RN Engage 2.0 - Infection Control and Isolation

Learning Objectives

• The lesson will cover elements of the chain of infection and the body’s defenses.
• It will describe manifestations of an inflammatory response, local and systemic infections, and related diagnostic tests.
• It will discuss principles of medical and surgical asepsis and their application to client care.
• It will differentiate between standard precautions and various types of isolation precautions.
• It will identify nursing interventions that can protect against infection.

Chain of Infection

• A sequence of factors needed for an infection to occur.
• Includes an infectious agent, an available reservoir, a portal of exit, a mode of transmission, a portal of entry, and a susceptible host.
• Breaking any link in the chain can prevent infection.

Infectious Agent

• Contains a bacterium, fungus, virus, parasite, or prion.
• Resident flora can become infectious if moved to a different body location.
• Infectious pathogens are destroyed by disinfecting, sterilizing, cleaning, or antimicrobial treatment.
• Antimicrobial treatment includes antibiotics and antifungals.

Reservoir

• The habitat where the infectious agent lives, grows, reproduces, and replicates.
• Reservoirs can be animate (people, insects, birds, animals) or inanimate (soil, water, food, medical equipment, IV fluids, feces).
• Human reservoirs may not show disease manifestations but can still transmit pathogens.
• Proper hand hygiene, preoperative skin preparation, and environmental cleansing are crucial in breaking the chain by disrupting reservoirs.

Portal of Exit

• The route by which an infectious pathogen leaves the reservoir.
• Can be any body orifice (ears, nose, mouth) or the skin.
• Other portals of exit include blood or body fluids from the gastrointestinal or respiratory tracts.
• The portal of exit and the portal of entry can be the same (e.g., influenza).
• Careful containment of body fluids and methods to decrease body secretions are strategies to break the chain.

Modes of Transmission

• Transmission occurs via contact, droplet, airborne, vehicle, and vector-borne routes.
• Hand hygiene and barrier devices can break the chain of infection by eliminating various modes of transmission.

Portal of Entry

• A way for the infectious agent to enter a susceptible host.
• Can be any body orifice or breaks in the mucous membranes or skin.
• Invasive lines and devices provide a portal of entry into the body.
• The portal of entry and portal of exit can be the same.

Susceptible Host

• Required for the infectious agent to take hold and become a reservoir for infection.
• Methods to increase the host’s line of defense helps break this link.
• Immunizations, proper nutrition, hygiene, and blood sugar control can decrease host susceptibility.
• The host's reaction is affected by their level of current immunity and the infectious agent's virulence.
• Virulence correlates to how efficient the infectious agent is at making people ill.

Factors That Increase Host Susceptibility

• Age
• Underlying diseases like HIV/AIDS
• Malignancy
• Transplants
• Medications like immunosuppressants, antirejection medications, antineoplastics, antimicrobials, corticosteroids, and gastric suppressants
• Surgical procedures
• Radiation therapy
• Indwelling devices like endotracheal tubes, urinary catheters, central venous catheters, arterial catheters, pacemakers, and artificial joints

Modes of Transmission

• Contact (direct or indirect), droplet, and airborne are the main modes.
• Pathogens can also be transmitted through vectors (insects) or vehicles (contaminated water).

Contact Transmission

• Direct: Micro-organisms move directly from the infected person to another person.
• Example: A client’s blood contacting an open abrasion on a nurse’s skin.
• Indirect: Micro-organisms are transmitted via a contaminated object or person.
• Staphylococcus aureus is notorious for spreading through indirect contact transmission in the hospital setting.
• Proper use and disposal of personal protective equipment (PPE) is critical to prevent indirect transmission.
• Shared equipment must be properly cleaned and disinfected between uses.

Droplet Transmission

• Infectious droplets travel through the air and contact the mucosa of a host.
• Examples of pathogens: influenza virus and Bordetella pertussis.
• Droplets spread by sneezing, coughing, singing, talking, CPR, endotracheal intubation, and chest physiotherapy.
• Covering coughs/sneezes, and wearing a surgical mask when out of the room will reduce the risk of transmission.

Airborne Transmission

• Small particulates in the air carry infectious agents into another person’s airspace.
• Requires a private room with negative air pressure.
• Examples of infections: tuberculosis, rubeola (measles), and varicella (chickenpox).

Vehicle and Vector-Borne Transmission

• Vehicle transmission: Pathogens spread from contaminated items to multiple persons (e.g., E. coli in produce).
• Vector-borne transmission: Insects or animals carry micro-organisms from one location or person to another (e.g. mosquitoes, rats).

Body Defenses

• The body has multiple mechanisms to fight off pathogens.
• Three specific types of defenses are classified as physical and chemical barriers, nonspecific immunity, and specific immunity.

Physical and Chemical Barriers

• Skin: Primary physical defense mechanism.
  • Reduces water loss.
  • Protects against abrasion and micro-organisms.
  • Provides a permeable barrier against the environment.
  • The lipid layer deters water loss and helps fight infection; detergents destroy this layer.
• Mucous membranes: Secrete mucus to protect the body.
  • Drying can lead to cracking, allowing micro-organisms to enter; moist membranes provide protection.
• Tears, sweat, and white blood cells (WBCs) help remove waste.
• Cilia help prevent particulates from entering the body.
• The GI tract secretes acids and enzymes to destroy/neutralize foreign invaders.
• Natural flora in the GI tract limits transmission and overgrowth of some bacteria.
• The genitourinary (GU) tract is longer in males than in females, resulting in fewer bacteria moving into the bladder and kidneys in male clients compared to female clients.
• The vagina has a natural pH that inhibits bacterial growth.

Nonspecific Immunity

• Maintained by neutrophils and macrophages (types of white blood cells).
• Phagocytes eat and destroy micro-organisms.
• Neutrophils and macrophages are released during the inflammatory response.

Specific Immunity

• Antibodies (immunoglobulins) and lymphocytes are key.
• Antibodies bind to infectious agents and activate WBCs and complement to destroy the infectious agent.

Inflammatory Response

• The body’s natural defense activated when injured or attacked by foreign substances.
• Recognition of harmful stimuli by pattern receptors.
• Activation of the inflammatory pathway.
• Release of inflammatory markers.
• Recruitment of inflammatory cells.

Inflammatory Response Triggers

• Infectious triggers: Viruses, bacteria, other micro-organisms.
• Noninfectious triggers:
  • Physical: Burns, frostbite, injury, foreign bodies, trauma, radiation.
  • Chemical: Glucose, fatty acids, toxins, alcohol, irritants.
  • Biological: Damaged cells.
  • Psychological: Excitement.

Medications to Manage Inflammatory Responses

• Antihistamines block histamine and help prevent swelling (e.g., diphenhydramine).
• Anti-inflammatory medications decrease painful inflammation (e.g., NSAIDs like ibuprofen).
• Inflammation may be solitary or chronic (repeating). Ex. Asthma or GERD.

Manifestations of Inflammation

• Heat
• Redness
• Swelling
• Pain
• Loss of function

Stages of Infection

• Incubation: No visible manifestations, but pathology changes occur. Lasts from the time the client is exposed until the first symptom appears.
• Prodromal: Initial, nonspecific manifestations (fever, aches, poor appetite, malaise).
• Acute illness: Manifestations of a specific infectious disease process become obvious and the infection is considered severe.
• Period of decline: Manifestations subside as the number of infectious agents decreases.
• Period of convalescence: The client returns to a previous or new, balanced state of health.

Types of Infection

• Local: Confined to one area of the body. Treated with topical and/or oral antibiotics.
• Systemic: Starts as a local infection and moves into the bloodstream, infecting the entire body. Treated with intraveneous antibiotics and careful monitoring.
• Factors influencing duration and severity: type of infectious agent, soundness of the client’s immune system, and timeliness of treatment.

Diagnostic Tests

• Should be prescribed only when needed.

Diagnostic Tests for UTI

• Urinalysis (UA): Prescribed to clients with manifestations of a urinary tract infection (UTI).
• Culture and sensitivity test (C&S): Used to determine the specific organism if white blood cells (WBCs) are present in the urine.

Diagnostic Tests for Respiratory Infections

• Chest x-rays: Help confirm atelectasis or pneumonia (but not the type of pneumonia).
• Ultrasound and magnetic resonance imaging (MRI) scans: May offer further insights and detect inflammation/infection in some cases.

Throat Cultures

• Used to determine the presence of infection locally in the throat.
• Nurse should collect the sample.
• Ensure the swab touches the surface of the tonsils, tonsillar pillars, or back of the pharyngeal wall, and does not touch other areas of the mouth or pharynx.

Blood Tests

• WBC count and differential: Useful for determining the presence and severity of infection.
• Increased WBCs indicate inflammation or infection.
• Expected WBC count: 5,000 to 10,000 per cubic milliliter (mm3).
• Decreased WBC counts indicate a decreased ability to fight infections.
• Neutropenia: Abnormally low WBC count, indicating the body is unable to fight infections.

Types of White Blood Cells:

• Neutrophils: 55% to 70%. First responder to injury. Eat bacteria (phagocytosis). Immature neutrophils (bands or stabs) indicate a left shift / ongoing infection.
• Lymphocytes: 20% to 40%. Fight chronic bacterial infections and acute viruses. Divided into T cells and B cells.
• Monocytes: 2% to 8%. Phagocytes that clean up tissue damage from injury or infection. Enhance the immune response.
• Eosinophils: 1% to 4%. Active in allergic reactions and parasitic infections. Decrease as allergic reaction diminishes.
• Basophils: 0.5% to 1%. Release histamine, serotonin, and heparin.

Other Blood Tests

• C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)/procalcitonin (PCT): Levels increase when inflammation is present.
• Levels are not standardized across laboratories meaning the same lab should process all samples for a single client.
• ESR levels vary depending on client age and biological sex.
• Elevated levels of CRP and ESR are difficult to interpret because the markers are nonspecific to a particular disease process.

Newer Blood Tests

• Neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR), and the systemic immune inflammation index (SII):
• Can help determine the client’s chronic inflammation status, which is important for cancer and cardiovascular disease.

Asepsis

• Interventions to eliminate or decrease the presence of micro-organisms that can cause infection.
• Hand hygiene, medical, and surgical asepsis keep both nurses and clients safe.

Hand Hygiene

• Any type of cleansing of the hands.
• Includes using soap and water, alcohol-based hand sanitizers, antiseptic handwash/rub, and surgical hand antisepsis.
• Perform prior to medical procedures, preparing a sterile field, or donning gloves.

Antimicrobial Soap

• Removes dirt and debris from surfaces, but does not have antimicrobial properties.
• Scrub with warm water.
• Proper handwashing takes about 15 to 30 seconds (singing “Happy Birthday” twice).

Alcohol-Based Hand Sanitizer

• Used to decrease number of micro-organisms on the hands.
• Products with a minimum of 60% alcohol are effective against gram-positive and gram-negative bacteria, many viruses, and fungi.
• Not effective on visibly soiled hands.
• Apply, rub to cover all surfaces, and rub until dry (15 to 30 seconds).

Antimicrobials and Antiseptics

• Antimicrobial handwashes/rubs contain an antimicrobial solution.
• Antiseptic solutions clean the skin; nurses who care for clients with a spore infection should use soap and water.
• Alcohol-based products, antiseptics, and antimicrobials are not effective in removing spores.

Types of Antiseptic Agents

• Alcohols
• Chlorhexidine
• Chlorine
• Chloroxylenol (parachlorometaxylenol [PCMX])
• Hexachlorophene
• Iodine/iodophors
• Quaternary ammonium compounds
• Triclosan

Hygiene Special Considerations

• Keep fingernails short (less than 0.25 inch) to avoid bacteria growth.
• Nail polish should not be chipped.
• Artificial nails should be discouraged as they may harbor bacteria.
• Gel nail polish is difficult to clean effectively.
• Nurses in high-risk areas (operating rooms, ICUs) should not have artificial fingernails or nail extenders.
• Wearing rings is associated with colonization of bacteria.
• Health care facilities should:
  • Monitor hand hygiene.
  • Provide adequate supplies for handwashing.
  • Educate workers on proper practices.
  • Evaluate practices during infection outbreaks.

Medical Asepsis

• Clean technique: Reduction of disease-causing micro-organisms.
• Isolation precautions are an example.

Surgical Asepsis

• Used during surgical procedures to prevent transmission of pathogens.
• Ensures items are sterile (no micro-organisms present).
• Prevents surgical-site infections (SSIs).
• Before cleansing hands, remove all rings, watches, and bracelets.
• Scrub under the nails with a nail brush to remove pathogens.

Sterilization

• Cleaning instruments to eradicate all micro-organisms, including bacterial spores.
• Methods: Thermal (autoclaving), chemical (ethylene glycol, hydrogen peroxide gas), and radiation (high-energy gamma rays).
• Necessary for surgical instruments.
• Sterile fields ensure the smallest number of micro-organisms possible are present.
• Prepare sterile fields close to the procedure time.

How to Prepare a Sterile Field

• Position a flat work surface close to the client, but 12 to 18 inches from any walls or potentially contaminating objects.
• Check supplies; ensure the package has not been damaged.
• The outer 1-inch border of the field is considered contaminated.
• To open the sterile package:
  • Peel back the first flap away from the nurse’s body.
  • Peel the sides back one at a time.
  • Peel the flap closest to the nurse’s body.
• Sterilized equipment must be placed on a sterile field.

Disinfection

• Cleans instruments to eradicate almost all micro-organisms, but not all.
• High-level disinfection: Some spores remain. Uses pasteurization or chemicals.
• Low-level disinfection: Most vegetative bacteria destroyed, but some spores, fungi, and viruses may remain. Uses hospital-grade disinfectants on surfaces.
• Equipment must be cleaned to remove visible soil before sterilization and disinfection.
• Cleaning can be completed manually or mechanically.

Standard Precautions

• Infection prevention practices applied to all clients, whether or not they are known to have an infectious agent.
• Used to protect from blood, body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes.
• PPE is chosen based on expected contact.
• Surfaces and reusable equipment must be properly cleaned.
• Medications are prepared in a designated clean area.

Contact Precautions

• Prevent transmission by direct or indirect contact.
• Common pathogens: vancomycin-resistant Enterococcus (VRE), Clostridium difficile, noroviruses, intestinal tract pathogens, and respiratory syncytial virus (RSV).
• Don PPE (gown/gloves minimum) when entering the room.
• Place clients in a private room if possible.
• If a private room is not an option, cohorting with another client who has a similar diagnosis is acceptable.

Droplet Precautions

• Wear a surgical mask when entering the room or in close contact with the client.
• Clients should have a private room, if possible, or cohort with someone who has the same infection.
• Maintain at least 3 feet of separation between clients, if possible.
• When clients leave their room, they should wear a mask.
• Infectious agents: influenza virus, adenovirus, SARS-CoV1, rhinovirus (common cold), and Mycoplasma pneumoniae.

Airborne Precautions

• Clients should be assigned to a private room, and the door should remain closed.
• Airborne infection isolation room (AIIR): Negative-pressure room with special air handling/ventilation.
• Minimum air exchanges each hour: 12 for a newly constructed room, 6 for a renovated room.
• Exhaust air directly outside or circulate through a HEPA filtration system.
• Clients must wear a surgical mask if they are without an AIIR or when leaving their room.
• Nurses must don a respirator/mask (N95 or higher) prior to entering the room.
• N95 respirators must be specially fitted to each individual wearing them.

World Health Organization COVID-19 Guidelines

• Maintain a physical distance of at least 3 feet between clients, health care workers, staff, and visitors.
• Health care workers should don PPE when caring for clients with known or suspected COVID-19.
• Cohort health care workers to care exclusively for COVID-19 clients.
• Health care providers should don a respirator when performing procedures that can produce aerosolization.

Protective Isolation

• Clients who become immunocompromised after having an allogenic hematopoietic stem cell transplant (HSCT) need a special protective isolation environment during the first 100 days after the transplant.
• Recommendations: Direct airflow (positive) with HEPA filtration and at least 12 air exchanges per hour, well-sealed rooms, and preventing dust from entering.
• Typically, plants are prohibited.

Health Care–Associated Infections (HAIs)

• Infections acquired in a health care facility.
• Four major HAIs:
  • Central line–associated bloodstream infections (CLABSIs)
  • Catheter-associated urinary tract infections (CAUTIs)
  • Surgical-site infections (SSIs)
  • Ventilator-assisted pneumonias (VAPs)
• Invasive devices create extra portals of entry for infectious agents.

Infection Control Bundles

• Guidelines for practice bundled together to prevent HAIs such as CAUTIs, CLABSIs, VAPs, and SSIs.
• Vary from facility to facility, but generally include a protocol for how to minimize infection risk, starting with hand hygiene.

Multidrug-Resistant Infections

• Caused by multidrug-resistant organisms (MDROs).
• MDROs are resistant to one or more classes of existing antimicrobials.
• Typically respond to only one or two medications.
• Precautions when caring for clients: Proper handwashing, wearing gloves, and using contact precautions.

Multidrug-Resistant Organisms (MDROs)

• Methicillin-resistant Staphylococcus aureus (MRSA)
• Vancomycin-resistant Enterococcus (VRE)
• Vancomycin-resistant Staphylococcus aureus (VRSA)
• Vancomycin-intermediate Staphylococcus aureus (VISA)
• Extended-spectrum beta-lactamase (ESBL)–producing organisms
• Multidrug-resistant Streptococcus pneumoniae (MDRSP)

Enhanced Barrier Precautions

• Staff must wear gowns and gloves to prevent transfer of organisms:
  • Bathing or showering
  • Providing hygiene
  • Dressing
  • Changing linens or briefs
  • Assisting with toileting
  • Providing wound care
  • Transferring the client
  • Caring for devices

Factors Increasing Client Risk of Infection

• The health care environment (proximity to infections).
• Medical devices, tubes, lines, drains, or wounds.
• Institutionalized clients (nursing homes, care facilities, or prisons).

Nurse's Obligations

• Nurses have an obligation, both professionally and ethically, to model the same health standards they prescribe to their clients.
• Keep up to date on immunizations to control and prevent the spread of infectious diseases.

Recommended Immunizations for Health Care Workers

• Varicella
• Hepatitis B
• Influenza
• Measles/mumps/rubella (MMR)
• Meningococcal meningitis
• Tetanus/diphtheria/pertussis (Tdap)
• COVID-19

Medical Personal Protective Equipment

• It is the nurse’s responsibility to know which types of PPE are needed and to follow protocols for donning and removing PPE appropriately.
• Disposable PPE is single use only.
• N95 masks are multiple use with a single user.
• Includes items such as gloves, gowns or suits, masks, protective eyewear, and shoe covers.

Gloves

• Made of latex, vinyl, or nitrile to protect hands from contamination.
• Wear when there is potential for direct contact with blood or bodily fluids, nonintact skin, mucous membranes, or potentially infectious material.
• Wear when there is direct contact with clients colonized/infected with pathogens that require contact precautions.
• Gloves donned last when worn with other PPE.
• Change gloves if they become torn or punctured during care, to avoid cross-contamination of sites on the client, to avoid contamination from the client to keyboards or computers, and in between clients.
• Should not be washed or reused.

Sterile Gloving Techniques

• Closed-glove technique: Performed once the nurse is already wearing a sterile gown. Keep both hands within the cuffs of the gown, keeping hands inside the cuff edges.
• Open-glove technique: Donning sterile gloves with hands. Used when a gown is not worn.

Gowns

• Wear whenever there is the potential for contact with infected material or the potential for blood or body fluids to penetrate and contaminate the nurse.
• Cover the nurse’s arms and front portion of the body. Always worn when the client has contact precautions.
• Place gloves over the hand/wrist portion of the gown.
• Use only once and then discard before leaving the client’s room.

Sterile Gowning

• The procedure used for donning a gown that must remain sterile.
• Sterile only from just above the cuff to 2 inches above the elbows. The axilla is not considered sterile, and neither is the back of the gown.

Masks, Goggles, and Shields

• Wear masks as needed when the client is on standard or droplet precautions.
• Masks are single use and should be discarded just before leaving the client’s room.
• Goggles may be used with masks to protect the eyes, nose, and mouth. Alternatively, a face shield may be used in place.
• Use face shields that extend from the crown of the head down to the chin, and that wrap around the sides of the face.
• The front area of a mask, goggles, or face shield is considered dirty or contaminated.

How to Remove PPE

• Remove gloves first, then goggles or face shield, then gown, and then the mask.
• Grasp the ties, earpieces, or headband.
• Perform hand hygiene immediately after exiting the room.

Needlestick Injury Prevention

• Needlestick injuries can transmit infectious agents, including hepatitis B and C and human immunodeficiency virus.
• Engage safety devices immediately after withdrawing the needle, promptly disposing of needles in the sharps container, assuring that the sharps box is less than three-fourths full, and choosing needleless systems.

Linens and Medical Waste

• Any object in the client’s environment should be considered contaminated.
• Use a leak-resistant biohazard bag for disposal of general waste. Use a second bag if the first bag becomes punctured or contaminated on the outside.

How to Dispose Sharp Objects

• Dispose of sharp objects in puncture-resistant containers at the point of care.

How to Handle Client Linens

• Handle with care.
• Bag contaminated linens at the site of client care and secure. Use a second bag if needed.
• Avoid sorting linens in the client care area, and avoid shaking or agitating to prevent dispersal of micro-organisms.
• Wear gloves when handling any soiled or contaminated linens.

Hand Hygiene

• Cleaning the hands with an antiseptic hand rub or washing the hands with soap and water.
• Should perform hand hygiene: before and after touching a client, before and after procedures, after exposure to body fluids, and after touching client surroundings.

Soap and Water Hand Washing Technique

• Inspect hands for cuts and abrasions.
• Ensure natural nails are short.
• Push uniform sleeves above the wrists along with wristwatch and remove jewelry.
• Stand in front of the sink.
• Turn on water and adjust the temperature to warm.
• Wet the hands and wrists while ensuring they are below the level of the elbows.
• Dispense liquid soap into hands and lather (3 to 5 mL).
• Scrub all areas of the hands, using firm circular motions.
• Clean underneath fingernails.
• Rinse hands and wrists.
• Dry hands using a disposable paper towel.
• Turn off water using a disposable paper towel and discard.

Antiseptic Hand Rub Technique

• Inspect hands for cuts and abrasions.
• Ensure natural nails are short.
• Push uniform sleeves above the wrists and remove jewelry.
• Dispense product into the palm of the hand.
• Rub all areas of the hands, using firm circular motions.
• Ensure hands are completely dry.

Obtaining a Throat Culture

• Used to determine the cause of a bacterial or fungal infection involving the oropharynx.
• Do not delegate to an assistive personnel (AP).
• Safety Considerations:
  • Determine whether the client has allergies.
  • Verify client identity.
  • Review the facility protocol.
  • Ensure resuscitation equipment is nearby.
  • Avoid if the epiglottis is severely inflamed.

Obtaining a Throat Culture Technique

• Review the client’s medical record.
• Obtain supplies.
• Provide privacy.
• Introduce yourself to the client.
• Perform hand hygiene and apply nonsterile gloves.
• Identify the client using two unique identifiers.
• Provide client education.
• Check the client for indications of a throat infection.
• Determine whether the client has recently used an antiseptic mouthwash or is currently taking antibiotics.
• Determine the client's current pain level.
• Assist the client into a sitting or upright position as tolerated.
• Instruct the client to hyperextend the neck and open their mouth wide, saying "Ah" while sticking out their tongue.
• Apply pressure to the anterior third of the tongue with the tongue blade while visualizing the oropharynx using a penlight.
• Remove the tongue blade.
• Carefully remove the sterile swab from the packaging.
• Insert the swab into the mouth to the posterior oropharynx, avoiding contact with the lips, tongue, teeth, sides of the oral cavity or the uvula.
• Gently swab the oropharynx, including the tonsils (if present) and any areas of redness/exudate. Avoid the epiglottis, any oral structures, and saliva
• Determine the client's current pain level caused by swabbing the oropharynx.
• Carefully remove the swab. Insert the swab into the media in the culture tube and tighten the lid.
• Squeeze the tube in the area containing the culture media.
• Label the culture tube.
• Complete the laboratory requisition form.
• Place the culture tube and laboratory requisition form into a biohazard bag.
• Arrange for transport of the specimen to the laboratory.
• Assist the client into a safe position and ensure the call light is within reach.
• Dispose of materials used during the procedure, remove PPE, and complete hand hygiene.

Explore the chain of infection, body's defenses, and inflammatory responses. Learn about medical and surgical asepsis and standard vs. isolation precautions. Discover nursing interventions for infection protection and control.