2Standard PrecautionsOR ….How to prevent the spread of disease
3NORMAL DEFENSESNormal Defenses: Body Flora Cilia in Lungs Intact Skin pH of Body Fluids acidic gastric secretions/alkanline vaginal secretions
4Types of Infections HAIs Heath Care-Associated Infections formerly called nosocomialHAIsIatrogenic:Exogenous:Endogenous:Types of InfectionsHAIs: nosocomial: result from delivery of health services in a health care facilityIatrogenic: a type of HAI from a diagnostic or therapeutic procedureExogenous: an infection that is present outside the client, i.e. a post-op infectionEndogenous: an infection that occurs when part of the client’s flora becomes altered or overgrowth results, i.e. C. Diff, vaginal yeast infection
6Cholera Outbreak in Haiti Nepalese peacekeeping forcePoopLatrines near waterRiverDrinking contaminated water
7Historical Perspective 1847 Dr. Ignaz Philip SemmelweissSignificance of hand washing is demonstratedConcept of nosocomial infection is born18% Mortality from puerperal fever caused by Streptococcus organism First simple case control study
8More History1950sPost WWII hospital-based outbreaks of Staphylococcus Aureus occur, mostly in newborn nurseriesOutbreaks demand an organized response for investigation and control: Infection control as an organized and recognized discipline is born.
9Infectious Disease Process Infection:Normal flora:Colonization:Infection: presence and multiplication of microorganisms in the tissue of the host which may or may not have signs or symptomsNormal flora: bacteria that are frequently found in everyone in specific parts of the bodyColonization: presence of bacteria without multiplication and damage to the host tissue
10Chain of InfectionThe interaction in the 6 elements in the chain of infection will determine whether an infection results
12Characteristics of Causative Agents Infective dosePathogenicityInvasivenessVirulenceHost specificityViabilityResisitance
13Reservoirs Humans: Patients and Healthcare Workers Shellfish EnvironmentPatient Care EquipmentEnvironmental SurfacesFoodAnimalsRodentsInsects
14NCLEX ?Which of the following is an example of a nursing intervention that is implemented to reduce a reservoir of infection for a client?A) Covering the mouth and nose when sneezing B) Wearing disposable gloves C) Isolating client’s articles D) Changing soiled dressingsCorrect answer is D
15Portal of Exit: The path by which the infectious agent leaves the reservoir Respiratory Tract:GU TractGI Tract:Skin/Mucous Membranes:TransplacentalBlood:Respiratory Tract: coughing, sneezing, talking, suctioningGU Tract: Foleys, STIsGI Tract: Feces, VomitusSkin/Mucous Membranes: Wounds & Skin BreaksTransplacentalBlood: Needle Stick, Blood Transfusion
16Mode of TransmissionThe mechanism for transfer of an infectious agent from the reservoir to the susceptible host
17VIGNETTEAn older adult, hospitalized with a GI disorder is on bedrest and requires assistance for uncontrolled diarrhea stools.Following one episode of cleaning the patient and changing the bed linens, the nurse went to a second patient to provide tracheostomy care.The nurse’s hands were not washed before assisting the second patient
18VIGNETTE ANALYSIS Infectious agent → Escherichia Coli Reservoir → Large IntestinesPortal of Exit → FecesMode of Transmission → Nurses HandsPortal of Entry → TracheostomySusceptible Host → Older Adult with Trach
19Modes of TransmissionContactAirborneVector-Borne
20Contact Direct: Indirect: Direct: Immediate transmission, person-to-person, actual personal contact between the patient and the sourceIndirect: Patient to contaminated indirect object (contaminated endoscope) or Droplet spread (large particles that rapidly settle out on horizontal surfaces-usually within 3 feet of the source
21Modes of Transmission Direct Indirect Person to Person (Fecal-Oral) Hepatitis AStaphIndirectContact with contaminated objectHepatitis B and CHIVRSVMRSA
22AirborneDroplets suspended in air after coughing and sneezing or carried on dust particlesTBChicken PoxMeasles (Rubeola)AspergillusOrganisms contained within droplet nuclei or dust particles (ie. droplet nuclei of tuberculosis)Suspended in air for extended periods, may be spread through ventillation systemsAirborneDroplets suspended in air after coughing and sneezing or carried on dust particlesTBChicken PoxMeasles (Rubeola)Aspergillus
23Droplet transmission Large particles Can travel up to 3 feet Influenza Rubella (3- day/German Measles)Bacterial Meningitis
24Vector-Borne Vector External mechanical transfer Mosquito, Louse, Flea, Tick, FlyWest Nile VirusMalariaLyme DiseaseHanta VirusExternal vector-borne transmission; mechanical transfer of microbes on external appendages (feet of flies)Harbored by vector, but no biological interaction between vector and agent (ie.Yellow fever)VectorExternal mechanical transferMosquito, Louse, Flea, Tick, FlyWest Nile VirusMalariaLyme DiseaseHanta Virus
25Portal of Entry: path by which an infectious agent enters the susceptible host Respiratory tractGU tractGI tractTransplacental (fetus from mother)Parenteral: percutaneous, via bloodSkin/Mucous Membranes
26Susceptible HostA person or animal lacking effective resistance to a particular pathogenic agentClient SusceptibilityStatus of defense mechanisms (smoker?)Age – very young and very oldNutritional status – decreased protein intake reduces the body’s defenses against infection and impairs wound healingStress – lowers immunityDisease process – HIV, Leukemia, Lymphoma
27Man-Made Epidemics (NYT July 15, 2012) Most epidemics of infectious disease just don’t happen. They are a result of things people do to nature.Disease is largely an environmental issue.60% of emerging infectious diseases that effect humans are zoonotic-they originate in animals.Deforestation of the Amazon by 4% increased malaria by 50% (mosquitoes thrived in the right mix of sunlight and water)
28Diseases have always come out of the woods and wildlife and found their way into humansMalaria and the plagueEmerging diseases have quadrupled in the past 50 years due to increased human encroachment into habitat in “hot spots”, modern air travel and robust trafficking in wildlifeDeveloping the forest in the wrong way can be like opening Pandora’s box.
29West Nile VirusA mosquito-borne illness that causes sx in about a fifth of those exposed. One in 150 becomes severely ill with encephalitis.Animal reservoir: various birds, especially robins in the U.S.First human case: West Nile district of Uganda, 1937; first U.S. case was in Queens in 1999.Why it emerged: International travelSusceptible hosts: humans, birds, especially crows and horses.
30American Robin Thrives in our backyards and agriculture fields Mosquitoes that spread the disease find robins particularly appealing
31H1N1 “Swine flu”, killed thousands and infected millions in 2009 Humans in turn spread the disease to pigs, triggering a pandemic in livestock.Animal reservoir: waterfowl and pigsFirst Human Case: Veracruz, Mexico, 2009; first U.S. case was in San Diego in 2009.Why: Livestock production (pigs and poultry); contact with wild waterfowl.Susceptible: Humans, pigs
32Lyme Disease . East Coast scourge Very much a product of human changes to the environmentReduction of large forests & development chased off predators-foxes, wolves and hawksResulted in 5 fold increase in white-footed mice, which are a great reservoir for the bacteria probably because they have weak immune systems and they are terrible groomersWhen possums or grey squirrels groom they remove 90% of the larval ticks that spread disease, while mice kill just half.Mice produce huge numbers of infected nymphs.
33EbolaHemorrhagic fever is among the most virulent known diseases. There is no specific treatment or vaccine available; patients must be strictly isolated.Animal reservoir: Various batsFirst human case: Yambuku region, Zaire (now Democratic Republic of Congo, 1976)Why: Contact with or eating infected wildlife, especially gorillas.Susceptible: Humans, chimpanzees, gorillas duilers (small African antelope)
34SARSA severe viral respiratory infection that quickly spread from China to more than two dozen countries. The outbreak was contained, and since 2004 no new cases have been reported.Animal Reservoir: Horseshoe batsFirst human case: Guangdong Province, China, 2003Why: Wildlife markets and trade; global travelSusceptible: Humans, civats
35Bird FluA deadly strain of the avian virus called H5N1 has spread to humans via contact with live or dead poultryAnimal Reservoir:Wild waterfowlFirst human case: Hong Kong, It re-emerged widely in 2003 and 2004.Why: global expansion of intensive poultry farming; contact with infected birdsSusceptible: Humans, poultry, cats
36Isolation Precautions Historical perspective 1877 to present1877Aseptic technique19101877: first published recommendations for isolation precautions, birth of infectious disease hospitals where pts with infectious disease processes were placed in separate hospitalsAseptic technique used to combat transmission of disease1910: isolation practices are altered by the introduction of the “cubical” system, replaced isolation hospitals, multiple bed wards
37“Barrier” Nursing Hospital personnel wear gowns between patients Handwashing between patients with antiseptic solutions after patient contactDisinfection of objects contaminated by patientsHospital personnel wear gowns between patientsHandwashing between patients with antiseptic solutions after patient contactDisinfection of objects contaminated by patients
38More Hx1950s: Infectious Disease hospitals begin to shut down except for TB sanitariums1960s: TB hospitals begin to shut down1970: CDC publishes first manual on Isolation Techniques for Use in Hospitals. Diseases were lumped into categories1980s: Hospitals began to experience new endemic and epidemic nosocomial infection problems caused by multi-drug-resistant organisms
39HX 1980: CDC publishes new Isolation guidelines 1985: Universal precautions come into being (HIV, HBV, blood borne pathogens)1990s HICPAC: 2 tier systemStandard PrecautionsTransmission-Based Precautions (Contact, Droplet, Airborne)
40HAIs Surgical Sites Blood Stream Urinary System Cardiovascular Eye/Ear/Throat/Mout h InfectionReproductive SystemRespiratoryBone and Joint InfectionCNSGastrointestinalSkin and Soft Tissue
41Immunocompromised Pts Vary in their susceptibility to HAIsDepends on the severity and duration of immunosupression.Use the two-tiered systemNeutropenic precautions
42Critical Thinking Question Clients in the healthcare setting are at risk for acquiring or developing infections because:
43PreventionMost HAIs are transmitted by the HCWs and clients as the result of direct contactWe as nurses must pay attention to handwashing after contact with clients and equipment
44Prevention Microorganisms move through space on air currents Microorganisms are transferred from one surface to another whenever objects touch, a clean item touching a less clean item becomes “dirty”Microorganisms are transferred by gravity when one item is held above anotherMicroorganisms move through space on air currents: avoid shaking or tossing linenMicroorganisms are transferred from one surface to another whenever objects touch, a clean item touching a less clean item becomes “dirty”- keep hands away from face, keep linens away from uniforms an item dropped on the floor is considered dirty.Microorganisms are transferred by gravity when one item is held above another, avoid passing dirty items over clean items eg clean items on upper shelves dirty items on lower shelves (bedpan
45PreventionMicroorganisms are released into the air on droplet nuclei whenever a person breaths or speaks-Microroganisms move slowly on dry surfaces, but very quickly through moisture –Proper handwashing removes many of the microorganaisms that would be transferred by the hands from one item to another- always wash hands between patients.Microorganisms are released into the air on droplet nuclei whenever a person breaths or speaks- avoid breathing directly in someone’s face; when someone coughs/sneezes, cover mouth with kleenex, dicard and wash handsMicroroganisms move slowly on dry surfaces, but very quickly through moisture – use paper towels to turn off faucets, dry bath basin before returning to bedside table.Proper handwashing removes many of the microorganaisms that would be transferred by the hands from one item to another- always wash hands between patients.
46PreventionTo reduce susceptibility provide adequate nutrition and rest, promote body defenses against infection and provide immunization
48Break The Chain!Implement ASEPSIS: absence of disease-producing microorganisms; refers to practices/procedures that assist in reducing the risk of infection2 TypesMedical (clean technique)Surgical (sterile technique)
49MEDICAL ASEPSIS Clean technique: 3 components to the technique: Aseptic technique3 components to the technique:Hand washing,Barriers of PPE (gloves, gowns, mask, protective eyewear)Routine environmental cleaningContaminated area:A clean technique that limits the number of pathogens that could cause infectionsAseptic technique: practices/procedures that assist in reducing the risk for infection3 components to the technique:Hand washing,Barriers of PPE (gloves, gowns, mask, protective eyewear)Routine environmental cleaningContaminated area: one suspected of containing pathogens eg. used bedpan, wet gauze, soiled linen, laboratory specimens, etc49
50Disinfection/Sterilization Disinfection = the process that eliminates many or all microorganisms, with the exception of bacterial spores, from inanimate objectsSterilization = complete elimination or destruction of all microorganism, including sporesDisinfection = the process that eliminates many or all microorganisms, with the exception of bacterial spores, from inanimate objectsDisinfection of surfacesHigh-level disinfectionAlcohols, chlorines, glutaraldehydes, hydrogen peroxideSterilization = complete elimination or destruction of all microorganism, including sporesSteam under pressure, ethylene oxide gas (ETO)
51Aseptic techniqueHandwashing is the single most important procedure for preventing the transfer of microorganisms and therefore preventing the spread of HAIsCD recommends second hand wash.Handwashing is the single most important procedure for preventing the transfer of microorganisms and therefore preventing the spread of HAIsCD recommends second hand wash. This will remove most transient organisms form the skin resident: normally reside on the skin in stable #sTransient: attach loosely to the skin by contact with another-easily removed by handwashing.
52Personal HygieneRestrain Hair: hair falling forward may drop organismsKeep nails short: no acrylic nails or chipped nail polishMinimum jewelry (see agency policy)Cover open wounds with an occlusive dressing.
53When should hands be washed When visibly soiledBefore and after client contactAfter contract with a source of microorganism: blood, body fluids, mucous membrane, non-intact skin or inanimate objects that might be contaminatedPrior to an invasive procedure: IV catheter, indwelling cathBefore and after removing gloves: wearing gloves does not remove the need to wash handsAt the beginning and end of every shift.
54CDC GUIDELINES Standard Precautions apply to: Blood All body fluids and secretions (feces, urine, mucus, wound drainage) except sweatNon-intact skinMucous membranesRespiratory secretions54
55STANDARD PRECAUTIONS TIER 1 Hand Hygiene: see next slideGloves: for touching blood, body fluids, secretions, excretions, non-intact skin, mucous membranes or contaminated areasMasks, Eye Protection or Face Shields: if in contact w/ sprays or splashes of body fluidsGowns: to protect your clothingContaminated Linen: place in leak-proof bag so no contact with skin or mucous membranesRespiratory Hygiene/Cough Etiquette: provide client with tissues and containers for disposal; stand ~3 feet away from coughing; use masks prn55
56Hand Hygiene Number one defense against infection Soap and water if hands are visibly soiledFriction for 15 secondsAfter 3-5 uses of hand gelAlcohol-based hand products are accepted if hands not visibly soiledBefore and after providing client careBefore eatingAfter contact with body fluids or excretaAfter contact with inanimate objects in immediate area of the clientBefore proceduresAfter removing glovesIs NOT effective against C-Diff
62Donning and Removing PPE GownMask or respiratorGoggles/face shieldGlovesKeep hands away from faceWork from clean to dirtyLime surfaces touchedChange when torn or heavily soiledRemovingGlovesGoggles/face shieldGownMask or respiratorRemove at doorway before leaving pt. roomPerform hand hygiene immediately after removing all PPE
63Surgical AsepsisSterile technique that prevents contamination of an open wound, serves to isolate the operative area from the unsterile environment, and maintains sterile field for surgeryIncludes procedures used to eliminate all microorganisms, including pathogens and spores from an object or areaUsed in the following situations:Procedures requiring perforation of the skinWhen the skin’s integrity is broken as a result of trauma, surgery or burnsDuring procedures that involve insertion of catheters or surgical instruments into sterile body cavities
64Principles of Surgical Asepsis A sterile object remains sterile only when touched by another sterile objectOnly sterile objects may be placed on a sterile fieldA sterile object or field out of the range of vision or an object held below a person’s waist is contaminatedA sterile object or field becomes contaminated by prolonged exposure to airWhen a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary actionFluid flows in the direction of gravity so a sterile object becomes contaminated if gravity causes a contaminated liquid to flow over the object’s surfaceThe edges of a sterile field or container are considered to be contaminated – a 1 inch border around the drape is considered contaminated
65For which procedure would the nurse use aseptic technique and which would require the nurse to use sterile technique?A) Aseptic technique for urinary catheterization in the hospital and sterile technique for cleaning surgical woundB) Aseptic technique for changing the patient’s linen and sterile technique for assisting in surgeryC) Aseptic technique for food preparation and sterile technique for starting an IV lineD) Aseptic technique for a spinal tap and sterile technique for placing a central lineCorrect answer is B
66LAB Practice: Isolation Precautions Demonstrate donning Isolation Gown, Mask, Gloves, EyewearDemonstrate removing Isolation Gown, Mask, Gloves, EyewearDemonstrate proper disposal of PPE before leaving Isolation RoomWhen performing care/treatments use hospital provided stethoscope and leave in the room66
67Lab Practice Cont’d.Practice pretending you are entering patient room (use curtains) and give Complete Bed Bath and do Bed Linen Change wearing PPE (gown, mask, gloves)Remember to dispose of PPE INSIDE the patient’s room before you leavePractice bringing in all the supplies you need so you can stay in the room & not have to leave (de-gown etc) and come back in (re-gown etc)
68LAB Practice: Sterile Procedures Opening sterile packages – Flap fartherest away from nurse first, then sides, then flap closest to nursePreparing a sterile fieldPouring sterile solutions – label to palm, “lip” itDonning sterile gown and gloves
69Critical Thinking Exercise Mrs. Jaycock had an indwelling urethral catheter for 1 week. The catheter has now been out for 24 hours. She complains of frequency and pain on urination. Mrs. Jaycock suggests reinsertion of the catheter because of the need to get up frequently. What can frequency or pain on urination be an indication of?
70AnswerUTIShould the catheter be reinserted?Why or why not?
71AnswerNo reinserting the catheter may aggravate the infection and promote the spread of the infection to the bloodstream.Describe at least one appropriate assessment measure and one independent nursing action or intervention for Mrs. Jaycock
72Nursing ResponseIncrease her fluid intake if not clnically contraindicatedCheck her urinalysis
73SituationYou are caring for Mr. Huang, who has a large open, and draining abdominal wound. You notice another health care worker changing Mr. Huang’s dressing without wearing gloves or using sterile technique. When you question the health care worker regarding his or her practice, this person says, “Don’t worry, the wound is already infected, and the antibiotics and drainng will take care of any contaminants.” How would you respond to this comment?
74ResponseIt is important to not only protect Mr. Huang from additional infection, but also to protect ourselves from becoming contaminated.What would your next steps be in following up on this incident?
75SituationMrs. Niles is 83 years of age and lives alone. She has difficulty walking and relies on a church volunteer group to deliver lunches during the week. Her fixed income limits her ability to buy food. Last week, Mrs. Niles’ 79-year-old sister died. The two sisters had been very close. As a home care nurse, explain the factors that might increase Mrs. Niles’ risk for infection.
76ResponseAgePotential for poor nutritionPotential for depression
77SituationMr. Vargas is admitted to the facility with a history of recent weight loss, a cough that has persisted for 2 months, and hemoptysis. His chest x-ray film shows a cavity lesion in one lung, and his physician suspects tuberculosis. What type of isolation precautions would you use for Mr. Vargas? What protection would you use to provide care? What education would you provide to the family?
78Response Airborne precautions Wear an N95 mask Keep the door closed Educate the pt and family on transmission of TB and reason for isolation.