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a disease state that results from the presence of pathogens in/on the body
agent capable of producing infection; some of the more prevalent agents are bacteria, virus, and fungi
the most significant and most commonly observed infection-causing agents in HC institutions can be categorized in different ways.
rod shaped bacteria
corkscrew shaped bacteria
have a thick cell wall that resists decolorization (loss of color) and are stained violet
have chemically more complex cell walls and can be decolorized by alcohol. They do not stain.
require oxygen to live and grow
those that can live w/o oxygen
smallest of all organisms, visible only by an electron microscope. many infections are caused by viruses, such as the common cold and the deadly disease, acquired immunodeficiency syndrome (AIDS). when antiviral meds are given in the prodomal stg of certain viruses, these meds can shorted the full stg of the illness.
plant-like organisms (molds and yeasts) that also can cause infection, are present in the air, soil, and water. are treated with antifungal meds;however many infections due to fungi are resistant to treatment.
an organism's potential to produce disease in a person depends on a variety of factors:
- - number of organisms
- - virulence of the organism
- - competence of the person's immune system
- - length and intimacy of the contact between the person and the microorganism
its ability to cause disease
occurs with predictability in one specific region or population can appear in a different geographical location
under normal conditions, some organisms may not produce disease. microorganims that commonly inhabit various body sites and are part of the body's natural defense system.
other factors that may intervene, causing this usually harmless organism to generate an infection. bacteria that normally cause no problem but, with certain factors, may potentially be harmful. for example, e. coli normally resides in the gi tract and causes no harm, but if it migrates into the urinary tract, it can lead to a UTI.
natural habit for the organism. Example: people, animals, soil, food, water, milk, and inanimate objects (fomites)
act as reserviors but are asymptomatic and can transmit the disease. for example, a person who has tested for HIV antibody is probably infected with HIV; however, this person may not show s/s of the disease at time of testing. moreover s/s of aids may not occur for years. however, the person may transmit the virus to other people by intimate sexual contact or sharing of contaminated needle or syringe.
portal of exit
point of escape for organism from reservior. In humans, common ones are GI tract, GU tract, resp, or skin break. Blood and tissue can also be portals of exit for pathogens.
means of transmission
can be directly/indirectly. Vectors like misquitos, ticks, and lice can transport. Can be airbourne route when an infected host coughs, sneezes, or talks, or when the organism becomes attached to dust particles. Droplet transmission is similar to airbourne tranmission. Airbourne particles are less than 5 microns. Droplet particles are greater than 5 microns.
involves proximity between the susceptible host and an infected person or a carrier, such as touching, kissing, or sexual intercourse. HC workers have the potential to directly transmit organisms to susceptible individuals through touching. Proper hand hygiene or glove use can interrupt this means of transmission. (cut chain of infection)
involves personal contact with an inanimate object, such an touching a contaminated instrument.
vehicles of transmission
contaminated blood, food, water, or inanimated object (fomite)
such as misquitoes, ticks, and lice, are nonhuman carriers, that transmit organisms from one host to another, that is, by injecting salivary fluid when a huamn bit occurs.
less than five microns
more than five microns
portals of entry
point at which an organism enters new host; entry route can be same as exit: GI/GU tract, skin break, etc.
microorganism can continue to exist only in a source that is acceptable (a host) and only if they overcome any resistance mounted by the hosts's defense
time between pathogen's invasion of the body and the appearance of symptoms of infection. During this stage, organisms are growing and multiplying. Length of incubation may vary.
time person is most infectious. Early s/s of disease are present, but these are often vague and nonspecific, ranging from fatigue and malaise to a low-grade fever. Lasts hours to several days. during this phase, pt often does not realize that he/she is contagious. as a result, the infection spreads.
full stage of illness
prescence of specific s/s. type of infection determines length of the illness and the severity of the manifestations.
symptoms that limited or occur in only one body area
symptoms manifested throughout the entire body
recovery period from the infection. may vary according to the severity of the infection and the pt's general condition. s/s disappear, and the person returns to a healthy state. depending on the type of infection, the person may have a temporary/permanent change to his/her previous health state even after the convalescent period. Person may continually pass through the four phases with the same infectious process, such as with herpes simplex. Although there may have been only one infectious exposure, the infection may continue to cycle through the phases.
First line of defense against infection
body's normal flora
Second line of defense against infection
Third line of defense against infection
antigen-antibody reaction/humoral immunity
one component of the overall immune response.
cell-mediated defense/cellular immunity
increase in the number of lymphocytes (WBCs) that destroy or react with cells the body recognizes as harmful.
helps to keep potentially harmful bacteria from invading the body.
are redness, heat, swelling, pain, and loss of fx and usually appear at the site of the injury/inflammation. The vasular and cellular and these physiological processes are responsible for the appearance of the cardinal signs.
the susceptibility of the host depends on various factors
- -integrity of skin and mucous membranes
- - pH lvls of the GI tract and GU tract as well as the skin
- - integrity and number of the body's WBC
- - age, sex, race, and hereditary, which influence susceptibilty
- - immunizations, natural/acquired
- - lvl of fatigue, nutritonal and general health status, the prescence of preexisting illnesses, previous/current treatments, and certain meds
- - stress lvl
- - use of invasive/indwelling medical devices, which provide exposure to and entry for more potential sources of disease-producing organism, particularly in a pt whose defenses are already weakened by disease
can result in redness, swelling, warmth in the involved area, pain/tenderness, and loss of fx of the affected part
fever, often accompanied by an increase in pulse and respiratory rate, lethragy, anorexia, and tenderness and enlargement of lymph nodes that drain the rea when an infection is present.
includes all activies to prevent infection/break the chain of infection.
medical asepsis/clean technique
involves procedures and practices that reduce the number and transfer of pathogens, include performing hand hygiene and wearing gloves.
surgical asepsis/sterile technique
includes practices used to render and keep objects and areas free from microorganisms. Surgical asepsis procedures could include inserting an indwelling urinary catheter/inserting an IV catheter.
used to decrease the spread of pathogens and include hand hygiene, PPE, and other barrier techniques.
contibuting factors to poor compliance with hand hygiene practices
- - lack of access to sinks
- - lack of time
- - skin irritation
- - ignorance about the importance of hand hygiene
- - individual preferences and habits
- - insufficent institutional commitment to appropriate hand hygiene procedures
although usually easily removed by thorough handwashing, have the potential to adjust to the environment of the skin when they are present in large numbers over a long period and become resident bacteria.
if pathogenic organisms become resident bacteria on the skin, the hands then become carriers of the particular organism. Therefore, to help prevent transient bacteria from becoming resident bacteria, it is important to clean the hands promptly when they are visibly soiled, after each contact with contaminated materials, and after removing gloves.
soaps and detergents are considered adequate for routine mechanical cleansing often hands and removal of most transient microorganisms. Help remove soil because they lower surface tension and act as emulsifying agents. Bar, liquid, leaflet, and powdered soaps are all effective. Sue of a particular type of a HC agency often depends on personnel or agency preference.
antimicrobial or antibacterial ingredient
recommended in any setting where the risk for infection is high. When present in certain concentrations, these agents can kill bacteria or suppress their growth. Numerous studies have documented alcohol-based handrubs more effectively reduce bacterial counts on the hands of HC personnel than antimicrobial soap does.
an alcohol-based handrub can be used to decontaminated hands in thefollowing clinical situations
- - before and after direct contact with pts
- - before and after using gloves
- - before inserting urinary catheters, peripheral vascular catheters, or invasive devices that do not require surgical placement
- - if moving form a contaminated body site to a clean body site during pt care
- - after contact with objects (including equipment) located in the pt's environment
gram-positive, anaerobic, spore-forming bacterium that is normally found in the intestine of many adults. Responsible for 75% of the HC-associated diarrhea diagnosed particularly in elderly pts and long-term care residents. Antibiotic therapy is frequently identified as the underlying cause of C. diff because it changes the normal intestinal flora, decreases resistance, and allows C. diff to colonize the large intestine.
surgical hand scrub
hand antisepsis before assisting with a surgical procedure involves a more lengthy scrub, reducing resident and transient flora from the forearms and hands. Incorporates surgical asepsis.
when the causative organism is acquired from other people
occurs when the causative organism comes from microbial life harbored in the person.
when it results from a treatment or diagnostic procedure. not all nosocomial infections are iatrogenic
With its focus on pt safety, the Joint Commission mandates that death/serious injury caused by an infection-related event must be reported as a sentinel event. (Joint Commission defines a sentinel event as any anticipated event in a HC setting resulting in death/serious physical/psychological injury to a pt/pts not related to the natural cause of the pt's illness.)
The Centers for Medicare and Medicaid Services (CMS) will no longer reimburse hospitals for 8 preventable hospital-acquired conditions, such as urinary tract infections from improper use of catheter, vascular catheter-associated infections, and certain surgical site infectons are included on the list. 9 other HAIs are also being considered for addition to the list.
to address HAIs, HC agencies have found the following measures to be successful in reducing their incidence
- instituting constant surveillance by infection-control committees and nurse epidemiologists.- Having written infection-prevention practices for all agency personnel. adherence to hand hygiene recommendations and infection-control precaution techniques can prevent many HAIs.- Using practices to promote and keep pts in the best possible physical condition. Measures include meeting the pt's needs for nutrition, fluids, rest, oxygen, and physical and psychological comfort and security.
Research has also indicated that staffing issues may have an impact on HAIs. That there was evidence that, when nurses worked overtime, there was an increase in catheter-associated UTIs.
Most HAIs are caused by bacteria, such as E. coli, Staph aureus, Streptococcus faecalis, Pseudomonas aeruginosa, and Klebsiella species. Many of the HAIs can be traced to an invasive device, such as a urinary catheter or venous access catheter. The increasing use of biomedical equipment is often cited as a causative factor. Other devices associated with causing infection include hemodynamic monitoring lines, homodialysis equipment, and respiratory equipment. Pts receiving mechanical ventilation are especially at risk for HC associated pneumonia. It is the hands of the HC worker using the instruments or equipment that are the most significant meas for the transmission of the pathogens.
methicillin-resistant Staaphylococcus aureus (MRSA)
bacteria normally found in the nasal mucous membranes, on the skin, and in the respiratory tract and GI tract. Approximately one-third of the people in the U.S. are colonized with "staph" meaning that the organism is present in these locations but the individual does not have symptoms and remains healthy and uninfected. They can, however, pass the organism on to others. In the 1960s, a strain of this bacteria emerged that was resistant to the broad-spectrum antibiotic (methicillin) normally the drug of choice used to treat it. The very powerful antibiotic, vancomycin, had to be used to teat the MRSA infections that primarily occurred in HC settings. The HC-associated MRSA strain has more serious implications and accounts for more than 60% of the infections that occur in hospitals. Can be responsible for bloodstream infections, wound infections, ventiliator-associated pneumonia, and mulitdrug resistance. Intravenous vancomycin is the drug of choice for HC-associated MRSA, but if the bacteria develop resistance to vancomycin, then the infection can be treated with a synthetic antibiotic, such as linezolid (Zyvox). In a HC setting, the main mode of transmission is through contact with the contaminated hand of HC personnel or contact w/equipment. Basic infection control practices are key to the prevent and control of MRSA.
community associated mrsa (CA-MRSA)
in 1980s, a type of mrsa appeared in wider community. a common cause of skin infections in the us, has been rapidly spreading into hospitals. most at risk are young children, older adults, and pts diagnosed with HIV or aids. contact sports and sharing of personal items also increase the risk.
treatment guidelines for community acquired mrsa include the following
- - incision and drainage of abcesses in pts with mild to moderate infections. antimicrobial therapy may not be required.
- - if incision and drainage are not effective and systemic or serious infection results, antimicrobial therapy may be neccesary.
- - antimicrobial therapy may be prescribed for 7 to 10 days dependign on the severity of the infection. medications may include trimethoprim-sulfamethoxazole (Bactrim and others), minoccline (Minocin), doxycycline (Vibramycin and others), and clindamycin (Cleocin and others).
- - Tetracycline hydrochloride (Achromycin) is not recommended for any pregnant pt or children under the age of 8.
Vancomycin intermediate-resistant Staphylococcus aureus (VISA)
emerged in 2002 in the US that was totally resistant to vancomycin, followed closely by vancomycin-resistant S. aureus (VRSA). Once bacteria develop resistance, they progress from being sensitive to an antibiotic to an intermediate resistance followed by complete resistance to the antibiotic. Treating these two organisms has provided a formidable challenge because antibiotics that are available and able to treat this organism are limited. Linezolid (Zyvox) and quinupristin-dalfopristin (Synercid) are alternative antibiotics that can be used in place of vancomycin. They are very expensive and resistance to linezolid has been reported. Pts at risk of devloping VISA and VRSA are individuals with a hisotry of renal failure requiring either hemodialysis or peritoneal dialysis, a previous MRSA infection, or a history of prior and possibly prolonged use of vancomycin. Effective infection control measures are imperative to control the spread of VISA and VRSA and prudent use of vancomycin is an important preventive measure.
Vancomycin-resistant enterococci (VRE)
is another serious pathogen in hospitals. Entrococci, a species of steptococcus often found in normal intestinal and female genital tracts, can cause HC-associated infections with a high mortality rate if the organism is vancomycin resistant. Originally treated with penicillin, ampicillin and then gentamicin, the enterococci became resistant to each drug. Subsequently, physicians again prescribed vancomycin as the drug of choice. However, resistance has developed to this and treatment options are limited to the 2 newer antibiotics previously mentioned for VISA and VRSA--linezolid and quinupristin-dalfopristin. VRE is spread via contact with feces, urine, or blood of an infected/colonized person. HC providers have the potential to spread VRE on their hands from one pt to another. Medical equipment and environmental surfaces can also harbor this organism. Hand hygiene and contact precautions can halt the spread of VRE. Careful assessment, intervention, and evaluation of high-risk pts and situations by nurses helps to minimize infection and reduce unnecessary suffering imposed on pts.
Risk factors for VRE include
- - Compromised immune systems
- - Recent abd/chest surgery
- - Presence of urinary/central IV catheter
- - Prolonged antibiotic use, esp. with vancomycin
- - lengthy hospital stay esp. in the ICU
destroys all pathogenic organisms except spores... can be used when preparing the skin for a procedure or cleaning a piece of equipment that does not enter a sterile body part.
destroys all microorganisms, including spores... is usually performed on equipment that is entering a sterile portion of the body. Disinfection and sterilization of contaminated or infected objects and good hand hygiene diminish and often eliminate microorganisms as potential sources of infection.
various factors influence the choice of sterilization and disinfection methods
- - nature of organisms present: the CDC recommends that all supplies, linens, and equipment in a HC seting should be treated as if the pt were infectious.
- - number of organisms present: the more organisms present on an item, the longer it takes to destory them.
- - type of equipment: equipment with small lumens, crevices, or joints requires special care. Certain articles taht may be damaged by various sterilization and disinfection methods require special handling
- - intended use of equipment: the need for medical/surgical asepsis influences the preparation and cleaning of equipment. In the home, it may be safe to use equipment and supplies that are clean, but most HC agencies prefer to use sterilized articles for pt care.
- - available means for sterilization and disinfection: the choice of chemical/physical means of sterilization and disinfection depends on the nature and number of organisms, type and intended use of the equipment, and the availability and practicality of the means.
- - Time: time is key factor when sterilizing/disinfecting articles. Failure to following the recommended time periods is grossly negligent
The following techniques are recommended for cleaning equipment
- - wear waterproof gloves at all times
- - rinse the articles first with cold running water to remove organic material. Heat coagulates certain organic material, which makes removal more difficult.
- - wash the articles, after rinsing them, in warm water that contains detergent/soap. Combination of warm water and soap facilitates emulsification and removal of dirt and debris
- - use a brush with stiff bristles, as indicated, to clean the articles thoroughly. Friction aids in the removal of organisms and debris from difficult-to-reach areas.
- - Rinse and dry the article thoroughly
- - Prepare the cleaned equipment for sterilization or disinfection
- - Consider the brush, gloves, sink/basin in which the articles were cleaned as highly contaminated, and treat/discard them accordingly
OSHA ruling HC agnecies must provide employees w/ the equipment and supplies necessary to minimize or prevent exposure to infectious material
personal protective equipment (PPE)
includes gloves, gowns, masks, and protective eye gear.
not a substitute for good hand hygiene, are worn only once and discarded appropriately according to agency policy. (Actually, the warmth and moisture inside gloves create an ideal environment for bact to grow, making it more important to perform hand hygiene.) Then hands are thoroughly decontaminated with hand hygiene. Each pt. interaction requires a clean pair of gloves, and some care activities for an individual pt may necessitate changing gloves more than once. Gloves should always be changed prior to moving from a contaminated task to a clean one. While wearing gloves do not: leave the pt's room (unless transporting a contaminated item/a pt requiring transmission-based precautions), write in the pt's chart, or use the computer keyboard/telephone in the nurse's station. Also HC workers should not touch their pagers/cell phones w/o performing good hand hygiene first
putting on two gloves. is recommended if the HC worker is going to be exposed to blood/body fluids. double gloving with a colored glove under a translucent outer glove is an alternative solution to detect a breach in glove integrity.
frequenly used products that contain latex
- - blood pressure cuffs
- - electrode pads
- - IV tubing
- - foley catheters
- - baby bottle nipples
- - stethoscopes
- - tourniquets
- - syringes
- - surgical masks
- - pacifiers
diagnosis of latex
- - RAST: blood test for IgE antibodies to latex
- - Skin prick: small amount of serum derived from latex placed on small prick of skin
- - Glove challenge: pt wearing a latex glove for period of time, w/periodic checking for any signs of latex reactions
treatment for latex allergies
- - avoidance of latex-containing products
- - localized reaction treated w/oral diphenhydramine, cool compresses, and hydrocortisone 1% cream
- - systemic reaction possibly treated with epinephrine subcutaneously, systemic steroids, antihistamines, with transport to the emergency department.
risk factors for latex allergies
- - HC workers who wear latex gloves
- - people w/allergic tendencies
- - people w/food allergies, specifically banana, papaya, avocado, potatoes, kiwi fruit, chestnuts, and pineapples
- - Latex-industry workers
- - People w/asthma, spina bifida, or a hx of multiple surgical procedures/exposures to latex
types of reactions to latex
- - irritant contact dermatitis: nonallergic dermatitis, restricted to area that has made contact w/ the latex. Gloves may cause erythematous and pruritic hands. This is not a true allergy.
- - chemical sensitivity dermatitis/delayed hypersensitivity: allergic contact dermatitis, displayed as dry, crusty bumps, erythema, pruritus, scaling vesicles, papular lesions at site of contact, including the palms; not a life-threatening reaction, however, person should be aware of latex contact
- - latex allergy/type I hypersensitivity: systemic reactions, displayed as rhinitis, conjunctivis, angioedema, bronchospasm, shock, and/or systemic anaphylactic reactions; this is a life-threatening sensitivity
protocols for pts with latex allergies
- - assess pt for allergies to latex products
- - place allergy sticker on chart, a caution sign on door, and an allergy bracelet band on the pt's wrist
- - remove all latex-containing articles from room
- - place 3-way stopcocks in IV lines for med administration. place tape over an injection ports on IV tubing
- - remove rubber stoppers from vials before drawing up meds
- - if available, place a cart containing all latex-free supplies in/outside of pt's room
- - use glass syringes if no latex-free alternative is available
- - cover latex portion of blood pressure cuff or stethoscope before using on pt
- - wearing vinyl/synthetic gloves when caring for pts
an exaggerated allergic reaction that can result in death
prevent soiling of the HC worker's clothing by the pt's blood and body fluids. Provide barrier protection and are donned immediately before entering the pt's room. Individual gown technique is recommended; means that a gown is worn only once and then discarded.
used if there is an increased likelihood of contact with the pt's blood/body fluids. If gown becomes heavily soaked, remove it, perform hand hygiene, and put on a clean gown.
- help prevent the wearer from inhaling large particle aerosols, which usually travel short distances (about 3ft) and small-particle droplet nuclei, which can remain suspended in the air and travel longer distances. Also discourage the wearer from touching the eyes, nose and mouth, thus limiting contact of organisms w/mucous membranes.
- Various mask practices are used. In some instances, all personnel and all pt's visitors wear masks; in other situations, a pt requiring specific precautions wears the mask when transported outside his/her room to protect HC personnel and other pts from any exposure to pathogens
- A mask is worn only once and never lowered around the neck and then brought back over the mouth and nose for reuse. How long one can wear one mask while caring for one pt is the subject for debate. Regardless of the time worn, a mask must be changed before it becomes damp from the wearer's exhalations.
high-efficiency particulate air (HEPA) filter respirator vs. N95 respirator
- Serious increase in the number of multidrug resistant TB cases prompted new guidelines to prevent the transmission of this disease. According to CDC guidelines, either a HEPA or N95 certified respirator by NIOSH must be worn when entering the room of a pt with known or suspected TB. Respirators filter inspired air, whereas surgical masks filter expired air.
- Caregivers have expressed difficulty wearing the HEPA-style respirator for extended periods of time, but the N95 respirator, which is designed to filter out particles as small as 1 mcm with 95% efficiency, fits more comfortably against the face. The N95 mask also considerably less than the HEPA filter respirators. Elastic straps on these respirators provide more protection and a better fit than the ties on regular surgical masks.
- such as goggles and faceshields.
- Must be available whenever there is a risk of contaminating the mucous membranes of the eyes. For example, suctioning a tracheostomy/assisting w/an invasive procedure that may result in splattering of blood or other body fluids requires protections for the caregiver.
handling and disposing of supplies
- used equipment may be disposed of after use, or if reuseable, bagged according to agency policy, sent to a central cleaning area, and sterilized/disinfected
- double bagging
- combined hot water and detergent used in commercial dishwashers sufficiently decontaminates dishes, glasses, and utensils. All spills of body fluids or substances must be immediately cleaned w/the appropriate chemical germicide/disinfectant.
- When collecting a specimen, take care to prevent the outside of the container from becoming contaminated with any secretions/body fluids. Place all lab specimens in plastic bags and seal the bags to prevent leakage during transportation. A bag marked "BIOHAZARDS" is used to dispose of trash that contains liquid or semiliquid blood or other potentially infective material (OPIM), trash contaminated with blood or OPIM that would release these substances if compressed, and trash that is caked with dried blood or OPIM and is capable of releasing these materials during handling.
- may be required if the single bag is not secure/is soiled on the outside. a contaminated item must never be used for another pt.
- double bagging of trash and linen is usually needed only if the outside of the bag is visibly soiled. some linen bags are water proof soluble and dissolve in hot water, making it unnecessary for the workers to handle the contaminated linen.
a protective procedure that limits the spread of infectious diseases among hospitalized pts, hospital personnel, and visitors, has been used.
infectious disease hospitals
where isolation efforts were placed at moving infected individuals together in one hospital or a hospital ward where caregivers used gowns and antiseptic solutions for hand washing as barriers to disease transmission. Eventually, infectious disease hospitals closed, including those set aside for people with TB. Pts who were considered infectious were routinely placed on general hospital units in separate rooms/in multiple-pt rooms with other pts who had the same infection.
Hepatitis B virus (HBV) poses the greatest bloodbourne risk to HC workers. OSHA also required that employers offer HBV vaccine free of charge to employees to prevent its transmission. ANA continues to urge OSHA to extend this directive to provide immunization and mandate protection against bloodbourne diseases for nursing students who practice in these HC facilities. OSHA has also fined hospitals that fail to use equipment/devices that reduce the risk for needlestick injuries for employees.
name the two tiers of precautions
standard precautions and transmission based precautions
used in the care of all hospitalized individuals regardless of their diagnosis or possible infection status. Apply to blood, all body fluids, secretions, and excretions, except sweat (whether or not blood is present or visible), nonintact skin, and mucous membranes. New additions here are Respiratory Hygiene/Cough Etiquette, safe injection practices, and directions to use a mask when performing high-risk prolonged procedures involving spinal canal punctures.
- used in addition to standard precautions for pts in hospitals w/suspected infection w/pathogens that can be transmitted by airbourne, droplet, or contact routes. New to the 2007 guidelines is a directive to don PPE when entering the room of a pt on contact/droplet precautions. Previously, PPE was only required when the RN was delivering care within 3 feet of the pt. These categories recognize that a disease may have multiple routes of transmission. Three types of transmission based precautions (airbourne, droplet, or contact) may be used alone or in combination, but always in addition to standard precautions.
- CDC continues to recommend the use of puncture-resistant containers for disposal of all needles and sharps. Since most needlestick injuries occur during recapping, never recap needles. Most serious risk associated w/needlestick injury is the possible exposure to bloodbourne pathogens, such as HBV, hepatitis C virus (HCV), and HIV. Hospitals now purchase needleless, protected, or recessed IV systems, even though they are expensive.
Standard precautions (Tier 1) guidelines
- - follow hand hygiene techniques
- - wear clean non-sterile gloves when touching blood, body fluids, excretions, secretions, contaminated items, mucous membranes, and nonintact skin. Change gloves between tasks on the same pt as necessary and remove gloves promply after use.
- - wear PPE during procedures and care activities that are likely to generate splashes or sprays of blood or body fluids. Use gown to protect skin and prevent soiling of clothing
- - Follow respiratory hygiene/cough etiquette. Any pts, family members, and visitors w/undiagnosed, transmissible respiratory infections require education to cover their mouth and nose with a tissue when coughing and promptly dispose of the tissue. During periods of increased occurrence of respiratory infections, offer a surgical mask to coughing pts and other symptomatic persons upon entry to the HC facility/office. Encourage the coughing pt to maintain more than a 3-foot separation from other persons in the HC facility or office.
- - Avoid recapping used needles. If you must recap, never use two hands. Use a needle-recapping device or the one-handed scoop technique. Place needles, sharps, and scapels in appropriate puncture-resistant containers after use.
- - use safe injection practices including single dose vials when possible; use disposable needles and syringes for each injection, and prevent contamination of injection equipment and medication
- - wear face mask if placing a catheter or injecting material into the spinal or epidural space
- - handle used pt care equipment that is soiled with blood or identified body fluids, secretions, and excretions carefully to prevent transfer of microorganisms. Clean and reprocess items appropriately if used for another pt.
- - use adequate environmental controls to ensure that routine care, cleaning, and disinfection procedures are followed.
- - review room assignments carefully. place pts who may contaminate the environment in private rooms (such as an incontinent pt)
airbourne precautions (tier 2) guidelines
- - use these for pts who have infections that spread through the air such as TB, varicella (chicken pox), rubeloa (measles), and possibly SARS
- - place pt in private room that has monitored negative air pressure in relation to surrounding areas, 6 to 12 air changes per hour and appropriate discharge of air outside or monitored filtration if air is recirculated. Keep door closed and pt in room
- - wear a mask/respirator when entering room of pt w/known/suspected TB. If pt has known/suspected rubeola (measles) or varicella (chicken pox), respiratory protection should be worn unless person entering room is immune to these diseases.
- - transport pt out of room only when necessary and place a surgical mask on the pt if possible.
droplet precautions (tier 2) guidelines
- - use these for pts with an infection that is spread by large-particle droplets, such as rubella, mumps, and diphtheria, and the adenovirus infection in infants and young children.
- - use a private room, if available. Door may remain open
- - wear PPE upon entry into the room for all interactions that may involve contact with the pt and potentially contaminated areas in the pt's environment
- - transport pt out of the room only when necessary and place a surgical mask on the pt if possible
- - keep visitors 3 ft from the infected person
contact precautions (tier 2) guidelines
- - use these for pts who are infected or colonized by a multidrug-resistant organism (MDRO)
- - place the pt in a private room, if available
- - wear PPE whenever you enter the room for all interactions that may involve contact with the pt and potentially contaminated areas in the pt's envornment. Change gloves after having contact with infective material. Remove PPE before leaving the pt environment, and wash hands with an antimicrobial/waterless antiseptic agent.
- - limit movement of the pt out of the room
- - avoid sharing pt-care equipment
- used for pts with compromised immune systems, such as pts recovering from transplantation surgery or receiving chemotherapy. Those who are immunosuppressed more often than not become infected by organisms harbored in their own bodies. As with all pts, standard precautions are required, but some additional measures are helpful when a pt's ability to withstand any bacterial invasion is compromised. Recommendations in this situation include the following:
- - Ensure the caregiver is healthy
- - Restrict visits from family/friends who have colds/contagious illnesses
- - avoid collection of standing water in the room (e.g., with flowers or in humidifiers) to prevent bacteria typically found in this water.
- Latest CDC isolation guidelines also address environmental controls that foster a "protective environment" to decrease the risk of infection in the MOST severly immunocompromised pts.
- increasing number of individuals who are ill/immunocompromised poses sterilization and disinfection concerns for home environments.
common measures that reduce the risk of infection at home include the following
- - wash hands frequently--before preparing food, before eating, and after using the bathroom
- - keep immunizations up to date
- - clean and disinfect kitchen surfaces, esp when preparing meat, chicken, and fish
- After thorough cleaning, some contaminated items may be disinfected by placing them in boiling water/using common household disinfectants, such as bleach, isopropyl alcohol (70%), or acetic acid (white vinegar).
- - avoid sharing personal items
- - cook food to the proper internal temp
- - promptly refrigerate or freeze perishables, prepare foods and leftovers
practicing basic principles of surgical asepsis
- - allow only a sterile object to touch another sterile object. unsterile touching sterile means contamination has occurred
- - open sterile packages so that the first edge of the wrapper is directed away from the worker to avoid the possibility of a sterile surface touching unsterile clothing. The outside of the sterile package is considered contaminated.
- - Avoid spilling any solution on a cloth/paper used a sterile for a sterile setup. The moisture penetrates through the sterile cloth or paper and carries organisms by capillary action to contaminate the field. A wet field is considered contaminated if the surface immediately below it is not sterile.
- - Hold sterile objects above the level of the waist. This will ensure keeping the object within sight and preventing accidentally contamination.
- - avoid talking, coughing, sneezing, or reaching over the sterile field/object. This helps to prevent contamination by droplets from the mouth and nose/by particles dropping from the worker's arm
- - never walk away from/turn your back on a sterile field. This prevents possible contamination while the field is out of the worker's view.
- - keep all items sterile that are brought into contact with broken skin, or used to penetrate the skin to inject substances into the body, or to enter normally sterile body and incision, needles for injection, and tubes (catheters) used to drain urine from the bladder
- - use dry, sterile forceps when necessary. Forceps soaked in disinfectant are not considered sterile
- - consider the edge (outer 1 inch) of a sterile field to be contaminated
- - consider an object contaminated if you have any doubt as to its sterility
surgical asepsis vs medical asespsis
when observing medical asepsis, areas are considered contaminated if they bear or are suspected of bearing pathogens; whereas when following surgical asepsis, areas are considered contaminated if they are touched by any object that is not also sterile. One of the most important aspects of surgical and medical asepsis is that the effectiveness of both depends on faithful and conscientious practice by those carrying them out. It is better to err on the side of safety when using surgical asepsis than to take the slightest chance of possible contamination. Being a pt advocate requires vigilant aseptic technique and a willingness to speak up if the pt's safety has been compromised by improper procedures.
opening a sterile package and preparing a sterile field`
commercially prepared sterile items may be sealed in paper or packaged in plastic containers. Sterile packages may be opened on a flat surface/while held in the hands. A sterile item should be covered if it is used immediately. Reapply the cover by touching only the outside of the wrapper and reversing the opening order.
pouring sterile solutions
outer surfaces of the bottle and cap are considered unsterile, whereas the inside areas and the solution are considered sterile. After a solution has been opened, the outer bottle should be labeled and dated if it is to be reused. Most solutions are considered sterile for 24hrs after they are opened. When pouring from a bottle, grasp the bottle so that the label is in the palm of your hand. This action prevents liquids from running down the label and making it illegible. Avoid splashing the liquid since this would contaminate the sterile field.
adding sterile supplies to a sterile field
once the sterile field is established, the objects on the sterile field may be handled only with sterile forceps or with hands wearing sterile gloves
putting on sterile gloves
sterile gloves are donned in a way that allows only the inside of the gloves to come in contact w/the hands. After the gloves are on, only sterile items may be handled with the sterile-gloved hands. Careful removal of the gloves reduces any hand contact with contaminated materials. Good hand hygiene technique before and after putting on sterile gloves is imperative.
positioning a sterile drape
the sterile drape, which is ideally waterproof, may be used to extend the sterile working area. Using sterile gloves allows the nurse to handle the entire drape surface. For protection when positioning, fold the upper edges of the drape over the sterile-gloved hands. When sterile gloves are not worn, the nurse can touch only the outer 1 inch. Use caution when gently shaking the drape open so as not to touch one's clothing or an unsterile object. Hold the drape by the 1-inch upper edge and position the drape over the desired area. Do not reach over the drape because this would contaminate a sterile area.
Sensory deprivation and loss of self-esteem may occur with transmission-based precautions. Research has also verified that pts may suffer unintended consequences such as an increase in incidents of depression, fewer visits from HC staff, and an increase in the number of med errors.
Health teaching about transmission-based precautions can ease the fear of pts and family members. Both must understand the pertinent epidemiologic facts and how to carry the specific precautions. It is helpful to emphasize the following:
- - precautions are temporary
- - the precautions and PPE worn by the staff protect the pt, the caregiver, and other pts
- - proper hand hygiene before and after visiting the pt is the most effective measure to prevent spread of the disease
- - continued explanations about procedures and continued updates on progress help to minimize anxiety
nurse are responsible for their own safety. any needlestick injury/accidental exposure to blood/body fluids must be reported immediately so that appropriate interventions can be used. Failure to notify an employer of an exposure may result in personal jeopardy as well as loss of compensation if an infection develops. Agency's plan for this type of exposure typically includes the following:
- - washing the exposed area immediately with warm water and soap
- - reporting the incident to the appropriate person and completing an incident/injury report if required by the agency
- - informing the agency of the source (pt's name) and nature of the exposure
- - consenting to an initial baseline blood test, if agreeable, to determine personal HIV and HBV status, with repeat blood testing 6 wks after exposure and at 3-month, 6-month, and 1-yr intervals
- - consenting to postexposure prophylaxis, if recommended, at the appropriate time
- - awaiting blood test results of the involved pt (w/ his or her consent) to determine HIV, HBV, and HCV status. State laws may vary concerning this practice.
- - attending counseling session regarding safe practices to protect self and others.
many hospitals rely on a specialized practitioner to survey lab reports and review records for pts at risk, as well as suggest approaches to potentially dangerous situations. the infection preventionist knows the devastating effects of infection and is intent on promoting health and fostering a systematic approach to infection control.
responsibilities of an infection preventionist
- - developing a plan to reduce the occurrence of HAIs
- - collaborating w/state and local health departments regarding recommended/mandatory reporting of HAIs
- - developing a plan to respond to an act of bioterrorism
- - evaluating new products
- - providing routine consultations to staff and pts regarding infection control issues
- - in the home, the infection preventionist's duties include surveillance for agency-associated infections, education, consultation, epidemiologic investigation, quality-improvement activities, and policy and procedure development.
medical asepsis techniques are appropriate for most procedures in the home, except for self-injection technique and venous catheter care, which require surgical asepsis.
pts should be taught to use basic principles of asepsis at home and in public facilities. these involve the ADL. Examples of medical asepsis practices recommended in the home:
- - washing hands before preparing food and before eating
- - preparing foods at temps high enough to ensure that they are safe to eat, the most common example being the preapation of fresh meat
- - washing hands, cutting boards, and utensils with hot, soapy water before and after handling raw poultry and meat
- - keeping foods refrigerated, esp those containing mayo
- - washing raw fruits and vegs before serving them
- - using pasteurized milk and fruit juices
- - washing hands after using the bathroom
- - using individual personal care items, such as washcloths, towels, and toothbrushes, rather than sharing
pts may need teaching about ways to prevent infection in public facilities
- - wash hands after using any public restroom
- - use paper towels/hot-air dryers in restrooms
- - use individually wrapped drinking straws
- - use tongs to lift food from common service trays in cafeterias, food stores, and salad bars
community reinforces medical asepsis practices in various ways
- - using sterilized combs and brushes in barber and beauty shops
- - performing examination of food handlers for evidence of disease
- - encouraging food handlers to receive hepatitis A vaccination
- - enforcing frequent handwashing by food handlers
If pt goals have been met and evaluative criteria have been satisfied, the pt will accomplish the following:
- - correctly use techniques of medical asepsis
- - identify health habits and lifestyle patterns that promote health
- - state the s/s of an infection
- - identify unsafe situations in the home environment