Chapter 22 Treas

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Neutrophils

55-70% of total WBCs Phagocytize pathogens

Susceptible host

6th chain of infection A susceptible (or compromised) host is a person who is at risk for infection because of inadequate defenses against the invading pathogen. Among the factors that increase susceptibility are: Age (very young, very old) Compromised immune system (immune suppression for organ transplantation or treatment of cancer) Chronic illness Immune deficiency (e.g., HIV, leukemia, malnutrition)

Performing a Surgical Scrub

A surgical scrub is a modification of the hand-washing procedure described earlier (see Table 22-3 for a comparison). It traditionally involves an extended scrub of the hands using a sponge, nail cleaner, and a bactericidal scrubbing agent. A newer method uses a brushless scrub, using a bactericidal scrubbing agent. All methods require a prewash before the surgical scrub. For the steps, refer to Procedures 22-4 and 22-5.

Surgical antisepsis

AGENT 1. Water and antimicrobial soap (e.g., chlorhexidine, iodine, and iodophors) 2. Water and non-antimicrobial soap (i.e., plain soap) followed by long-acting, alcohol-based surgical hand scrub product PURPOSE Remove or destroy transient microorganisms and reduce resident flora (persistent activity) AREA Hands and forearms DURATION (MINIMUM) 1. 2-6 minutes 2. Follow manufacturer instructions for surgical hand scrub product with persistent activity

Antiseptic handrub

AGENT Alcohol-based handrub PURPOSE Remove or destroy transient microorganisms and reduce resident flora (persistent activity) AREA All surfaces of the hands and fingers DURATION (MINIMUM) Until the hands are dry

Antiseptic handwash

AGENT Water and antimicrobial soap (e.g., chlorhexidine, iodine, and iodophors) PURPOSE Remove or destroy transient microorganisms and reduce resident flora (persistent activity) AREA All surfaces of the hands and fingers DURATION (MINIMUM) 15 sec

Routine handwash

AGENT Water and non-antimicrobial soap (i.e., plain soap) PURPOSE Remove soil and transient microorganisms AREA All surfaces of the hands and fingers DURATION (MINIMUM) 15 sec

Acute infections

have a rapid onset but last only a short time (e.g., the common cold).

Multiple sexual partners: host susceptibility

he more sexual partners a person has, the higher his risk of acquiring a sexually transmitted infection.

immunoglobulin

Indirect Contact

involves contact with a fomite, a contaminated object that transfers a pathogen. For example, suppose while you are entering data into the patient record, you sneeze or cough. If you cover your nose and mouth with your hand and then resume using the keyboard, you may transmit pathogens to the next person who touches that surface. Shoes, eyeglasses, stethoscopes, and other commonly worn items also serve as fomites. Some microbes can live only a few seconds on fomites; others can live for years, depending on the environment.

Complement casade

is a process by which a set of blood proteins, called complement, triggers the release of chemicals that attack the cell membranes of pathogens, causing them to rupture. Complement also signals basophils (WBCs) to release histamine, which prompts inflammation.

Pandemic

is an exceptionally widespread epidemic—that is, one that affects many people in an entire country or worldwide. Examples of pandemics are Ebola, H1N1 influenza ("swine flu"), and malaria.

Vector

is an organism that carries a pathogen to a susceptible. The mosquito is a common vector for diseases, including malaria, yellow fever, and the West Nile virus. Ticks, fleas, and some animals can also be vectors.

Epidemic

is an outbreak of a disease that suddenly affects a large group of people in a geographic region (e.g., a city or state) or in a defined population group (e.g., children, healthcare workers).

Infection

is invasion of and multiplication in the body by a pathogen (a microorganism capable of causing disease). A grasp of the broad concept of infection will enable you to use infection prevention and control measures to promote biological safety for your clients.

Secondary infection

is one that follows a primary infection, especially in immunocompromised patients. Example: A frail client is infected with pneumonia. Under the stress of illness, she may develop herpes zoster (shingles), a viral infection related to past infection with varicella.

Septicemia

is symptomatic systemic infection spread via the blood.

Primary infection

is the first infection that occurs in a patient.

Bioterrorism

is the intentional release, or threatened release, of disease-producing organisms or substances intended to cause death, illness, harm, economic damage, or fear. Diseases with recognized bioterrorism potential are anthrax, botulism, pneumonic plague, smallpox, viral hemorrhagic fevers, and tularemia.

Phagocytosis

is the process by which phagocytes (specialized white blood cells [WBCs]) engulf and destroy pathogens directly. Table 22-1 summarizes the types of WBCs and their roles in defending against infection.

Helper T cells

play a supportive role in cell-mediated responses by secreting interleukin, which attracts infection-fighting white blood cells.

Bacteremia

presence of bacteria in the blood

Infection prevention and control

promote biological safety for your clients. Those activities include medical and surgical asepsis and interventions to support patients' body defenses.

Nosocomial infection

refers more specifically to hospital-acquired infections.

Healthcare-associated infection (HAI)

refers to infections associated with healthcare given in any setting (e.g., hospitals, home care, long-term care, and ambulatory settings). HAIs aggravate existing illness and lengthen hospital stay and recovery time. HAIs are the leading complication of hospital care and one of the 10 leading causes of death in the United States (Agency for Healthcare Research and Quality, 2011; Siegel, Rhinehart, Jackson, et al., 2007); however, they are preventable (Cardo, Dennehy, Halverson, et al., 2010). Approximately 1 out of every 25 hospitalized patients will contract an HAI (Centers for Disease Control and Prevention, 2016b). Clostridium difficile was the most commonly reported pathogen (causing 12.1% of HAIs) (Magill, Edwards, Star, et al., 2014).

Disinfecting

removes pathogens on inanimate objects by physical or chemical means, including steam, gas, chemicals, and ultraviolet light. Chemical germicides can achieve three levels of disinfection (Box 22-3). Disinfection is used for semicritical and noncritical items:

Direct contact transmission

usually involves physical contact, sexual intercourse, and contact with wound drainage, but it can involve scratching and biting.

Cleaning

Cleaning is the removal of visible soil (organic and inorganic) from objects and surfaces. In healthcare agencies, it is usually accomplished manually or mechanically using water with detergents or enzymatic products formulated to inhibit microbial growth. A goal of medical asepsis is to keep all public and patient care areas within the facility clean and free from dust, debris, and contamination. Any spilled liquids, dirty surfaces, or potentially contaminated areas should be cleaned immediately. Items must be cleaned thoroughly before they can be disinfected or sterilized.

Needles and Sharps

Never recap, bend, or break used needles; otherwise manipulate them using both hands; or use any other technique that involves directing the point of a needle toward any part of the body. Instead, use either a one-handed "scoop" technique or a mechanical device designed for holding the needle sheath (see Procedure 25-10, Recapping Needles ...). Use safety features when available. Place "sharps" (e.g., scalpels, needles) in puncture-resistant containers for disposal.

Genitourinary tract and the anus.

The epithelial cells lining the mucous membranes of the urethra, vagina, and anus secrete mucus, which adheres to pathogens to promote their excretion through urine and stool. Urine itself is highly acidic and contains lysozyme (an antibacterial enzyme). In addition, the high acidity and normal flora of the vagina keep pathogens in check.

IgM

The first antibody to appear when an antigen (e.g., pathogen) is encountered Involved in agglutination with incompatible blood types

Memory T cells

The first time an antigen invades the body, T cells form that respond to that specific antigen. The memory T cells increase the speed and amount of the T-cell response.

WHAT ARE THE BODY'S DEFENSES AGAINST INFECTION?

The human body has three "lines of defense" against infectious disease: Certain anatomical features limit the entry of pathogens. Protective biochemical processes fight pathogens that do enter. The presence of pathogens activates immune responses against specific, recognized invaders. The first two (primary and secondary) lines of defense are nonspecific; that is, they have no means of adapting their response to each specific invader. Instead, they act in precisely the same way against all intruders, from a simple cold virus to deadly fungal spores.

humoral immunity

The humoral immune response (or antibody-mediated response) protects the body by circulating antibodies to fight against pathogens (e.g., bacteria). The body's defense system acts by producing specialized white blood cells (leukocytes) to seek out and destroy invaders by any of the following methods phagocytosis neutralization agglutination activation of complement and inflammation

Eyes

The lacrimal glands produce tears that contain lysozyme, an antimicrobial enzyme. The tears help wash infective organisms from the eyes.

CDC guidelines for disease control and prevention

The mission of this federal agency is to protect Americans from health, safety, and security threats through education, research, and action.

IgG

The most common immunoglobulin in the body Takes at least 10 days for IgG to be produced in response to an initial infection The only immunoglobulin that can cross the placenta to provide temporary immunity to the fetus/infant

Mouth

The mouth normally has many pathogenic microorganisms, but saliva, like tears, contains lysozyme and continually washes microbes from the teeth and gums. The rich blood supply of the mouth swiftly transports defensive blood cells, and the normal flora of the mouth compete with invading organisms for nutrition, thus keeping the microorganisms in check.

Respiratory tree

The nares, trachea, and bronchi are covered with mucous membranes that trap pathogens. The nose contains hairs that filter the upper airway; the nasal passages, sinuses, trachea, and larger bronchi are lined with cilia, tiny hair-like cells that sweep microorganisms upward from the lower airways. Coughing and sneezing forcefully expel organisms from the respiratory tract.

Tobacco use: host susceptibility

Tobacco interferes with the ability to move the chest, cough, sneeze, or have full air exchange. Chemicals in tobacco paralyze cilia, so secretions pool in the lower airways, creating a hospitable environment for bacteria. Smoking adversely affects the immune system, so along with chronic exposure to secondhand smoke (e.g., bartenders, children of smokers) are at risk for a wide range of infections.

Pathogens

are microorganisms capable of causing disease. -The largest groups of pathogenic microorganisms are bacteria, viruses, and fungi (which include yeasts and molds). -Less common pathogens are protozoa, helminths (commonly called worms), and prions, which are infectious protein particles that cause certain neurological diseases. -Normal flora may become pathogenic when a patient is especially vulnerable to disease, or if they enter regions of the body they do not normally inhabit (Escherichia coli, harmless in the bowel, cause infection when they multiply in the urinary tract).

Transient flora

are normal microbes you acquire by coming in contact with objects or another person (e.g., when you touch a soiled dressing). Hand washing can remove these.

Resident flora

are permanent inhabitants of the skin and cannot usually be removed with routine hand washing. They live and multiply harmlessly deep in skin layers.

Noncritical items

are supplies and equipment that come in contact with intact skin but not mucous membranes. They do not carry a high risk of infection transmission, and they can be decontaminated where they are used. Disinfection is adequate for noncritical items. Examples: Bedpans, stethoscopes, and blood pressure cuffs Examples of noncritical environmental surfaces: Floors, food utensils, bed linens, and bed rails (CDC, 2009a).

Local infections

are those that cause harm in a limited region of the body, such as the upper respiratory tract, the urethra, or a single bone or joint.

Suppressor T cells

are thought to stop the immune response when the infection has been contained.

Known diseases that dramatically increase in incidence

as a result of failed or poor compliance with public health measures to control outbreaks, such as immunization (mumps) and water treatment (cholera) (e.g., mumps and pertussis, also known as whooping cough).

Latent infections

cause no symptoms for long periods of time, even decades. Tuberculosis and HIV are examples.

Newly identified diseases

caused either by an unrecognized microorganism (e.g., the virus causing AIDS was unknown before 1981) or by a known organism (e.g., Streptococcus infection causing toxic shock syndrome).

Individualised goals/outcomes statements

depend on the specific nursing diagnosis and etiology. For example, for an undernourished woman, if the nursing diagnosis is Risk for Infection r/t indwelling central line and inadequate nutrition, an appropriate goal would be the following: Patient will show no signs of localized infection at the infusion site, as evidenced by the absence of swelling, redness, excessive warmth, pain, or drainage. You will evaluate the nursing care plan by examining the extent to which such goals have been met.

Chronic infections

develop slowly and last for weeks, months, or even years. Some chronic infections (e.g., relapsing fever caused by an infection from a tick bite) recur after periods of remission.

Cytotoxic (killer) T cells

directly attack and kill pathogens and infected body cells.

Medical asepsis

("clean technique") refers to procedures that decrease the potential for the spread of infections. You probably already practice medical asepsis in other settings without realizing it. For example, at home you wash your hands before and after handling foods. In the healthcare setting, medical asepsis includes hand hygiene, environmental cleanliness, standard precautions, and protective isolation. Infection prevention, including the patient's safety, depend on nurses' rigorously and consistently following the principles of asepsis. When you are hurrying, you may be tempted to take shortcuts or forget to follow a guideline. Remember: Cutting corners can put your patient, and possibly yourself, at risk for a serious infection.

Diseases occurring in new geographic areas

(e.g., Ebola virus in western Africa) or settings (e.g., C. difficile was primarily a hospital-acquired infection and now occurs in the community).

Microorganisms in animals or insects that extend their host range to begin infecting humans

(e.g., H1N1 virus from swine, or Zika virus, which is carried by mosquitos and can cause birth defects when acquired during pregnancy).

Microbes that evolve to become more virulent

(e.g., a strain of E. coli, which now causes severe illness).

Organisms that are deliberately altered for bioterrorism

(e.g., the contamination of U.S. government mail with Bacillus anthracis [anthrax]).

Once a pathogen enters a host, four factors determine whether the person develops infection:

-Virulence of the organism (its power to cause disease) -Ability of the organism to survive in the host environment - Number of organisms (the greater their number, the more likely they are to cause disease) -Ability of the host's defenses to prevent infection

Proctective isolation

. If a client is in protective isolation, be sure that equipment has been disinfected before it is taken into the room. Take linen and dishes directly to the protective isolation room, and hand them to someone wearing the required protective clothing.

Basophils

.5-1% of total WBC Release histamine and heparin granules as part of the inflammatory response. Percentage normal during infections.

eosinophils

1%-3% of total WBC Bind to helminthes and release toxins to destroy them; mediate allergic reactions; have limited role in phagocytosis. Percentage increases in parasitic infections.

lymphocytes

20-35% of totwl WBC T cells—responsible for cell-mediated immunity; recognize, attack, and destroy antigens. B cells—responsible for humoral immunity; produce immunoglobulins to attack and destroy antigens. Percentage of total lymphocytes increases in viral infection and chronic bacterial infection

monocytes

3-8% total WBC Able to phagocytize directly as well as to differentiate into macrophages, which help clean up damaged tissue, infection, and cellular debris. Percentage increases in tuberculosis, protozoal, and rickettsial infections.

C-reactice protein (CRP)

A blood test to measure inflammatory change or bacterial infection

Breaks in the first line of defense: host susceptibility

A break in the skin, whether caused by a surgical procedure, skin breakdown, an insect bite, or insertion of an intravenous device, creates a portal of entry for infectious microorganisms.

White blood cell count with differential

A breakdown of the number and types of WBCs; normal WBC count is 5,000-10,000/mm3.

Maintaining a clean environment

A clean environment includes the surfaces in a patient's room, as well as supplies, equipment, and other objects brought into the room. The floor, soiled dressings, used tissues, sinks, commodes, and bedpans are examples of contaminated items. An object becomes contaminated or unclean if it comes in contact with a contaminated surface—or if you suspect, for whatever reason, that it may contain pathogens. Agency policies determine whether a reusable item is cleaned, disinfected, or sterilized, based on how the item is used.

Erythrocyte (RBC) sedimentation rate (ESR or sed rate)

A measure of inflammatory changes. Sed rate increases with inflammation. Normally it is at 15 mm/hr for men and < 20 mm/hr for women.

Blood cultures

A sample of blood placed on culture media and evaluated for growth of pathogens. Normally, should show no growth of infectious microorganisms.

What Areas Are Considered Sterile?

A sterile field is sterile only on the horizontal plane (e.g., the draped table top). Material that drapes over the horizontal plane may easily be contacted by nonsterile clothing or equipment. Consider a 1-inch margin along the borders of a sterile drape unsterile even if it remains on a horizontal surface. Because it is in contact with contaminated surfaces. If you are wearing sterile attire, consider only the front of your body from the chest to the level of the sterile field to be sterile, nothing else. Sleeve cuffs are considered unsterile when your hands pass beyond the cuff (cuffs are sterile if you don gloves using the closed method).

Carriers

are capable of defending themselves from active disease but harbor the pathogenic organisms within their bodies. They have no symptoms, yet they serve as reservoirs and can pass the disease to others.

Actual infection

Actual Infection There is no NANDA-I diagnosis of "actual infection" because once an infection develops, it is managed collaboratively with the healthcare team. Infection is a medical diagnosis. Infection may be the etiology of other nursing diagnoses, such as Fatigue, Risk for Imbalanced Body Temperature, or Pain. Patients with infection may have other nursing diagnoses due to their infected status. For example: Social Isolation r/t communicable disease (e.g., tuberculosis [TB]) Decreased Diversional Activity r/t inability to leave room secondary to protective isolation Other diagnostic statements may apply, depending upon the patient's condition, treatment ordered, and the patient's response to illness. For a care plan and care map for Risk for Infection,

Adding Sterile Solutions to a Sterile Field

Add sterile liquids to a sterile field by slowly pouring them into a container on the field. Some sterile drapes contain an impermeable membrane between layers that serves as a barrier to moisture and prevents wicking. With this type of drape, you may pour sterile liquid directly on gauze pads on the field. Pour only an amount of liquid that is sufficient to make the gauze pads damp. Excess fluid may run off the field, causing the field to become contaminated—a wet field is not sterile because it does not provide a barrier to microorganisms on the unsterile surface under the drape (see Box 22-4 about common breaks in sterility). For step-by-step instruction in how to add sterile solutions to a sterile field, refer to Procedure 22-8C.

natural active immunity

After a person acquires an infection, the body produces its own antibodies to fight the disease-causing organism and protect from infection by this organism in the future (e.g., influenza).

Notify the Safety Officer

After identifying a suspicious pattern, you should notify the institution's interventionist or safety officer as soon as possible. Appropriate cultures will be needed, and the federal and state health departments should be notified. If the infectious organism is unknown, samples must be preserved for future analysis.

SUMMARY

After studying this chapter, you should be armed with the basic concepts and skills you need to protect yourself and your clients from infection. However, knowledge and skill are not enough. KEY POINT: Research continues to show that healthcare professionals too often fail to comply with guidelines for infection prevention, even the simple measures such as hand hygiene and standard precautions. Although healthcare workers must wash their hands, patients do not necessarily feel comfortable asking them to do so (Ottum, Sethi, Jacobs, et al., 2012). Your role as a nurse is to integrate the best current evidence with your clinical expertise and to minimize harm to patients and others with your own performance. This includes using technology and standardized practices that support patient safety and quality. Wash your hands! Follow standard precautions!

artificial active immunity

An immune response occurs when the body is exposed to weakened or dead pathogens in a vaccine. The body then makes T cells or antibodies to keep from developing the illness (e.g., tetanus, measles). This type of immunity offers long-lasting or even lifetime protection.

Multidrug-resistant organisms

Antibiotic resistance is one of the most significant challenges in treating patients with severe infectious diseases. During the past several decades, the prevalence of multidrug-resistant organisms (MDROs) in U.S. hospitals and medical centers has increased steadily. MDROs are a serious problem because options for treating MDRO infections are limited. Furthermore, they are associated with serious illness, increased mortality, and increased hospital lengths of stay and costs. See the Example Problem: Multidrug-Resistant Organism (MDRO) Infections—Prevention.

agglutination

Antibodies have two attachment sites; therefore, each antibody can attach to two pathogenic cells in a population. This characteristic causes the pathogens to clump together (agglutinate), reducing their activity and increasing the likelihood that the group will be detected and phagocytized by leukocytes.

Activation of complement and inflammation.

Antibodies trigger the complement cascade and stimulate the release of inflammatory chemicals to destroy the antigen.

Nursing history questions on infection

Any exposure to pathogens in the environment, including at work, recent or international travel, contact with people who are ill, and unprotected sexual behavior If the patient is febrile, ask, "Have you recently traveled outside the country?" Any unusual foods or products ingested Past and present disease or injury history Medications, over-the-counter preparations, herbal products, alcohol intake, and any substances currently in use Current level of stress Immunization history Symptoms of illness

Normal flora of the body.

Any treatment that disturbs the balance between the normal flora and other microorganisms can increase the risk of developing disease. For example, when broad-spectrum antibiotics are used to treat infection, they may eliminate normal flora in addition to those causing the infection. This allows other kinds of pathogens to multiply, producing a superinfection or another opportunistic infection

WHAT FACTORS INCREASE HOST SUSCEPTIBILITY?

Anything that weakens the defenses makes a person more susceptible to infection. In addition, any factors that increase the person's exposure to pathogens, such as working at a daycare center or being a nurse, increase the risk for infection. Developmental stage Breaks in the first line of defense Illness or injury Tobacco use Substance use Multiple sex partners Environmental factors Chronic disease Medications Nursing and medical procedures

Disease titers

Blood tests for specific disease immunity (e.g., to rubella)

Panels to evaluate specific disease exposure

Blood tests to evaluate exposure to specific diseases (e.g., HIV, hepatitis)

Immunoglobulin (IgG, IgM) levels

Blood tests to evaluate humoral immunity status

Donning Surgical Attire

Burn units; labor and birth units; and some surgical suites, intensive care units, newborn nurseries, and oncology floors require surgical attire for aspects of patient caregiving. In each of these units, nurses care for clients who are at increased risk for infection or are undergoing an invasive procedure that places them at increased risk. The goal is to protect patients from infection transmitted by healthcare workers.

neutralization

By binding to a pathogen's attachment sites, antibodies disable the pathogens' machinery for adhering to and invading body cells. Thus, although they are not destroyed, the pathogens become ineffective.

Teaching Infection Prevention

Clients and caregivers are usually at less risk for infection in their homes than they are in the hospital because: They share the same potential pathogens and antibodies. There is limited exposure to others with illness. Nevertheless, to protect their own health and the health of others, clients need to understand basic principles of medical asepsis, personal hygiene, and infection control. You should also teach them to recognize signs and symptoms of infection; and for those who have an infection, help them to understand their specific organism and disease process. See the following boxes: Home Care: Preventing Infection in the Home and Community—For information about teaching infection control in the home and community Self-Care: Teaching Your Patient About Preventing the Spread of Community-Acquired MRSA—To help clients avoid acquiring or spreading community-acquired MRSA (CA-MRSA)

Uniforms and Lab Coats

Coats Do not wear a uniform (e.g., scrubs) or a lab coat for more than 1 day without laundering. Care provider clothing is often contaminated when moving from patient to patient. The traditional white lab coats are considered vehicles for the transfer of pathogens (Association for Surgical Technologists, 2008b; CDC, 2009a). Visibly soiled, wet, and/or contaminated scrub attire must be changed as soon as possible. (Scott, Goodyear, Nicoloro, et al., 2015). If you wash your clinical uniforms at home, use warm or hot water and detergent (except in the case of possible exposure to multidrug-resistant organisms, for which you should add bleach). Home laundering of surgical attire is not recommended.

NOC standaradized outcomes for diagnosis of Risk for infection are:

Community risk control Communicable disease Immune status Immunization behavior Infection severity Risk control: STD's Wound healing: primary intention Wound healing: secondary intention

Limiting the Spread of Infectious Diseases

Cooperative efforts among many disciplines and organizations worldwide are required to limit the spread of infectious diseases. The World Health Organization (WHO) is committed to reducing healthcare-associated complications, prevent surgical site infection, combat antimicrobial resistance (also called MDROs), prevent sepsis and catheter-associated bloodstream infections, prevent catheter-associated urinary tract infections, and improve Ebola response and recovery (WHO, n.d.). The Joint Commission (Soule, Memish, & Malani, 2012) requires hospitals to have an emergency management plan for responding to large numbers of infectious patients who might need to be treated as a result of an epidemic or pandemic event.

Needles and Sharps

Do not recap, bend, break, or hand-manipulate used needles. If recapping is necessary, use a one-handed "scoop" technique. Place used sharps in puncture-resistant containers.

Supplies and Equipment

Do not stock rooms with unnecessary supplies. Consider supplies brought into a patient's room contaminated. Do not return them to the linen or supply cart; handle them according to agency policy. Items brought from the patient's home, gifts from visitors are considered unclean. Mobile computing devices should be cleaned (e.g., pagers, smartphones, point-of-care keyboards, and medication administration devices). Be sure to wash your hands after using such a device. Wipe stethoscopes with alcohol before use on a patient. Stethoscopes are often contaminated with S. aureus. Disinfect reusable equipment that is soiled with blood or body fluids according to agency policy—typically, cleaning then autoclaving or using ethylene oxide gas or dry heat. Do not reuse equipment for the care of another patient until it has been cleaned and reprocessed appropriately. Dispose of single-use equipment soiled with blood or body fluids in biohazard containers. Wear gloves when handling visibly contaminated equipment. Perform hand hygiene.

Specific nursing activities will be based on the unique situation of the client, as described in the etiology of the diagnostic statement. For example: For older adults, especially those who are frail or in a debilitated state and those living in a group residence—

Encourage immunizations that can help them to acquire immunity from some communicable diseases, such as influenza.

Spills and Waste

Empty and clean bedpans, urinals, and emesis basins immediately after use. Place soiled dressings, drains, and so forth in appropriate waterproof bags for disposal; never in an open trashcan. Wipe up small spills from tabletops and floors. Notify the housekeeping or environmental services department for large spills.

Immunizations

Encourage clients to follow recommendations for immunizations (e.g., via vaccination). Encourage clients to follow recommendations for immunizations to protect against several common infectious diseases (e.g., measles, mumps, pertussis, polio, pneumonia, influenza, smallpox, and shingles). Unfortunately, some pathogens, such as the common cold virus, mutate too rapidly for an immunization to be developed. KEY POINT: For most diseases, at least 85% of the population must be immunized in order to protect the entire population from the disease.

Hygiene

Encourage frequent hand washing and regular showering or bathing. Good hygiene is crucial to decrease the bacterial count on the skin and maintain intact skin, a primary host defense. However, overzealous cleanliness diminishes the skin's natural oils and may lead to cracking of the skin. Chapter 24 focuses on the importance of hygiene for health. Also see the Home Care box Preventing Infection in the Home and Community. For the immunocompromised or bed-bound hospitalized patient, provide daily bedside baths using filtered tap water, disposable basins, and prepackaged bathing products. Nurses should use disposable cloths with 2% chlorhexidine gluconate (CHG) to reduce colonization of specific bacteria and infections with MDROs (Petlin, Schallom, Prentice, et al., 2014; Power, Peed, Burns, et al., 2012).

Environmental factors: host susceptibility

Environmental factors can increase exposure to pathogens, irritate respiratory airways, or cause breaks in the skin that increase risk for infection. Increased exposure to pathogens occurs in some work situations (e.g., kindergarten teacher, healthcare worker) and living situations (e.g., nursing home, parents with young children who are in preschool).

Hand Hygiene

Equipment Liquid soap (antimicrobial) or alcohol-based handrub Paper towels Warm, running water Hand moisturizer (optional) Pre-Procedure Assessments Check your hands for breaks in the skin. Breaks in the skin provide a route for microbial entry. Inspect the condition of your nails. Nails should be no longer than ¼ inch from the fingertips. Do not wear artificial nails or extensions. Nail polish should not be chipped. Preferably, do not use polish. Research indicates the area under the nails, artificial nails/extensions, and chipped polish act as reservoirs for microorganisms. Additionally, if your glove were to tear or perforate, chipped nail polish could potentially go into the surgical wound. Procedure 22-1A ■ Using Soap and Water When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation. Procedure Steps 1. Bare your hands and forearms. Push your sleeves above your wrists, and remove your wristwatch and rings. Moist clothing facilitates transfer of microorganisms; jewelry harbors bacteria and creates a moist area on the skin, which facilitates bacterial growth. 2. Turn on water. Use electronic faucet when possible. Adjust water to warm, not hot. Hands-free electronic faucets lessen risk of recontamination of hands after washing as there is no need to manually turn off the water. Warm water opens pores and helps remove microorganisms without removing skin oils. It also reduces chapping. Hot water increases the risk for skin breakdown. 3. Wet your hands and wrists. Keep your hands below your wrists and forearms. Prevents water from running from hands to the wrists and forearms. Hands are considered more contaminated than the wrists and arms. a. Avoid splashing water onto clothing. b. Avoid touching the inside of the sink. Microorganisms travel in moisture. The inside of the sink is considered contaminated. 4. Apply enough liquid soap to cover all hand surfaces (typically 3 to 4 pumps from a dispenser). From 3 to 5 mL of liquid soap provides enough to completely cover the hands for maximum removal of transient microorganisms. 5. Vigorously rub your hands together for at least 15 seconds Lather all surfaces, interlacing fingers, rubbing around each finger and thumb, rubbing the backs and palms of the hands in a circular motion. It takes at least 15 seconds for mechanical removal of microorganisms and for antimicrobial products to be effective. Research indicates areas of the hands most often missed are the thumb, the wrist, and areas between the fingers. 6. Clean under your fingernails, if needed, using a disposable nail cleaner. Areas under the nails harbor high concentrations of microorganisms. 7. Rinse your hands thoroughly. Keep your hands below your wrists and forearms. 8. Dry your hands thoroughly, moving from your fingers up to your forearms and blotting with paper towel. Move from the area you wish to keep cleanest (hands). Blotting decreases skin irritation. 9. Turn off the faucet. If faucet is not hands-free, hold a dry paper towel in your hand to turn it off. Do not handle the paper towel with the opposite hand. A paper towel acts as a barrier to prevent contamination of hands from the faucet. After the towel has contacted the contaminated faucet, it can transfer microorganisms to your clean hand. Many pathogens can live on faucets and countertops. 10. Apply a hand moisturizer at least twice daily; use hand care products recommended by infection preventionists. (Many agencies use soaps that contain moisturizers.) Hand moisturizer helps prevent drying and chafing, which may lead to skin damage and increase the risk for transmission of infection. Petroleum-based products cause latex gloves to become permeable. Procedure 22-1B ■ Using Alcohol-Based Handrubs When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation. Procedure Steps 1. Use alcohol-based handrubs when hands are not visibly soiled and when certain pathogens are suspected. Antiseptic solutions are not effective when organic material or dirt is present. Alcohol handrubs cannot remove spores, and therefore should not be used for hand hygiene when Clostridium difficile or Bacillus anthracis is suspected of being present. 2. Bare your hands and forearms. Push your sleeves above your wrists. Remove jewelry and wristwatch. 3. Apply antiseptic solution in a quantity sufficient (at least 3 mL) to cover the hands and wrists. 4. Vigorously rub antiseptic solution into your hands, covering all surfaces, for at least 20 seconds (or if no clock is available, as long as it takes to sing "Happy Birthday"). Cover all surfaces of the hands: interlacing fingers, rubbing around each finger and thumb, and rubbing the backs and palms of the hands in a circular motion, including under the nails, until the solution is completely dry. A period of15 to 30 seconds is required for effective disinfection by alcohol handrubs (CDC, 2009b). All surfaces must be thoroughly covered with product to effectively remove microorganisms. Evaluation Hands are free of handrub and dry. Documentation Hand hygiene is a responsibility of all healthcare providers. It usually does not require documentation.

Donning Personal Protective Equipment (PPE)

Equipment Following CDC recommendations, you will usually use some combination of gloves, gown, mask, and eye protection; depending on the organism and level of precaution. In certain situations, you may need hair covers and shoe covers (e.g., when full barrier precautions are needed). Determine the availability of appropriate PPE. Disposable gloves of the proper size Disposable isolation gown Face mask (or N-95 respirator mask, as indicated) Face shield or goggles Hair cover (if needed) Shoe covers (if needed) When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation. Procedure Steps 1. Assess the need for and gather PPE. a. Gloves: When you may be exposed to body secretions directly or indirectly Gloves provide a barrier against body fluids. All patients are considered potentially infected per standard precautions. b. Gowns: When your uniform (e.g., scrubs) may become exposed to potentially infective secretions. Examples include excessive wound drainage, fecal incontinence, or other discharges from the body, or when fluids may be splashed (as in eye irrigation). c. Face mask: To prevent transmission of pathogens spread through close respiratory (3 ft or less) or mucous membrane contact with respiratory secretions. Surgical masks provide a barrier to large-particle droplets (> 5 microns in diameter), helping prevent transmission of pathogens to the nurse's mucous membranes. d. Face shield or eye goggles: When splashing might occur and fluids enter your eyes (e.g., blood splashes, respiratory droplets, wound débridement). To protect the entire facial area, wear a face shield. It should protect the crown and chin and wrap around the face to the ear. Helps prevent pathogens from entering the conjunctiva directly or indirectly. e. N-95 respirator mask: When caring for clients infected with airborne organisms (< 5 microns) such as the tuberculosis bacillus. This device prevents airborne transmission of the tuberculosis bacterium. The respirator mask is disposable; others are reusable. f. Hair covers: When there is a potential for spraying or splashing body fluids. Although not included in the CDC report (Siegel, Rhinehart, Jackson, et al., 2007), agency policy may advise hair covers in certain situations. g. Shoe covers: When there is a potential for contamination of shoes with body fluids. The floor (and anything in contact with it) is considered contaminated. However, certain categories of pathogens require full protective gear, and in those circumstances shoe covers are necessary. 2. Don the isolation gown. KEY POINT: Do not substitute a patient gown for a disposable isolation or protective gown. Isolation gowns must be made of moisture-repelling materials to prevent contamination of underlying clothing and skin. a. Pick up the gown by the shoulders, allowing it to fall open without touching the floor or other surfaces. Touching the floor or other surfaces will contaminate the gown with environmental pathogens. b. Slip your arms into the sleeves. c. Fasten ties at the neck. d. Position the gown so that it covers the back, and fasten the ties at the waist. Do not bring ties around to the front of the gown. The front of the gown is considered contaminated after you enter the patient's room. If the ties are at the front of the gown, they will be contaminated, making it difficult to remove the gown safely. e. If the gown does not completely cover your clothing in the back, wear two gowns. Put on the first gown so that the opening is in the front. Then place the second gown over the first, so that the opening is in the back. 3. Don the face mask or N-95 respirator. a. Determine how the mask is secured. Identify the top edge of the mask by locating the thin metal strip (nosepiece) that goes over the bridge of the nose. Surgical masks may be secured by ties at the back of the head and neck, loops around the ears, or elastic bands. b. Pick up the mask with the top ties or ear loops. Place the mask over your nose, mouth, and chin. Press the flexible metal strip so that it conforms to the bridge of your nose. The mask must fit snugly to your face for maximum barrier protection. Correct positioning will also keep your glasses or goggles from fogging. c. Tie the upper ties to the back of your head and the lower ties to the back of your neck or slip the loops around your ears or place the elastic bands as with the ties. d. Place the lower edge of the mask below your chin and tie the lower ties. Covering the nose and mouth creates a barrier to prevent droplet pathogens from entering through the nasal and oral mucous membranes or the respiratory system. 4. Don the face shield or goggles. a. Face shield: Place the shield over your eyes, adjust the metal strip over the bridge of your nose, and tuck the lower edge below your chin. Secure the straps behind your head. b. Safety glasses or goggles: Set them over the top edge of the mask. 5. Don hair cover, if indicated. 6. Don shoe covers, if indicated. 7. Don gloves. a. Select nonsterile disposable gloves of the appropriate size. The correct size will prevent gloves from falling off or ripping while you are working with the client. b. If you are wearing a gown, make sure that the glove cuff extends over the cuff of the gown. If skin is visible between the gown and the glove, tape the glove cuff to the gown cuff, covering all visible skin. Patient Teaching Answer questions the patient may have and educate about the need for PPE, his disease process, and the purpose of isolation. Home Care Identify the type of PPE needed and ensure that the necessary supplies are available. Develop a plan with the client and family for using and disposing of personal protective equipment and contaminated items. Teach family members to don PPE as needed. Obtain referral for a home health agency to provide support. Documentation The use of personal protective equipment is generally assumed and usually does not require documentation. Practice Resources AORN (2013a); Minnesota Dept. of Health (n.d.); Siegel, J. D., Rhinehart, E., Jackson, M., et al. (2007).

Exercise and activity

Exercise is just as important as rest and sleep. Too little activity causes circulation to slow and the lungs to supply less oxygen. Too much exercise leads to fatigue and joint injury. Chapters 33 and 35 provide in-depth discussion on activity, exercise, rest, and sleep.

What Should I Do If I Am Exposed to Bloodborne Pathogens?

Exposure to blood, body secretions, or body tissues containing blood or secretions requires immediate action. See Box 22-5 for complete instructions. The first step is to minimize the exposure by washing the area thoroughly. Then notify the appropriate people, complete an injury report, and seek medical attention. Anyone exposed to bloodborne pathogens should have baseline lab work done to check for hepatitis and HIV. If the patient source is known, the infection preventionist will arrange to have the patient tested. Subsequent testing and possible preventive treatment are based on the type of exposure and what is known about the source and the injured person. To limit risks from the exposure, the infection prevention team will provide counseling and recommendations as soon as possible after the event. Chapters 23 and 25 present information on preventing needlestick injuries

Portal of entry

Fifth chain of infection Pathogens can enter the body through various portals of entry. Normal body openings, such as the conjunctiva of the eye, the nares (nostrils), mouth, urethra, vagina, and anus are potential portals of entry, as are abnormal openings, such as minor wounds and abrasions. Vectors, such as mosquitoes, create portals of entry when they bite or sting through the skin. In healthcare settings, common portals of entry include more severe wounds, surgical sites, and insertion sites for tubes or needles.

infectious agent

First chain in chain of infection Some microorganisms are harmful. Others live on or in the human body without causing harm (e.g., the Staphylococcus bacteria that grow on human skin). Other microorganisms are beneficial or even essential for human health and well-being. They are referred to as normal flora. Normal Flora Normal flora in the intestine aid in digestion; synthesize vitamin K; and release vitamin B12, thiamine, and riboflavin when they die. In addition, they limit the growth of harmful bacteria by competing with them for available nutrients. There are two types of normal flora: transient and resident.

Temperature

For most pathogens, the ideal temperature is 95°F (35°C). Environments that are too hot or too cold for a species will slow its growth or even kill the entire population. In part, the microbes that are pathogenic to humans are so because they thrive at about the same temperature as the human body. Thus, the body produces a fever in response to infection to inhibit and even kill invading pathogens.

Sterile Fields

For steps to follow in all procedures, refer to the Universal Steps for All Procedures found on the inside back cover. For this procedure, also refer to Clinical Insights 22-3, 22-4, and 22-5. If you need more information, review the section Using Sterile Technique in Nursing Care and Box 22-4, earlier in this chapter. Equipment Package of sterile supplies required for the procedure Sterile gloves of the correct size Procedure 22-8A ■ Setting Up a Sterile Field When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation. Procedure Steps Close doors and limit the number of people in the area. Air currents can carry dust and microorganisms. Prepare a sterile field as close as possible to the time of use. To minimize the opportunity for contamination via air currents. 1. Assess the sterility of all packages and equipment. Check to make sure the packaging is intact and the expiration dates have not passed. Only sterile items should enter a sterile field. Any compromise in packaging means that the item is assumed not to be sterile. 2. Arrange the environment for performing the sterile procedure. a. Remove all items from the surface you will use to set up the sterile field. Inadequate space causes inadvertent contamination during sterile procedures. b. Position the patient as needed for the procedure. Allows you to immediately proceed with the planned procedure. Once the sterile field is established, air movement can create contamination of the sterile items. Procedure Variation Using Sterile Packaged Equipment 3. Place the sterile package on a clean, dry surface. Prevents contamination of the sterile item. If a surface is damp, strike through of moisture may occur, making the item unsterile. 4. Open the flap away from you first. To prevent passing an unsterile arm over the sterile items. If you move an unsterile item over a sterile field, the field is no longer considered to be sterile. 5. Open the side flaps. 6. Pull the final flap toward you. The wrapper is now the sterile field. Touch the inside of the wrapper only after you don sterile gloves. The area 1 inch from the edge of the wrapper and 1 inch from the table edge is considered unsterile. Do not readjust the sterile area after the package has been opened. Only the horizontal surface of the draped area is considered sterile. Any part of the sterile wrapper that falls below the level of the sterile area (e.g., top of the table) is considered unsterile. If you move the field after opening, the field shifts and places unsterile areas of the wrapper on the surface. Procedure Variation Opening a Fabric- or Paper-Wrapped Sterile Package 7. Check and remove the chemical indicator strip. The indicator tape per manufacturer or institution confirms that the package was sterilized. The pack usually is also dated. 8. Remove the outer wrapper and place the inner wrapped package on a clean, dry surface. The outer wrapper is not considered sterile and is discarded. 9. Open the inner wrapper following the same technique described in steps 3 through 6. Procedure Variation Placing a Sterile Drape Omit steps 3 through 9. 10. To place the package on a clean, dry surface: a. With the outer wrapper still on the package, hold the edge of the package flap down toward the table. b. Grasp the top edge of the package, and peel back. The sterile drape is inside the outer wrapper. This maneuver opens the package without contaminating the sterile drape. 11. Pick up the sterile drape by the corner. Allow the drape to fall open, away from your body and away from unsterile surface, touching only the outside (unsterile side) and edge of the drape. Avoid fanning the sterile drape as you unfold it to cover the table surface. Drape musts extend over the edge of the table, but not touch the floor. A 1-inch border around the sterile drape is considered unsterile. 12. In some situations, when placing a sterile drape (e.g., under a patient) you may need to protect your gloved hands by cuffing the drape over your hands.

Surgical Hand Washing: Traditional Method

Sterile Gown and Gloves (Closed Method)

For steps to follow in all procedures, refer to the Universal Steps for All Procedures found on the page facing the inside back cover. For this procedure, also refer to Clinical Insights 22-3 and 22-4, if you need more information. Equipment Sterile gloves of the correct size Sterile gown You should find these lying on a sterile field. If they are not, you will need to create a sterile field to place them on. When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation. Procedure Steps 1. Grasp the gown at the neckline. Hold the gown up and allow it to fall open as you step back from the table. Be careful not to allow the gown to come into contact with nonsterile areas while you are lifting it off the table and opening it. The gown will be contaminated if it touches unsterile objects. 2. Slide both arms into the sleeves, but do not extend your hands through the cuffs. 3. Keep the sleeves of the gown above waist level. Hands will contaminate the sleeve edge if allowed to pass through the cuff. 4. Have a coworker (or the circulating nurse, if you are in the operating room) stand behind you and pull the shoulders of the gown up and tie the neck tie. The coworker touches only the inside of the gown while pulling it up. Touching only the inside prevents contamination of the gown with the nurse's hands. 5. Don sterile gloves using the closed method. Open the sterile glove wrapper, keeping your fingers inside the sleeve of the gown. (The outer wrapper has already been discarded.) Glove the dominant hand first: a. With your nondominant hand, keeping your hands inside the gown sleeves, grasp the cuff of the glove for your dominant hand. Turn your dominant hand palm up. Keeping the hand inside the cuff ensures that you are making contact with the sterile gown; sterile is touching sterile. b. Lay the glove on the dominant gown cuff, thumb side down with the glove opening pointed toward the fingers, and thumb of glove positioned over the thumb side of the hand. c. Keeping your dominant hand inside the sleeve, grasp the inside of the glove cuff. d. With your other hand (inside its sleeve), grasp the upper side of the glove cuff and stretch it over the gown cuff. e. Pull the sleeve of your gown up to pull the glove cuff over your wrist as you move your fingers into the glove fingers. Glove the nondominant hand. a. Place the fingers of your gloved hand under the cuff of the second glove. Lay the glove on the forearm of your nondominant hand. Grasp and anchor the inside glove cuff with your nondominant (ungloved) hand through the gown, being careful to keep fingers inside the gown. b. With your dominant (gloved) hand, pull the glove cuff over the cuff of the gown as you move your fingers into the glove. c. Adjust the fingers in both gloves so the excess glove is pulled over the fingertips. Maintains sterility of the gown and gloves by maintaining a closed system. The final adjustment of the gloves is done when both gloves are in place to prevent contaminating the gloves. Taut gloves, especially over the fingertips, allow better feel and dexterity. 6. Grasp the waist tie on the gown, and hand the tie to the circulating nurse or a coworker who is wearing a hair cover and mask. Your coworker will grab the tie with sterile forceps. The tie is considered sterile. You will need help pulling it around you. A coworker can help you. Using sterile forceps keeps the tie sterile. 7. Make a three-quarter turn and receive the tie from your coworker. Because only areas within your field of vision are considered sterile, a coworker must pull the waist tie around you. 8. Secure the waist tie. Ensures that the gown is secured and will not expose clothing to a sterile field. Patient Teaching If the patient is alert during the procedure, explain: The need for the sterile procedure Why he must not touch the drapes Why he must not move or talk once the drapes are in place Any special precautions during the procedure Documentation Donning sterile gown and gloves does not require documentation. You will need to chart the procedure performed and how the patient tolerated it. In the operating room, the circulating nurse charts about the surgery and the patient's response. What if ... Your hand inadvertently comes through the cuff opening when putting on the gown? Change gowns. The cuff would have been contaminated and would then contaminate your glove. Practice Resources AORN (2013a, 2013b, 2016); CDC (2002).

Surgical Hand Washing: Brushless System

For steps to follow in all procedures, refer to the Universal Steps for All Procedures found on the page facing the inside back cover. For this procedure, also refer to Clinical Insights 22-3, 22-4 if you need more information. Equipment Antimicrobial soap (60% to 95% alcohol or other FDA-approved for surgical hand asepsis) Disposable single-use nail cleaner Deep sink with foot or knee controls Surgical shoe covers, cap, and face mask Sterile gloves of the correct size Surgical pack containing a sterile towel When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation. Procedure Steps 1. Determine agency policy for the type of cleansing product to be used and for duration of the surgical scrub (typically 2 to 6 minutes). Policies vary from institution to institution, although all should be based on sound principles for infection control in accordance with guidelines from CDC and the Association of periOperative Registered Nurses (AORN), as well as manufacturer's directions for product use. The type of cleansing agent determines how long to scrub. Typically, alcohol-based handrub is rubbed on to hands and arms until dry. 2. Before starting the surgical scrub, gather supplies and set up sterile gloves, gown, and towel for use after the scrub. To maintain sterility of the hands after the scrub, the sterile gloves, gown, and towel must be ready before washing. 3. Observe recommended hygiene. a. Avoid wearing artificial nails and extenders; nails should be free of polish and not extend beyond the end of the fingers. The AORN and CDC recommend this when in direct contact with patients, in high-risk situations such as the perioperative setting, or among those receiving immunosuppressant therapy. Artificial nails have been shown to harbor more pathogenic organisms in the subungual area than natural nails, particularly gram-negative bacilli (especially Pseudomonas) and various strains of yeast. Long and poorly groomed nails can tear gloves. b. Remove rings, watches, and bracelets before starting the surgical scrub. Hand jewelry can prevent the handrub from reaching all skin areas, leaving potential pathogens on the skin. Risk of infection from microorganisms increases exponentially in relation to the number of rings worn. 4. Don shoe covers, a cap, and a mask. Tuck hair completely under the cap. Masks filter out possible airborne pathogens carried in the nose or mouth, preventing contamination of sterile areas. Covering the hair reduces the transmission of pathogenic organisms that adhere to the hair shaft or scalp. 5. Perform a prewash before the surgical scrub. Use a pick and running water to remove dirt and debris from under the nails; discard. Prewash removes any visible soil, reduces the number of microorganisms on your skin, and allows you to begin the surgical scrub with clean hands. The area under the nails harbors dirt, debris, and microorganisms. 6. Turn on the water, using the knee or foot controls or motion controls. The temperature usually adjusts automatically in a surgical scrub sink. If it does not, adjust to warm. Water temperature that is too hot can cause injury to the skin, making it prone to drying, chafing, and cracks. It can also remove normal flora and natural oil, which have a protective effect on the skin. 7. Wet hands and forearms from the fingertips to elbows, keeping hands above the elbows and away from the body at all times. Prevents water running down from your elbows and forearm over washed and rinsed hands. 8. Dispense a palm full of antibacterial soap into your dominant hand. a. Insert the fingertips of your nondominant hand into the soap using a twisting motion to apply the product to the fingertips and nails. b. Then rub the hands together to distribute the soap over the hands. 9. Vigorously rub all surfaces of your nondominant hand and fingers, adding water as needed. Be sure to rub each finger on all sides. Do not touch the inside of the sink during the cleansing procedure. Complete contact and friction are necessary for removal of microorganisms adherent to the skin's surface. The inside of the sink is considered contaminated with microbes. Incidental contact necessitates repeating the cleansing procedure. a. Rub the hands together palm to palm. b. Using your dominant palm, clean the back of your nondominant hand. c. Then rub your nondominant palm over your dominant hand. d. Then rub your palms together with your fingers interlaced. e. Rub the back of your fingers on your closed right hand back and forth across your nondominant palm, with your curved fingers interlaced. Do the same with your other hand. f. With your nondominant hand, clasp your dominant thumb and make rotational movements to cleanse the thumb. Repeat on the other hand. g. Hold your fingers together on the dominant hand and move them back and forth and in a circular pattern against your other palm, and vice versa. Although the palmar surface carries more organisms than the back side of the hands and arms, this area nonetheless should be cleansed thoroughly to reduce microbial count. 10. Rinse, using deep basin sink with knee-, foot-, or motion-operated controls. Improved adherence to sterile technique commonly results from use of motion- or foot/knee-operated controls for faucets. 11. Next cleanse the remaining ⅔ of the arms, beginning at the wrist, to 2 inches above the elbow. Cover every aspect of the middle and upper third of the forearm. 12. Dispense cleansing solution into the hands each time you cleanse a new area. Be sure the dispenser is not blocked A blocked dispenser can interfere with obtaining the amount of product needed for reducing bacterial colonization. 13. First, scrub the nondominant arm wrist-to-elbow. Then repeat the wrist-to-elbow scrub on the dominant arm. Rinse each arm thoroughly and independently. 14. This completes one washing cycle. a. Using the same motions, beginning with step 8, perform a second cycle. b. Then finish with a third cycle in which you scrub only the hands (steps 8-11). c. The scrub is complete after cleansing every aspect of the hands and forearms for 3 full minutes. AORN promotes a 2- to 3-minute scrub time using an antiseptic detergent to achieve maximal microbicidal activity while avoiding irritant contact dermatitis. Reduced time required to perform the surgical scrub often results in increased compliance with the prescribed technique. 15. With arms flexed and hands held higher than the elbows away from the body, move to the area with the sterile towel and gown. This position prevents water running down from your elbows and forearm over rinsed hands. 16. Grasp the sterile towel, and back away from the sterile field. Lean forward slightly and allow the towel to fall open, being careful not to let it touch clothing or gown. This motion is performed to maintain a dry sterile field and prevent inadvertent brushing against the table and contaminating the field. Do not turn your back on any sterile field. 17. Use one end of the towel to dry one hand and arm. Dry the other hand and arm with the opposite end of the towel. Use of a separate section of the towel guards against inadvertently rewetting the skin or contaminating an already clean area. 18. Allow time for the skin to dry thoroughly before donning sterile gloves. Dry skin prevents maceration and allows the gloves to go on more easily. Moisture left on the skin can be a source of further microbial contamination. 19. Once the brushless scrub is complete, keep your hands in front of your body and above the waist. It may be necessary to enter backward through the door of the surgical suite. These actions help prevent contamination of the hands and forearms when moving from the scrub sink. Documentation A brushless surgical hand scrub does not require documentation in the patient's medical record, although there may be a checklist. However, you must adhere to the institution's policy for performing the technique. Patient Teaching If the patient is able to observe the procedure, explain the purpose of a diligent approach to surgical scrub for promoting a low-risk environment for infection. Home Care Sinks in the home environment typically do not have knee- or foot-operated controls or motion-sensor on/off devices. Therefore, when scrubbing for a sterile procedure in the home, contact with the faucet handles is performed with barrier objects (e.g., a paper towel or a sterile towel for a sterile scrub) between the clean hands and the environmental surface. Practice Resources AORN (2013a, 2013b); Association for Surgical Technologists (2008a); CDC (2002); George, D., & Bhabra, M. A. (2010).

IgD

Forms on the surface of B cells Traps the pathogen to prevent it from replicating and causing disease

IgA

Found in mucous membranes in the intestines, respiratory and urinary tracts, saliva, tears, and breast milk Provides additional immune protection by secreting around body openings

mode of tansmission

Fourth chain in chain of infection Direct or indirect contact, droplet transmission, airborne transmission, vector,

Endogenous

In endogenous healthcare-related infections, the pathogen arises from the patient's normal flora, when some form of treatment (e.g., chemotherapy or antibiotics) causes the normally harmless microbe to multiply and cause infection. Example: Candidal vaginitis (yeast infection) may develop in a client after frequent use of antibiotics.

Exogenous

In exogenous healthcare-related infections, the pathogen is acquired from the healthcare environment.

Physical assesment

General appearance. Does he seem fatigued? Is he diaphoretic (perspiring profusely)? Is he wrapped in blankets or complaining of feeling chilled? Does the patient appear well nourished? Are the mucous membranes dry? Skin. Examine the skin thoroughly for: Normal elasticity (turgor) Signs of local infection evidenced by pain, redness, swelling, and warmth Presence or absence of any rashes, skin breaks, or reddened areas Note: Patients with poor peripheral circulation often have skin discoloration, rather than signs of inflammation, when experiencing an infection. Lymph nodes. Swollen lymph nodes may indicate the presence of an infection in the area that drains into the nodes. Temperature and pulse. Elevated temperature and pulse rate are classic signs of an infection. The presence of one infection does not eliminate the risk for an additional infection. For example, a patient being treated with IV medications for a wound infection is at risk for infection at the IV site, as well as for a superinfection or an infection related to insufficient immunizations. For a list of tests commonly used to evaluate evidence of or risk for infection, see the accompanying Diagnostic Testing box. Each specific test should be evaluated based on the patient's condition, age, and coexisting conditions.

Maintaining clean hands

Hand hygiene is the single most important activity for preventing and controlling infection. The WHO (2009) chose as the first Global Patient Safety Challenge the reduction of HAIs, with the theme, clean care is safer care. Hand hygiene is the cornerstone strategy because it is simple, standardized, low-cost, and based on solid scientific evidence. Although you may think you already know how to wash your hands, decisions about the type of hand hygiene to use, how long to wash, when to wash, and so on are based on the amount of contact you have with patients or contaminated objects, as well as the patient's infection status and susceptibility to infection. Hand washing involves five key factors: time, water, soap, friction, and drying. Time. In a nonsurgical setting, wash the hands vigorously for at least 15 seconds, longer if hands are visibly soiled. In a surgical setting wash for 2 to 6 minutes, depending on the soap or other product used. Water. Use warm water and rinse off soap completely. Soap. Use agency-approved soap; or The CDC recommends (2002) use a 60% alcohol-based solution (rubs, sprays, gels) for routine hand cleansing and plain or antimicrobial soap and water when hands are visibly dirty. Iodine compounds are also effective, but usually too irritating for regular hand hygiene. If there is a potential for contact with bacterial spores (e.g., when caring for a client with a C. difficile infection), you must wash your hands with soap and water; alcohol-based solutions are not effective against spores. For more specific details and guidelines for hand hygiene, see Clinical Insight 22-1 and Procedure 22-1, Hand Hygiene. Friction. Rub all surfaces of the hands and wrists vigorously, including the backs of the hands and between the fingers. Remove jewelry and clean areas underneath. Clean underneath the fingernails using an orangewood stick. Drying. Use single-use towels or hand dryers to remove all moisture after washing the hands. If using antimicrobial hand gels, apply and rub hands until dry. Failure to perform standards of care constitutes medical negligence and can result in harm to the patient. In addition, Medicare does not reimburse for patient complications arising from certain HAIs, many of which result from poor hand washing. Despite the importance of clean hands, research demonstrates that clinical staff do not consistently observe hand hygiene guidelines (Pratt, Pellowe, Wilson, et al., 2007). You can help improve clinical practice by serving as a role model for good hand hygiene.

Convalesence

Healing begins as the remaining number of microorganisms approaches zero. Convalescence may require only a day or two or, for severe infections, as long as a year or more.

Reasons for high incidence of healthcare-related infections

In hospitals and other facilities, patients encounter many care providers who can transmit pathogens to them. Ill patients are vulnerable to infection due to lowered resistance, and they are a source of infection for others. Inpatients undergo many invasive procedures (e.g., injections), which can be a source for microbes to enter.

Using Sterile Technique in Nursing Care

Healthcare providers use sterile technique to perform a variety of procedures. Some of the procedures require full surgical PPE; others do not. Examples of procedures that use both sterile technique and principles of medical asepsis are administering an injection, starting an IV line, and performing a sterile dressing change. To clarify, when administering an injection, you prepare the patient; cleanse the injection site; and remove the needle cap using standard precautions. You do not don sterile gloves, but for the rest of the procedure you observe sterile technique by taking care not to touch or otherwise contaminate the exposed needle. Before performing a sterile procedure, determine what supplies you will need and whether you will need assistance. If the patient is unable to maintain a position required for the procedure, you will need a helper to hold the patient during the procedure.

Level of disinfection

High-level disinfection kills all organisms except high levels of bacterial spores. Intermediate-level disinfection kills bacteria, mycobacteria, and most viruses. Low-level disinfection kills some viruses and bacteria.

PRACTICING SURGICAL ASEPSIS

If an object is sterile, it contains no life and therefore no infectious organisms. Inanimate objects, such as surgical equipment, gauze dressings, or wound irrigation fluid may be sterilized. However, it is impossible to rid the human body of all microorganisms, either in or on it.

Transmition based isolation

If the client is in transmission-based isolation, disinfect the equipment on removal from the room. When removing linen or nondisposable items from a room with contact, droplet, or airborne isolation, place them in special isolation bag

Closed Gloving.

If you are applying full surgical attire, you will need to don gloves using a closed method, after you have put on your gown. Once you are wearing sterile gloves, you may touch only sterile items. To learn how to don sterile gloves and gown using the closed method, see Procedure 22-6.

If You Are Exposed to Blood or Other Body Fluids

If you are stuck by a needle or other sharp or get blood or other potentially infectious materials in your eyes, nose, mouth, or on broken skin: 1. Immediately flood the exposed area with water and clean any wound with soap and water or a skin disinfectant if available. 2. Report the exposure immediately to the appropriate person in the agency. If you are a student, also report immediately to your instructor. 3. Seek immediate medical attention. Consent to testing and follow-up treatment as advised. 4. Complete an incident or injury report. 5. Attend counseling sessions provided by the agency.

Tetiary Defenses

Immunity against an infection is achieved through the presence of antibodies that neutralize or destroy toxins or disease-producing organisms. Active immunity occurs when the body makes its own antibodies or T cells to protect the body against a pathogen. Immunity can also be achieved when a person is given antibodies to a pathogen rather than producing them through her own immune system, called passive immunity (Box 22-1). Why is it that most people who recover from an infectious disease such as measles or chickenpox never get the disease again, even if they are repeatedly exposed to the virus? The answer lies in specific immunity: the process by which the body's immune cells "learn" to recognize and destroy pathogens they have encountered before. The cells involved in specific immunity are the lymphocytes, WBCs produced from stem cells in the red bone marrow. Refer to the heading, Cellular Immunity, following.

natural passive. immunity

Immunity results when natural antibodies are passed from one body to another, such as from mother to baby through the placenta or through breastfeeding.

Phagocytosis

Immunoglobulins, which are the specialized proteins in the body's immune system that function as antibodies. Antibodies (see Box 22-2) signal leukocytes (macrophages and neutrophils) to phagocytize the pathogens to which the antibodies are bound.

Many emerging pathogens are viruses.

In 2015 the World Health Organization prioritized the following emerging pathogens for which few or no medical countermeasures exist: ebola virus, Zika virus, SARS, MERS, Crimean Congo haemorrhagic fever, and others.

CDC guidelinges for preventing Trnasmission of pathogens

In addition to hand washing and maintaining a clean environment, you should follow other precautions to protect yourself and your patients. CDC guidelines provide for two tiers of protection (Siegel, Rhinehart, Jackson, et al., 2007): standard precautions and tranasmission-based precautions

Incubation

Infection begins in this stage between successful invasion of the pathogen into the body and the first appearance of symptoms. In this stage, the person does not suspect that he has been infected but may be capable of infecting others. This stage may last only a day, as with the influenza virus, or as long as several months or even years, as with tuberculosis.

Chain of infection

Infections spread through a chain of infection. It is made up of six links (described below), all of which must be present for the infection to be transmitted from one individual to another (Fig. 22-1). Later in the chapter we discuss how to interrupt the chain to limit the spread of infection. Infectious agent Reservoir Portal of exit Mode of transmission Portal of entry Susceptible host

Predictable stages of infection

Infections usually follow a predictable course, although the precise duration and intensity of symptoms in each stage vary from one individual to another: Incubation Prodrome Illness Decline Convalescence

Respiratory Hygiene/Cough Etiquette for Patients

Instruct symptomatic persons to cover mouth/nose when sneezing/coughing. Provide and use tissues and dispose in a no-touch receptacle. Perform hand hygiene after soiling hands with respiratory secretions or after using a tissue or covering the mouth/nose. Wear a surgical mask if tolerated or do not come within 3 feet of another person if possible. Some patients may not be able to tolerate the decreased oxygen that is available when breathing room air through a mask.

Skin

Intact, healthy skin prevents entry of many pathogens. Normal skin flora inhibit multiplication of other organisms that land on the skin.

Prepare Clients for a Pandemic Disease Outbreak

Isolation and personal protective equipment (PPE) are important in preventing the spread of most pandemic infections. Preparing for pandemic disease is similar to preparing for other general kinds of emergency preparedness, such as natural disasters.

INFECTION CONTROL AND PREVENTION FOR HEALTHCARE WORKERS

It is critical that you learn how to protect yourself from infections—not only to avoid personal illness but also to avoid becoming a reservoir for infection. Nurses and other patient care workers are at increased risk of acquiring infections because they come in contact with a variety of pathogens. Skin and mucous membrane contact and puncture wounds often serve as portals of entry. As a nurse, you need to monitor other healthcare workers, patients, and visitors for adherence to infection control measures. As well, nursing assistive personnel (NAP), hospital personnel, and volunteers are often present on nursing units. You need to protect them and yourself from potential hazardous exposure as well as from microorganisms brought into the unit.

Jewelry

Jewelry Remove all jewelry before beginning hand hygiene, or surgical hand scrub. CDC (2013). Hand jewelry may make donning gloves more difficult and cause gloves to tear more readily. The WHO (2009) prohibits any jewelry or watches on the hands of the surgical team. Skin underneath rings is more heavily colonized than comparable areas of skin on bare fingers. We recommend that you not wear a watch or rings in the clinical setting, especially rings with stones. If your agency permits you to wear jewelry, clean it thoroughly and often.

Institute Appropriate Level of Standard Precautions

KEY POINT: In the event of an epidemic, the essential principles of hand hygiene and standard precautions will be the core of your infection prevention and control measures. Patients with similar symptoms should be cared for by a minimum number of healthcare personnel, and those personnel must use appropriate isolation precautions. If the etiology and transmission route of the causative organism are unknown, standard, contact, and airborne precautions should be implemented as needed. The U.S. Department of Labor (n.d.a) defines types of personal protective equipment and situations in which you are required to wear it.

Protecting the Equipment on the Sterile Field

KEY POINT: Sterile touches sterile. Unsterile touches unsterile. Only sterile items can be placed on a sterile field. Wash your hands before gathering materials from the sterile supply area and then gather the other required supplies and equipment. Handle sterile equipment only if you are wearing sterile gloves. Sterile liquids must be contained in sterile containers on the field or the sterile drape must be nonpermeable to avoid wicking. If the drape is permeable, liquid can seep through to the underlying surface and act as a wick for contaminants to travel upward to the sterile field. Make sure you are opening equipment packaged with labels indicating it has been sterilized properly, packaging intact and dry, and not expired. If packages are light and small, gently add them to the sterile field by separating the package flaps and allowing them to fall onto the field. If the object is large (e.g., an irrigation bowl), slowly unwrap the packaging and, grasping it through the outside wrapper, place the bowl on the field.

About Supporting the Psychological Needs of Patients in Isolation

Keep in mind that it is the disease that is being isolated, not the person who has the disease. Patients in isolation continue to have a need for human contact. In fact, isolation may produce anxiety and increase the desire for human contact. Search for ways to reassure and maintain contact with the patient in protective isolation. Use touch as much as possible (when wearing required protective equipment). Set aside time to ask about how the client is coping with isolation. If the patient is in droplet isolation, remember that the danger area is 3 feet from the patient. You can go to the door of the room and speak to the patient without a mask. Reassure the patient that precautions are temporary. Explain that the precautions and the PPE protect you and the patient, as well as family members and other patients. Toward Evidence-Based Practice

Fingernails

Keep natural fingernails short (1/4 inch or less) and avoid wearing fingernail polish or artificial nails in the perioperative setting (AORN, 2013a;WHO, 2009). Chipped nail polish can contaminate a sterile environment when gloves are not worn or are punctured or torn. Artificial nails, including gels, acrylics, and resins harbor microorganisms and impede proper hand hygiene. Scrub the undersides of fingernail with soap and water and nail brush every time you wash your hands. Clean nail grooming tools before use. Avoid biting or chewing nails or cuticles. Never rip a hangnail; instead, trim with a sanitized nail trimmer (CDC, 2009b).

laboratory specimens DISPOSAL

Laboratory specimens contain blood and body fluids and are always considered contaminated. Label the specimen container in a clean area before taking it to the patient. Have the specimen collected by a healthcare worker wearing appropriate protective clothing. Once the specimen is collected, place it in a special transport bag. Do not allow the outside of the bag to touch any contaminated item, especially your gloves.

Stress reduction

Laughing increases immune responses, improves oxygenation, and promotes body movement. In contrast, physical or mental stress decreases the body's immune defenses. Studies demonstrate a correlation between stress and disease (Cousins, 1979; Franco, de Barros, Nogueira-Martins, et al., 2003; Tegethoff, Greene, Olsen, et al., 2011). See Chapter 12 if you want further details on the effects of stress.

Wellness Promotion to Support Host Defenses

Lifestyle factors that strengthen host defenses and help break the chain of infection are healthful nutrition, good hydration, adequate hygiene, rest and exercise, stress reduction, and immunizations. Nutrition It is important to monitor and support client nutrition, including protein, vitamins, minerals, and water. An acute infection depletes the body's nutritional stores. Nutrients are required to replace lost stores, to maintain production of white blood cells, and to repair damaged tissues. Common defenses against infection are increased mucus secretions and fever (which increases the metabolic rate). These common defenses against infection increase water loss. Chapter 28 further discusses the importance of adequate nutrition.

Linens

Linens While wearing gloves, carefully handle contaminated linens. To prevent skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other patients or the environment. Bag and remove soiled linens from the room immediately. Linens may harbor microorganisms that may transfer to your clothing, open skin, or mucous membranes, which could then be carried to other clients or environment.

Oxygen

Many bacteria and most protozoa and fungi are aerobic. That is, they must have oxygen to live and grow (e.g., the yeast Candida albicans). Anaerobic organisms do not require oxygen for growth and may even be killed in its presence. One example is Clostridium tetani, which can cause tetanus.

Emerging infectious disease

Many definitions Newly identified diseases Diseases occurring in new geographic areas Microorganisms in animals or insects that extend their host range to begin infecting humans Microbes that evolve to become more virulent Known diseases that dramatacally increase in incidence Mamy viruses show a high mutation rate Organisms that are deliberately altered for bioterrism Many emerging pathogens are viruses

Gastrointestinal tract.

Many pathogens are destroyed in the acidic environment of the stomach. Those that enter the small intestine face the antimicrobial action of bile. Normal peristalsis as well as diarrhea and vomiting remove pathogens that invade the gastrointestinal tract. In addition, normal flora in the intestine secrete antibacterial substances.

Protecting the Sterile Field

Move slowly and deliberately. Never reach across a sterile field. If you see someone else contaminate a sterile field or object, identify the break and cover the area with sterile drapes or replace with a new sterile setup, gown, or gloves. Remain at least 1 foot away from nonsterile areas if you are wearing sterile garb. Never turn your back to a sterile field. A sterile field and open sterile items must be kept above waist level and in constant view. You are responsible for monitoring and maintaining the sterility. If you cannot see the field, you do not know whether it has become contaminated. Make sure your clothing or lab coat never touches any part of the sterile field. Keep your fingernails short and clean. Avoid nail polish and artificial nails. Avoid wearing jewelry that dangles or can fall into the sterile field. Keep long hair pulled back or covered by a head covering designed for sterility. Change your gown or reinforce with additional sterile drapes if it is soaked through. Avoid splashing any kind of solution onto the sterile field. Keep doors closed so turbulent airflow does not contaminate a sterile area with airborne microbes. Clean wounds and prep sterile sites from clean to dirty.

Protective isolation

Nevertheless, in practice you may see what has been called protective isolation being used for clients with low WBC counts, clients undergoing chemotherapy, or clients with large open wounds or weak immune systems. Protective isolation usually includes following standard precautions; placing the patient in a private room; restricting visitors; wearing a mask, gown, and gloves for patient care; and special cleaning or disposal of the patient's equipment and supplies. Some units, such as neonatal intensive care units, burn units, and labor and delivery suites, may follow some aspects of protective isolation all the time.

Normal Flora

Normal flora in the intestine aid in digestion; synthesize vitamin K; and release vitamin B12, thiamine, and riboflavin when they die. In addition, they limit the growth of harmful bacteria by competing with them for available nutrients. There are two types of normal flora: transient and resident.

Iron Level

Normally 60-90 g/100 mg. Lower in chronic infection.

Analysis/nursing diagnosis

Only one NANDA-I diagnosis directly pertains to infection: Risk for Infection. Infection, Risk for Virtually all patients in a healthcare setting are at risk for becoming infected because of exposure to pathogens in the environment. KEY POINT: Use this diagnosis only for patients who are at higher than usual risk (e.g., those with poor nutritional status) and who need nursing interventions to help prevent infection. Do not use it for the generic assessments you do routinely for all patients (e.g., assessing temperature, routine examination of surgical incision). Examples of appropriate use of this diagnosis include the following: Risk for Infection r/t altered immune response secondary to corticosteroid therapy Risk for Infection r/t impaired skin integrity and poor nutritional status. Risk for surgical site infection r/t transverse abdominal incision.

Moisture

Pathogens require moisture for survival, for example, the moist environment of wounds, the genitourinary tract, and the throat and airways. However, bacteria form spores that allow them to live without water (e.g., the Bacillus and Clostridium species, both of which cause food-borne disease).

Secondary defenses

Pathogens that dodge the primary defenses and enter the body begin to release wastes and secretions and to cause the breakdown of cells and tissues. The presence of such chemicals activates a set of secondary defenses. Phagocytes Complement cascade Infammation Fever

Protective Environment in Special Situations

Patients who are immunosuppressed (e.g., receiving chemotherapy) are sometimes placed in a special form of isolation, called protective isolation or reverse isolation. However, the CDC states that standard and transmission-based precautions are adequate protection for most of those patients. They recommend a "protective environment" only for a special class of stem cell-transplant patients who have neutropenia (low white blood cell count) secondary to chemotherapy. Most of the recommendations are engineering and environmental services rather than nursing measures. Refer to Clinical Insight 22-5 as a guide to providing a protective environment.

Hand Hygiene

Perform hand hygiene after touching blood, body fluids, secretions, excretions, contaminated items; immediately after removing gloves; between patient contacts. Refer to Clinical Insight 22-1 for details.

PPE

Personal Protective Equipment The CDC recommends and the U.S. Occupational Safety and Health Administration requires employers to provide personal protective equipment (PPE) for healthcare workers (e.g., gloves, gowns, face masks, and eye protection [Fig. 22-3]) (U.S. Department of Labor, n.d.a). This equipment is to be used in standard precautions as well as transmission-based precautions. To learn how to don and remove PPE, refer to Procedures 22-2 and 22-3.

Sterile Surgical Attire

Personnel involved in surgery or certain invasive procedures must dress in sterile surgical attire. As a beginning student, you will soon find yourself in such a situation. Initially your role will be limited to observation, but you will need to be prepared for these experiences. First you will change into scrub apparel, apply shoe coverings, and put on a disposable hat; wash your hands; and apply a facemask. If there is potential for spray of fluids, wear a face mask with an eye shield. Be sure to fit the mask so that it is comfortable to breathe through. Then perform the surgical scrub. If a surgical gown is required, don it after the hand scrub.

Disposing of used isolation supplies

Place contaminated disposable equipment and materials containing body fluids in special isolation bags; use the bags only for contaminated materials. This process requires two healthcare workers. The worker inside the room wears protective clothing and handles only contaminated items. The second worker stands at the door and holds the isolation bag open. The first worker places items inside the bag without touching the outside of the bag. If the bag contains linens, the isolation bag is closed and placed in a laundry hamper. Securely close the isolation trash bag and place it in a special isolation trash container. Special disposal methods are used to prevent these objects from going into a landfill, where they could become a reservoir of infection.

Patient Placement

Place in a single-patient room if: 1) the patient is at increased risk of transmitting or acquiring infection, 2) does not maintain appropriate hygiene, 3) is likely to contaminate the environment, or 4) is at increased risk of developing adverse outcome following infection

Chronic disease: host susceptibility

Poor circulation prevents antibodies and T cells from reaching the pathogens and damages tissue, making it easier for pathogens to enter and thrive. Diseases that impair peripheral circulation, such as uncontrolled hypertension (high blood pressure) and diabetes mellitus, make the patient prone to infection in the extremities. Leukemia, a form of cancer of the blood, increases the production of abnormal white blood cells, but these cells are ineffective in combating infection. Because HIV infects T cells, patients with AIDS have a reduced ability to fight off secondary infections.

Throat cultures, wound culture

Presence of microorganisms is normal, but there should be no growth of infectious microorganisms. To yield the most reliable results, blood cultures should be obtained from peripheral sites, using venipuncture by trained phlebotomists, unless a culture is specifically ordered from a central catheter or peripherally inserted central catheter.

Nursing and medical procedures: host susceptibility

Several procedures are associated with an increased risk of infection. For example, urinary catheterization may injure the fragile urethral mucosa, provide a direct pathway for pathogens into the bladder, and prevent the normal flushing of the urethra

IgE

Primarily responsible for the allergic response

■ Sterile Gloves (Open Method)

Procedure 22-7 ■ Sterile Gloves (Open Method) For steps to follow in all procedures, refer to the Universal Steps for All Procedures found on the page facing the inside back cover. For this procedure, also refer to Clinical Insights 22-3 and 22-4 if you need more information. Equipment Sterile gloves of the correct size When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation. Procedure Steps 1. Determine the correct size of sterile gloves. The gloves should be snug but not tight. Gloves that are too loose are more easily contaminated and make handling equipment or supplies difficult. Gloves that are too tight are uncomfortable and may tear during use. 2. Assess the glove package for intactness and expiration date. Do not use the gloves if the package is torn, has become moist, or is past the expiration date. Torn packaging may allow the gloves to become contaminated. Moisture allows wicking and may cause contamination. Expired gloves are not considered sterile. 3. Assess the patient's environment for a space that is clean and has adequate space to allow you to open the glove package. Don the gloves without touching a nonsterile item. 4. Open the outer wrapper and place the inner glove package on a clean, dry surface. Prevents contamination of the gloves inside the package. 5. Open the inner glove package so that the glove cuffs are closest to you. Be careful to fully open the package flaps so that they do not fold back over and contaminate the gloves. The outer 1-inch border of the glove package is considered contaminated. 6. With your nondominant hand, grasp the inner surface of the glove for the dominant hand. Lift the glove up and away from the table, keeping it away from your body. Take care to not touch anything else on the sterile field. The inside of the glove is not sterile because it is in contact with your skin. Lifting the glove up and away from the table prevents you from contaminating the glove by accidentally touching the table or your clothing while donning it. 7. Slide your dominant hand into the glove, keeping your hand and fingers above your waist and away from your body. The area below the waistline is considered contaminated. Keeping gloves away from your body prevents accidental contamination. 8. Slide your gloved fingers under the cuff of the remaining glove, keeping your gloved thumb well away from your ungloved hand. Lift the glove up and away from the table and away from your body. The outside of the glove is sterile and may be touched with your sterile gloved hand. 9. With gloved fingers still under the cuff, slide your nondominant hand into the glove and pull it on, being careful to avoid contact with your gloved hand, especially the thumb. 10. Adjust both gloves to fit your fingers. If necessary, pull the fingers of the gloves down so that no excess is at the fingertips. Adjusting your gloves after both have been donned decreases the risk of contamination and allows for greater dexterity during the procedure. 11. Keep your hands between shoulder and waist level in front of you. Keeps the gloves within your field of vision to avoid contamination. To remove soiled gloves after the procedure, refer to Procedure 22-3. Patient Teaching Explain why sterile gloves are needed for the procedure. Home Care Many home care procedures are clean rather than sterile. The client is in his own environment and not surrounded by other patients, who may serve as hosts for infection. You may need to teach caregivers how to apply sterile gloves for some procedures. No modifications are required. Demonstrate the procedure, and have the caregiver do a return demonstration. Documentation No special documentation is needed for sterile gloving. Chart the procedure you performed and the patient's response to the procedure. Practice Resources AORN (2013a, 2013b, 2016), Thinking About the Procedure To practice applying clinical reasoning to this procedure,

Specific nursing activities will be based on the unique situation of the client, as described in the etiology of the diagnostic statement. For example: For clients who have had surgery and general anesthesia or who are at risk for pneumonia—

Promote coughing and deep breathing on a regular basis.

goals of infection prevention and control for nurses are to:

Protect patients from infections. Meet professional standards and guidelines. Protect yourself from diseases (e.g., how to avoid contact with infectious material and microorganisms, especially MDROs). Help lower the cost of healthcare.

artificial passive immunity

Protection from infection is achieved when a person receives serum from another person or animal that has already produced antibodies against the pathogen (e.g., serum for treatment of rabies or botulism).

Specific nursing activities will be based on the unique situation of the client, as described in the etiology of the diagnostic statement. For example:For all clients at risk for infection

Provide care that is based on principles of medical asepsis.

Specific nursing activities will be based on the unique situation of the client, as described in the etiology of the diagnostic statement. For example:For clients who have surgical incisions or breaks in the skin

Provide regular assessment for infection status and follow appropriate medical or surgical asepsis guidelines.

Specific nursing activities will be based on the unique situation of the client, as described in the etiology of the diagnostic statement. For example: For clients being mechanically ventilated

Provide special oral care designed to prevent ventilator-associated pneumonia.

Levels of Asepsis

Recent guidelines suggest using modified sterile technique for many bedside procedures that have traditionally used sterile technique (e.g., tracheostomy care and wound care). The following summarizes the practical differences in sterile, modified sterile, and clean techniques: Sterile technique Modified sterile technique Clean technique

Illness or injury: host susceptibility

Recuperation from infection or injury limits the physical resources available to combat a new pathogen.

Following Transmission-Based Precautions

Refer to Clinical Insight 22-3 if you need to review standard precautions. When to Use: Pathogens may be transmitted by contact, droplet, or air. Each mode of transmission requires a different approach to prevent infection and has a different set of precautions. Use transmission-based (Tier 2) precautions when the routes of transmission are not completely interrupted using standard precautions alone. Contact Precautions When to Use: Use contact precautions when direct contact with the patient or the patient's environment can lead to spread of the pathogen. Indirect contact, or contact with fomites, can also transmit pathogens that spread by this method. Patient Placement and Transport Ideally, consult with an infection preventionist for patient placement. Place in a private room, if available. If no private room is available, place patient in a room with a patient with an active infection caused by the same organism and no other infections. When transporting the patient, ensure that infected or colonized areas of the body are contained and covered. Ambulatory care: Place the patient in an exam room or cubicle as soon as possible. Personal Protective Equipment (PPE) Don clean, nonsterile gloves when touching the patient's intact skin. Put them on when entering the patient's room. Wear a clean gown if you anticipate your clothing may contact the patient or any contaminated items in the room. Remove PPE and observe hand hygiene before leaving the room. Be careful that your skin and clothing do not contact environmental surfaces on your way out of the room. Equipment, Supplies, and Environment Keep contact precaution supplies just outside the patient's room on a cart. Double bag all linen and trash (or use a single waterproof bag) and clearly mark them contaminated. Use disposable equipment (e.g., blood pressure cuffs) if possible; otherwise, clean and disinfect the equipment per institutional policy before removing it from the room and before use on another patient. Ensure that the patient room is cleaned and disinfected at least daily. Home care: Limit nondisposable equipment brought into the home. If possible, leave the equipment in the home until discharge from home care. If not, clean and disinfect items before taking them from the home or place them in a plastic bag for transport to a reprocessing area. Other Follow additional precautions specific to the microorganism. Discontinue contact precautions according to pathogen-specific recommendations. Droplet Precautions When to Use: Droplets can spread infection by direct contact with mucous membranes or through indirect contact—for example, suctioning or touching a bedside table that was contaminated with droplets and then rubbing your eyes. Use droplet precautions when the pathogen can be spread via large droplets (e.g., sneezing, coughing, talking). Patient Placement and Transport If no private room is available, ensure patients are physically separated by more than 3 feet. Keep the privacy curtain closed. Consult with an infection preventionist for patient placement. A private room provides the most effective protection. Limit transport outside the room to medically necessary purposes; if transport is necessary, the patient should wear a mask. Personal Protective Equipment Keep droplet precaution supplies near the patient's room on a cart. Wear a mask when working within 3 feet of the patient. Don the mask on entry into the room. Whether to wear goggles is an unresolved issue. Follow agency policy. Change PPE and perform hand hygiene between contact with patients in the same room, regardless of whether one or both patients are on droplet precautions. Other Instruct patients to observe respiratory hygiene/cough etiquette. Discontinue droplet precautions according to pathogen-specific recommendations. Airborne Precautions When to Use: Use airborne precautions to control the spread of infections that are transmitted person-to-person on air currents. Patient Placement and Transport Place the patient in an airborne infection isolation room (AIIR)—one with negative pressure that discharges and exchanges the air outside or through a high-efficiency particulate air (HEPA) filtration system. Monitor air pressure daily (usually this is via an electronic device with an alarm). If such a room is not available, transfer the patient to a facility where one is available. Keep the room door closed when not required for entry and exit.To maintain the negative pressure and contain the airborne organisms. In the event of an outbreak involving large numbers of patients who require airborne precautions, consult with infection preventionists for patient placement. Limit moving the patient outside the room to medically necessary purposes. If transport is necessary, cover any infectious skin lesions and have the patient wear a mask. Notify the receiving department. The receiving department can take airborne precautions if notified. Ambulatory or emergency care: Triage and identify patients with suspected airborne precautions upon entry to the agency. Place the patient in an AIIR as soon as possible. If one is not available, place a mask on the patient and place him in an exam room. Do not reuse the room for at least an hour after the infected patient leaves it. Personal Protective Equipment Keep airborne isolation supplies just outside the patient's room on a cart. Don a mask on entering the room. Wear a special fit-tested and approved mask (e.g., N-95 respirator) if the patient is suspected of having pulmonary tuberculosis or smallpox. Remove your respirator/mask outside the room after closing the door. If the respirator is not disposable, clean and store according to the manufacturer's instructions. When using a respirator mask, check the seal. Hold your hands over the respirator and exhale. If you feel air around your nose, adjust the nosepiece; if you feel air at the edges, adjust the straps. When the patient has rubeola, varicella (chickenpox), or disseminated zoster, the CDC makes no recommendation about use of PPE if, based on your history of vaccination or disease, you think you are presumed immune to the disease. If the hospitalized patient has or is suspected of having rubeola or varicella, only immune caregivers should provide care. Other Discontinue airborne precautions according to pathogen-specific recommendations of the CDC. Tape a waterproof bag to the bedside. To facilitate proper disposal of tissues. Practice Resources

How to Wash

Refer to Procedure 22-1, Hand Hygiene.

Removing Personal Protective Equipment (PPE)

Removing Personal Protective Equipment (PPE) For steps to follow in all procedures, refer to the Universal Steps for All Procedures found on the page facing inside back cover. For this procedure, also refer to Clinical Insights 22-3 and 22-4 if you need more information. KEY POINT: Considered contaminated: front areas, sleeves, mask, and gloves of the PPE (as well as head and shoe covers if you are wearing them). KEY POINT: Considered clean: the inside of the gown, gloves, the ties on the mask, and ties at the back of the gown (as well as the inside of the head and shoe covers if you are wearing them). When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation. Procedure Steps 1. Remove gloves first (unless the gown ties in front; in that case, see "What if ..."). Gloves are the most contaminated PPE and must be removed first to avoid contamination of clean areas of the PPE during removal. a. Remove the first glove by grasping the outside cuff of the glove with the opposite gloved hand and pulling downward so that the glove turns inside out. Do not touch the skin of your wrist or hand with your gloved hand. The outside of both gloves are contaminated. To prevent contamination of your skin, touch only the outside (contaminated) surface of first glove to outside (contaminated) surface of second glove. "Dirty touches dirty" and "clean touches clean." b. To remove the second glove: Hold the removed glove in the palm of your gloved hand. Slip two ungloved fingers inside the cuff of the remaining glove. Pull the glove off, inside out, over the glove that hand is holding. The insides of the gloves are considered "clean" because they have not been in contact with client or contaminated surfaces. Therefore, you can touch the insides with your bare hands. c. Dispose of gloves in a designated waste receptacle. Keep them away from your body. 2. Remove the gown: a. Release the waist ties and the neck ties of the gown, bending slightly forward to allow the gown to fall forward. Allowing the gown to fall forward exposes the clean area for the hands to grasp more readily. b. Slip your hands inside the neck and peel the gown away from the shoulders. Reach inside to pull off the cuff and remove your arm from the sleeve. Repeat the maneuver to remove the second sleeve. Do not touch the front of the gown, even if it is not visibly soiled. 3. Fold the gown so the inside of the gown is to the outside. Holding the gown away from your uniform, roll it up with the contaminated front and sleeves in the center, and place in the designated waste receptacle. Folding the gown prevents contamination of your hands, the clothing, and the environment. 4. Remove goggles. a. Grasp only the earpieces or head band of the goggles and pull off the face. b. If the goggles are not disposable, place in the receptacle provided for disinfection. Earpieces are considered clean. Some goggles are cleaned and reused. 5. Remove your mask or face shield. a. Untie the lower ties first. b. Untie the upper ties next, being careful not to let go of the ties. c. Touch only the ties; do not touch the front of the mask. d. Dispose of the mask, placing it in a designated waste receptacle. Touching it would contaminate your bare hands. 6. Remove your hair covering. a. Slip your bare fingers under the edge of the hair cover—do not touch the outside of it. b. Lift it up and away from your hair. c. Touching only the inside, place the mask in a designated waste receptacle. The inside of the hair covering is considered clean, so you may touch it with your bare hands. 7. Remove shoe covers. Be careful to touch only the insides of the covers. 8. Perform hand hygiene before leaving the room. Even if wearing gloves, hands may become contaminated. 9. Close the door. Keeping the door closed contains contaminants and makes signage more visible. What if ... The gown is tied in front? Untie the front gown ties before removing your gloves; then remove the gloves and untie any back ties (e.g., at the neck). (This would be an unusual circumstance.) Because the front of the gown (including a front tie) is considered contaminated, once you remove your gloves, you could not use your bare hands to untie a front tie. You are wearing two gowns (top one tied in back, inner one tied in front)? Remove gloves; untie waist ties of outer gown, remove the gown and fold it inside out. Remove the inner gown by untying it in front. Fold inner gown inside out. Take off goggles and face mask or shield. Patient Teaching See Procedure 22-2. Home Care See Procedure 22-2. Documentation The removal of personal protective equipment is generally assumed and does not require documentation. Practice Resources

Sharps dispposal

Sharps Disposal Always place disposable needles, syringes, and other sharp items and glass in special disposable sharps containers immediately after use. Never recap a contaminated needle. Refer to Chapters 23 and 25 if you need further information on preventing needlestick injuries.

reservoir

Second chain in chain of infections A reservoir is a source of infection: a place where pathogens survive and multiply. KEY POINT: Most pathogens flourish in a warm, moist, dark environment. This is why the human body is the most common reservoir for pathogens. Animals and insects are other living reservoirs. Nonliving reservoirs include soil, water, food, and environmental surfaces (e.g., contaminated water, soiled diapers, wet equipment or medical fabrics, and wound dressings). In healthcare facilities, many surfaces act as reservoirs, such as sinks, toilets, bed rails, and bed linens, because of their proximity to patients, family members, and healthcare providers harboring pathogens. Some people, called carriers, are capable of defending themselves from active disease but harbor the pathogenic organisms within their bodies. They have no symptoms, yet they serve as reservoirs and can pass the disease to others.

Soiled Patient-care Equipment, Environment, Textiles, & Laundry

See Clinical Insight 22-2 for details. Wear gloves if the equipment or laundry is visibly contaminated. Handle equipment, textiles, and laundry in a manner to prevent transfer of microorganisms to others and the environment. Perform hand hygiene. Develop procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient care areas.

Recognize an Outbreak

Should a biological event occur, either as a result of bioterrorism or a naturally occurring epidemic, a major factor in minimizing its effects is the ability to quickly recognize unusual disease patterns and detect the presence of infectious diseases. Some electronic health record systems include special features to identify the pattern of infectious diseases. However, there is no substitute for direct, clinical observation skills. Nurses need to assess not only the individual patient's condition but also clusters of symptoms. Hospital, emergency department, and clinic nurses are in key positions to recognize outbreaks because they see patients from multiple primary care providers. Nurses must keep the following questions in mind: Am I seeing an unexpected number of infectious diseases or diseases possibly caused by infectious organisms? Am I seeing similar cases that are not responding to medical treatment? Are healthcare workers who provide care to infectious patients becoming ill?

rest and sleep

Sleep of 6 to 9 hours per night is considered fully restorative for most people. However, sleep needs and patterns vary. Rest and sleep conserve energy needed for healing.

Medications: host susceptibility

Some medications are given to intentionally reduce the immune response, for example, to patients receiving organ or tissue transplants. For most patients, though, decreased immunity is an unwanted side effect of treatment. Even common medications, such as NSAIDs (e.g., ibuprofen), decrease the immune response. As a side effect, some medications, such as chemotherapeutic agents, decrease the production of white blood cells or cause the cells produced to be abnormal. Antibiotics can also increase the risk for infection. For example, an antibiotic given for a respiratory infection may cause a vaginal yeast infection because it destroys colonies of normal vaginal flora, allowing the harmful microbes to thrive. Such superinfections (opportunistic growth of harmful transient pathogens that are normally kept in check) can be extremely challenging to treat.

Adding Supplies to a Sterile Field

Some supplies (e.g., urinary catheter kits) are packaged in a wrapper that can serve as a sterile field. The outside of these packages is considered clean, and the inside is sterile. You must open these packages in a way that does not contaminate the inside of the wrapping. Be cautious when adding supplies to a sterile field. If any object falls only partly on the field, it is no longer sterile. For detailed instructions on how to add supplies to a sterile field, see Procedure 22-8B.0

Clean Surgical Attire

Staff working in these areas don clean, not sterile, surgical attire, or scrub suits, when they arrive on the unit. These scrub suits should not be worn outside the unit. If you must transport a patient to another area or leave the unit to gather supplies, wear a covering over the scrub suit. Remove the covering on your return to the unit. Additional precautions may include a disposable head cover, shoe coverings, and face masks.

American Nurses Association

Standard 5 of the ANA Nursing: Scope and Standards of Practice (2015) applies to infection prevention and control: "Partners with the healthcare consumer to implement the plan in a safe and timely manner. Implements the plan in a timely manner in accordance with the patient safety goals" (ANA, 2015, p. 61).

Sterile technique

Sterile technique is the use of sterile gloves and sterile supplies (e.g., drapes, bandages, instruments, water).

Steilizing

Sterilization is the elimination of all microorganisms (except prions) in or on an object. The major sterilizing methods used in hospitals are (1) autoclaving with moist heat, also called immediate use steam sterilization, (2) gas or vapor (e.g., ethylene oxide or hydrogen peroxide), (3) dry heat, (4) ozone, and (5) liquid chemicals (e.g., peracetic acid) (Spry & Connor, 2012). Critical items are those that pose a high risk for infection if they are contaminated with any microorganism—that is, those that enter the vascular system or sterile tissue or those items through which blood flows. Examples: Intravenous catheters, needles for injections, urinary catheters, surgical instruments, some wound dressings, and chest tubes As a nurse, you must be familiar with the agency's policies and procedures for cleaning, handling, and transporting items to be disinfected and sterilized, and for working collaboratively with other departments and specially trained personnel (e.g., Environmental Services) to keep the patient care area as clean and free of clutter as possible. For more specific information about maintaining a clean environment in institutional and home care, see Clinical Insight 22-2.

Primary defenses

The "soldiers" in the first line of defense are the structural barriers of the human body. These primary defenses prevent organisms from entering the body. Normal flora of the body. Skin Respiratory tree Eyes Mouth Gastrointestinal tract Genitourinary trait and anus

The Agency for Healthcare Research and Quality (AHRQ) T

The AHRQ Web site features links to information, tools, and resources on HAIs for both healthcare providers and consumers. To access this site,

Maintaining a Protective Environment in Special Situations

The CDC recommends a protective environment (isolation) for a special class of stem cell transplant patients, who are neutropenic (and therefore immunocompromised) secondary to chemotherapy. Some facilities may use protective isolation for other types of patients, as well. However, in most instances, standard and transmission-based precautions are adequate protection for those patients. In special situations: Follow standard precautions meticulously, including hand hygiene before and after patient contact. Follow transmission-based precautions as indicated by a suspected or proven infection. Patient Room Maintain a protective environment (PE) room. Avoid a standing collection of water in the room (e.g., vases containing fresh flowers or humidifier containing water). To prevent fungi and bacteria typically found in this water. Personal Protective Equipment PPE is not required for care providers or visitors for routine entry into the room, unless approaching the patient. If the patient must be taken out of the PE room for diagnostic or other procedures, provide respiratory protection (e.g., an N-95 respirator, minimal contact with others). Visitors and care providers should don gown, gloves, and mask according to standard precautions and as indicated for suspected or proven infections for which they are recommended. Refer to Procedures 22-2 and 22-3 to review donning and removing PPE. Care Providers, Visitors Only healthy caregivers should provide care. Also restrict visitors who have a cold or contagious illness. Healthcare workers caring for patients in protective isolation should not also be providing care for other patients with active infections. Housekeeping/Environmental Services Carpeting in patient rooms or halls traps soil and can wick moisture, facilitating growth of microbes. Upholstered furniture and furnishings tend to harbor microbes. Avoid dusting methods that scatter particles in the air. If vacuum cleaning is necessary, use a vacuum cleaner equipped with a HEPA filter. Wet-dust horizontal surfaces daily with EPA-registered disinfectant or detergent. Engineering Use of 99.7% efficiency particulate air (HEPA) filters to remove particles for incoming air at a specified flow rate of air Well-sealed rooms—no air leaks Ventilation as for airborne precautions Directed air flow within the room Positive room air pressure in relation to the corridor Backup ventilation equipment (e.g., portable fans or filters) For patients who require both protected environment and airborne isolation, use an anteroom to control air in and out of the room. Practice Resources

Illness

The patient becomes ill when the first signs and symptoms of the disease occur. If the patient's immune defenses and medical treatments (if any) are ineffective, this stage can end in death.

Prodrome

The prodromal stage is characterized by the first appearance of vague symptoms at the onset of illness. For example, a person infected with a cold virus may experience a mild throat irritation. Not all infections have a prodromal stage.

What Role Does the Infection Preventionist Nurse Play?

The task of the infection prevention nurse is to minimize the number of infections in the healthcare facility. Infection preventionists must keep current with information about pathogens, antibiotic resistance, and infection control. The infection prevention nurse also functions as an epidemiologist, tracking down the source of HAIs and strengthening measures to prevent their recurrence. Finally, all members of the infection prevention team enforce compliance with federal, state, and local regulations related to infection control and prevention.

Preparing and Maintaining Sterile Fields

There are some variations in how you might set up sterile fields. Sometimes it is as simple as opening a package of supplies wrapped in a sterile disposable cover. At other times, you may work with a larger, reusable or disposable sterile drape (wrapped in an outer wrapping). To learn a procedure for maintaining a sterile field, as well as adding supplies and sterile liquids to it, see Procedure 22-8A.

Light Microbes

These grow best in dark environments (e.g., inside the body, deep in wounds, and under dressings). Ultraviolet light is sometimes used to remove pathogens such as Staphylococcus, Salmonella, and viruses from surgical instruments and other objects. It is also used to disinfect contaminated drinking water.

Portal of exit

Third chain in chain of infection A contained reservoir is only a potential source of infection. For infection to spread, a pathogen must exit the reservoir. In the case of human or animal reservoirs, the most frequent portal of exit is through body fluids. Expelling foreign materials. The body's natural response to foreign materials, including pathogens, is to try to expel them. For example, if you have a pathogen in the respiratory system, they exit when you cough and sneeze. If it is in the gastrointestinal system, they exit when you vomit or experience diarrhea. Non-intact skin. Wounds, bites, and abrasions also provide an exit for body fluid. Blood and pus seeping from a wound help transport pathogens away from the broken skin. In healthcare-related infections, puncture sites, drainage tubes, feeding tubes, and intravenous lines serve as exit routes for pathogens.

Substance Abuse: host susceptibility

This includes alcohol as well as other substances. Alcohol curbs hunger. As a result, many chronic alcohol users do not consume an adequate diet, leading to vitamin, mineral, and protein deficiency. Alcohol is also toxic to the liver and to the cells lining the intestinal mucosa. Inhaled substances, such as marijuana and cocaine, affect respiratory cilia in a manner similar to tobacco. Any substances that affect orientation and energy level (e.g., heroin, cocaine) will diminish food intake, activity, rest, and hygiene—factors that support host defenses. Injecting substances leads to breaks in skin integrity, further increasing the risk of infection.

Quality and Safety Education for Nurses (QSEN)

This is a group of educators that was formed to identify the competencies necessary to improve the quality and safety of nurses' places of work. Some nursing schools have adopted these as standards. Safety is one of the competencies you should have on completing your nursing education. Although QSEN does not specifically say so, you should assume that safety includes being safe from infection (Cronenwett, Sherwood, Barnsteiner, et al., 2007). To access the QSEN Web site,

The Joint Commission

This is a quality oversight agency. Its standards of performance include extensive criteria describing what healthcare organizations must do to minimize the risks of infection. In addition, Goal 7 of the National Patient Safety Goals for 2016 is to "reduce the risk of health care associated-infections" (The Joint Commission, 2016). They include strategies for healthcare providers to prevent infection in inpatient and community-based settings. To read these initiatives,

Specific nursing activities will be based on the unique situation of the client, as described in the etiology of the diagnostic statement. For example:Community health nurses can limit disease transmission—

Through surveillance of the community, tracking of disease patterns, and initiation of prompt treatment.

nutrients

To live and thrive in humans, microbes must be able to use the body's precise balance of nutrients, electrolytes, pH, and temperature. Bacteria can rapidly multiply in food left at room temperature. For example, the bacteria Salmonella enteritidis, which causes salmonellosis ("food poisoning"), can multiply in raw and undercooked meat and eggs.

pH and electrolytes

To live in humans, pathogens need the body's precise balance of sugars, pH (acidity), and electrolytes. Most prefer a pH range of 5 to 8. Therefore, they cannot survive in the highly acidic environment of the stomach. When patients take antacids, stomach pH increases (acidity decreases) and removes this defense, allowing the pathogens to multiply and cause infection in other organs, such as the lungs.

Urine cultures

Urine is normally sterile with no microorganism growth.

What to Use

Use alcohol-based handrub (at least 60% alcohol) for routine hand hygiene and if hands are not visibly soiled. Note: Iodine compounds are also effective, but usually too irritating for regular hand hygiene. Use soap and water: When hands are dirty or visibly soiled. After using a restroom. If there is potential for exposure to Bacillus anthracis (or other spore-producing bacteria such a C. difficile). Alcohol-based solutions are not effective against spores. Use warm, not hot, water. Use disposable paper towels. Apply non-petroleum-based, fragrance-free lotions. Drying, chafing, and chapping commonly occur with frequent hand washing and application of petroleum-based skin products. Breaks in the skin can harbor microbes.

tier 2 precautions transmission- based

Use for patients known or suspected to be infected or colonized with infectious agents. Principle: Routes of transmission for some microorganisms are not completely interrupted using standard precautions alone. Used in addition to standard precautions.' Three categories of precautions: Contact Precautions—For organisms spread by direct contact with the patient or his environment. This is the most common form of transmission. Droplet Precautions—For pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (e.g., sneezing, coughing, talking); pathogens that do not remain infectious over long distances. Airborne Precautions—For pathogens that are very small and remain infectious over long distances when suspended in the air and are easily transmitted through air currents (e.g., fanning linens, ventilating systems).

Patient Resuscitation

Use one-way valve mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation methods in situations when the need for resuscitation is predictable. To prevent contact between rescuer's and client's mucous membranes and airflow, preventing transmission of microorganisms.

tier one precautions/ standard precautions

Use with all clients, in all settings, regardless of suspected or confirmed presence of infection. Principle: All blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain pathogens. Include: Hand hygiene; use of gloves, gown, mask, eye protection, or face shield (depending on expected exposure) and safe injection practices. Added for protection of patients more than of healthcare personnel: Safe injection practices, respiratory hygiene and cough etiquette, and wearing a mask when performing special lumbar puncture procedures. Standard precautions do not completely protect against microorganisms spread by contact, droplets, or through the air.

Agglutinins, warm or cold

Used to diagnose atypical infections by detecting antigens in the blood

Gowns

Wear a clean, nonsterile, nonpermeable gown during procedures and activities when you anticipate contact of clothing or exposed skin with blood or body fluids, secretions, and excretions (e.g., when there is a risk of spray or splash onto clothing). Promptly remove the gown once it is soiled. Avoid contaminating clothing when removing the gown. Wash hands after removing the gown. See Procedures 22-2 and 22-3, Donning and Removing PPE.

Masks and Eye Protection (for the Nurse)

Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. Barrier protection helps keep microorganisms from accidentally entering your mucous membranes, eyes, nose, or mouth.

PLANNING INTERVENTIONS/IMPLEMENTATION NP

When caring for a patient at risk for infection, nursing activities are aimed at breaking the chain of infection at every possible link. Some of the most common reasons that patients are diagnosed with Risk for Infection are exposure to pathogens, bypass of their normal defense mechanisms, increased physiological stress, or inadequate immune response. Direct nursing care toward these concerns and provide the following broad interventions: Reduce exposure to pathogens by using aseptic technique. Maintain skin integrity and support natural defenses against infection. Reduce stress. Promote immune function through immunization, healthy diet and activity, sleep, and lifestyle. Provide supportive measures to decrease the length of time that a patient needs invasive devices, such as intravenous lines and urinary catheters. NIC standardized interventions for patients with infections include: Communicable Disease Management Infection Protection Immunization/Vaccination Management Surveillance Incision Site Care Teaching: Safe Sex Infection Control Wound Care For more information about NIC interventions, refer to a standardized language handbook. Also,

Hand Washing When to Wash

When hands are visibly dirty or soiled with blood or body fluids When arriving on and leaving the patient care unit Before direct contact with a patient, even if you intend to wear procedure gloves Before donning and after removing gloves (either procedure or sterile) When gloves are changed during a procedure After removing gloves After contact with a patient's intact skin (e.g., when taking a blood pressure) After contact with body fluids, mucous membranes, nonintact skin, and wound dressings even if hands are not visibly soiled When moving from a contaminated body site to a clean body site during patient care Before and after contact with objects and equipment in the patient's immediate vicinity Before and after touching any area on your face and hair

Adding Supplies to a Sterile Field

Adding Sterile Solutions to a Sterile Field

When performing the procedure, always identify your patient according to agency policy, using two identifiers, and be attentive to standard precautions, hand hygiene, patient safety and privacy, body mechanics, and documentation. Procedure Steps. 1. Use a sterile bowl or receptacle. Place it on the side of the sterile field closest to you. Prevents you from reaching over and thereby contaminating the field. 2. Check that the sterile solution is correct and confirm that the expiration date has not passed and that the solution and concentration are correct and have not expired. 3. Remove the cap from the solution bottle by lifting it directly up. Throw it away. The edge of the container is considered contaminated after the contents have been poured and the sterility of the contents cannot be ensured if the cap is replaced. 4. Hold the bottle 4 to 6 inches above the bowl and pour the needed amount of the solution into the bowl. Prevents you from inadvertently touching the sterile bowl with the bottle and thereby contaminating the bowl. Limited height reduces the risk of splashing, with strike through of a permeable sterile field. A disposable sterile drape generally has a plastic membrane in the middle to prevent strike through. 5. Discard the remaining solution. Reusing open containers may cause contamination because of drops contacting the unsterile areas and running back over the container opening. 6. Before donning sterile gloves to perform the procedure, double-check that all supplies have been added to the field. Do not leave the sterile field unattended. Do not turn your back to the sterile field. If a sterile item is out of your field of vision, it is no longer considered sterile because airborne particles, insects, or liquids could contaminate the field. Home Care Most sterile procedures in the home are done by visiting nurses. Procedures performed by clients or family members are usually clean rather than sterile. Documentation You will not usually document the actual setting up of the sterile field. Document the procedure, your assessment of the patient's tolerance for the procedure, and your assessment of the area being treated by the procedure. What if ... The nurse observes a breach in sterility by the surgeon? The nurse's duty is to protect the patient above all else, even when fearing an uncomfortable confrontation with the healthcare provider. The nurse is obligated to follow the institution's policy and advocate for patient safety. Practice Resources AORN (2013b, 2016); Association for Surgical Technologists (2008a); Siegel, J. D., Rhinehart, E., Jackson, M., et al. (2006); Simko, L. (2012). Thinking About the Procedure To practice applying clinical reasoning to this procedure,

Decline

When the patient's immune defenses, along with medical therapies, successfully reduce the number of pathogenic microbes, the infection begins to decline. As a result, the clinical manifestations of the infection begin to fade.

Gloves

When to Wear If you have an area of irritation or a break in the skin, wear gloves or apply an occlusive dressing during patient contact. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and nonintact skin could occur. When to Remove or Change Remove gloves immediately after caring for a patient. Avoid touching clean items, environmental surfaces, or another patient. Do not wear the same gloves for care of more than one patient; do not wash gloves and reuse gloves between patient contact. Change gloves during patient care if moving from a contaminated body site to a clean. Change gloves between tasks or procedures on the same patient if you have made contact with material that may contain a high concentration of microorganisms. Use and Storage When preparing for a procedure, first collect equipment and place at the bedside ready for use; then wash your hands and put on gloves just before performing the procedure. Donning gloves ahead of time allows them to become contaminated before the procedure. Do not carry gloves in your pocket. Keep them in their original box and remove them when and where required. Do not store gloves on top of trash containers or on windowsills. Hand washing or disinfection is required regardless of whether gloves are used or changed. Gloves are not completely impermeable to microorganisms; furthermore, they may leak or tear. Hands can be easily contaminated when removing gloves.

Control of Potentially Contaminated Equipment and Supplies

Whenever possible, use disposable equipment in an isolation room. Nondisposable equipment and supplies require special handling.

Open Gloving.

You will often wear sterile gloves for procedures that do not require full surgical attire. For this, you will use the open method of gloving. For complete instructions for open-method sterile gloving, refer to Procedure 22-7. KEY POINT: Be sure to open the glove packaging slowly, avoid fanning the wrapping or touching the gloves, and put the first glove on your dominant hand. (See Figure 22-4.) KEY POINT: A general rule to consider when applying the second glove is to touch glove-to-glove and skin-to-skin. The already-gloved hand may touch any of the sterile surfaces of the second glove. The second hand may touch only the inside of the glove—the portion that will have contact with the skin. (See Figure 22-5.)

Developmental Stage: host susceptibility

Young children are vulnerable because their immune systems are immature and they have had limited exposure to pathogens. Children frequently begin to have more infections when they start interacting with people outside of their family (e.g., when they begin day care or start school). Acquiring active immunity is a part of the developmental process. Older adults are also susceptible hosts because the immune response declines with aging. Skin, a primary defense, becomes less elastic and more prone to breakdown with aging. Elders also tend to be less active, and their nutrition may be inadequate.

Asepsis

a term that means absence of contamination by disease-causing microorganisms.

Cellular (cell-mediated) immune response

acts directly to destroy pathogens (i.e., viruses, fungi, protozoans, cancers) without using antibodies but rather activating phagocytes and T and B cells (lymphocytes). After maturing, most T cells and B cells travel to the lymph nodes, spleen, and other sites of lymphatic tissue. Some circulate in blood and lymph. Four types of T cells play a role in fighting infection: cytotoxic (Killer) T cells helper T cells Memory T cells Suppressor T cells

Many viruses show a high mutation rate

and can rapidly yield new strains. For example, the influenza virus is difficult to eradicate and immunize against because of its adaptability.

patients with compromised immunity are more likely to

become infected by pathogens harbored in their own bodies than from pathogens transmitted by other people. Therefore, except for the special situations described above, standard and transmission-based precautions should protect nearly all vulnerable patients from organisms brought in by healthcare workers and visitors.

Inflammation

is the process that begins when histamine and other chemicals are released either from damaged cells or from basophils being activated by complement. With inflammation, blood vessels dilate and become more permeable, which increases the flow of phagocytes, antimicrobial chemicals, oxygen, and nutrients to the affected area. The classic signs and symptoms of inflammation are localized warmth and erythema (redness), which develop as blood flow is increased. In addition, fluid leaking from the more permeable blood vessels accumulates in the surrounding tissue, causing edema, which in turn exerts pressure on nerve endings, causing prompts pain.

Clean technique

is use of clean hands or nonsterile gloves and clean, rather than sterile, supplies (e.g., tap water).

Modified sterile technique

is use of nonsterile procedure gloves with sterile supplies.

US department of health and human services

keep patients from becoming injured or sicker during their care. Specific aims are to reduce: Central line-associated bloodstream infections (CLABSI) Surgical site infections (SSI) Catheter-associated urinary tract infections (CAUTI) Ventilator-associated pneumonia (VAP) Multidrug-resistant organisms (MDROs) The Agency for Healthcare Research and Quality (AHRQ) The AHRQ Web site features links to information, tools, and resources on HAIs for both healthcare providers and consumers. To access this site,

Agranular WBC

lymphocytes and monocytes

Granular WBC

neutrophils, eosinophils, basophils

Systemic infections

occur when pathogens invade the blood or lymph and spread throughout the body.

droplet transmission

occurs when a pathogen travels in water droplets expelled as an infected person exhales, coughs, sneezes, or talks, or during suctioning and oral care. The droplet usually enters the eye of or is inhaled by a susceptible host. Although droplets can travel only a few feet, within that distance they readily contaminate fomites that then transmit the organism by contact.

Airborne transmission

occurs when microorganisms float considerable distances on air currents to infect large numbers of people. Airborne pathogens can travel through heating and air-conditioning systems. Sweeping a floor or shaking out contaminated bed linens can also launch microorganisms into the air. Common airborne pathogens are the agents of measles, tuberculosis, and many fungal infections.

Surgical asepsis, or sterile technique

requires creation of a sterile environment and use of sterile equipment. It differs from medical asepsis in that it is more complex and it is not necessary to use it with all patients. Sterilization can be accomplished through the use of special gases or high heat. Surgical equipment and implanted devices are examples of materials that must be sterilized. To create a sterile area, environmental services personnel perform thorough cleaning using special solutions and procedures. All personnel working in the area must wear appropriate surgical attire and perform a surgical hand scru

Standard precautions

the first tier of protection, apply to care of all patients. You must assume that every patient is potentially colonized or infected with an organism that could be passed to others in the healthcare setting.

Transmission-based precautions

the second tier of protection, are for patients with known or suspected infection or colonization with pathogens. Recall from the discussion on the chain of infection that pathogens may be transmitted by contact, droplet, or air. Each mode of transmission requires a different approach to prevent infection. iCare For all transmission-based precautions, institute measures to counteract negative effects of isolation on patients (i.e., anxiety, depression, perceptions of stigma, reduced contact with staff, and increases in preventable adverse events).

Semicritical items

those that contact mucous membranes or nonintact skin. They must be free of all microorganisms except bacterial spores, so they must at least be disinfected and sometimes sterilized. Examples: Reusable devices, such as flexible endoscopes, and respiratory therapy and anesthesia equipment

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