Vancomycin-resistant enterococci

Nursing Considerations-Nursing Diagnoses

Acute pain Decreased cardiac output Deficient fluid volume Hyperthermia Impaired tissue integrity Risk for decreased cardiac perfusion Risk for infection

Treatment-Medications

Antimicrobials (VRE isolates not susceptible to vancomycin are generally susceptible to other antimicrobial drugs); drug selection is highly variable and is based on specific culture and sensitivity testing and may include linezolid, daptomycin, tigecycline, or quinupristin-dalfopristin; telavancin for highly resistant strains Chlorhexidine bathing (for intensive care unit patients)

Nursing Considerations-Associated Nursing Procedures

Blood culture sample collection Blood pressure assessment Clean-catch (midstream) urine collection, female Clean-catch (midstream) urine collection, male Contact precautions Hand hygiene Health history interview and physical assessment Pain management Pulse assessment Respiration assessment Stool specimen collection, random Temperature assessment Venipuncture Wound specimen collection

Overview-Causes

Direct contact with an infected or colonized patient or colonized health care worker or contact with a contaminated surface, such as an overbed table

Overview-Pathophysiology

Genes encode resistance and are carried on plasmids that transfer themselves from cell to cell. Resistance is mediated by enzymes that substitute a different molecule for the terminal amino acid so that vancomycin can't bind.

Overview

Mutation of a common bacterium Easily spread by direct person-to-person contact Also called VRE

Nursing Considerations-Nursing Interventions

Place the patient in a private room and minimize the number of staff caring for him. Use standard and contact precautions during patient care. Perform meticulous hand hygiene. Use disposable equipment when possible; when not possible, use nondisposable items only on the infected patient. Ensure judicious and careful use of antibiotics. Encourage physicians to limit the use of antibiotics. Double-bag all specimens for transport. Enlist the aid of an infection-control specialist as indicated. Remove any invasive devices if they are indicated as the source of infection; ensure that invasive devices are used for the shortest time possible. Administer fluids as ordered. Encourage frequent turning and position changes. Obtain specimens as ordered to evaluate the course of the infection and the effectiveness of the treatment.

Assessment-History

Possible breach in the immune system, surgery, or condition predisposing the patient to the infection Asymptomatic carrier state in most cases Multiple antibiotic use

Overview-Risk Factors

Previous treatment with antimicrobials, including multiple broad-spectrum agents Immunocompromised condition Old age Indwelling catheter Major surgery Open wounds Invasive devices History of taking vancomycin or a third-generation cephalosporin History of enterococcal bacteremia, often linked to endocarditis Organ transplantation Prolonged or repeated hospital admissions Chronic renal failure Exposure to contaminated equipment or a VRE-positive patient

Treatment-Activity

Rest periods when fatigued

Overview-Complications

Sepsis

Overview-Incidence

VRE infection can occur throughout the body but is most common in the urinary tract, surgical wounds, and the bloodstream. Since first identified in the United States in 1987, rates of VRE infection have increased, with resistance increased to 33%. According to the Centers for Disease Control and Prevention, 1 of every 8 infections occurring in hospitals is caused by enterococci; of these, 30% are VRE.

Diagnostic Test Results-Laboratory

VRE is isolated from stool or from a rectal swab, wound, blood, or urine.

Assessment-Physical Findings

Variable, depending on the site of the infection

Nursing Considerations-Monitoring

Vital signs, especially temperature Cardiac status Fluid balance Tissue integrity Response to treatment Complications

Treatment-General

With colonization and no infection, possibly no treatment Standard and contact precautions Removal of the invasive device if it is the source

Patient Teaching-General

disorder, diagnosis, and treatment, including possible methods for disease transmission (see Taking precautions at home) importance of the patient and family adhering to infection control precautions, including the need for family members to wear personal protective equipment when they visit the patient proper disposal of disposable and nondisposable supplies and equipment importance of adhering to strict hand-washing and hand hygiene measures measures to prevent transmission, such as using a disinfectant or a mixture of ¼ cup bleach to 1 qt water to clean frequently touched areas and surfaces and wearing gloves if contact with body fluids (such as stool that may contain VRE) is possible.

Nursing Considerations-Expected Outcomes

report decreased pain levels maintain adequate cardiac output have an adequate fluid volume remain afebrile demonstrate adequate tissue integrity attain and maintain hemodynamic stability demonstrate resolution of the infection.