1. Chapter 26 Asepsis and Infection Control

2.  Infection = establishment of a pathogen in a susceptible host  Asepsis = freedom from and prevention of disease-causing contamination.  First line of defense: Normal flora = a group of non–disease-causing microorganisms (e.g., bacteria, fungi, protozoa) that live in or on the body. Normal Structure and Function of the Body’s Defense System 2

3.  Second line of defense: Inflammation  Inflammation = a local response to cellular injury or infection that includes capillary dilation and leukocyte infiltration.  Produces redness, heat, pain, and swelling.  Inflammation causes the body to mount the third defense, which is the immune response. Inflammatory Response 3

4.  Third line of defense: Immune response  The body’s attempt to protect itself from foreign and harmful substances  Initiated by recognition of antigens An antigen is any substance that provokes an adaptive immune response.  The immune system recognizes and destroys substances that contain foreign antigens.  Innate (nonspecific) Immunity  Skin, cough reflex, mucus, enzymes on the skin and in tears, and acid in the GI tract prohibit harmful substances from entering the body. Immune Response 4

5.  Adaptive immunity (acquired/specific) = when exposed to an antigen  Humoral immunity = WBC (B lymphocytes) produce antibodies in response to antigens or pathogens  Cellular immunity = defense that the body does not recognize; white blood cells (cytotoxic T lymphocytes) directly attack antigens; helper T cells stimulate antibody production by B cells  Adaptive immunity is antigen specific because of long-term immunologic memory  Passive immunity = receipt of antibodies from another person Immune Response (Cont.) 5

6.  Integumentary  Skin as a barrier; break is a portal of entry  Squamous epithelial cells help remove infectious agents  Sweat’s low pH inhibits bacterial growth  Respiratory  Cilia and mucus  Proteins with antimicrobial properties  Gastrointestinal  Flora and low pH in stomach Other Body Systems 6

7. Infectious Agent Susceptible HostSource Portal of EntryPortal of Exit Mode of Transmission Chain of Infection 7

8.  Infectious agents that cause disease are pathogens  Bacteria Single-cell organisms, named by shape Classified +/- oxygen, staining qualities Vary in size, shape, growth pattern, means of replication  Viruses Smallest microorganisms; not killed by antibiotics Reproduce inside living host cells  Fungi Single-cell organisms, such as mold and yeast  Parasites Live on or in other organisms Altered Structure and Function of the Body’s Defense System 8

9.  Source of infection = Reservoir or host  Inanimate objects (contaminated equipment, medications, air, food, water)  Humans  Animals  Portal of exit: the means by which the pathogen escapes from the reservoir of infection  Emesis, sputum, urine, stool, blood, genital secretions, wound drainage Chain of Infection (Cont.) 9

10.  Mode of transmission = form of transport  Contact = junction of body surfaces with other bodies or objects Direct: In the health care setting, the most common means of transmission are contaminated hands. Indirect Vehicle (e.g., food, water, contaminated objects)  Airborne = microorganisms dispersed by air, then inhaled or deposited  Droplet  Vector borne (e.g., insects) Carry pathogens from one host to another Chain of Infection (Cont.) 10

11.  Portal of entry = the means by which the microorganism enters the susceptible host  GI tract, GU tract, respiratory tract, skin break  The nurse can take steps at any link in the chain to halt the spread of infection.  Standard precautions and handwashing  Susceptible host = someone exposed to an infectious disease. Increased susceptibility:  Age extremes, those with chronic diseases  Immune or nutritionally compromised  Recent trauma or surgery Chain of Infection (Cont.) 11

12.  Health care–associated infections (HAIs), formerly referred to as nosocomial infections, are infections acquired while the patient is receiving treatment in a health care facility such as a hospital, long-term care facility, clinic, or primary care office.  Handwashing is the most effective method for preventing hospital-acquired infections. Health–Care Associated Infections 12

13.  Drug resistance = microorganisms developing resistance to medications that had been previously successful at treating the infection  Factors contributing to resistance:  Prescribing antibiotics for nonbacterial infections  Use of inappropriate antibiotics  Incomplete courses of antibiotics  Infections are becoming increasingly hard to treat. Resistant Organisms 13

14.  Safe Practice Alert!  Drug-resistant microorganisms pose a considerable health risk for the general population and health care workers.  Appropriate use of personal protective equipment and handwashing can decrease the risk of transmission. Resistant Organisms (Cont.) 14

15.  Put patients and health care providers at risk for infection  Hepatitis B virus, Hepatitis C virus, HIV  Exposure through contact with contaminated blood or body fluids  Exposure does not necessarily mean disease will develop.  Exposure and disease development can be decreased with appropriate precautions and barriers. Bloodborne Organisms 15

16. 1. A patient is admitted to a medical unit for a home-acquired pressure ulcer. The patient has Alzheimer’s disease and has been incontinent of urine. The nurse inserts a Foley catheter. You will identify a link in the infection chain as: A.Restraints. B.Poor hygiene. C.Foley catheter bag. D.Improper positioning. Quick Quiz! 16

17.  Localized infections  Redness, swelling, warmth, pain, tenderness  Numbness or tingling, loss of function to the affected area  Systemic infections (infiltrate the bloodstream)  Fever, increased heart rate, increased respiratory rate  Lethargy, anorexia, lymph node tenderness or enlargement Signs and Symptoms of Infection 17

18.  Extremes in age  Infants’ immature immune systems  Elderly at risk for respiratory, urinary, and skin infections  Gender  Females at greater risk for UTIs  Males with enlarged prostate at risk for UTIs  Culture, ethnicity, and religion  Influence ability/desire to seek medical attention  Disabilities causing immobility  Obesity linked to increased risk Factors Affecting Susceptibility 18

19. Health Assessment Questions Do you feel tired or fatigued? Do you often feel chilled and require a blanket when others in the room are comfortable? Do you feel short of breath? Do you have any areas of pain, redness, swelling, and warmth? How is your appetite?Do you have any rashes, breaks in the skin, or reddened areas? Do you have swollen lymph nodes? Do you feel that you empty your bladder when you go to the bathroom? Have you had a fever?Do you have a cough or difficulty swallowing? Are your immunizations up to date? What medications are you on? Have you taken an antibiotic recently? Infection Assessment 19

20.  Infections classified:  Acute  Chronic  Signs and symptoms vary  Fever  Chills  Malaise  Altered mental status (confusion)  Headache  Fatigue Effects of Infection on the Body’s Defense System 20

21.  Mrs. Eldredge is a 63-year-old woman who underwent a total hip replacement. Kathy Jackson is a nursing student caring for Mrs. Eldredge on her home health clinical rotation.  Two weeks after surgery, Mrs. Eldredge complains to Kathy that she has increased pain in her hip and low-grade fever.  Kathy observes the incision and notes that it is red, swollen, and warm. Case Study 21

22.  Assessment of vital signs  Elevated temperature, blood pressure, pulse and respiratory rates  Nutritional assessment  Skin, mucous membranes, appearance  Dietary intake  Risk assessment  Chronic diseases  Medications  Altered skin integrity  Lack of proper immunizations Effects of Infection on the Body’s Defense System (Cont.) 22

23.  Laboratory and diagnostic tests  Complete blood count (CBC)  Differential white blood cell (WBC) count Proportion of each type of WBC  Culture and sensitivity testing of specimens Determines which microorganism is causative The presence of pathogens in a specimen is a positive result.  Erythrocyte sedimentation rate (ESR) Measures degree of inflammation Effects of Infection on the Body’s Defense System (Cont.) 23

24.  Many appropriate nursing diagnoses can be used for a patient with an infection.  Risk for Infection  Knowledge Deficit  Impaired Skin Integrity  Imbalanced Nutrition: Less than Body Requirements  Nursing diagnoses based on the effects of infection on various body systems may also be appropriate. Nursing Diagnosis 24

25.  The planning stage of the nursing process involves prioritizing identified nursing diagnoses, evaluating patient abilities and resources, and setting goals.  The nurse carefully considers the importance of each nursing diagnosis and addresses the most critical ones first in the nursing care plan.  Maslow’s hierarchy of needs is a helpful resource for ranking nursing diagnoses. Planning 25

26.  Infection control measures are constantly updated so that the best and most evidence- based practices can be accessed and used.  Evidence-based practice and informatics  Centers for Disease Control and Prevention (CDC)  National Guideline Clearinghouse (NGC)  National Institute for Health and Clinical Excellence (NICE)  National Resource for Infection Control  Cochrane Collaboration Implementation and Evaluation 26

27.  Nurses can implement many interventions to decrease the risk of infectious illness.  Hand hygiene  Breaks the chain of infection  Surgical hand scrub for surgical procedures  Precautions and isolations  Standard precautions for every patient  Transmission precautions: airborne, droplet, and contact precautions  Protective isolation for patients who are immunocompromised Infection Control and Aseptic Interventions 27

28.  Purpose  Hand hygiene is essential to prevent the spread of microorganisms.  It is standard practice for patient care.  Collaboration and delegation  Hand hygiene is mandatory for all health care workers who come in contact with patients or their belongings; it is not delegated. Hand hygiene is mandated for all patients.  It is important for the nurse to speak up when observing anyone not following required hand hygiene. Skill 26-1: Hand Hygiene 28

29.  Evidence-based practice  Alcohol-based products and sanitizers should not be used when one or both hands are visibly soiled.  Natural fingernails should be kept short and be trimmed often.  If health care providers do not wash their hands in accordance with the CDC’s guidelines, it leads to an increased rate of hospital-acquired infections.  The rate of handwashing can be increased and the rate of infections decreased by implementing an educational model aimed at increasing the behavior of handwashing. Skill 26-1: Hand Hygiene (Cont.) 29

30.  The use of standard precautions (i.e., basic aseptic techniques) prevents and controls the spread of microorganisms among patients and providers.  Use standard precautions for all patients when contact with potentially infectious bodily materials is possible.  Patient and family education regarding standard precautions should be documented.  Respiratory etiquette is included. Nursing Care Guideline: Standard Precautions 30

31.  Never recap a dirty or used needle because doing so increases the risk of exposure to bloodborne pathogens! Safe Practice Alert 31

32.  Basic standard precaution principles apply to all patients  Personal protective equipment and supplies are usually found on an isolation cart outside the room (in an anteroom). Nursing Care Guideline: Contact, Airborne, + Droplet Precautions; Protective Isolation Types of Precautions ContactDroplet AirborneProtective Isolation 32

33.  Contact precautions: used when a known or suspected contagious disease may be present  Transmission may occur through: Direct transmission (contact with the patient). Indirect transmission (contact with equipment or items in the patient’s environment).  Examples include: Multidrug-resistant organisms Scabies and herpes simplex virus Draining wounds in which certain organisms have been cultured Nursing Care Guideline: Contact, Airborne, + Droplet Precautions; Protective Isolation (Cont.) 33

34.  Airborne precautions: Used when known or suspected contagious diseases can be transmitted by means of small droplets or particles that can remain suspended in the air for prolonged periods.  Droplet precautions: Used when known or suspected contagious diseases can be transmitted through large droplets suspended in the air. Nursing Care Guideline: Contact, Airborne, + Droplet Precautions; Protective Isolation (Cont.) 34

35.  Protective isolation is used for patients who have compromised immune systems.  This type of isolation protects the patient from microorganisms in the environment.  Protective isolation varies according to the reason that the patient’s immune system is compromised, and a variety of protective precautions may be used:  Filters  Masks  Meticulous handwashing  No live items may be brought into the room Nursing Care Guideline: Contact, Airborne, + Droplet Precautions; Protective Isolation (Cont.) 35

36.  Documentation concerns  Document isolation when it is begun and discontinued.  Document patient and family education concerning the proper procedures.  Mark “Isolation Precautions Required” on the chart.  Place signs in clear view on the door: “Visitors should report to the nurses’ station before entering the room.”  If isolation is broken, refer to institutional policy and procedures. Nursing Care Guideline: Contact, Airborne, + Droplet Precautions; Protective Isolation (Cont.) 36

37.  Standard precautions: Teach patients and their families the importance of the following on admission to the health care facility:  Appropriate hand hygiene  Respiratory hygiene and cough etiquette  Importance of vaccinations (especially against influenza) Patient Education and Health Literacy 37

38.  Transmission-based precautions: If a patient is diagnosed with a transmission-based illness and requires precautions, educate the patient and the family:  Provide fact sheets or pamphlets on the illness.  Provide rationales for the new precautions.  Explain any risk to family members.  Explain the personal protective equipment (PPE) being used and provide directions for its use by the family.  Be available to explain and ask questions as necessary. Patient Education and Health Literacy (Cont.) 38

39.  Mrs. Eldredge’s wound was infected. She was admitted and received IV antibiotics and wound irrigation. She was discharged on day 4.  At present, the wound remains open, but it is healing with new granulation tissue that is healthy. Case Study (Cont.) 39

40.  The nurse demonstrates effective use of strategies to reduce the risk of harm to self or others by properly using PPE.  When abrasions or skin breakdown is noticed, be sure to wear gloves during patient care.  Clean, nonsterile gloves are used when direct contact with body secretions is possible. Personal Protective Equipment (PPE) 40

41.  Purpose:  Sterile gloving technique protects highly susceptible patients, open wounds, and sterile objects from the transfer of microorganisms.  Sterile gloving technique is required in procedures requiring sterile technique.  Collaboration and delegation:  Mandated for health care provider for procedures that require sterile or clean technique  May be performed by UAP who are assisting and have been trained in the proper application Skill 26-2: Sterile Gloving 41

42.  Masks  Protect against transmission through the air  Effectiveness decreased when wet or worn for long periods  Particulate respirators  When patient is suspected of having or has a contagious airborne disease  Waterproof gowns  Caps Personal Protective Equipment, (Cont.) 42

43.  Purpose:  Use of personal protective equipment prevents the spread of microorganisms.  PPE may be required for specialized procedures.  Use of PPE protects self and others when: Caring for patients on isolation precautions. Caring for patients when any contact with blood or body fluids may be expected. Skill 26-3: Personal Protective Equipment (PPE) 43

44.  Collaboration and delegation:  PPE is mandated for all health care workers who come in contact with patients on isolation or are in situations in which contact with blood or body fluids may be expected; it is not delegated. It is important to speak up when you see anyone not following appropriate and prescribed PPE requirements. Not following PPE requirements may cause harm to the health care worker and the patient.  Unlicensed assistive personnel should be instructed in appropriate PPE techniques. Skill 26-3: Personal Protective Equipment (Cont.) 44

45.  Evidence-based practice  The order of donning and removing PPE is important in preventing contamination. Equipment is put on in order, starting with whatever part of the body is considered most contaminated and moving to the cleanest. Removing PPE should occur in an isolation anteroom, if available, or just inside the patient’s door before leaving the room.  The mask is removed last because it prevents airborne particles from other garments from entering the respiratory system. Skill 26-3: Personal Protective Equipment (Cont.) 45

46.  Immunization is the process by which an individual develops immunity against a specific agent; it is important in preventing the spread of communicable diseases.  Immunizations can be acquired through various techniques, the most common of which is vaccination.  All women of childbearing age should be up to date on immunizations according to CDC recommendations. Urge women trying to conceive to avoid exposure to infectious diseases. Immunization 46

47. Medical asepsis is often referred to as clean technique. Medical aseptic procedures include handwashing, wearing gloves, gowning, and disinfecting. Surgical asepsis, or sterile technique, is used to prevent the introduction of microorganisms from the environment to the patient. Surgical asepsis is used for surgical procedures, invasive procedures such as catheterization, procedures that invade the bloodstream or break the skin, dressing changes, and wound care. Medical Asepsis versus Surgical Asepsis 47

48.  Purpose  Use of a sterile field prevents the spread of microorganisms.  A sterile field is used in procedures requiring sterile technique.  Collaboration and delegation  Preparing a sterile field may not be delegated to UAP without special training to work in areas such as surgical units or possibly the emergency room.  Check facility policy before considering delegation. Skill 26-4: Sterile Fields 48

49.  Disinfection is the removal of pathogenic microorganisms; it typically destroys all pathogenic microorganisms except spores from inanimate objects.  Sterilization is a process used to destroy all microorganisms, including their spores.  Sterilization is used on equipment that is entering a sterile body cavity.  Many items are purchased as sterile or can be sterilized through physical or chemical means. Disinfection and Sterilization 49

50. 2. You are caring for a patient who underwent surgery 48 hours ago. On physical assessment, you notice that the wound looks red and swollen. The patient’s WBCs are elevated. You should: A.Start antibiotics. B.Notify the physician. C.Document the findings and reassess in 2 hours. D.Place the patient on isolation precautions. Quick Quiz! 50

51.  Asepsis in the home environment requires educating patients and their families or caregivers about the mode of transmission of pathogens and the means of prevention.  Many aseptic procedures that are performed in the health care environment can be performed in the home with some modifications.  The nurse must know what these modifications are and how to teach patients and their families the necessary skills before discharge. Infection Control and Aseptic Interventions in the Home 51

52.  Mrs. Eldredge continues recovering at home. When she visits Mrs. Eldredge, Kathy teaches her about infection prevention and control practices. Case Study (Cont.) 52

53.  Evaluation allows the nurse to determine whether the patient has met his or her treatment goals.  Evaluation is also an analysis that determines the effectiveness of the nursing interventions.  Evaluation may allow trends in infection control in the health care environment to be observed and acted on. Evaluation 53