Chapter 8 Preventing and Controlling Infection

19 The nurse is preparing to leave the room of a client on transmission-based precautions. Place in the correct order the steps the nurse would follow to remove personal protective equipment and perform hand hygiene.

2. Remove gloves. 3. Remove mask. 1. Remove gown. 4. Remove eye protection. 5. Wash hands. Gloves are removed first, as they would be the most contaminated. The mask would be removed next, followed by the gown. Eye protection is removed last, followed by hand washing

13 The nurse is assisting a client who has methicillin-resistant Staphylococcus aureus in collecting a clean-catch urine specimen. Which protective equipment is unnecessary?

1. N95 particulate respirator

12 A client asks, "How did I get scarlet fever?" What would be the nurse's best response?

4. "You inhaled infected droplets in the air. : Scarlet fever is transmitted by particle droplets larger than 5 microns.

14 The nurse is preparing to irrigate a wound infected with vancomycin-resistant enterococci. What personal protective equipment (PPE) would the nurse wear?

4. Gloves, gown, eye protection, and surgical mask Since the nurse will be irrigating the wound and splatters of body fluids or exudates are possible, eye protection and surgical mask should be worn to protect the mucous membranes of the eyes, nose, and mouth. A gown would be worn when the nurse is in direct contact with the client. Contact precautions require gloves. Shoe covers are unnecessary.

18 The nurse is preparing to enter the room of a client with pneumonia caused by penicillin-resistant Streptococcus pneumoniae (PRSP). The client has a tracheostomy and requires suctioning. Put the following personal protective equipment in order of donning.

4. Gown 3. Mask 1. Eye protection 2. Gloves The gown is applied first, as it takes the most time to don. The mask is donned next, followed by eye protection. These items can be more securely applied with ungloved hands. Gloves are donned last, so the gloves can be pulled up to cover the cuffs of the gown.

15 The nurse assigned to the respiratory care unit is working with four clients who have pneumonia. The nurse should assign the only remaining private room on the nursing unit to the client infected with which organism?

Penicillin-resistant Streptococcus pneumoniae pneumonia. An organism that is "resistant" is a pathogenic microorganism that is difficult to treat and requires droplet precautions.

5. Purposes for dressing a wound

a. Absorb drainage b. Splint or immobilize wound to provide rest c. Protect wound from mechanical injury d. Promote hemostasis e. Prevent contamination f. Provide mental and physical comfort for client

6. Purposes for maintaining a wound undressed

a. Eliminate conditions that favor growth of microorganisms b. Allow for better wound observation and assessment c. Facilitate bathing and hygiene d. Avoid adhesive tape reaction e. Avoid friction and irritation that destroy new epithelial cells

1. Wounds are classified according to continuity of surface they cover (tissue involved)

a. Open wound: break in skin that can be superficial or deep; examples are an abrasion, laceration, or puncture b. Closed wound: injury with no break in skin; examples are contusion and ecchymosis; may be caused by a blow or other type of trauma

Complications that affect wound healing Dehiscence:

accidental reopening of suture line (usually abdominal, but could occur with any wound) with tissue separation under wound; results from infected suture line or factors that impede wound healing; clients often "feel something giving way"; place client in bed with head of bed low to eliminate gravity and with knees bent to decrease pull on suture line; cover wound with large, sterile, wet saline dressings; notify surgeon immediately because repair of surgical site is necessary

Airborne precautions Involves spread of infection through

airborne droplet nuclei smaller than 5microns, evaporated droplets that remain suspended in air for long periods of time, or dust particles containing infectious agent

Enzymatic debriding agent:

an enzyme paste or solution, such as Elase, that is applied to necrotic tissue; enzyme digests necrotic tissue

Factors affecting wound healing Medications:

anti-inflammatory drugs such as steroids and hormones slow formation of fibrous tissue and therefore impair healing

1. Etiologic agent:

any pathogen capable of causing infection; causative agents include bacteria, virus, fungi, protozoa, rickettsiae, and helminths

2.Surgical asepsis Is also known

as sterile technique; objects are designated as "sterile" (completely free of microorganisms) or "nonsterile" (contaminated)

Complications that affect wound healing Hemorrhage:

assess internal hemorrhage by distention in area of wound; external hemorrhage is noted by blood on dressing or leaking from dressing; if bleeding is severe, client may exhibit signs of shock; risk of hemorrhage is greater within first 48 hours; if pressure dressings do not successfully stop bleeding, surgical intervention may be needed

Wound healing Proliferative phase:

fibroblasts grow to form granulation tissue (4 to 21 days), which is very friable, soft, and pinkish red in color because of new capillaries; epithelial cells grow from edges; connective tissue fills area forming a scar that is stronger than granulation tissue; a large wound requiring excessive granulation tissue for closure can lead to formation of a keloid, a large, uneven scar

1.remove ___ first,

gloves

3.then

gloves

3.then

gown,

1.don ___ first, followed

gown, by mask,

1. Medical asepsis involves practices, such as

hand hygiene and use of PPE, to reduce the number and limit the spread of microorganisms

C. Standard precautions include

hand hygiene and use of personal protective equipment (PPE)

Wound closures Secondary intention:

healing occurs by granulation when wound is extensive and edges cannot or should not be approximated; healing time is prolonged; carries greater risk for infection and results in deeper, more extensive scarring

Factors affecting wound healing Age:

healthy children and adults heal faster than older clients; factors that inhibit healing in older adults include age-related vascular changes, cardiovascular disease or diabetes (which reduce blood flow to area), immune system changes, possible nutritional deficiencies, and slower rate of cell renewal

Pressure ulcers: Contributing factors include

immobility, fragile skin in older adults, moisture, malnutrition, shearing, and friction

6. Susceptible host:

individual at increased risk for infection; infection occurs when infectious agent overwhelms host's defenses against infection .

Complications that affect wound healing Evisceration:

internal organs (viscera) protrude through incisional edges after dehiscence; contributing factors include infection, poor nutrition, failure of suture material, dehydration, and excessive coughing; treated in a manner similar to dehiscence

Surgical asepsis Used in implementing sterile procedures, such as

intravenous therapy and urinary catheterization

An infected wound or septic wound has been

invaded by pathogenic microorganisms; clinical signs and symptoms of infection develop

1. Surgical asepsis involves practices to

maintain objects and areas free of microorganisms

Droplet precautions; Visitors should wear

mask if within 3 feet of client and should try to maintain distance of 3 feet whenever possible

2.followed by

mask,

Transmission-based precautions are

measures to limit spread of pathogenic microorganisms

4. Method of transmission:

mode by which microorganism is transferred from reservoir to host; transfer occurs by three mechanisms: direct, indirect, and airborne transmission

Complications that affect wound healing Infection:

noted by redness, swelling, heat, and pain at site; purulent exudate may be noted; client may be anorexic, nauseous, febrile, and have chills; health care provider will order a wound culture, and antibiotics will be administered after culture is obtained

Wound healing Maturation or remodeling phase (healing of scar):

often occurs by weeks 3 to 4,but can extend for 2 years after injury; reorganization of collagen fibers, wound remodeling, and tissue maturation occurs; a fully healed wound has tensile strength of up to 80% of preinjury state (more susceptible to future injury)

Droplet precautions Involves spread of infection by

particle droplets larger than 5 microns that can be generated when client coughs, sneezes, talks, laughs, and so on

For tuberculosis, wear

particulate respirator mask that is fit-tested to individual nurse

a. Direct contact involves physical transfer of causative agent from

person to person; routes of direct transmission include touching, kissing, biting, and sexual intercourse; transmission can also occur through droplets when person talks, coughs, sneezes, or spits, but only when source is within 3 feet of susceptible host

2. PPE is equipment worn by health care providers to

prevent transmission of microorganisms

Airborne precautions Place client in;

private, negative-air pressure room with 6 (older construction) to 12 (renovations or new construction) air exchanges per hour; air is exhausted directly to outdoors or recirculated through HEPA filtration before return. Client should remain in room with door closed.

b. Gown: worn to protect health care provider's skin and clothing; used during

procedures and care activities when splashing or spraying of blood, body fluids, secretions, and excretions is possible

Factors affecting wound healing Nutrition:

protein helps build new tissue; vitamin C aids maturation of fibrous tissue and protein synthesis; undernutrition results in inadequate nutrient stores, while obesity tends to decrease blood flow to tissue and increase risk of infection Remember that foods containing protein or vitamin C are good choices for clients who have healing wounds.

Droplet precautions; Use standard precautions; mask is required when

providing care or if within 3 feet of client; use other PPE as appropriate

3. Syringes, needles, and sharps: avoid

recapping needles or detaching needles from syringes; dispose of items in a rigid, puncture-resistant container immediately after use

5. Portal of entry to susceptible host:

route by which infectious agent enters susceptible host; examples include breaks in skin and respiratory, GI, reproductive, and urinary tracts

3. Portal of exit from reservoir:

route by which microorganism leaves reservoir; portal of exit can be breaks in skin, the blood, and respiratory, GI, reproductive, and urinary tracts in humans

Airborne precautions Examples of diseases include

rubella (measles), varicella (chicken pox), and tuberculosis

Contact precautions: Examples of diseases include

skin infections (scabies, pediculosis, herpes simplex or zoster), hepatitis A, and wound, GI or urinary infections, including those with multi-drug resistant organisms, such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE)

Droplet precautions; Client should remain in room; if transportation of client to other hospital departments is unavoidable, client should wear

surgical mask; notify personnel in receiving department of client's infection. Door to room may remain open

Wound closures Surgical interventions:

sutures, staples, and clips are devices used to approximate wound edges; some sutures absorb and others must be removed; staples and clips are alternatives to suturing and are usually made of silver; these require removal in approximately 7 to 10 days

Medical asepsis Used in implementing nonsterile procedures, such as

taking vital signs, nasogastric tube insertion, and tube feeding administration

c. Mask: worn to protect mucous membranes of nose and mouth; should fully cover nose and mouth;

used during care activities when splashes or sprays of blood, body fluids, secretions, and excretions can be expected

b. Indirect contact involves transfer from reservoir to susceptible host via either a

vehicle or a vector; vehicle-borne transmission requires inanimate object to serve as mode of transmission; intermediary agent, such as an animal or insect, is required in vector-borne transmission

Factors affecting wound healing Condition of tissues:

wound contamination and infection slow healing process; organisms present in wound will compete with body cells for O2 and nutrition

Wound closures Primary intention:

wound edges are well approximated and wound heals without infection; tissues return to a healthy state with minimal inflammation and little to no scarring

Assess existing pressure ulcers for healing using a tool such as Pressure Ulcer Scale for Healing (PUSH), which evaluates

wound size, exudate amount, and type of tissue present in wound bed

Clients with severe acute respiratory syndrome (SARS) require the use of both airborne and contact precautions;

SARS is a highly infectious viral infection that is transmitted by airborne respiratory droplets and by touching surfaces and objects contaminated with infectious droplets

2.then

eye protection,

4.then

eye protection;

Factors affecting wound healing Efficiency of circulation:

factors that restrict local blood supply to a wound (damaged arteries, edema of tissues, and dehydration) interfere with healing; anemia and blood dyscrasias may interfere with oxygen delivery; conditions such as diabetes and liver dysfunction can delay healing; regular exercise promotes circulation and faster healing; smoking may limit O2 supply to tissues

2. Reservoir:

favorable environment in which infectious organism grows and reproduces; reservoir may be animate (humans, animals, insects) or inanimate (food, water, soil, equipment); blood and respiratory, gastrointestinal (GI), reproductive, and urinary tracts serve as reservoirs in humans

Wound healing Inflammatory phase :

fibrin network of protein fibers forms in wound; blood flow increases to area; damaged tissue then heals; drying of fibrin and protein form a scab that seals skin in 3 to 4 days

c. Air born transmission involves transport of

droplet nuclei or dust bearing infectious agent by air currents

Eye protection: goggles are worn to protect eyes; do not use personal glasses as a substitute for goggles; face shield is worn to protect face, including eyes, nose, and mouth, and should cover forehead, extending below chin and wrapping around each side of face; eye protection is used

during care activities when splashes or sprays of blood, body fluids, secretions, and excretions are likely

For other airborne diseases such as rubella or varicella, susceptible persons should not

enter client's room; if entry is unavoidable, respiratory protection must be worn

Partial thickness involves

entire epidermis, part of dermis; sweat glands and hair follicles are intact

Superficial thickness involves

epidermal layer only, such as a mild sunburn or burn from contact with hot object

Full thickness involves

epidermis and dermis, extending to subcutaneous tissue and possibly even to muscle and bone

Contact precautions: Limit transportation of client to other hospital departments; infected wound should

be securely covered; notify personnel in receiving department of client's infection

lesions caused

by unrelieved pressure, which also damages underlying tissues

Airborne precautions If transportation of client to other hospital departments is unavoidable,

client should wear surgical mask

Contact precautions: Use standard precautions; gloves are required; wear gown when

contact with infected secretions is expected; use other PPE as appropriate for expected risk of exposure

Superficial, partial, and full thickness refer to

depth of injury and are used most often to describe burns

Droplet precautions; Examples of diseases include

diphtheria (pharyngeal), mycoplasma pneumonia, rubella, pertussis, mumps, streptococcal pharyngitis, pneumonia, and scarlet fever