inches in any direction
• Cool to touch
• Mild to moderate pain
3
• Possible numbness

• Skin blanched, translucent


• Skin tight, leaking
• Skin discolored, bruised, swollen
• Gross edema > 6 inches in any direction
• Deep pitting tissue edema 4
• Circulatory impairment
• Moderate – severe pain
• Infiltration of any amount of blood product, irritant, or vesicant
JENIS – JENIS PLEBITIS

1.Plebitis Kimia

2. Plebitis Mekanis

3. Plebitis Bakterial
1.Plebitis Kimia
 pH dan osmolaritas cairan infus yang ekstrem  pH ↓,
osmolaritas ↑

 Mikropartikel yang terlarut  yang terbentuk bila


partikel obat tidak larut sempurna selama
pencampuran  pemberian obat intravena
menggunakan filter 1 sampai 5 µm.

 Pemilihan material kateter intravaskuler yang


digunakan  silikon dan poliuretan kurang bersifat
iritasi dibanding politetrafluoroetilen (teflon),
polivinil klorida atau polietilen resiko tertinggi
Himpunan Perawat Pencegah dan
14
Pengendali Infeksi Indonesia (HIPPII)- Pusat
2. PLEBITIS MEKANIS

 Penempatan kateter intravaskuler yang


tidak tepat

 Ukuran kateter intravaskuler yang tidak


sesuai dengan ukuran vena

 Cara pemasangan, pengawasan dan


perawatan yang kurang baik

 Laju pemberian yang tidak sesuai


3. PLEBITIS BAKTERIAL
 Hand hygiene tidak dilakukan
 Preparasi kulit tidak baik sebelum pemasangan infus
 Teknik aseptik tidak baik saat akan pemberian obat
atau cairan
 Kateter dipasang terlalu lama
 Tempat Tusukan Kateter tidak/ jarang diinspeksi secara
visual
 Alat – alat yang di gunakan rusak atau bocor atau
kadaluarsa
 Larutan infus terkontaminasi karena teknik aseptik yang
kurang baik pada saat pencampuran larutan
 Faktor virulen instrinsik dari mikroorganisme itu sendiri
PENATALAKSANAAN PENCEGAHAN PLEBITIS

1.HAND HYGIENE
2. PREPARASI KULIT

 Use alcohol followed by application of main disinfectant 10%


Povidone Iodine or 2% Chlorhexidine prep.

 Provides immediate kill as well as residual activity


 For Iodophor - 2-3 hrs
 For Chlorhexidine prep. - 6 hrs

 Process - 2 Steps
 Apply alcohol in circular motion outwards, allow it to dry
 Apply Povidone Iodine or Chlorhexidine in circular motion
outwards, allow it to dry
3. DRESSING / PENUTUP INFUS

 Use either sterile gauze or sterile transparent,


semi permeable dressing to cover the catheter site

 Replace catheter dressing if the dressing becomes


damp, loose, or visibly soiled

 Replace dressings at every 2 days for gauze


dressing and 72 hour for transparent dressing

CDC, Centre for Disease Control and Prevention, Guidelines for prevention of Intravascular catheter
related Infections, MMWR, 2002: 51 ( No. RR 10 )
4.Catheter care - Flushing
 All vascular access devices used should be flushed with 0.9% sodium chloride
(normal saline) or heparin to*
 Maintain catheter patency
 Prevent contact between incompatible fluids and medications
 Appropriate Flushing helps to reduce catheter thrombosis and thus CR-BSI risk**
 As thrombi or fibrin deposits could serve as a nidus for microbial colonization
 When catheter flushing is to be performed
 Just after catheter insertion
 Before and after each administration of medication
 od sampling
 Every 6-8 hours when catheter is not in use (Once a day - home care PICC’s )
 INS standards, 2006
 Single use flushing systems to be used, that is, do not use multiple use vials
 8% Syringes prepared by nurses are contaminated - Syringe tip, Fluid***
Touch contamination
Multiple use vials or their inappropriate usage

page 394, ** CDC, Centre for Disease Control and Prevention, Guidelines for prevention of IV catheter related Infections, MMWR, 2002: 51, Page 9 ( No. RR 10 ), ** APIC, Lynn
Hadaway, Webinar series 2006
Infusion Therapy in clinical practice Judy Hankins et al, 2nd Edition, The Infusion Nursing Society,
5. Appropriate use of equipment
1. Intravasular Access

Monitor and inspect catheter site regularly, the site should be


observed for any signs of inflammation, infection or malfunction
2.For any intravascular access
 Replace IV tubing and add on devices no more frequently than 72
hours
 Replace tubing used to administer blood products or lipids with in 24
hrs
Clean injection ports with 70% alcohol or an iodophor before accessing

3.IVD replacement
 Peripheral Venous : 72-96 hrs in adults / first signs of phlebitis,
 In pediatric patients, Do not routinely replace peripheral venous
catheters unless clinically indicated
 CVC’s / PICC / Hemodialysis / PA / Peripheral Arterial : NOT routinely*
The Peripheral Vascular Catheter (PVC)
Bundle
1. Performed hand hygiene before and after all
PVC procedures
2. Checking the PVCs insitu are still requared
3. Removing PVCs where there is extra vasation
or inflamation
4. Checking PVC dressing are intact
5. Considering removal of PVCs insitu longer
than 72 hours
NHS
• Pengumpulan data setiap hari
• Perhitungan setiap bulan
• Laporan setiap bulan,triwulan,semester, tahunan
• Insiden rate Plebitis:
Jumlah plebitis
--------------------------------- X 1000 = (‰)
Hari pemakaian IV Kateter
Himpunan Perawat Pencegah dan
30
Pengendali Infeksi Indonesia (HIPPII)- Pusat