Chapter 23 Fundamentals of Nursing

What Are the Main Points in This Chapter?

-Healthcare-related infections (infections that are acquired in healthcare facilities) are a major health problem worldwide. - The chain of infection consists of six links that must all be present for infection to be transmitted from one individual to another: infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, and susceptible host. - Pathogens are strains of bacteria, viruses, fungi, protozoa, helminths, and prions that cause disease. - Drug-resistant and multidrug-resistant organisms (MDROs) have mutated to develop resistance to one or more classes of antimicrobial drugs. They are a serious problem because: (1) options for treating MDRO infections are limited; (2) they are associated with increased hospital lengths of stay and hospital charges; and (3) they are associated with serious illness and increased mortality. - Many emerging pathogens are airborne and widely spread by air travel before the carrier shows any symptoms. They have the potential for causing epidemics and pandemics. - Infectious illnesses typically follow five predictable stages: incubation, prodromal stage, illness, decline, and convalescence. - Primary body defenses, such as intact skin and mucous membranes, block entry of pathogens into the body. - Invading microorganisms trigger the body's secondary defenses, which include phagocytosis, the complement cascade, the inflammatory response, and fever. - The humoral immune response results in the production of antibodies that neutralize pathogens or trigger their destruction. - The cell-mediated immune response results in the production of T cells that destroy infected body cells. - Nutrition, hygiene, rest, exercise, stress reduction, and immunization protect the body against infection. - Anything that weakens the body's defenses or increases the person's exposure to pathogens makes the person more susceptible to infection. Such factors include illness, injury, medical treatment, infancy or old age, frequent public contact, and various lifestyle habits. - Medical asepsis requires that objects and surfaces in the healthcare environment be disinfected. - Scrupulous handwashing markedly decreases the transmission of infection and is the most important aspect of medical asepsis. - Standard precautions are used with all clients whenever there is a possibility of coming in contact with blood, body fluids (except sweat), excretions and secretions, mucous membranes, and any break in the skin. - Transmission-based precautions are added to standard precautions when there is concern about transmission of infection via contact, droplets, or air currents. - Isolation precautions are designed to prevent the spread of disease, not to isolate the person who has the disease. - Surgical asepsis is an attempt to prevent the patient from coming in contact with any microorganisms. - Sterile technique is required in many patient activities, such as administering an injection, starting an intravenous line, or performing a sterile dressing change. - Exposure to blood, body secretions, or body tissues containing blood or secretions requires immediate action. Minimize the exposure by washing hands or flushing the area thoroughly. Contact the infection preventionist or employee health nurse as soon after the exposure as possible, complete an injury report, and seek medical care. - The task of the infection preventionist is to minimize the number of infections in the healthcare facility. - A key factor in minimizing infectious outbreaks is recognizing unusual disease patterns.

You are the nurse caring for a patient who is on contact precautions for a wound infection. The patient's daughter comes to visit her mother, and comes out to the nurse's station wearing disposable gloves. What information do you give her daughter regarding contact precautions? 1) Perform hand hygiene on entering her mother's hospital room. 2) Review contact precautions, hand hygiene, and glove use. 3) Remove gloves when leaving her mother's hospital room. 4) Provide the daughter with an extra box of gloves for her mother's room.

Answer: Review contact precautions, hand hygiene, and glove use. Rationale: The daughter in this scenario is unclear about glove use and hand hygiene in the hospital setting. To improve family and patient compliance with contact precautions, the nurse needs to educate the daughter further about these topics while reviewing other measures for preventing the spread of infection from person to person in the healthcare setting. Hand hygiene should be performed when entering and leaving the patient's hospital room. Although removing gloves when leaving the hospital room is important, the daughter could also benefit from additional teaching about contact isolation precautions. Likewise, while having an adequate supply of gloves available in the room is important, the daughter appears to be lacking in understanding about how she could prevent the spread of infection between her mother and the hospital staff and other visitors.

List at least three actions clients can take to help avoid infection when they are out in the community.

Answer: -Washing hands and not touching surfaces in a public bathroom -Carrying and using antibacterial hand gel, as needed, while in public places -Using an antibacterial wipe on the receiver and mouthpiece of public phones before making a call -Washing hands when returning home (e.g., from shopping) -Asking healthcare providers to wash their hands before physical contact, if they have not done so -Using tongs, not fingers, to get food from serving trays in grocery stores and restaurants -Asking for clean silverware or napkins if an item is dropped on the floor in a restaurant

A client with a stage II pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions? 1) A clean gown and gloves must be worn when in contact with the client. 2) Everyone who enters the room must wear an N-95 respirator mask. 3) All linen and trash must be marked as contaminated and sent to biohazard waste. 4) Place the client in a room with a client with an upper respiratory infection.

Answer: 1) A clean gown and gloves must be worn when in contact with the client. Rationale: A clean gown and gloves must be worn when any contact is anticipated with the client or with contaminated items in the room. A respirator mask is required only with airborne precautions, not contact precautions. All linen must be double-bagged and clearly marked as contaminated. The client should be placed in a private room or in a room with a client with an active infection caused by the same organism and no other infections.

You are the nurse caring for a patient who recently had abdominal surgery. Her daughter tells you that she wants her mother to keep her Foley catheter in place because it will be easier for her mother. What should you tell the patient and her daughter about catheter use and urinary tract infections? Select all that apply. 1) Long-term indwelling catheter use is associated with urinary tract infections. 2) Support the daughter in judging that the catheter needs to stay in place. 3) Explain that the patient can ask for assistance to walk to the bathroom. 4) Inform her that handwashing is the best way to prevent urinary tract infection.

Answer: 1) Long-term indwelling catheter use is associated with urinary tract infections. 3) Explain that the patient can ask for assistance to walk to the bathroom. Rationale: Because patients are at a higher risk for acquiring urinary tract infection and other drug-resistant or multidrug-resistant infection when an invasive device is in place, such as a urinary catheter, this patient's indwelling urinary catheter needs to be removed as soon as possible after surgery. Although handwashing helps to reduce the risk for urinary tract infection, the priority action is to remove the indwelling urinary catheter, which is a vehicle for bacterial colonization and entry into the urinary tract. If the daughter is considering convenience as the compelling reason to keep the Foley catheter in place, the nurse would remind the patient's daughter that she can ask for assistance to walk to the bathroom, which is also an activity that will minimize the occurrence of other postsurgical complications.

Which of the following nursing activities is of highest priority for maintaining medical asepsis? 1) Washing hands 2) Donning gloves 3) Applying sterile drapes 4) Wearing a gown

Answer: 1) Washing hands Rationale: Scrupulous handwashing is the most important part of medical asepsis. Donning gloves, applying sterile drapes before procedures, and wearing a protective gown may be needed to ensure asepsis, but they are not the most important aspect because microbes causing most healthcare-related infections are transmitted by lack of or ineffective handwashing.

A client requires protective isolation. Which client can be safely paired with this client in a client-care assignment? One 1) admitted with unstable diabetes mellitus. 2) who underwent surgical repair of a perforated bowel. 3) with a stage III sacral pressure ulcer. 4) admitted with a urinary tract infection.

Answer: 1) admitted with unstable diabetes mellitus. Rationale: The client with unstable diabetes mellitus can safely be paired in a client-care assignment because the client is free from infection. Perforation of the bowel exposes the client to infection, requiring antibiotic therapy during the postoperative period. Therefore, this client should not be paired with a client in protective isolation. A client in protective isolation should not be paired with a client who has an open wound, such as a stage III pressure ulcer, or with a client who has a urinary tract infection.

What is the rationale for handwashing? Handwashing is expected to remove: 1) transient flora from the skin. 2) resident flora from the skin. 3) all microorganisms from the skin. 4) media for bacterial growth.

Answer: 1) transient flora from the skin. Rationale: There are two types of normal flora: transient and resident. Transient flora are normal flora that a person picks up by coming in contact with objects or another person (e.g., when you touch a soiled dressing). You can remove these with handwashing. Resident flora live deep in skin layers where they multiply harmlessly. They are permanent inhabitants of the skin and cannot usually be removed with routine handwashing. Removing all microorganisms from the skin (sterilization) is not possible without damaging the skin tissues. To live and thrive in humans, microbes must be able to use the body's precise balance of food, moisture, nutrients, electrolytes, pH, temperature, and light. Food, water, and soil that provide these conditions may serve as nonliving reservoirs. Handwashing does little to make the skin uninhabitable for microorganisms, except perhaps briefly when an antiseptic agent is used for cleansing.

Terms 1. Reservoir 2. Infectious agent 3. Portal of exit 4. Indirect contact 5. Vector (living) 6. Portal of entry Examples A. Seeping blood B. Mite C. Stethoscope D. Protozoa E. Bedside table F. Intramuscular injection site

Answer: 1, E 2, D 3, A 4, C 5, B 6, F

Identify and describe the purpose of the body's three major lines of defense against infection.

Answer: 1. The primary defense mechanisms prevent entry of pathogens into the body. Primary defense mechanisms include intact skin, mucous membranes at body openings, normal flora, and a rich vascular supply at potential sites of entry for infection, including the mouth and vagina. They also include processes such as crying, salivating, vomiting, peristalsis, and diarrhea. 2. The secondary defense mechanisms are activated if a pathogen gains entry into the body. Secondary defense mechanisms include phagocytosis, the complement cascade, inflammation, and fever. 3. Specific immunity, a third line of defense, protects against specific pathogens and builds immune "memory" in the process. The humoral response produces antibodies that inactivate invading antigens. The cell-mediated response results in the production of T cells that destroy body cells infected with invaders.

A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection? 1) Fever 2) Intact skin 3) Inflammation 4) Lethargy

Answer: 2) Intact skin Rationale: Intact skin acts as a primary defense against infection. Fever, the inflammatory response, and phagocytosis (a process of killing pathogens) are secondary defenses against infection.

You are changing your patient's sterile dressing and reach across the sterile field. Which nursing action is most appropriate? 1) Remove your sterile gloves and tell the patient you will be right back. 2) Obtain new sterile supplies and set up a new sterile field. 3) Pick up the sterile dressing with your gloved hand and tape it in place. 4) Ring the call bell to ask someone to bring you another pair.

Answer: 2) Obtain new sterile supplies and set up a new sterile field. Rationale: Be conscious of your body at all times, and never reach across a sterile field. The movement could cause your sleeve to contaminate the field. Avoid coughing, sneezing, and talking over a sterile field as these might cause air droplet contamination. If contamination occurs, you must start over with new gloves and sterile dressing supplies. New gloves (alone) are not sufficient. Keep the sterile field in constant view; never turn your back on a sterile field because inadvertently contamination can occur.

Which action demonstrates a break in sterile technique? 1) Remaining 1 foot away from nonsterile areas 2) Placing sterile items on the sterile field 3) Avoiding the border of the sterile drape 4) Reaching 1 foot over the sterile field

Answer: 4) Reaching 1 foot over the sterile field Rationale: Reaching over the sterile field while wearing sterile protective equipment breaks sterile technique. While observing sterile technique, healthcare workers should remain 1 foot away from nonsterile areas while wearing sterile garb; place sterile items needed for the procedure on the sterile drape; and avoid coming in contact with the 1-inch border of the sterile drape.

What part(s) of a sterile field are considered to be unsterile?

Answer: A 1-inch margin around the edges of the field and any material that extends beyond the horizontal plane are considered unsterile. You may also recall that a field is no longer sterile if it becomes wet, if you turn your back on it, or if someone not wearing sterile protective equipment comes within 1 foot of the sterile field.

If you needed to disinfect a sink in a client's home, what would you use?

Answer: A solution of 1 part household bleach and 50 parts water.

Which of the following is not included in the body's secondary defense against a pathogen? A. Lysozymes in the saliva in the mouth B. Differentiation of monocytes into macrophages C. Release of histamine and other chemical mediators D. An oral temperature of 101.8°F (38.8°C)

Answer: A. Lysozymes in the saliva in the mouth Rationale: Lysozymes are an example of the body's primary defense.

A 64-year-old patient has peripheral vascular disease. In assisting the patient to decrease her risk for infection, the clinic nurse would teach her to do which of the following? A. Change her bath habits and only bathe twice a week B. Begin an exercise program of yoga to decrease her stress C. Eat a high-fiber, low-protein, low-calorie diet D. Refuse the flu vaccine because it can be dangerous for her

Answer: B. Begin an exercise program of yoga to decrease her stress Rationale: Research has shown a positive correlation between stress and a decrease in immune functioning. Bathing only twice a week would not be enough to remove potentially harmful surface bacteria. Nutrients are needed to produce the cells of the immune system. Because this patient has a chronic illness, she should be encouraged to ask her healthcare provider for a flu shot; and flu vaccines are not considered dangerous.

Which of the following actions violates a principle that is key to proper handwashing at the bedside? A. Washing your hands for 1 minute B. Shaking your hands dry over the sink C. Using warm, not very hot, water D. Using the soap provided by the agency

Answer: B. Shaking your hands dry over the sink Rationale: Shaking your hands will not completely remove the excess moisture, allowing for the reacquisition of bacteria on the area. In addition, it splashes water into the environment, which could be contaminated with organisms from the hands.

A patient comes to the physician's office complaining of generalized malaise and states, "I just don't feel well." The nurse knows that the patient is in what stage of infection? A. Decline B. Illness C. Prodromal D. Convalescence

Answer: C. Prodromal Rationale: The prodromal stage is characterized by complaints of vague, nonspecific symptoms.

A patient who is HIV positive and immunocompromised develops an eye infection caused by the cytomegalovirus. The retinitis would be considered which of the following types of infection? A. Endogenous infection B. Primary infection C. Vector infection D. Secondary infection

Answer: D. Secondary infection Rationale: The HIV infection is the primary infection. There is no vector involved in cytomegalovirus transmission, and it does not arise from the patient's own flora.

An example of an activity requiring contact precautions would be when the spread of an organism is thought to occur when sheets are fanned during bed making. True False

Answer: False Rationale: Fanning sheets can lead to airborne transmission, requiring airborne precautions.

Secondary infections are one of the top 20 health problems in the United States. True False

Answer: False Rationale: Healthcare-related infections are one of the top 20 health problems.

If a patient's lab work reveals that IgM, but not IgG, is present in the blood, what could you conclude about this infection?

Answer: IgM is present the first time an individual is exposed to a particular pathogen. If IgG is not present, you can conclude that the exposure occurred less than 10 days ago.

What is the role of normal flora?

Answer: Normal flora are nonpathogenic microorganisms that help to control the growth of pathogenic microorganisms. Normal flora in the intestine also aid digestion and, when they die, release vitamins important to human health.

What is a pathogen?

Answer: Pathogens are bacteria, viruses, fungi, and other organisms that cause disease.

Identify at least five reservoirs of infection.

Answer: Potential answers include the following reservoirs of infection: Human body Animals Insects Food Floors in healthcare facilities Bathrooms Raw sewage Stagnant water Garbage Diapers Used wound dressings

Under what circumstances are standard precautions used?

Answer: Standard precautions are used on all clients whenever there is a possibility of coming in contact with blood, body fluids (except sweat), excretions and secretions, mucous membranes, and any break in the skin.

What actions improve host ability to prevent infection?

Answer: The following activities decrease the likelihood of infection: -Adequate nutrition, including vitamins, minerals, and water, are essential for combating infection. Nutrients are required to form the components of the immune response. -Hygiene is a crucial aspect of maintaining skin integrity. Intact skin is one of the best defenses against infection. -Both rest and exercise are necessary to rejuvenate the body. -Stress, whether physical or mental, decreases the body's immune defenses. -For some diseases, immunizations have been developed. Immunizations expose the body to weakened or killed pathogens and stimulate the body to produce IgG. At a later date, if the natural pathogen is encountered, IgG and specialized T cells are available to ward off an infection.

What factors increase a client's risk for infection?

Answer: The following factors increase a client's risk for infection: -Very young children and older adults are at increased risk for infection. Young children have limited exposure to pathogens and immature active immunity. Older adults have declining function of the immune system and limited physiological reserve. -Any break in the skin also increases risk. Illness and injury, especially chronic disease, limit an individual's ability to fight infection. Smoking, substance abuse, and multiple sex partners increase the risk of infection. -Some medications inhibit the immune response of the body. -Environmental factors that increase exposure to pathogens increase risk for infection. Finally, nursing and medical treatments often provide portals of entry and exit or bypass natural defense mechanisms.

Identify the six links in the chain of infection.

Answer: The following six links compose the chain of infection: 1. Infectious agent 2. Reservoir 3. Portal of exit 4. Mode of transmission 5. Portal of entry 6. Susceptible host

What kinds of microbes favor the human body as a reservoir of infection?

Answer: The human body provides a warm, moist environment. The microbes that are pathogenic to humans are so because they thrive at about the same temperature as the human body. To thrive in the human body, microbes also must be able to use the body's precise balance of moisture, nutrients, electrolytes, and pH to support their own reproduction.

A patient has acquired pneumonia after being hospitalized for 10 days. This is an example of a healthcare-related infection. True False

Answer: True

The use of standard precautions protects both the nurse and the patient from infection due to the transmission of microorganisms. True False

Answer: True

When will you need to don sterile gloves using the closed method?

Answer: When you are performing an activity that requires you to wear a sterile gown. The gloves must cover the gown cuffs.