IMMUNE SYSTEMASEPSIS

PRETEST 1. Define Nosocomial infection 2. Identify what DTP stands for 3. Identify the most common Nsg.

Intervention to prevent infection 4. Define sensory deprivation 5. Give one example of a Nsg.

Procedure that uses surgical asepsis.

PRETEST ANSWERS 1. Acute care or hospital acquired. 2. Diptheria, Tetanus, Pertussis 3. Handwashing 4. Mental alteration resulting from

severely decreased stimulation 5. Invasive procedures: Starting an

IV, injections, urinary catheterization

IMMUNITY:DEFINITION

Specific resistance of the body to infectious agents

SUSCEPTIBILITY:DEFINITION

Degree to which an individual can be affected

likelihood of an organism causing an infection in that person

CHAIN OF INFECTION6 LINKS

1. Etiologic agent (microorganism) 2. Reservoir (source) 3. Portal of exit from reservoir 4. Method of transmission 5. Portal of entry to the susceptible

host 6. Susceptible host

ETIOLOGIC AGENT BODY SOURCES (6)

1.Respiratory tract 2.GI tract 3.Urinary tract 4.Reproductive tract (including

genitals) 5.Blood 6.Tissue

RESERVOIRS & PORTALS OF EXIT (5)

1.Respiratory tract= nose/mouth, Endotracheal tubes or tracheostomies

2.GI tract= Mouth per saliva, vomitus, anus/ostomies: feces, drainage tubes (eg, NG or T-tubes)

3.Urinary tract= Urethral meatus & urinary diversion ostomies

Con’t 4. Reproductive tract= vagina: vaginal

discharge; may be further transported by urine; urinary meatus: semen, urine

5. Blood= open wound, needle puncture site, any disruption of intact skin or mucous membrane surfaces

METHODS OF TRANSMISSION (3)

Direct Transmission= 1. Immediate & direct contact

2. Droplet spread if source & host within 3 ft of each other

Indirect Transmission=

1. Vehicle borne = fomites

2. Vector-borne=animal, flying or crawling insect that serves as an intermediate means of transporting agent

(con’t) Airborne Transmission= droplet

nuclei or residue of evaporated droplets that

may remain in air for long periods of time emitted by infected host or dust particles containing the infectious agent are transmitted by air currents to a suitable portal of entry

BREAKING THE CHAIN OF

INFECTION

First link broken by use of antiseptics, disinfectants and sterilization

Aim of most isolation precautions & many hospital practices for infection prevention & control is breaking chain during transmission phase of cycle

ANTISEPTIC AGENTS VS DISINFECTANTS

Antiseptics= agents that inhibit growth of some microorganisms

chemical preparation used on skin or tissue

Disinfectants= agents that destroy pathogens other than spores

chemical preparation used to treat inanimate objects

more concentrated solution=can be toxic & caustic to tissue

BACTERICIDAL VS BACTERIOSATIC

Bactericidal= destroys bacteria

Bacteriostatic= prevents growth & reproduction of some bacteria

ANTISEPTICS & DISINFECTANTS

– “Commonly Used Antiseptics and Disinfectants, Effectiveness, and Use

STERILIZATION Process that destroys all micro org.

including spores & viruses METHODS (4): 1. Moist heat (steam) 2. Boiling water 3. Gas 4. Radiation

INFECTION RISK FACTORS HOST SUSCEPTIBILITY: age,

heredity, stress level, nutritional status, immunization status, current medical therapy, pre existing disease processes, & some past or recent surgical interventions

POPULATIONS AT RISK FOR INFECTION

Elderly, the very young poorly nourished individuals individuals with deficiency of serum

immunoglobulins individuals with insufficient immunizations or

existing disease process Individuals with multiple stressors Individuals with certain medical therapies

MEASURES THAT REDUCE A PERSON’S SUSCEPTIBILITY

Adequate hygiene Administration of immunizations on a

timely basis Nutrition that is balanced and

adequate Fluid intake that is adequate Rest and sleep that are adequate Reduce stress

STAGES OF AN INFECTIOUS PROCESS (4)

1. Incubation period=time between entry of microorg. Into body & onset of s/s

2. Prodromal Period=time from onset of nonspecific s/s until specific symptoms of infection appear

3. Illness Period=specific s/s develop & become evident: localized s/s & systemic s/s

(Con’t) 4. Convalescent Period=extends

from time s/s start to abate until person returns to normal state of health

NORMAL BODY DEFENSES

Nonspecific= intact skin & mucuous membranes, nasal passage cilia, lung alveolar macrophages & phagocytes, oral cavity lactoferrin & shedding, tears, GI pH,vaginal pH, inflammation

Specific= 1. Active: natural vs

artificial 2. Passive: natural

vs Artificial

STAGES OF INFLAMMATION

1. Vascular & cellular responses 2. Exudate a. Serous b. Purulent c. Hemorrhagic d. Serosanguineous 3. Reparative

LEUCOCYTOSIS Abnormally high levels of white blood

cells (leukocytes)= inflammation Normal WBC count can go from 4500-

11,000 per cubic millimeter of blood to 20,000 or more

IMMUNIZATIONS INITIAL

HBV=Hep B-1,Hep B-2=Hep B-3= Hepatitis B= birth

DTP= Diptheria, Tetanus, Pertussis=2,4,6 months

Hib= Haemophilus Influenzae type b=2,4, 6 months

OPV=Oral Poliovirus=2, 4, 6 months MMR= Measles, mumps, rubella=12 mo.

(Con’t) Varicella Zoster Virus Vaccine= 12-

18 months

BOOSTER SHOTS HBV= health care workers draw titer &

immunize with each exposure DTP= 12 months, 4-6 yrs; Tetanus

toxoid every 10 years thereafter Hib= 12-15 months (Depending on

type used) OPV= 4-6 yrs MMR= 4-6 yrs or 11-12 yrs

NOSOCOMIAL INFECTION:DEFINITION

Infections that are associated with the delivery of health care services in a health care facility

NOSOCOMIAL INFECTION ORIGINS

Endogenous Source= from the clients themselves

Exogenous sources= microorganisms originate from the hospital environment and personnel

IATROGENIC INFECTIONS Nosocomial infections that are due to

any aspect of medical therapy Example: Bacteremia resulting from

an IV line Other contributing factors: Presence of

compromised hosts, insufficient hand washing or poor healthcare provider compliance with asepsis

MAJOR SITES FOR NOSOCOMIAL INFECTIONS (4)

1. Respiratory tract 2. Urinary tract 3. Bloodstream 4. Surgical or open wounds

RISK FACTORS THAT CONTRIBUTE TO NOSOCOMIAL

INFECTION

1. Invasive procedures 2. Medical therapies 3. Existence of large number of

susceptible persons 4. Inappropriate use of antibiotics 5. Insufficient hand washing after

client contact & after contact with body substances

LOCALIZED vs SYSTEMIC INFECTIONS: DEFINITIONS

Localized: Infectious Process in only the affected body organ or area

Example: abscess of big toe of right foot

Systemic: Infectious process in the entire body

Example: bacteremia

S/S OF LOCAL VS SYSTEMIC INFECTION

Local infection= localized swelling, localized redness, pain or tenderness with palpation or movement, palpable heat of affected part, loss of function of affected body part, wound drainage

Systemic infection= ^ TPR,lassitude, malaise, loss of energy

anorexia & n/v enlargement &

tenderness of lymph nodes that drain area of infection

see Kozier pg. 641

LABORATORY DATA ^LEUCOCYTE COUNT

1. ^Neutrophils=acute suppurative infection 2. Neutrophils Decrease=acute bacterial

infection in elderly 3. Lymphocytes=^ in chronic bacterial &

viral infection 4. Monocytes ^ in some protozoal &

rickettsial infections & TB

(Con’t) 5. Eosinophils= unaltered in infectious

process 6. Basophils= unaltered in fection

process

^ ERYTHROCYTE SEDIMENTATION RATE (ESR)

Rate increases in presence of an inflammatory process

CULTURE & SENSITIVITY STUDIES

Specimens of: urine, blood, sputum, or other body drainage= cultures microorganisms in special growth medium to indicate presence of pathogenic microorganisms and chemical substance they are susceptible to

ASEPSISDEFINITION

Freedom from infection or infectious material

Example: handwashing

MEDICAL ASEPSIS vs SURGICAL ASEPSIS

All practices intended to confine a specific microorg. To a specific area, limiting the number, growth, & transmission of microorganisms

Example: 2-minute handwashing

Practices that keep an area or objects free of all microorg.; it includes practices that destroy all microorg and spores

Example: Invasive procedures=IV starts, injections urinary cath.

RELEVANT NANDA NURSING DIAGNOSES

High risk for infection Altered oral mucous membranes High risk for altered body temperature Impaired skin integrity Impaired tissue integrity Impaired physical mobility Altered nutrition: less than body

requirements

(Cont’) Pain Social isolation Diversional Activity deficit Self-esteem disturbance Anxiety Fear Hopelessness

NURSING INTERVENTIONS TO PREVENT INFECTION

Discuss risk factors which place pt. at risk for infection

Teach Pt.: purpose of meds, monitoring of health status, drsg. Chges., TCDB, frequent repositioning, isolation precautions

Monitor VS & skin color q shift for s/s of infection

Assess lab values for s/s of infection=CBC, cultures

(Cont’d) Ask Pt. About presence of subjective clinical

s/s of infection (chills, malaise, lethargy) Assess & document s/s of localized

infection(auscultate lungs & inspect urine, sputum & other drainage for alterations in color & consistency)

Inspect skin for s/s inflammation & impaired tissue integrity

(Cont’d) Collect wound, sputum, urine & other

specimens as ordered for C & S and report abnormalities

Assess Pt.’s immunization status & life-style practices

Develop & implement plan to teach Pt. About proper nutrition =high-protein, high-vitamin diet, adequate fluid intake, proper hygiene & importance of rest

Medical asepsis

METHODS OF KILLING OR REDUCING INFECTIOUS

AGENTS

Medical asepsis Surgical asepsis Use of Medications: antibiotics,

antivirals, antifungals

ANTIBIOTIC:DEFINITION

Natural or synthetic substance that has the capacity to inhibit the growth of or kill other microorganisms

Synonyms: anti-infectives, antimicrobials antibacterials

Several different characteristics may be used to classify antibiotics

RX CLASSIFICATION CHARACTERISTICS (3)

1. Spectrum of activity=Broad vs narrow spectrum

2. Antimicrobial activity= Bacteriostatic vs bacteriocidal

3. Mechanism of action= (5)=inhibition of bacterial cell wall synthesis, alt. in cell membrane function,

(con’t) Inhibition of protein synthesis,

inhibition of nucleic acid metabolism, interference with intermediate cell metabolism ( Malseed, et., al. Pharmacology Drug Therapy and Nursing Considerations, 1995 pg.583).

LIPPINCOTT’S NSG. GUIDEANTIBIOTIC CLASSIFICATION

(9) 1. Penicillins 2. Sulfonamides 3. Tetracyclines 4. Cephalosporins 5. Aminoglycosides 6. Fluoroquinolones 7. Lincosamides

(Con’t) 8. Macrolides 9. Antibacterials

ANTIBIOTICS & NSG. 1. Necessity of therapy; Prophylactic

antibiotic use vs Tx of infection 2. Identification of pathogen & sensitivity 3. Dosage & duration of therapy, level

monitoring 4. Hypersensitivity reactions 5. Organ toxicity 6. Superinfection 7. Resistance

CENTERS FOR DISEASE CONTROL (CDC)

Principal public health agency at the national US level concerned with disease prevention and control

Roles: 1. Develop policy re. Communicable

Diseases 2. Research 3. Educate public and healthcare providers

(Con’t) 4. Maintain national data bank on

prevalence and incidence of communicable diseases

ISOLATION:DEFINITION

Measures designed to prevent the spread of infections or potentially infectious microorg. to health personnel, clients & visitors

DISEASE SPECIFIC ISOLATION PRECAUTIONS

Provide for precautions for specific diseases

Example:pulmonary TB Precautions= Placing Pt. In private room with special ventilation or having Pt. Share a room with other Pt.s who are infected with same organism & use of special masks by staff entering room & gowning only to prevent gross soilage of clothes; no gloves indicated

CATEGORY-SPECIFIC ISOLATION

PRECAUTIONS Based on 7 categories: 1. Strict isolation 2. Contact isolation 3. Respiratory isolation 4. TB isolation 5. Enteric precautions 6. Drainage/secretions precautions 7. Blood/body fluid precautions

UNIVERSAL PRECAUTIONS

Apply to those body fluids associated with bloodborne pathogens= Hepatitis B virus, Hepatitis C virus and HIV

Applicable body fluids= blood, semen vaginal secretions cerebrospinal fluid, synovial fluid, pleural fluid,pericardial fluid, peritoneal fluid, amniotic fluid, saliva, body fluids containing blood & body fluids where it is difficult to differentiate among body fluids

(Con’t) NonApplicable body fluids= any fluid not

mentioned in above list unless they contain visible blood; these fluids are normally not associated with the transmission of bloodborne pathogens

Apply to all Pts to < transmission of unidentified pathogens

see Kozier page 651 CLINICAL GUIDELINES Universal Precautions

(Con’t) CDC recommends universal

precautions be used in conjunction with disease-specific or category-specific precautions and not replace them

OSHA STANDARDS BLOODBORNE PATHOGEN

EXPOSURE

Regulations to protect health care workers from occupational exposure to bloodborne pathogens

adapt CDC’s Universal Precautions+avoiding injury due to sharp instruments, measures to take in case of exposure to bloodborne pathogens & communication of biohazards to employees

BODY SUBSTANCE OR BODY FLUID ISOLATION

Employs generic infection control precautions for all Pts. except those with the few diseases transmitted through air

Purposes:Prevent cross-transmission of microorg. & protect health care worker from microorg. harbored by Pts.

Body substance=blood & body fluids & substance, urine, feces, wound drainage, oral secretions

(Con’t) When BSI precautions are used,

category-specific & disease-specific precautions are not required

Sufficient for all clients except those who have certain airborne disease= pulmonary TB & varicella or chicken pox

ISOLATION PRECAUTIONS IN HOSPITALS 1996

Standard precautions= Tier I

apply to all hospital persons

apply to blood, all body fluids, secretions & excretions except sweat, non-intact skin & mucous membranes

Transmission-Based Precautions= Tier II

Used in addition to Standard Precautions for Pts. With known or suspected infection that are spread by any of the following: airborne, droplet or contact

ISOLATION PRECAUTIONS (con’t)

Standard precautions

combine the major features of UP Universal Precautions & BSI

The three types of transmission-based precautions may be used alone or in combination but always in addition to Standard Precautions

Encompass all conditions or diseases listed in category-specific or disease specific

AIRBORNE, DROPLET & CONTACT PRECAUTIONS

BARRIER TECHNIQUE (REVERSE ISOLATION)

Protect compromised Pt.s from microorg. On health care personnel and non sterile items

Pts. with leukemia, extensive skin impairments

Use Standard Precautions and Transmission/Based Precautions

IMPLEMENTING ISOLATION PRECAUTIONS

Handwashing=Most effective infection control measures: CDC 10 secs using bar soap, granule soap, soap filled tissues or antimicrobial liquid soap

Wash hands: before eating, after using bedpan or toilet, after contact with any body substances, before and after care (even if gloves were used)

(Con’t) Wash from clean to dirty by holding hands down below elbows Surgical asepsis hands held above

elbows so H2O runs from cleanest to least clean

FACE MASKS Worn to reduce risk for transmission of

organisms by droplet contact, air-borne routes & splatters of body substances

Wear under following conditions: 1. Only by those close to Pt. If

infection is transmitted by large-particle aerosols (droplets)

FACE MASK (Con’t) 2. By all persons entering room if

infection is transmitted by small-particle aerosols (droplet nuclei)– CDC recommends using a disposable

dust/mist particulate respirator when caring for any Pt. who has pulmonary TB

NONDISPOSABLE SURGICAL MASKS

Effective for droplet transmission & splatters but are not effective against airborne microorganisms

CLINICAL GUIDELINES: Using disposable masks

EYEWEAR Protective eyewear (goggles or

glasses) and masks by be indicated in situations where body substances may splatter the face

GOWNS Single-use= non

reusable paper gowns

worn during procedures when staff’s uniform is likely to become soiled

Discarded into trash Wash hands after use

Sterile gowns: reusable cloth or paper

use for strict sterile technique

use for barrier technique or reverse isolation

GLOVES Non-sterile or

clean or rectal used for most

activities no special

technique required for donning

Sterile gloves used when the hands

will come in contact with an open wound or when the hands might introduce microorg. Into a body orifice

require special technique to don

SOILED EQUIMENT & SUPPLIES

Essential to: 1. Prevent inadvertent exposure of

health care workers to articles contaminated with body substances

2. To prevent contamination of the environment

PSYCH IMPLICATIONS OF ISOLATION (2)

Result of separation from others & of the special precautions taken in their care

1. Sensory deprivation 2. Decreased self-esteem related to

feelings of inferiority

SENSORY DEPRIVATION Occurs when the environment lacks

normal stimuli for the client Example: frequent communication

with others S/S: boredom, inactivity, slowness of

thought, daydreaming, increased sleeping, thought disorganization, anxiety, hallucinations and panic

FEELING OF INFERIORITY Due to the perception of infection itself

or to the required precautions Pt. Feels “soiled”, “contaminated” or

“dirty” and that they are at fault and substandard

NSG INTERVENTIONS TO < ISOLATION PSYCH PROBLEMS

1. Assess Pt’s.need for stimulation 2. Initiate measures to help meet need for

stimulation= reg. Communication with Pt & diversional activities, stimulate visual sense

3. Explain the infection & associated procedures to help clients & their support persons understand & accept the situation

(Con’t) 4. Demonstrate warm, accepting

behavior. Avoid conveying to the Pt. Any sense of annoyance about the precautions or any feelings of revulsion about the infection

WAYS TO ID STERILITY OF ITEMS IN HEALTH CARE

SETTING (3) 1. Ensure that pckg. is clean & dry; if moist

considered contaminated & must be discarded.

2. Check the sterilization expiration dates on pckg. & look for any indications that it has been previously opened

3. Follow agency practice about the disposal of possibly contaminated pckgs.

PRINCIPLES & PRACTICES OF SURGICAL ASEPSIS (9)

1. All objects used in a sterile field must be sterile

2. Sterile objects become unsterile when touched by unsterile objects

3. Sterile items that are out of vision or below the waist level of the nurse are considered unsterile

(Con’t) 4. Sterile objects can become unsterile by

prolonged exposure to airborne microorg. 5. Fluids flow in the direction of gravity. 6. Moisture that passes through a sterile

object draws microorg. from unsterile surfaces above or below to the sterile surface by capillary action.

(Con’t) 7. The edges of a sterile field are

considered unsterile. 8. The skin cannot be sterilized & is

unsterile. 9. Conscientiousness, alertness, &

honesty are essential qualities in maintaining surgical asepsis.

INFECTION CONTROL NURSE: ROLE IN

HOSPITAL SETTING Infection prevention 1. Education of

staff & pts. 2. Write policy re.

Infection control procedures

Infection Control 1.Surveillance of

prevalence & incidence of infections

2. Reporting to CDC as per guidelines