Health Safety: Chapter 27, Asepsis and Infection Control

Taylor's Fundamentals of Nursing
Ch 27, Asepsis and Infection Control

I am highlighting sections that I think could make good Select All That Apply questions

Infection Cycle

  • An infection occurs as a result of a cyclic process
  • There are six components:
    • Infectious Agent
    • Reservoir
    • Portal of exit
    • Means of transmission
    • Portals of EntrySusceptible host
  • Infectious Agent:
    • Most prevalent agents are bacteria, viruses, and fungi
  • Bacteria:
    • Have various categories:
      • Spherical (Cocci)
      • Rod shaped (bacilli)
      • Corkscrew (spirochetes)
      • Gram Positive- thicker cell wall, will stain violet
      • Gram negative- can be decolorized by alcohol and do not stain
      • Aerobic- needing oxygen
      • Anaerobic- not needing oxygen to survive
  • Viruses:
    • smallest of all microorganisms
    • when given in the prodromal stage of certain viruses, antivirals can shorten the flu stage of the illness
    • not susceptible to antibiotics 



  • Fungi:
    • plant like organism found in air, soil, and water
    • cause of athletes foot, ring worm, yeast infections
    • treated with anti fungal meds but many are resistant
  • An organisms potential to produce disease in a person depends on a variety of factors including:
    • Number of organisms
    • Virulence of the organism 
    • Competence of the persons immune system
    • length and intimacy of the contact between the person and the organism
  • Endemic: occurs with predictability in one region or population
  • Opportunists: bacteria that normally cause no problem but, with certain factors, may potentially be harmful (i.e., E.Coli- ok in GI tract, harmful in urinary tract)
Reservoir

  • The reservoir for growth and multiplication of the microorganism is the natural habitat of the organism. Possible reservoirs include:
    • other people
    • soil
    • food
    • water
    • milk
    • inanimate objects
  • Other people:
    • some people show sign and symptoms of a disease
    • those that do not show signs and symptoms are called carriers and can transmit the disease even though they are asymptomatic
    • example: HIV
    • Nurses can act as reservoirs by carrying microbes under long artificial nails or by ineffective hand washing and glove use
Portal Of Exit
  • the portal of exit is the escape for the organism from the reservoir
  • commons ports of escape in humans:
    • respiratory
    • gastrointestinal
    • genitourinary tracts
    • breaks in skin
    • blood and tissue
Means of Transmission

  • Organism scan enter by way f the contact route either directly or indirectly
  • Direct: touching, kissing, sexual intercourse
  • Proper hand hygiene and glove use can prevent this transmission
  • Vectors: on human carriers that transmit organisms from one host to another (mosquitoes, ticks, lice)
  • Airborne route: coughing, sneezing, talking
  • Droplets
  • Airborne particles are <5mcm and="" are="" droplet=""> than 5mcm
Portal of Entry
  • the point at which organism enter a new host
Susceptible Host
  • organisms can only continue to exist if they can find a host and overcome any resistance mounted by it's immune system
Stages of Infection

  • Infection progresses through the following stages:
    • Incubation period
      • the interval between the pathogens invasion of the body and the appearance of symptoms 
    • Prodromal Stage
      • time when person is most infectious, early signs and symptoms of disease are present but they are vague and non-specific
      • lasts from hours to days
      • person does not realize they are contagious
      • as result, infection spreads
    • Full Stage of Illness
      • presence of specific signs and symptoms
      • localized symptoms: limited or occur in only one body area
      • systemic symptoms occur throughout entire body
    • Convalescent period
      • period of recovery
      • depending on type of infection, person may have temporary or permanent change to baseline state of health
The Body's Defense Against Infection
Immune response and Inflammatory response

 Inflammatory Response

  • protective mechanism that eliminates the invading pathogen and allows for tissue repair to occure
  • helps body to neutralize, control, or eliminate offending agent
  • Cardinal signs of infection are:
    • redness
    • heat
    • swelling
    • pain
    • loss of function
  • Vascular and Cellular Stages are main components of Inflammatory Process
    • Vascular Stage
      • small blood vessels constrict
      • followed by vasodilation of arteries and venues that supply the area
      • increased blood flow and redness
      • Histamine is released leading to increased permeability of vessels, allowing protein rich fluid to pour in
      • now swelling, pain, and loss of function can occur
    • Cellular Stage
      • WBC's move into area
      • Neutrophills, primary phagocytes, engulf organism and consume debris
      • exudate composed of cells, fluid, and inflammatory byproducts is released and may be 
        • clear- serous
        • contain red blood cells- sanguinous
        • or contain pus- purulent
      • damaged cells are then repaired by regeneration of identical cells or by scar tissue
Immune Response

  • Involves specific responses such as the body's own proteins
  • foreign material is called an antigen
  • body responds by producing antibody
  • this is known as humoral immunity
  • other type of defense is cell mediated defense, cellular immunity
  • involves increase in lymphocytes that destroy invaders
Factors Affecting Risk for Infection
  • Integrity of skin, mucous membranes
  • pH levels of skin, GI tract dab genitourinary tract
  • number of body's white blood cells
  • Age, sex, race, heredity
  • Immunizations, natural or acquired immunity
  • Level of fatigue, nutritional and general health status, preexisting conditions, current treatments, medications
  • Stress level
  • Use of invasive or indwelling catheters
Nursing Process for Infection Prevention and Control

 Assessing

  • nurses role in preventing and controlling infection begins with early detection and surveillance techniques
  • inquire about a pts immunization status and previous or recurring infections
  • observe for signs and symptoms of a local or systemic infection
  • Localized Infection:
    • redness, swelling, warmth, pain, loss of function
  • Systemic Infection:
    • fever, lethargy, anorexia, tenderness and enlargement of lymph nodes
  • Labs for Infection
  • WBC- 5,000-10,000
  • A little mnemonic I used for WBC'S is "Sixty, forty, eight, two, 0... Never Let My Engine Blow
  • Neutrophils, Lymphocytes, Monocytes, Eosinophils, Basophils and they're respect amounts
  • Increased Ertythrocyte Sedimentation Rate- red blood cells settle more rapidly to bottom of tube of whole blood when inflammation is present
Outcome Identification and Planning
  • The patient will:
    • demonstrate effective hand washing
    • identify signs of infection
    • maintain adequate nutriiton intake
    • demonstrate proper disposal of soiled articles
    • demonstrate stress reduction techniques
    • verbalize understanding of latex allergy
Implementing
  • practice of asepsis includes all activities to prevent infection or break chain of infection
  • two categories of aseptic technique: Medical and Surgical
  • Medical Asepsis: clean technique, involves procedures and practices that reduce that number and transfer of pathogens (hand washing, wearing gloves)
  • Surgical Asepsis: sterile technique, practices to render and keep objects and areas free from microorganisms
  • Nearly every nursing activity includes practices of medical asepsis, therefore, the nurse assumes a major responsibility for breaking the cycle of infection
  • Barriers are ways to decrease spread f pathogens and include gloves, PPE, and hand hygiene 
Bacteria
  • two types are usually found on hands: Transient and Resident
  • Transient- usually removed through good hand washing but have the ability to adapt to the skin and when present in large number over time, become resident bacteria
    • occur on hands with ADL's
    • relatively few in number on clean and exposed areas of skin
    • attached loosely on skin usually in grease, dirt, and fats
    • can be pathogenic or nonpathogenic
    • can be removed easily by hand washing
  • Resident -
    • normally found in creases of skin
    • usually stable in number and type
    • cling to skin by adhesion and absorption
    • require friction with a brush t be removed, less susceptible to antiseptics
Hand Washing Techniques:

"If the healthcare worker's hands are not visibly soiled, alcohol based hand rubs are recommended because they  save time, do not require a sink, are easy to use, reduce bacterial count, and efficiently kill many fungi and viruses on the hands. In these clinical situations, alcohol based can be used:"
  • before and after direct contact with pts
  • before and after using gloves
  • before inserting urinary caterers, peripheral vascular catheters, or invasive devices that do not require surgical placement
  • if moving from a contaminated body site to a clean one
  • after contact with objects in a pts room
When used repeatedly, alcohol based hand rubs cause less dryness and irritation that soap products. Should be rubbed onto hands for at least 15 seconds until hands are dry.

Preventing Healthcare Associated Infections
  • Nosocomial- something originating or taking place in the hospital
  • Exogenous- causative organism is acquired from other people
  • Endogenous- causative organism comes from microbial life life harbored in the person
  • Iatrogenic- caused by treatment or diagnostic procedure
  • Not all nosocomial infections are iatrogenic
  • CMS will no longer reimburse hospitals for certain preventable hospital acquired infections including: urinary tract infection from improper use of catheters, vascular catheter associated infections, certain surgical site infections
  • To address Hospital acquired infections hospitals have implemented the following measures:
    • instituting constant surveillance by infection contra committees and nurse epidemiologists
    • having written infection prevention practices for al agency personnel
    • promoting physical health- meeting pts needs for nutrition, fluids, rest, oxygen, physical and psychological comfort
  • Staffing also seems to be related to HAI's
  • Many HAI's can be traced to an invasive device such as a urinary or venous access catheter
  • Urinary tract infections make up for 32% of HAI's annually followed by surgical site infections, pneumonia, and blood stream infections
  • Increasing use of biomedical equipment is cited as a causative factor

Dealing with Antibiotic Resistant Organisms
  • Healthcare associated pathogens that are resistant to antibiotics has become a significant continuing trend
  • Indiscriminate use of broad-spectrum abx has allowed once susceptible organism to develop defenses against abc
  • Some resistant organisms are
    • MRSA: methicillin resistant S aureus
    • VISA: vancomycin intermediate D aureus
    • VRSA: vanc resistant S aureus
    • VRE: vanc resistent enterocci
MRSA

  • normally found in nasal mucosa, respiratory, GI tract and skin
  • approximately 1/3 of the US is colonized with MRSA
  • in 1960's strain of staph emerged that was resistant to then popular abx methicillin
  • van had to be used to treat infections in healthcare setting
  • in 1980's type of MRSA appeared in wider community. Community acquired MRSA (CA-MRSA), a common cause of skin infections that has been making it's way into hospitals
  • most at risk pts are young children, older adults, and immune compromised pts
  • Treatment guidelines for MRSA:
    • incision and drainage of abcess in pts with mild to moderate infections. anitmicrobial therapy may not be required
    • if incision and drainage are not effective and systemic or serious infection results, antimicrobial therapy may be necessary
    • antimicrobial therapy may be prescribed for 7-10 days depending on severity of infection. Medications may include:
      • Bactrim (trimethoprim-sulfamethoxazole)
      • Minocin (minocycline)
      • Vibramycin (doxycycline)
      • Cleocin (clindamycin)                                                                                  
    • Achromycin (tetracyclin hydrochloride) is not recommended for pregnant pt or children under age of 8
  • the healthcare associated strain of MRSA is more serious and accounts for 60% of infections that occur in the hospital 
  • IV vancomycin is the drug of choice
  • if resistance to vanc occurs a synthetic abc can be used, ZYVOX
  • main mode of transmission in hospital is dirty hands or equipment
VISA, VRSA, and VRE

  • Once bacteria develop drug resistance they progress from being sensitive, to intermediate, to completely resistant
  • Vancomycin is used with synthetic options available
  • pts at risk are those with renal failure requiring hemodiaysis or peritoneal dialysis, a previous MRSA infection, history or prolonged use of vancomycin
  • VRE is a species of strep, normally found in the intestinal and female genital tracts
    • can cause high mortality if it is vanc resistant
    • originally treated with penicillin, ampicillin, and gentamicin it becomes resistant to each drug and was subsequently treated
    • risk factors for VRE are:
      • compromised immune system
      • recent abdominal or chest surgery presence of urinary or central IV catheter
      • prolonged abc use (especially vanc)
      • lengthy hospital stay  (especially ICU)
    • VRE is spread via contact with fecesm urine, or blood of an infected person
Sterilizing and Disinfecting
  • Sterilizing: destroys all pathogenic organisms except for spores (usually refers to skin)
  • Disinfecting: destroys all pathogens including spores (usually refers to equipment)
  • Techniques for cleaning:
    • always wear water proof gloves
    • rinse first with cold water! heat can make removal more difficult
    • after rinsing in cold water, wash in warm water with soap
    • use a brush to create friction to clean
    • rinse and dry thoroughly
    • prepare cleaned equipment for sterilization
    • consider brush, gloves, sink as being highly contaminated and treat or discard accordingly
Gloves
  • gloves are not  a sub for good hand hygiene
  • worn only once and discarded
  • each patient interaction requires a new pair of gloves and some care activities amy necessitate changing gloves more than once
  • when care activities do no involve silage of hands with body fluids, gloves are not necessary
  • Activities that do not require gloves as long as there is nO RISK for contact with body fluids:
    • turning pt
    • feeding pt
    • taking vitals
    • changing IV fluids
  • While wearing gloves never:
    • leave pts room
    • write in chart
    • use computer keyboard or telephone is nurses station
    • touch pagers or cell phones
  • double gloving is recommended when worker is going to be exposed to blood or body fluids
  • being exposed to body fluids and handling equipment are both risk factors for glove failure
  • 3 to 22% of healthcare workers are sensated to latex.  Reactions include:
    • local skin reactions, uticaria (hives)
    • systemic anaphylaxis
  • powder form latex gloves can be inhaled or absorbed into the skin or mucus membranes and enter bloodstream
  • there is no cure for latex allergy
  • according to OSHA an employer must provide alternate options to latex

A Deeper Look at Latex Allergies
Risk Factors:

  • healthcare workers that wear latex gloves
  • people with allergic tendencies
  • people with food allergies (banana, papaya, avocado, potatoes, kiwi, chestnuts, pineapples)
  • latex industry workers
  • people with asthma, spin bifid a, hx of multiple surgical procedures or exposures to latex
Types of Reactions:
  • Irritant Contact Dermatitis: non-allergic dermatitis, restricted to area that made contact with latex. may cause erythematous and pruritic hands. this is not a true allergy.
  • Chemical sensitivity dermatitis ro delayed hypersensitivity: allergic contact dermatitis, displayed as dry crusty bumps, erythema, pruritus, scaling vesicles, papular lesions at site of contact, not life threatening but person should be aware of latex allergy
  • Latex allergy or Type 1 Hypersensitivity: systemic reactions, rhinits, conjunctivitis, angioedema, bronchospasm, shock, and/or systemic anaphylactic reactions, this is life threatening
Diagnosis
  • RAST blood test for IgE antibodies to latex
  • skin prick
  • glove challenge
Treatment
  • avoid latex products
  • treat localized retain with oral dyphenhydramine, cool compress, and hydrocortisone 1% cream
  • treat systemic reaction with subq epi, systemic steroids, antihistamines, transport to ER
Protocols for Pts with Latex Allergy
  • assess pt for allergy
  • place allergy sticker on chart, sign on door, allergy band on wrist
  • remove all latex containing items from room
  • place 3 way stopcocks on IV lines and place tape over injection ports on IV tubing
  • remove rubber stoppers from vials
  • place cart containing all latex free item outside of door
  • cover latex portion of BP cuff or stethoscope
  • wear vinyl or synthetic gloves
Frequently Used Products that Contain Latex
  • blood pressure cuffs
  • electrode pads
  • IV tubing
  • foley catheters
  • baby bottle nipples
  • stethoscopes
  • tourniquettes
  • syringessurgical masks
  • pacifiers

Isolation Precautions

  • Standard precautions: precautions used in care of all hospitalized individuals regardless of their diagnosis or possible infection status
  • Transmission precautions: precautions used in addition to standard precautions for pts in hospitals with suspected infection with pathogens that can be transmitted by airborne, droplet, or contact routes
  • PPE must be worn when entering the room of any pt with precautions, previously it was only required when within 3 feet of the patient


















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