foundations chap 11.pdf

CHAPTER 11 UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT Active:Antibodies are produced in response to an antigen. SECTION: SAFETY AND INFECTION CONTROL Requires time to react to antigens...

CHAPTER 11 UNIT 1 SAFE, EFFECTIVE CARE ENVIRONMENT Active:Antibodies are produced in response to an antigen. SECTION: SAFETY AND INFECTION CONTROL Requires time to react to antigens Provides permanent immunity Infection Control Involves B‑ and T‑lymphocytes CHAPTER 11 Produces specific antibodies against specific antigens (immunoglobulins [IgA, IgD, IgE, IgG, IgM]) An infection occurs when the presence of a pathogen leads to a chain of events. All INFECTION PROCESS components of the chain must be present and Chain of infection (11.1) intact for the infection to occur. A nurse uses Causative agent(bacteria, virus, fungus, prion, parasite) infection control practices (medical asepsis, Reservoir(human, animal, food, organic matter on inanimate surfaces, water, soil, insects) surgical asepsis, standard precautions) to break Portal of exitfrom (means for leaving) the host the chain and thus stop the spread of infection. Respiratory tract (droplet, airborne): Mycobacterium tuberculosis and Streptococcus pneumoniae TYPES OF PATHOGENS Gastrointestinal tract: Shigella, Salmonella enteritidis, Salmonella typhi, hepatitis A Pathogens are the micro‑organisms or microbes that Genitourinary tract: Escherichia coli, hepatitis A, HSV, HIV cause infections. Skin/mucous membranes: HSV and varicella Bacteria(Staphylococcus aureus, Escherichia coli, Blood/body fluids: HIV and hepatitis B and C Mycobacterium tuberculosis) Transplacental Viruses:Organisms that use the host’s genetic machinery to reproduce (HIV, hepatitis, herpes zoster, Mode of transmission herpes simplex virus [HSV]) Contact Fungi:Molds and yeasts (Candida albicans, Aspergillus) ◯ Direct physical contact: Person to person Prions:Protein particles (new variant ◯ Indirect contact with an inanimate object: Creutzfeldt‑Jakob disease) Object to person Parasites:Protozoa (malaria, toxoplasmosis) and ◯ Fecal‑oral transmission: Handling food after using a helminths (worms [flatworms, roundworms], flukes restroom and failing to wash hands [Schistosoma]) Droplet: Sneezing, coughing, and talking Airborne: Sneezing and coughing Virulenceis the ability of a pathogen to invade and Vector borne: Animals or insects as intermediaries (ticks injure a host. transmit Lyme disease; mosquitoes transmit West Nile Herpes zosteris a common viral infection that erupts and malaria) years after exposure to chickenpox and invades a specific Portal of entryto the host: Might be the same as the nerve tract. portal of exit Susceptible host:Compromised defense mechanisms IMMUNE DEFENSES (immunocompromised, breaks in skin), leaving the host more susceptible to infections Nonspecific innate Native immunityrestricts entry or immediately responds to a foreign organism (antigen) through the activation of phagocytic cells, complement, and inflammation. This occurs 11.1 Chain of infection with all micro‑organisms, regardless of previous exposure. Passive:Antibodies are produced by an external source. Temporary immunity that does not have memory of past exposures Intact skin, the body’s first line of defense Mucous membranes, secretions, enzymes, phagocytic cells, and protective proteins Inflammatory response with phagocytic cells, the complement system, and interferons to localize the invasion and prevent its spread Specific adaptive immunity Specific adaptive immunityallows the body to make antibodies in response to a foreign organism (antigen). This reaction directs against an identifiable micro‑organism. FUNDAMENTALS FOR NURSING CHAPTER 11 Infection Control 53  Stages of an infection OLDER ADULT CLIENTS: Older adults can have a slowed response to antibiotic therapy, slowed immune response, Incubation:interval between the pathogen entering the loss of subcutaneous tissue and thinning of the skin, body and the presentation of the first finding decreased vascularity and slowed wound healing, Prodromal stage:interval from onset of general findings decreased cough and gag reflexes, chronic illnesses, to more distinct findings; during this time, the pathogen decreased gastric acid production, decreased mobility, multiplies bowel and bladder incontinence, dementia, and greater incidence of invasive devices (a urinary catheter or Illness stage:interval when findings specific to the feeding tube). infection occur Individuals who make poor lifestyle choices that put Convalescence:interval when acute findings disappear, them at risk, which include: total recovery taking days to months ◯ Clients who use IV drugs and share needles ◯ Clients who engage in unprotected sex Clients who have recently been exposed to: ASSESSMENT/DATA COLLECTION ◯ Poor sanitation ◯ Mosquito‑borne or parasitic diseases ◯ Diseases endemic to the area visited, but not in the RISK FACTORS client’s home country A nurse should assess each client for the risks of infection specific to the client, the disease or injury, and the environment. The most common risks include: EXPECTED FINDINGS Inadequate hand hygiene (client and caregivers) Findings identifiable in the nursing assessment of Individuals who have compromised health or defenses generalized or systemic infection include the following. against infection, which include: ◯ Fever ◯ Those who are immunocompromised ◯ Presence of chills, which occur when temperature ◯ Those who have had surgery is rising, and diaphoresis, which occurs when ◯ Those with indwelling devices temperature is decreasing ◯ A break in the skin (the body’s best protection ◯ Increased pulse and respiratory rate (in response to against infection). the high fever) ◯ Those with poor oxygenation ◯ Malaise ◯ Those with impaired circulation ◯ Fatigue ◯ Those who have chronic or acute disease (diabetes ◯ Anorexia, nausea, and vomiting mellitus, adrenal insufficiency, renal failure, hepatic ◯ Abdominal cramping and diarrhea failure, or chronic lung disease) ◯ Enlarged lymph nodes (repositories for “waste”) Caregivers using medical or surgical asepsis that does OLDER ADULT CLIENTS not follow the established standards (11.2) ◯ Older adults have a reduced inflammatory and Clients who have poor personal hygiene or poor immune response and thus might have an advanced nutrition, smoke, or consume excessive amounts of infection before it is identified. Atypical findings alcohol, and those experiencing stress (agitation, confusion, or incontinence) can be the only Clients who live in a very crowded environment manifestations. ◯ Other findings can vary depending on the site of the infection (dyspnea, cough, purulent sputum, and crackles in lung fields, dysuria, urinary frequency, 11.2 Health‑care associated infections hematuria and pyuria, rash, skin lesions, purulent Health‑care associated infections (HAIs) are infections wound drainage, erythema and odynophagia, dysphagia, that a client acquires while receiving care in a health hyperemia, enlarged tonsils, change in level of care setting. Formerly called nosocomial infections, these can come from an exogenous source (from consciousness, nuchal rigidity, photophobia, headache). outside the client) or an endogenous source (inside Inflammation is the body’s local response to injury or the client when part of the client’s flora is altered). infection. The inflammatory response has three stages. Often occur in the intensive care unit. ◯ Findings during the first stage of the inflammatory The best way to prevent HAIs is through response (local infection) include the following. frequent and effective hand hygiene. Redness (from dilation of arterioles bringing blood A common site of HAIs is the urinary tract and these are often caused by Escherichia coli, Staphylococcus to the area) aureus, and enterococci. Other sites of HAIs are surgical Warmth of the area on palpation wounds, the respiratory tract, and the bloodstream. Edema An iatrogenic infection is a type of HAI resulting Pain or tenderness from a diagnostic or therapeutic procedure. Loss of use of the affected part HAIs are not always preventable and are not always iatrogenic. Use current evidence‑based practice guidelines to prevent HAIs due to multidrug‑resistant organisms. 54 CHAPTER 11 Infection Control CONTENT MASTERY SERIES  Online Video: Precautions ◯ In the second stage, the micro‑organisms are For immobile clients, ensure that pulmonary hygiene killed. Fluid containing dead tissue cells and WBCs (turning, coughing, deep breathing, incentive spirometry) accumulates and exudate appears at the site of the is done every 2 hr, or as prescribed. Good pulmonary infection. The exudate leaves the body by draining hygiene decreases the growth of micro‑organisms and into the lymph system. The types of exudate are: the development of pneumonia by preventing stasis of Serous (clear). pulmonary excretions, stimulating ciliary movement and Sanguineous (contains red blood cells). clearance, and expanding the lungs. Purulent (contains leukocytes and bacteria). Use of aseptic technique and proper personal protective ◯ In the third stage, damaged tissue is replaced by scar equipment (gloves, masks, gowns, and goggles) in the tissue. Gradually, the new cells take on characteristics provision of care to all clients prevents unnecessary that are similar in structure and function to the old cells. exposure to micro‑organisms. Teach and use respiratory hygiene/cough etiquette. It applies to anyone entering a health care setting LABORATORY TESTS (clients, visitors, staff) with manifestations of illness, Leukocytosis (WBCs greater than 10,000/µL) whether diagnosed or undiagnosed. This includes cough, Increases in the specific types of WBCs on differential congestion, rhinorrhea, or an increase in the production (left shift = an increase in neutrophils) of respiratory secretions. The components of respiratory Elevated erythrocyte sedimentation rate (ESR) over hygiene and cough etiquette include: 20 mm/hr; an increase indicates an active inflammatory ◯ Covering the mouth and nose when coughing process or infection and sneezing. Presence of micro‑organisms on culture of the ◯ Using facial tissues to contain respiratory secretions and specific fluid/area disposing of them promptly into a hands‑free receptacle. ◯ Wearing a surgical mask when coughing to minimize contamination of the surrounding environment. DIAGNOSTIC PROCEDURES ◯ Turning the head when coughing and staying a Gallium scan: Nuclear scan that uses a radioactive minimum of 3 ft away from others, especially in substance to identify hot spots of WBCs common waiting areas. Radioactive gallium citrate: Injected by IV and ◯ Performing hand hygiene after contact with respiratory accumulates in area of inflammation secretions and contaminated objects/materials. X‑rays, CT scan, magnetic resonance imaging (MRI), and biopsies to determine the presence of infection, abscesses, and lesions ISOLATION GUIDELINES Isolation guidelines are a group of actions that include hand hygiene and the use of barrier precautions, which PATIENT‑CENTERED CARE intend to reduce the transmission of infectious organisms. The precautions apply to every client, regardless of the diagnosis, and implementation of them must occur NURSING CARE whenever there’s anticipation of coming into contact Use frequent and effective hand hygiene before and with a potentially infectious material. after care. Change personal protective equipment after contact with Educate the client about the required and recommended each client and between procedures with the same client immunizations and where to obtain them. The target if in contact with large amounts of blood and body fluids. groups include children, older adults, those with chronic Clients in isolation are at a higher risk for depression and disease, and those who are immunocompromised and loneliness. Assist the client and their family to understand their families and contacts. the reason for isolation and provide sensory stimulation. Educate the client and ask for a return demonstration of good oral hygiene. Good oral hygiene decreases the protein Standard precautions (tier one) (which attracts micro‑organisms) in the oral cavity, which This tier of standard precautions applies to all body fluids thereby decreases the growth of micro‑organisms that (except sweat), non-intact skin, and mucous membranes. A can migrate through breaks in the oral mucosa. nurse should implement standard precautions for all clients. Encourage the client to consume an adequate amount of Hand hygiene using an alcohol‑based waterless product fluids. Adequate fluid intake prevents the stasis of urine is recommended after contact with the client when the by flushing the urinary tract and decreasing the growth hands are not visibly soiled or contaminated with blood of micro‑organisms. Adequate hydration also keeps or body fluids and after the removal of gloves. the skin from breaking down. Intact skin prevents Alcohol‑based waterless antiseptic is preferred unless micro‑organisms from entering the body. the hands are visibly dirty, because the alcohol‑based product is more effective in removing micro‑organisms. Wash hands with soap and water if contamination with spores is suspected. Hand hygiene using nonantimicrobial soap or an antimicrobial soap and water is recommended when visibly soiled or contaminated with blood or body fluids. FUNDAMENTALS FOR NURSING CHAPTER 11 Infection Control 55  Use soap and water (not alcohol) for C. difficile. Contact precautions Remove gloves and complete hand hygiene between Contact precautions protect visitors and caregivers each client. when they are within 3 ft of the client against direct Masks, eye protection, and face shields are required when client and environmental contact infections (respiratory care might cause splashing or spraying of body fluids. syncytial virus, shigella, enteric diseases caused by Clean gloves are worn when touching anything that has micro‑organisms, wound infections, herpes simplex, the potential to contaminate the hands of the nurse. impetigo, scabies, multidrug‑resistant organisms). This includes body secretions, excretions, blood and Contact precautions require: body fluids, non-intact skin, mucous membranes, and A private room or a room with other clients who have contaminated items. the same infection. Hand hygiene is required after removal of the gown. Use Gloves and gowns worn by the caregivers and visitors. a sturdy, moisture‑resistant bag for soiled items and tie Disposal of infectious dressing material into a single, the bag securely in a knot at the top. nonporous bag without touching the outside of the bag. Properly clean all equipment for client care; dispose of one‑time use items according to facility policy. Protective environment Bag and handle contaminated laundry to prevent Protective environment is an intervention (not leaking or contamination of clothing or skin. type of precautions) to protect clients who are Enable safety devices on all equipment and supplies after immunocompromised. This includes clients who have had use; dispose of all sharps in a puncture‑resistant container. an allogeneic hematopoietic stem cell transplant. A client does not need a private room unless they are A protective environment requires: unable to maintain appropriate hygienic practices. Private room. Positive airflow 12 or more air exchanges/hr. Transmission precautions (tier two) HEPA filtration for incoming air. Airborne precautions Mask for the client when out of room. Use airborne precautions to protect against droplet infections smaller than 5 mcg (measles, varicella, pulmonary or laryngeal tuberculosis). MEDICATIONS Airborne precautions require: Antipyretics A private room. Antipyretics (acetaminophen and aspirin) are used for Masks and respiratory protection devices for caregivers fever and discomfort as prescribed. and visitors. NURSING ACTIONS Use an N95 or high‑efficiency particulate Monitor fever to determine effectiveness of medication. air (HEPA) respirator if the client is known Document the client’s temperature fluctuations on the or suspected to have tuberculosis. medical record for trending. Negative pressure airflow exchange in the room of at least six to 12 exchanges per hour, depending on the age Antimicrobial therapy of the structure. Antimicrobial therapy kills or inhibits the growth of If splashing or spraying is a possibility, wear full face micro‑organisms (bacteria, fungi, viruses, protozoans). (eyes, nose, mouth) protection. Antimicrobial medications either kill pathogens or prevent Clients who have an airborne infection should wear a their growth. Give anthelmintics for worm infestations. (11.3) mask while outside of the room/home. NURSING ACTIONS Droplet precautions Administer antimicrobial therapy as prescribed. Droplet precautions protect against droplets larger than Monitor for medication effectiveness (reduced fever, 5 mcg and travel 3 to 6 ft from the client (streptococcal increase in the level of comfort, decreasing WBC count). pharyngitis or pneumonia, Haemophilus influenzae type Maintain a medication schedule to ensure consistent B, scarlet fever, rubella, pertussis, mumps, mycoplasma therapeutic blood levels of the antibiotic. pneumonia, meningococcal pneumonia and sepsis, pneumonic plague). Droplet precautions require: INTERPROFESSIONAL CARE A private room or a room with other clients who have Transporting a client the same infectious disease. Ensure that clients have their own equipment. If movement of the client to another area of the facility is Masks for providers and visitors. unavoidable, the nurse takes precautions to ensure that Clients who have a droplet infection should wear a mask the environment is not contaminated. For example, a while outside of the room/home. surgical mask is placed on the client who has an airborne or droplet infection, and a draining wound is well covered. 56 CHAPTER 11 Infection Control CONTENT MASTERY SERIES  Reporting communicable diseases Application Exercises A complete list of reportable diseases and the reporting system are available through the Centers for Disease 1. A nurse is caring for a client who has severe acute Control and Prevention’s website (www.cdc.gov). There respiratory syndrome (SARS). The nurse knows are more than 60 communicable diseases that must be that health care professionals are required to reported to the public health departments to allow for report communicable and infectious diseases. officials to: Which of the following illustrate the rationale Ensure appropriate medical treatment of diseases for reporting? (Select all that apply.) (tuberculosis). A. Planning and evaluating control Monitor for common‑source outbreaks (foodborne— and prevention strategies hepatitis A). B. Determining public health priorities Plan and evaluate control and prevention plans C. Ensuring proper medical treatment (immunizations for preventable diseases). D. Identifying endemic disease Identify outbreaks and epidemics. E. Monitoring for common‑source outbreaks Determine public health priorities based on trends. 2. A nurse is caring for a client who has had a cough for 3 CLIENT EDUCATION weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions? Teach the client about: A. Allergic reaction Any infection control measures at home. B. Ringworm Self‑administration of medication therapy. C. Systemic lupus erythematosus Complications to report immediately. D. Tuberculosis 3. A nurse is caring for a client who reports a 11.3 Multidrug‑resistant infection severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing Antimicrobials are becoming less effective for some which of the following stages of infection? strains of pathogens due to the pathogen’s ability to adapt and become resistant to previously sensitive A. Prodromal antibiotics. This significantly limits the number of B. Incubation antibiotics that are effective against the pathogen. C. Convalescence Use of antibiotics, especially broad‑spectrum antibiotics, D. Illness has significantly decreased to prevent new strains from evolving. Taking the measures below can ensure that an antimicrobial is necessary and therapy is effective. Methicillin‑resistant Staphylococcus aureus 4. A charge nurse is reviewing with a newly (MRSA) is a strain of Staphylococcus aureus that hired nurse the difference in manifestations is resistant to many antibiotics. Vancomycin of a localized versus a systemic infection. and linezolid are used to treat MRSA. Which of the following are manifestations of a Vancomycin‑resistant Staphylococcus aureus systemic infection? (Select all that apply.) (VRSA) is a strain of Staphylococcus aureus that is A. Fever resistant to vancomycin, but so far is sensitive to other antibiotics specific to a client’s strain. B. Malaise NURSING ACTIONS C. Edema Obtain specimens for culture and sensitivity D. Pain or tenderness prior to initiation of antimicrobial therapy. E. Increase in pulse and respiratory rate Monitor antimicrobial levels and ensure that therapeutic levels are maintained. CLIENT EDUCATION 5. A nurse is contributing to the plan of care for a client who is being admitted to the facility Complete the full course of antimicrobial therapy. with a suspected diagnosis of pertussis. Avoid overuse of antimicrobials. Which of the following interventions should the nurse include? (Select all that apply.) A. Place the client in a room that has negative air pressure of at least six exchanges per hour. Active Learning Scenario B. Wear a mask when providing care within 3 ft of the client. A nurse manager is teaching a module on the chain C. Place a surgical mask on the client if transportation of infection during nursing orientation to a group of to another department is unavoidable. newly licensed nurses. Use the ATI Active Learning D. Use sterile gloves when handling soiled linens. Template: Basic Concept to complete this item. E. Wear a gown when performing care that might RELATED CONTENT: List the six links in the chain of result in contamination from secretions. infection that must be present for an infection to occur. FUNDAMENTALS FOR NURSING CHAPTER 11 Infection Control 57