Chapter 29: Infection Prevention and Control

latrogenic infections

Type of HAI caused by an invasive diagnostic or theropeutic procedure. Treatments with broad spectrum antibiotics cause these.

exogenous infection

comes from microorganisms found outside the individual (salmonella, clostridium tetani, aspergillus).

Sterilization

eliminates or destroying all forms of microbial life, including spores.

Vehicles

• Contaminated items • Water • Drugs, solutions • Blood • Food (improperly handled, stored, or cooked; fresh or thawed meats)

endemic

infection that are always present in a community usually at a low, almost constant frequency

localized infection

(e.g., a wound infection), a patient usually experiences localized symptoms such as pain, tenderness, warmth, and redness at the wound site.

body system defense mechanisms

(table 29-2) skin - sebum, multilayered surface mouth - saliva, mucosa eye - tearing, blinking respiratory tract - cilia, macrophages urinary tract - flushing action, multilayered epithelium GI tract - acidity of secretions, peristalsis vagina - pH

Assessing the risk of infection

- Immunizations and vaccines - Status of defense mechanisms - Patient susceptibility - Review of past diseases, travel history - Clinical appearance

Isolation precautions

-Airborne -Droplet -Contact (indirect or direct) -Protective environment

Risk Factors: Populations at greatest risk

-Very young -Poor -Uninsured -Residents of areas where an infection is prevalent -pretty sure the elderly also

9. The infection control nurse has asked the staff to work on reducing the number of iatrogenic infections on the unit. Which of the following actions on your part would contribute to reducing health care-acquired infections? (Select all that apply.) 1. Teaching correct handwashing to assigned patients 2. Using correct procedures in starting and caring for an intravenous infusion 3. Providing perineal care to a patient with an indwelling urinary catheter 4. Isolating a patient who has just been diagnosed as having tuberculosis 5. Decreasing a patient's environmental stimuli to decrease nausea

1, 2, 3,

14. A patient's surgical wound has become swollen, red, and tender. The nurse notes that the patient has a new fever, purulent wound drainage, and leukocytosis. Which interventions would be appropriate and in what order? 1. Notify the health care provider of the patient's status. 2. Reassure the patient and recheck the wound later. 3. Support the patient's fluid and nutritional needs. 4. Use aseptic technique to change the dressing.

1, 2, 3, 4 in what order would you do these? 4, 2, 3, 1

15. Which of these statements are true regarding disinfection and cleaning? (Select all that apply.) 1. Proper cleaning requires mechanical removal of all soil from an object or area. 2. General environmental cleaning is an example of medical asepsis. 3. When cleaning a wound, wipe around the wound edge first and then clean inward toward the center of the wound. 4. Cleaning in a direction from the least to the most contaminated area helps reduce infections. 5. Disinfecting and sterilizing medical devices and equipment involve the same procedures.

1, 2, 4,

8. Which type of personal protective equipment are staff required to wear when caring for a pediatric patient who is placed into airborne precautions for confirmed chickenpox/herpes zoster? (Select all that apply.) 1. Disposable gown 2. N 95 respirator mask 3. Face shield or goggles 4. Surgical mask 5. Gloves

1, 2, 5

11. A patient has an indwelling urinary catheter. Why does an indwelling urinary catheter present a risk for urinary tract infection? (Select all that apply.) 1. It allows migration of organisms into the bladder. 2. The insertion procedure is not done under sterile conditions. 3. It obstructs the normal flushing action of urine flow. 4. It keeps an incontinent patient's skin dry. 5. The outer surface of the catheter is not considered sterile.

1, 3

12. Put the following steps for removal of protective barriers after leaving an isolation room in order. 1. Remove gloves. 2. Perform hand hygiene. 3. Remove eyewear or goggles. 4. Untie top and then bottom mask strings and remove from face. 5. Untie waist and neck strings of gown. Remove gown, rolling it onto itself without touching the contaminated side.

1, 3, 5, 4, 2

2. A patient who has been isolated for Clostridium difficile (C. difficile) asks you to explain what he should know about this organism. What is the most appropriate information to include in patient teaching? (Select all that apply.) 1. The organism is usually transmitted through the fecal-oral route. 2. Hands should always be cleaned with soap and water versus alcohol-based hand sanitizer. 3. Everyone coming into the room must be wearing a gown and gloves. 4. While the patient is in contact precautions, he cannot leave the room. 5. C. difficile dies quickly once outside the body.

1,2,3

when to handwash?

1. When hands are visibly dirty, when hands are soiled with blood or other body fluids, before eating, and after using the toilet, wash hands with water and either a nonantimicrobial or antimicrobial soap. 2. Wash hands if exposed to spore-forming organisms such as C. difficile, Bacillus anthracis, or Norovirus (CDC, 2014). 3. If hands are not visibly soiled (WHO, 2009), use an alcohol-based, waterless antiseptic agent for routinely decontaminating hands in the following clinical situations: • Before, after, and between direct patient contact (e.g., taking a pulse, lifting a patient) • Before putting on sterile gloves and before inserting invasive devices such as a peripheral vascular catheter or urinary catheter • After contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings (even if gloves are worn) • When moving from a contaminated to a clean body site during care • After contact with surfaces or objects in the patient's room (e.g., overbed table, IV pump) • After removing gloves

Defenses against infection

1. normal flora 2. body system defense mechanisms 3. inflammatory response

4. A patient is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) pneumonia. Which type of isolation precaution is most appropriate for this patient? 1. Reverse isolation 2. Droplet precautions 3. Standard precautions 4. Contact precautions

2 The patient has a multidrug resistant organism within his respiratory tract that has become pathogenic. The route of transmission for this type of condition is respiratory; thus whenever the patient coughs or sneezes, organisms are sprayed into the air and then drop onto surfaces in the room. In addition to gown and gloves, a mask must also be worn.

10. Which of the following actions by the nurse comply with core principles of surgical asepsis? (Select all that apply.) 1. Set up sterile field before patient and other staff come to the operating suite. 2. Keep the sterile field in view at all times. 3. Consider the outer 2.5 cm (1 inch) of the sterile field as contaminated. 4. Only health care personnel within the sterile field must wear personal protective equipment. 5. The sterile gown must be put on before the surgical scrub is performed.

2, 3

13. What does it mean when a patient is diagnosed with a multidrug-resistant organism in his or her surgical wound? (Select all that apply.) 1. There is more than one organism in the wound that is causing the infection. 2. The antibiotics the patient has received are not strong enough to kill the organism. 3. The patient will need more than one type of antibiotic to kill the organism. 4. The organism has developed a resistance to one or more broad-spectrum antibiotics, indicating that the organism will be hard to treat effectively. 5. There are no longer any antibiotic options available to treat the patient's infection.

2, 4

7. When should a nurse wear a mask? (Select all that apply.) 1. The patient's dental hygiene is poor. 2. The nurse is assisting with an aerosolizing respiratory procedure such as suctioning. 3. The patient has acquired immunodeficiency syndrome (AIDS) and a congested cough. 4. The patient is in droplet precautions. 5. The nurse is assisting a health care provider in the insertion of a central line catheter.

2, 4, 5

1. What is the most effective way to control transmission of infection? 1. Isolation precautions 2. Identifying the infectious agent 3. Hand hygiene practices 4. Vaccinations

3

6. A patient is isolated for pulmonary tuberculosis. The nurse notes that the patient seems to be angry, but he knows that this is a normal response to isolation. Which is the best intervention? 1. Provide a dark, quiet room to calm the patient. 2. Reduce the level of precautions to keep the patient from becoming angry. 3. Explain the reasons for isolation procedures and provide meaningful stimulation. 4. Limit family and other caregiver visits to reduce the risk of spreading the infection.

3

3. Your assigned patient has a leg ulcer that has a dressing on it. During your assessment you find that the dressing is saturated with purulent drainage. Which action would be best on your part? 1. Reinforce dressing with a clean, dry dressing and call the health care provider. 2. Remove wet dressing and apply new dressing using sterile procedure. 3. Put on gloves before removing the old dressing; then obtain a wound culture. 4. Remove saturated dressing with gloves, remove gloves, then perform hand hygiene and apply new gloves before putting on a clean dressing.

4

5. A family member is providing care to a loved one who has an infected leg wound. What should the nurse instruct the family member to do after providing care and handling contaminated equipment or organic material? 1. Wear gloves before eating or handling food. 2. Place any soiled materials into a bag and double bag it. 3. Have the family member check with the health care provider about need for immunization. 4. Perform hand hygiene after care and/or handling contaminated equipment or material.

4

disinfection

A process that eliminates many or all microorganisms, with the exception of bacteria spores, from inanimate objects

To thrive, organisms require ~6 things..

A proper environment with appropriate 1. food 2. oxygen 3. water 4. temperature 5. pH 6. light

exudate

Accumulation of fluid, dead tissue cells, and WBCs at the sit of inflammation. May be: serous - clear, plasma-like sanguineous - containing RBCs purulent - containing WBCs and bacteria

immune senescence

Age related decline in immune system function.

factors that influence prevention and control

Age, nutritional status, stress, disease process.

Asymptomatic

Clinical signs and symptoms are not present (Hepatitis C)

Symptomatic

Clinical signs and symptoms are present

common laboratory tests

Complete Blood Count (with WBC differential) Culture and sensitivity C-reactive protein (CRP) Erythrocyte sedimentation rate (ESR) Serologic tests to detect specific antibodies or viruses

opportunistic

Describes a microorganism that does not normally cause disease but will do so if the right conditions are present

Modes of transmission

Direct, indirect, droplet, airborne, vehicles, vectors

pathogen

Disease-causing microorganism

Infection

Entry and multiplication of pathogen resulting in infection

WBC count in normal adult? what about during inflammation?

In the adult a serum WBC count is normally 5,000 to 10,000/mm3 but typically rises to 15,000 to 20,000/mm3 and higher during inflammation.

Chain of Infection

Infection occurs in a cycle that depends on the presence of all of the following elements: • An infectious agent or pathogen • A reservoir or source for pathogen growth • A port of exit from the reservoir • A mode of transmission • A port of entry to a host • A susceptible host

systemic infection

Infection that affects the entire body instead of just a single organ or part.

Communicable disease

Infection transmitted from one person to another

incubation period

Interval between entrance of pathogen into body and appearance of first symptoms (e.g., chickenpox, 14 to 16 days after exposure; common cold, 1 to 2 days; influenza, 1 to 4 days; measles, 10 to 12 days; mumps, 16 to 18 days; Ebola 2 to 21 days

Prodromal period

Interval from onset of nonspecific signs and symptoms (malaise, low-grade fever, fatigue) to more specific symptoms. (During this time microorganisms grow and multiply, and patient may be capable of spreading disease to others.) For example, herpes simplex begins with itching and tingling at the site before the lesion appears.

convalescence

Interval when acute symptoms of infection disappear. (Length of recovery depends on severity of infection and patient's host resistance; recovery may take several days to months.)

illness stage

Interval when patient manifests signs and symptoms specific to type of infection. For example, strep throat is manifested by sore throat, pain, and swelling; mumps is manifested by high fever, parotid and salivary gland swelling.

normal flora

Microorganisms that live in or on the body without causing disease

sepsis

Presence of pathogens in the blood or other tissues throughout the body

standard precautions

Prevent and control infection and its spread -apply to ally patients -includes the use of PPE (personal protective equipment -- gloves, gowns, masks, eye protection)

Health care-associated infections (HAIs)

Result from the delivery of health services in a health care facility. Major sites for HAIs include surgical or traumatic wounds, urinary and respiratory tracts, and the bloodstream. Significantly increase the costs of healthcare.

epidemiology

Study of the distribution, cause, and control of disease in human populations

normal flora (extended)

The body normally contains microorganisms that reside on the surface and deep layers of skin, in the saliva and oral mucosa, and in the GI and GU tracts. These participate in maintaining health. Exist in large intestine in large numbers.

Inflammation

The cellular response of the body to injury, infection, or irritation. Protective vascular reaction that delivers fluid, blood products, and nutrients to an area of injury. includes swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. When inflammation becomes systemic, other signs and symptoms develop, including fever, increased white blood cells (WBCs), malaise, anorexia, nausea, vomiting, lymph node enlargement, or organ failure.

immunocompromised

When someone has an impaired immune system

epidemic

When the number of new cases of an infection during a specific timeframe in a population exceed the expected number of new cases based on recent experience

reservoir

a place where microorganisms survive, multiple, and await transfer to a susceptible host. common reservoirs are humans, animals, insects, food, water and organic matter on inanimate surfaces (fomites)

bactericidal

a temperature or chemical that destroys bacteria

microorganism

bacteria, viruses, fungi and protozoa

Portals of exit

blood, skin and mucous membranes, respiratory tract, GI tract, transplacental (mother to fetus), GU tract

virulence

capacity of a microorganism to cause disease

necrotic

dead (tissue)

suprainfection

develops when broad-spectrum antibiotics eliminate a wide range of normal flora organisms, not just those causing infection. When normal bacterial floras are eliminated, body defenses are reduced, which allows disease-producing microorganisms to multiply, causing illness

most effective way to break the chain of infection?

hand hygiene

medical asepsis

hand hygiene, barrier techniques, and routine environmental cleaning

Course of infection (infectious process)

incubation period - prodromal stage - illness stage - convalescence

Susceptibility

individual's degree of resistance to pathogens

pandemic

infections that spread to other countries or continents

endogenous infection

occurs when part of the patient's flora becomes altered and an overgrowth results (staphylococci, enterococci, yeasts, strep).

Antibacterials (antibiotics)

penicillin cephalosporins fluoroquinolones tetracyclines macrolides aminoglycosides sulfonamides (we need to look these up in the drug book)

Aerobic

require oxygen for survival and multiplication

Surgical asepsis

sterile technique prevents contamination of an open wound, serves to isolate an operative area from the unsterile environment, and maintains a sterile field for surgery. 1. A sterile object remains sterile only when touched by another sterile object. 2. Only sterile objects may be placed on a sterile field 3. A sterile object or field out of the range of vision or an object held below a person's waist is contaminated. 4. A sterile object or field becomes contaminated by prolonged exposure to air. 5. When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action. 6. Fluid flows in the direction of gravity 7. The edges of a sterile field or container are considered to be contaminated.

edema

swelling

Colonization

the presence and growth of microorganisms within a host but without tissue invasion or damage (different than infection)

Portals of entry

the same as exiting

anaerobic

thrive where little or no free oxygen is available

bacteriostasis

when cold temperatures prevent growth and reproduction of bacteria without killing it

items that are NONCRITICAL to be sterile

• Bedpans • Blood pressure cuffs • Bedrails • Linens • Stethoscopes • Bedside trays and patient furniture • Food utensils

airborne

• Droplet nuclei or residue or evaporated droplets suspended in air during coughing or sneezing or carried on dust particles

Vectors

• External mechanical transfer (flies) • Internal transmission such as parasitic conditions between vector and host such as: • Mosquito • Louse • Flea • Tick

KEY POINTS

• Hand hygiene practices are the most important techniques to use in the prevention and control of infection. • The potential for microorganisms to cause disease depends on the number of organisms, virulence, and ability to enter and survive in a host and susceptibility of the host. • Normal body floras help to resist infection by releasing antibacterial substances and inhibiting multiplication of pathogenic microorganisms. • An infection can develop as long as the six elements composing the infection chain are uninterrupted. • Microorganisms are transmitted by direct and indirect contact, airborne spread, and vectors and contaminated articles. • Increasing age, poor nutrition, stress, inherited conditions, chronic disease, and treatments or conditions that compromise the immune response increase susceptibility to infection. • The major sites for HAIs include the urinary and respiratory tracts, bloodstream, and surgical or traumatic wounds. • Invasive procedures, medical therapies, long hospitalization, and contact with health care personnel increase a hospitalized patient's risk for acquiring an HAI. • Isolation practices may prevent personnel and patients from acquiring infections and transmitting microorganisms to other people. • Standard precautions involve the use of generic barrier techniques when caring for all patients. • Proper cleaning requires mechanical removal of all soil from an object or area. • The overall experience of isolation is commonly viewed negatively due to barriers affecting the expression of a patient's identity and normal interpersonal relationships. • An infection prevention and control professional monitors the incidence of infection within an institution, introduces evidence-based practices and provides educational and consulting services. • Surgical asepsis requires more stringent techniques than medical asepsis and is directed at eliminating microorganisms. • If the skin is broken or if an invasive procedure into a body cavity normally free of microorganisms is performed, follow surgical aseptic practices.

Droplet

• Large particles that travel up to 3 feet during coughing, sneezing, or talking and come in contact with susceptible host

Direct

• Person-to-person (fecal, oral) physical contact between source and susceptible host (e.g., touching patient feces and then touching your inner mouth or consuming contaminated food)

Indirect

• Personal contact of susceptible host with contaminated inanimate object (e.g., needles or sharp objects, dressings, environment)

items that must be sterile SEMICRITICALLY

• Respiratory and anesthesia equipment • Endoscopes • Endotracheal tubes • GI endoscopes • Diaphragm fitting rings After rinsing, dry items and store in a manner to protect from damage and contamination.

items that must be sterile CRITICALLY

• Surgical instruments • Cardiac or intravascular catheters • Urinary catheters • Implants