Chapter 23: Asepsis and Infection Control

Bacteria pg. 540

There are two types of bacteria flora on the hands 1. transient bacteria 2. resident bacteria

Adding sterile supplies to a sterile field pg. 554

after establishing sterile field, it may be necessary to add additional supplies or instruments to the sterile field -once a sterile field is established, objects on a field may be handled only by using sterile forceps or with hands wearing sterile gloves

Handwashing pg. 544

effective handwashing requires at least 20-second scrub with plain soap or disinfectant and warm water -if visibly soiled, scrub longer -Hand antisepsis before assisting with a surgical procedure involves a more lengthy scrub, reducing resident and transient flora from the forearms and hands -CDC guideline recommends using an antimicrobial soap or alcohol-based surgical hand scrub product with persistent activity for surgical hand antisepsis

Antimicrobial Agent pg. 542

highly recommended in any setting where the risk for infection is high -if present in certain concentrations, they can kill the bacteria or supress their growth -Studies indicate that alcohol-based rubs (in most situations), more effectively reduce bacterial and viral counts on the hands of health care personnel than antimicrobial soap does -alcohol based rubs have concentration between 60% and 95% and are available as foam, gel, or lotions

Asepsis pg. 538

includes all activities to prevent infection or break the chain of infection -nurse uses aseptic technique to stop the spread of microorganisms and minimize the threat of infection -there are 2 asepsis categories: 1. medical asepsis -or *clean technique*, involves procedures and practices that reduce the number and transfer of pathogens (this includes performing hand hygiene and wearing gloves) -Barriers are ways to decrease the spread of pathogens and include hand hygiene, personal protective equipment, and other barrier techniques. 2. Surgical asepsis - or *sterile technique*, includes practices used to render and keep objects and areas free from microorganisms (this includes inserting an indwelling urinary catheter or inserting an IV catheter)

Demonstrate and describe the correct technique for applying and removing personal protective equipment (PPE) and describe the rationale for the use of the different types of PPE pg. 548

According to 1992 Occupational Safety and Health Administration, health care agencies must provide employees with the equipment and supplies necessary to minimize or prevent exposure to infectious material. *PPE* (Personal Protective Equipment) - includes gloves, gowns, masks, and protective eye gear

Resident Bacteria Table 23-2 pg 541

CHARACTERISTICS: -Normally found in creases in the skin -Usually stable in number and type -Cling tenaciously to skin by adhesion and absorption EFFECTIVE HAND HYGIENE MEASURES: -Considerable friction with a brush is required to remove them. -Less susceptible to antiseptics than are transient bacteria

Transient Bacteria Table 23-2 pg 541

CHARACTERISTICS: -Occur on hands with activities of daily living -Relatively few in number on clean and exposed areas of skin -Attached loosely on skin usually in grease, fats, and dirts -Found in greatest number under the fingernails -Can be pathogenic or nonpathogenic EFFECTIVE HAND HYGIENE MEASURES: -Can be removed relatively easily by frequent and thorough hand washing

Transient bacteria pg. 541

Can be usually easily removed by thorough handwashing, but have the potential to adjust to the environment of the skin when they are present in large numbers over a long period and become resident bacteria. -if pathogenic organisms become resident bacteria on the skin, the hands become carriers of the organism -to prevent transient bacteria from becoming resident bacteria, it is important to clean the hands promptly when they are visibly soiled, after each contact with contaminated materials, and after removing gloves.

Pouring sterile solutions pg. 554

Care is needed when pouring sterile liquid onto sterile dressing or sterile basin -outer surfaces of the bottle and cap are considered unsterile and the inside area and the solutions are considered sterile -after solution has been opened, the outer bottle should be labeled with date/time if it is to be reused -many solutions considered sterile for 24 hrs after opened -when pouring, grasp bottle so that the label is in the palm of your hand (this prevents any liquid from running over the label and making it illegible) -avoid splashing the liquid since this would contaminate the sterile field

Disinfection V. Sterilization

Disinfection: destroys all pathogenic organisms, EXCEPT spores Sterilization: destroys all pathogenic organisms, INCLUDING spores

Gowns pg. 548

Gowns are used to prevent soiling nurses clothing by patient's blood or bodily fluids -they provide a barrier protection and are donned immediately before entering the patient's room -individual gown technique is recommended (wear it once and then discard it properly) -a waterproof or impervious gown is used if there is an increased likelihood of contact with the the patient's blood or body fluids -if gown becomes heavily soiled or moistened with blood or bodily fluids when caring for patient, remove it, perform hand hygiene, and put on clean gown. -there is no special technique for applying a gown used as a barrier, but there is recommended practices for removing a soiled gown

Techinque for handwashing pg. 542

If health care worker's hands aren't soiled, the use of alcohol based handrubs are recommended bc they save time, are more accessible, and easy to use, AND reduce the bacteria count on the hands You may use an alcohol-based handrub to decontaminate hands: 1. before direct contact with patients 2. after direct contact with patient's skin 3. after contact with body fluid, mucous membranes, nonintact skin, and wound dressings, if hands are not visibly soiled 4. after removing gloves 5. before inserting urinary catheter, peripheral vascular catheters, or invasive devices that do not require surgical placement 6. Before donning sterile gloves prior to an invasive procedure 7. If moving from a contaminated body site to a clean body site during patient care 8. After contact with objects (including equipment) located in the patient's envirtoment

The World Health Organization (WHO) clearly defined the "Five Moments for Hand Hygiene": pg. 540

Moment 1 - Before touching a patient Moment 2 - Before a clean or aseptic procedure Moment 3- After a body fluid exposure risk Moment 4 - After touching a patient Moment 5 - After touching patient surroundings

Demonstrate and describe proper hand hygiene using soap and water and no-rinse hand rubs. pg. 540

"Hand hygiene" applies to either handwashing with plain soap and water, use of antiseptic handrubs including waterless alcohol-based products, or surgical hand antisepsis.

Prepare and maintain a sterile field pg. 554

(Opening sterile package and preparing sterile field) Commercially prepared sterile items may be sealed in paper or packaged in plastic containers -you may open package on a flat surface or while held in the hands -a sterile item should be covered if it is not used immediately -reapply the cover by touching only the OUTSIDE of the wrapper and reversing the opening order

Protective Eyewear pg. 549

(goggles or a face shield) must be available whenever there is a risk of contaminating the mucous membranes of the eyes. ex. suctioning a tracheostomy or assisting with an invasive procedure that may result in splattering of blood or other bodily fluids requires protection of caregiver -regular vision glasses are unacceptable bc they lack side shields

Masks pg. 548

-Masks help prevent the wearer from inhaling large-particle aerosols which can usually travel short distances (3 feet) and small particle droplet nuclei, which can remain suspended in the air and travel long distances -also protect the patient from the respiratory secretions of the health care worker -masks discourage wearer from touching eyes, nose, and mouth, thus limiting contact of organisms with mucous membranes -Various mask practices are used, some, all personnel and all the patient's visitors wear masks, in other situations, a patient requiring specific precautions wears the mask when transported outside his/her room to protect health care personnel and other patients from exposure to pathogens -mask is worn only once and never lowered around the neck and then brought back over the mouth and nose for reuse -mask must be changed before it becomes damp from the wearer's exhalations -the serious increase in the number of multidrug-resistant tuberculosis cases prompted new guidelines to prevent transmission of TB -According to CDC, either a high efficiency particulate air (HEPA) filter respiratory or N95 respirator certified by NIOSH must be worn when entering the room of a patient with known or suspected TB, SARS, or flu. -respirators filter inspired air, wheras surgical masks filter only expired air. -N95 respirator is designed to filter out particles as small as 1 mcm with 95% efficiency fits more comfortably against the face.

Transmission-based precautions: pg. 550

-Precautions used in *addition* to standard precautions for patients in hospitals with known OR suspected infection with pathogens that can be transmitted by airborne, droplet, or contact routes -the CDC 2007 guidelines include a directive to don PPE when entering the room of a patient on contact or droplet precautions -previously, PPE was only required when the nurse was delivering care within 3 feet of the patient

Putting on Sterile Gloves pg. 554

-Sterile gloves are donned in a way that allows on the inside of the gloves to come in contact with the hands -After the gloves are on, only sterile items may be handled with the sterile-gloved hands -Careful removal of the gloves reduces any hand contact with contaminated material -Good hand hygiene technique before and after putting on sterile gloves is imperative

Handling and disposing of Supplies pg. 550

-Used equipment may be disposed of after use, or bagged if reusuable and sent to a central cleaning area to be sterilized and disinfected -double bagging may be required if single bag is not secure or is soiled on the outside -contaminated item should never be used for another patient -double bagging of trash/linen usually only needed if outside of bag is visibly soiled -the use of paper trays and plastic eating utensils does not prevent transmission of organisms and is no longer recommended -combination of hot water and detergent used in commercial dishwashers is sufficient to decontaminate dishes, glasses, and utensils -spills of body fluids or substances must be cleaned immediately with appropriate chemical germicide or disinfectant -while collecting specimen, take care to prevent the outside of the container from becoming contaminated with any secretions/body fluids -seal in a plastic bag to prevent leakage during transportation -bag marked "BIOHAZARDS" is sued to dispose of trash that contains liquid or semiliquid blood or other potentially infective material (OPIM), trash contaminated with blood or OPIM that would release substances if compressed, and trash that is caked with dried blood or OPIM and is capable of releasing these materials during handling

Gloves pg. 548 Reference table 23-3 on pg. 549 (Latex Allergy Summary)

-Worn only once and discarded appropriately according to agency policy -are not necessary if there is no possibility of soiling the the hands with body fluids -Activities such as turning a patient, feeding a patient, taking vital signs, and changing IV fluid bags do not require the use of gloves as long as the potential contact with body fluid is not present -if gloves are being used, they should always be changed prior to moving from a contaminated task to a clean one -when gloves are on, NEVER LEAVE A PATIENTS ROOM (unless transporting a contaminated item or a patient requiring transmission-based precautions), never write in the patient's chart, and never use the computer keyboard or telephone in the nurses' station. Do not touch pagers/cellphones without performing good hand hygiene first -Perform proper hand hygiene before and after the use of gloves because the inside of the gloves can create warmth and moisture making it an ideal environment for bacteria to multiply -Research also indicates that gloves are just a barrier but are not impenetrable so protection is not guaranteed -Double gloving is recommended if the health care worker is involved in a procedure during which exposure to blood or body fluids is expected, such as in an OR setting. -Some people are sensitized to traditional latex with reactions ranging from local skin reactions to urticaria (hives) to systemic anaphylaxis, an exaggerated allergic reaction that can result in death -The cornstarch powder or talc used to make gloves easier to put on is a major causative factor in any latex allergy (the powder binds with the latex protein and becomes airborne, where it can remain for 5 to 12 hours after health care workers don or remove gloves -if the person with latex sensitivity continues to be exposed to latex, the person may demonstrate signs of a latex allergy -the national institute for occupational safety and health recommends that nonlatex gloves or power-free low-allergen latex gloves be available for use.

Practicing the Basic Principles of *Surgical Asepsis* pg. 553 Box 23-6

1. Allow only a sterile object to touch another sterile object. Unsterile touching sterile means contamination has occurred. 2. Open sterile packages so that he first edge of the wrapper is directed away from the worker to avoid the possibility of a sterile surface touching unsterile clothing. The outside of the sterile package is considered contaminated. Opening a sterile package is shown and described in Skill 23-3. 3. Avoid spilling any solution on a cloth or paper used as a field for a sterile setup. The moisture penetrates through the sterile cloth or paper and carries organisms by capillary action to contaminate the field. A wet field is considered contaminated if the surface immediately below it is not sterile. 4. Hold sterile objects above the level of the waist. This will ensure keeping the object within sight and preventing accidental contamination. 5. Avoid talking, coughing, sneezing, or reaching over a sterile field or object. This helps to prevent contamination by droplets from the nose and the mouth or by particles dropping from the worker's arm. 6. Never walk away from or turn your back on a sterile field. This prevents possible contamination while the field is out of the worker's view. 7. Keep all items sterile that are brought into contact with broken skin, or used to penetrate the skin to inject substances into the body, or to enter normally sterile body cavities. These items include dressings used to cover wounds and incisions, needles for injection, and tubes (catheters) used to drain urine from the bladder. 8. User dry, sterile forceps when necessary. Forceps soaked in disinfectant are not considered sterile. 9. Consider the edge (outer 1 inch) of a sterile field to be contaminated. 10. Consider an object contaminated if you have any doubt as to its sterility.

Guideline on how to use an alcohol based handrub pg. 543 Table 23-1

1. Apply product to the palm of one hand, using the amount of product recommended on the package (it will vary according to the manufacturer but usually is 1 to 3 mL) 2. Rub hands together, making sure to cover ALL surfaces of the hands, fingers, and in between the fingers. Also, clean the fingertips and the area beneath the fingernails. 3. CONTINUE RUBBING UNTIL THE HANDS ARE DRY (AT LEAST 15 SECONDS)

WORDS TO WATCH

1. CDC - Centers for Disease Prevention and Control US government agency responsible for investigating, preventing, and controlling disease 2. WHO - World Health Organization 3. CMS - Centers for Medicare and Medicaid Services -no longer reimburses hospitals for preventable hospital-aquired conditions in ten categories 4. AHRQ - Agency for Healthcare Research and Quality 5. OSHA - Occupational Safety and Health Administration 6. HAI - Health-care associated infections 7. PPE - Personal Protective Equipment 8. CDI - C. difficile infection -must wear PPE with C.diff patient 9. MRSA- Staphlococcus aureus bacteria that is normally found in nasal mucous membrane, on the skin, and in the respiratory and gastrointestinal tract. Also known as "staph" 10. VRSA - vancomycin resistant staphylococcus aureas -Totally resistant to vancomycin 11. VRE - vancomycin-resistant enterococci -species of streptococcus often found in normal intestinal and female genital tracts -spread via contact with feces, urine, or blood of an infected or colonized person 12. HIV - human immunodeficiency virus 13. HBV - hepatitis B virus 14. HCV - hepatitis C virus

Practicing the basic principles of *Medical Asepsis* in patient care pg. 539 Box 23-2

1. practice good hand hygiene 2. keep soiled items and equipment from touching the clothing. carry soiled linens or other used articles so that they do not touch your clothing 3. do not place soiled bed linen on any other items on the floor, which is grossly contaminated. It increases contamination of both surfaces. 4. avoid allowing patients to cough, sneeze, or breathe directly on others. Provide them with disposable tissues and instruct them, as indicated, to cover their mouth and nose to prevent spread by airborne droplets. 5. Move equipment away from you when brushing, dusting or scrubbing articles. This helps prevent contaminated articles from settling on the hair, face, and clothing. 6. Avoid raising dust. Use a specially treated cloth or dampened cloth. Do not shake linens. Dust and lint particles constitute a vehicle by which organisms may be transported from one area to another. 7. Clean the least soiled areas first and then the more soiled ones. This helps prevent having the cleaner areas soiled by the dirtier areas. 8. Dispose of soiled or used items directly into appropriate containers. Wrap items that are moist from body discharge or drainage in waterproof containers, such as plastic bags, before discarding into the refuse holder so that handlers will not come in contact with them. 9. Pour liquids that are to be discarded, such as bath water, mouth rinse, and the like, directly into the drain to avoid splattering in the sink and onto you. 10. Sterilize items that are suspected of containing pathogens. After sterilization, they can be managed as clean items, if appropriate. 11. Use practices of personal grooming that help prevent spreading microorganisms. Examples include shampooing the hair regularly, keeping it short or pinned up to limit the possibility of carrying microorganisms on hair shafts, keeping the finger nails short and free of broken cuticles and ragged nail edges, and avoid wearing rings with grooves and stones that may harbor microorganisms. 12. Follow guidelines conscientiously for standard and transmission-based precautions as prescribed by your agency.

Using Standard and Transmission-Based Isolation Precautions (Please refer to Box 23-4 on pg. 551)

Isolation- a protective procedure that limits the spread of infectious diseases among hospitalized patients, hospital personnel, and visitors

Standard Precautions: pg. 550

Precautions used in the care of all hospitalized patients regardless of their diagnosis of possible infection status -these precautions apply to blood, all body fluids, secretions, and excretions except sweat, non intact skin, and mucous membranes -additions are respiratory hygiene/cough etiquette, safe injection practices, and directions to use a mask when performing high-risk prolonged procedures involving spinal canal punctures

Cleansing Agents pg. 541

Soaps and detergents (non-antimicrobial agents) - considered adequate for routine mechanical cleansing of the hands and removal of most transient microorganism. -they help remove soil bc they lower the surface tension and act as emulsifying agents -Bar, liquid, leaflet, and powdered soaps are all effective

CDC Guideline for Hand Hygiene in Health-Care Settings pg. 541

Specifies that health care personnel involved in patient care should NOT wear artificial nails because they are more likely to be associated with higher bacterial counts -wearing artificial nails in the operating room is a citable offense during the Joint Comission accreditation process -natural nails should be less than 1/4 of an inch long

Positioning a Sterile Drape pg. 554

The sterile drape, (usually waterproof), may be used to extend sterile area -using sterile gloves allows the nurse to handle the entire drape surface -for protection while positioning, fold the upper edges of the drape over the sterile-gloved hands -when sterile gloves are not being worn, the nurse can touch only the outer *1 Inch* of the drape. -Use caution when gently shaking the drape open so as not to touch one's clothing or an unsterile object -Hold the drape by 1-inch upper edge and position the drape over the desired area -DO NOT reach over the drape because this would contaminate a sterile area