Foundations: Fundamentals of Nursing, Chapter 28 Infection Prevention and Control

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Infection Prevention and Control
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A reservoir is a...

A reservoir is a place where microorganisms survive, multiply, and await transfer to a susceptible host. Common reservoirs are humans and animals (hosts), insects, food, water, and organic matter on inanimate surfaces (fomites). Frequent reservoirs for health care-associated infections (HAIs) include health care workers, especially their hands; patients; equipment; and the environment. Human reservoirs are divided into two types: those with acute or symptomatic disease and those who show no signs of disease but are carriers of it. Humans can transmit microorganisms in either case. Animals, food, water, insects, and inanimate objects can also be reservoirs for infectious organisms. To thrive, organisms require a proper environment, including appropriate food, oxygen, water, temperature, pH, and light.

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Aerobic bacteria/Anaerobic bacteria

Aerobic bacteria require oxygen for survival and for multiplication sufficient to cause disease. Aerobic organisms cause more infections in humans than anaerobic organisms. An example of an aerobic organism is Staphylococcus aureus. Anaerobic bacteria thrive where little or no free oxygen is available. Infections deep within the pleural cavity, in a joint, or in a deep sinus tract are typically caused by anaerobes. An example of an anaerobic organism is Clostridium difficile, an organism that causes antibiotic-induced diarrhea.

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BACTERIA:Escherichia coli

Escherichia coli
Colon
Gastroenteritis, urinary tract infection

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BACTERIA:Staphylococcus aureus

Staphylococcus aureus

Skin, hair, anterior nares, mouth

Wound infection, pneumonia, food poisoning, cellulitis

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BACTERIA:Streptococcus (beta-hemolytic group A) organisms

Streptococcus (beta-hemolytic group A) organisms

Oropharynx, skin, perianal area

"Strep throat," rheumatic fever, scarlet fever, impetigo, wound infection

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BACTERIA:Streptococcus (beta-hemolytic group B) organisms

Streptococcus (beta-hemolytic group B) organisms

Adult genitalia

Urinary tract infection, wound infection, postpartum sepsis, neonatal sepsis

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BACTERIA:Mycobacterium tuberculosis

Mycobacterium tuberculosis

Droplet nuclei from lungs, larynx
Tuberculosis

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BACTERIA:Neisseria gonorrhoeae

Neisseria gonorrhoeae

Genitourinary tract, rectum, mouth

Gonorrhea, pelvic inflammatory disease, infectious arthritis, conjunctivitis

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BACTERIA:Staphylococcus epidermidis

Staphylococcus epidermidis

Skin

Wound infection, bacteremia
Viruses:Hepatitis A virus Hepatitis A virus

Feces

Hepatitis A

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Viruses:Hepatitis B virus

Hepatitis B virus
Blood and certain body fluids, sexual contact
Hepatitis B

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Viruses:Hepatitis C virus

Hepatitis C virus
Blood, certain body fluids, sexual contact
Hepatitis C

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Viruses:Herpes simplex virus (type 1)

Herpes simplex virus (type 1)

Lesions of mouth or skin, saliva, genitalia

Cold sores, aseptic meningitis, sexually transmitted disease, herpetic whitlow

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Colonization occurs when a....

Colonization occurs when a mircoorganism invades the host but does not cause infection.
An infection is the invasion of a susceptible host by pathogens or microorganisms, resulting in disease. It is important to know the difference between an infection and colonization. Colonization is the presence and growth of microorganisms within a host but without tissue invasion or damage (Tweeten, 2009). Disease or infection results only if the pathogens multiply and alter normal tissue function. Some infectious diseases such as viral meningitis and pneumonia have a low or no risk for transmission. Although these illnesses can be serious for the patient, they do not pose a risk to others, including caregivers.

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Bacteria that require oxygen
Bacteria that do not require oxygen

Aerobic bacteria require oxygen for survival and for multiplication sufficient to cause disease. Aerobic organisms cause more infections in humans than anaerobic organisms. An example of an aerobic organism is Staphylococcus aureus. Anaerobic bacteria thrive where little or no free oxygen is available. Infections deep within the pleural cavity, in a joint, or in a deep sinus tract are typically caused by anaerobes. An example of an anaerobic organism is Clostridium difficile, an organism that causes antibiotic-induced diarrhea.

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Symptomatic AND asymptomatic infections.

If an infectious disease can be transmitted directly from one person to another, it is termed a communicable disease (Tweeten, 2009). If the pathogens multiply and cause clinical signs and symptoms, the infection is symptomatic. If clinical signs and symptoms are not present, the illness is termed asymptomatic. Hepatitis C is an example of a communicable disease that can be asymptomatic. It is most efficiently transmitted through the direct passage of blood into the skin from a percutaneous exposure, even if the source patient is asymptomatic

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Chain of Infection

The presence of a pathogen does not mean that an infection will occur. Infection occurs in a cycle that depends on the presence of all of the following elements:

•An infectious agent or pathogen
•A reservoir or source for pathogen growth
•A port of exit from the reservoir
•A mode of transmission
•A port of entry to a host
•A susceptible host
(Infectious agent, reservoir, portal of exit, mode of transmission, portal of entry, host.)

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Bacteria and Temperature

Microorganisms can live only in certain temperature ranges. Each species of bacteria has a specific temperature at which it grows best. The ideal temperature for most human pathogens is 20° to 43° C (68° to 109° F). For example, Legionella pneumophila grows best in water at 25° to 42° C (77° to 108° F) (. Cold temperatures tend to prevent growth and reproduction of bacteria (bacteriostasis). A temperature or chemical that destroys bacteria is bactericidal.

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Modes of Transmission

Direct
• Person-to-person (fecal, oral) physical contact between source and susceptible host (e.g., touching patient feces and then touching your inner mouth or consuming
Contaminated food)
Indirect
. Personal contact of susceptible host with contaminated inanimate object (e.g., needles or sharp objects, dressings, environment)
Droplet
• Large particles that travel up to 3 feet during coughing, sneezing, or talking and come in contact with susceptible host
Airborne
• Droplet nuclei or residue or evaporated droplets suspended in air during coughing or sneezing or carried on dust particles
Vehicles
• Contaminated items
• Water
• Drugs, solutions
• Blood
• Food (improperly handled, stored, or cooked; fresh or thawed meats)
Vector
• External mechanical transfer (flies)
• Internal transmission such as parasitic conditions between vector and host such as:
•Mosquito
•Louse
•Flea
•Tick

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Course of Infection by Stage

Incubation Period

Interval between entrance of pathogen into body and appearance of first symptoms (e.g., chickenpox, 10 to 21 days after exposure; common cold, 1 to 2 days; influenza, 1 to 5 days; mumps, 12 to 26 days).

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Prodromal Stage

Interval from onset of nonspecific signs and symptoms (malaise, low-grade fever, fatigue) to more specific symptoms. (During this time microorganisms grow and multiply, and patient may be capable of spreading disease to others.) For example, herpes simplex begins with itching and tingling at the site before the lesion appears.

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Illness Stage

Interval when patient manifests signs and symptoms specific to type of infection. For example, strep throat is manifested by sore throat, pain, and swelling; mumps is manifested by high fever, parotid and salivary gland swelling.

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Convalescence

Interval when acute symptoms of infection disappear. (Length of recovery depends on severity of infection and patient's host resistance; recovery may take several days to months.)

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infection:
localized \
systemic

If an infection is localized (e.g., a wound infection), the patient usually experiences localized symptoms such as pain, tenderness, and redness at the wound site. Use standard precautions, appropriate PPE, and hand hygiene when assessing the wound. The use of these precautions and hand hygiene blocks the spread of infection to other sites or other patients. An infection that affects the entire body instead of just a single organ or part is systemic and can become fatal if undetected and untreated.

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Normal Floras

The body normally contains microorganisms that reside on the surface and deep layers of skin, in the saliva and oral mucosa, and in the gastrointestinal and genitourinary tracts. A person normally excretes trillions of microbes daily through the intestines. Normal floras do not usually cause disease when residing in their usual area of the body but instead participate in maintaining health.

Normal floras of the large intestine exist in large numbers without causing illness. They also secrete antibacterial substances within the walls of the intestine. The normal floras of the skin exert a protective, bactericidal action that kills organisms landing on the skin. The mouth and pharynx are also protected by floras that impair growth of invading microbes. Normal floras maintain a sensitive balance with other microorganisms to prevent infection. Any factor that disrupts this balance places a person at increased risk for acquiring a disease. For example, the use of broad-spectrum antibiotics for the treatment of infection can lead to suprainfection. A suprainfection develops when broad-spectrum antibiotics eliminate a wide range of normal flora organisms, not just those causing infection. When normal bacterial floras are eliminated, body defenses are reduced, which allows for disease-producing microorganisms to multiply, causing illness

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Inflammation

The cellular response of the body to injury, infection, or irritation is termed inflammation. Inflammation is a protective vascular reaction that delivers fluid, blood products, and nutrients to an area of injury. The process neutralizes and eliminates pathogens or dead (necrotic) tissues and establishes a means of repairing body cells and tissues. Signs of localized inflammation include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. When inflammation becomes systemic, other signs and symptoms develop, including fever, leukocytosis, malaise, anorexia, nausea, vomiting, lymph node enlargement, or organ failure.
Physical agents, chemical agents, or microorganisms trigger the inflammatory response. Mechanical trauma, temperature extremes, and radiation are examples of physical agents. Chemical agents include external and internal irritants such as harsh poisons or gastric acid. Sometimes microorganisms also trigger this response.

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After tissues are injured, a series of well-coordinated events occurs. The inflammatory response includes the following:

1 Vascular and cellular responses
2 Formation of inflammatory exudates (fluid and cells that are discharged from cells or blood vessels [e.g., pus or serum])
3 Tissue repair

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The inflammatory response:Vascular and Cellular Responses

Acute inflammation is an immediate response to cellular injury. Rapid vasodilation occurs, allowing more blood near the location of the injury. The increase in local blood flow causes the redness and localized warmth at the site of inflammation.

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Injury causes

tissue damage and possibly necrosis. As a result the body releases chemical mediators that increase the permeability of small blood vessels; and fluid, protein, and cells enter interstitial spaces. The accumulation of fluid appears as localized swelling (edema). Another sign of inflammation is pain. The swelling of inflamed tissues increases pressure on nerve endings, causing pain. As a result of physiological changes occurring with inflammation, the involved body part may have a temporary loss of function. For example, a localized infection of the hand causes the fingers to become swollen, painful, and discolored. Joints become stiff as a result of swelling, but function of the fingers returns when inflammation subsides.

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The cellular response of inflammation involves

white blood cells (WBCs) arriving at the site. WBCs pass through blood vessels and into the tissues. Phagocytosis is a process that involves the destruction and absorption of bacteria. Through the process of phagocytosis, specialized WBCs, called neutrophils and monocytes, ingest and destroy microorganisms or other small particles. If inflammation becomes systemic, other signs and symptoms develop. Leukocytosis, or an increase in the number of circulating WBCs, is the response of the body to WBCs leaving blood vessels. A serum WBC count is normally 5,000 to 10,000/mm3 but typically rise to 15,000 to 20,000/mm3 and higher during inflammation. Fever is caused by phagocytic release of pyrogens from bacterial cells, which causes a rise in the hypothalamic set point (see Chapter 29).

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The inflammatory response:Inflammatory Exudate

Inflammatory Exudate

Accumulation of fluid and dead tissue cells and WBCs forms an exudate at the site of inflammation. Exudate may be serous (clear, like plasma), sanguineous (containing red blood cells), or purulent (containing WBCs and bacteria). Usually the exudate is cleared away through lymphatic drainage. Platelets and plasma proteins such as fibrinogen form a meshlike matrix at the site of inflammation to prevent its spread.

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The inflammatory response:Tissue Repair

When there is injury to tissue cells, healing involves the defensive, reconstructive, and maturative stages (see Chapter 48). Damaged cells are eventually replaced with healthy new cells. The new cells undergo a gradual maturation until they take on the same structural characteristics and appearance as the previous cells. If inflammation is chronic, tissue defects sometimes fill with fragile granulation tissue. Granulation tissue is not as strong as tissue collagen and assumes the form of scar tissue.

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Health care-associated infections (HAIs)

Patients in health care settings, especially hospitals and long-term care facilities, have an increased risk of acquiring infections. Health care-associated infections (HAIs), formerly called nosocomial or health care-acquired infections, result from the delivery of health services in a health care facility. They occur as the result of invasive procedures, antibiotic administration, the presence of multidrug-resistant organisms, and breaks in infection prevention and control activities.

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Patients who develop HAIs

often have multiple illnesses, are older adults, and are poorly nourished; thus they are more susceptible to infections. In addition, many patients have a lowered resistance to infection because of underlying medical conditions (e.g., diabetes mellitus or malignancies) that impair or damage the immune response of the body. Invasive treatment devices such as intravenous (IV) catheters or indwelling urinary catheters impair or bypass the natural defenses of the body against microorganisms. Critical illness increases patients' susceptibility to infections, especially multidrug-resistant bacteria. Meticulous hand hygiene practices, the use of chlorhexidine washes, and other advances in intensive care unit (ICU) infection prevention help to prevent these infections

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TYPES OF HAI INFECTION:

Iatrogenic infections
exogenous infection
Endogenous infection

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Iatrogenic infections

Iatrogenic infections are a type of HAI from a diagnostic or therapeutic procedure. For example, procedures such as a bronchoscopy and treatment with broad-spectrum antibiotics increase the risk for certain infections (Arnold, 2009; Stricof, 2009). Use critical thinking when practicing aseptic techniques and follow basic infection prevention and control policies and procedures to reduce the risk of HAIs. Always consider the patient's risks for infection and anticipate how the approach to care increases or decreases the risk.

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exogenous infection

An exogenous infection comes from microorganisms found outside the individual such as Salmonella, Clostridium tetani, and Aspergillus. They do not exist as normal floras.

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Endogenous infection

Endogenous infection occurs when part of the patient's flora becomes altered and an overgrowth results (e.g., staphylococci, enterococci, yeasts, and streptococci). This often happens when a patient receives broad-spectrum antibiotics that alter the normal floras. When sufficient numbers of microorganisms normally found in one body site move to another site, an endogenous infection develops. The number of microorganisms needed to cause a health care-associated infection depends on the virulence of the organism, the susceptibility of the host, and the body site affected.

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Clinical Appearance

The signs and symptoms of infection may be local or systemic. Localized infections are most common in areas of skin or mucous membrane breakdown such as surgical and traumatic wounds, pressure ulcers, oral lesions, and abscesses.

To assess an area for localized infection, first inspect it for redness and swelling caused by inflammation. Because there may be drainage from open lesions or wounds, wear clean gloves. Infected drainage may be yellow, green, or brown, depending on the pathogen. For example, green nasal secretions often indicate a sinus infection. Ask the patient about pain or tenderness around the site. Some patients complain of tightness and pain caused by edema. If the infected area is large enough, movement is restricted. Gentle palpation of an infected area usually results in some degree of tenderness. Wear protective eyewear and a surgical mask when there is a risk for splash or spray with blood or body fluids.

Systemic infections cause more generalized symptoms than local infection. These symptoms often include fever, fatigue, nausea/vomiting, and malaise. Lymph nodes that drain the area of infection often become enlarged, swollen, and tender during palpation. For example, an abscess in the peritoneal cavity causes enlargement of lymph nodes in the groin. An infection of the upper respiratory tract causes cervical lymph node enlargement. If an infection is serious and widespread, all major lymph nodes may enlarge.

Systemic infections sometimes develop after treatment for localized infection has failed. Be alert for changes in the patient's level of activity and responsiveness. As systemic infections develop, an elevation in body temperature can lead to episodes of increased heart and respiratory rates and low blood pressure. Involvement of major body systems produces specific symptoms. For example, a pulmonary infection results in a productive cough with purulent sputum. A UTI results in cloudy, foul-smelling urine.

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Nursing Diagnosis

During assessment gather objective data such as inspection of an open incision or a reduced caloric intake record and subjective data such as a patient's complaint of tenderness over a surgical wound site. Review the data carefully, looking for clusters of defining characteristics or risk factors that create a pattern. This pattern suggests a specific nursing diagnosis (Box 28-6). The following are examples of nursing diagnoses that often apply:

•Risk for infection
•Imbalanced nutrition: less than body requirements
•Impaired oral mucous membrane
•Risk for impaired skin integrity
•Social isolation
•Impaired tissue integrity
•Readiness for enhanced immunization status

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Asepsis

Base efforts to minimize the onset and spread of infection on the principles of aseptic technique. Asepsis is the absence of pathogenic (disease-producing) microorganisms. Aseptic technique refers to practices/procedures that help reduce the risk for infection. The two types of aseptic technique are medical and surgical asepsis.

Medical asepsis, or clean technique, includes procedures for reducing the number of organisms present and preventing the transfer of organisms. Hand hygiene, barrier techniques, and routine environmental cleaning are examples of medical asepsis.

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standard precautions

You will learn to follow certain principles and procedures, including standard precautions, to prevent and control infection and its spread. Standard precautions apply to contact with blood, body fluid, nonintact skin, and mucous membranes from all patients. These precautions protect the patient and provide protection for the health care worker. A major component of patient and worker protection is hand hygiene (Skill 28-1, pp. 425-427). Hand hygiene includes using an instant alcohol hand antiseptic before and after providing patient care, washing hands with soap and water when they are visibly soiled, and performing a surgical scrub. Handwashing is the act of washing hands with soap and water, followed by rinsing under a stream of water for 15 seconds (CDC, 2002). The friction of rubbing hands together removes soil and transient organisms from the hands.

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Disinfection and Sterilization

Disinfection describes a process that eliminates many or all microorganisms, with the exception of bacterial spores, from inanimate objects (Rutala and Weber, 2008, 2009). There are two types of disinfection: the disinfection of surfaces and high-level disinfection, which is required for some patient care items such as endoscopes and bronchoscopes. You accomplish disinfection using a chemical disinfectant or wet pasteurization (used for respiratory therapy equipment). Examples of disinfectants are alcohols, chlorines, glutaraldehydes, hydrogen peroxide, and phenols. Glutaraldehydes are caustic and toxic to tissues and pose a potential health risk. Sterilization is the complete elimination or destruction of all microorganisms, including spores. Steam under pressure, ethylene oxide (ETO) gas, hydrogen peroxide plasma, and chemicals are the most common sterilizing agents. ETO poses a potential health risk to staff processing with this agent, and exposure must be monitored.

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To control organisms exiting via the respiratory tract, cover your mouth or nose when coughing or sneezing. Teach patients, health care staff, patient's families, and visitors respiratory hygiene....or

cough etiquette

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Contact precautions:

Contact precautions: Used for direct and indirect contact with patients and their environment. Direct contact refers to the care and handling of contaminated body fluids. An example includes blood or other body fluids from an infected patient that enter the health care worker's body through direct contact with compromised skin or mucous membranes. Indirect contact involves the transfer of an infectious agent through a contaminated intermediate object such as contaminated instruments or hands of health care workers. The health care worker may transmit microorganisms from one patient site to another if hand hygiene is not performed between patients

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Droplet precautions:

Droplet precautions: Focus on diseases that are transmitted by large droplets expelled into the air and travel 3 to 6 feet from the patient. Droplet precautions require the wearing of a surgical mask when within 3 feet of the patient, proper hand hygiene, and some dedicated-care equipment. An example is a patient with influenza.

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Airborne precautions:

Airborne precautions: Focus on diseases that are transmitted by smaller droplets, which remain in the air for longer periods of time. This requires a specially equipped room with a negative air flow referred to as an airborne infection isolation room. Air is not returned to the inside ventilation system but is filtered through a high-efficiency particulate air (HEPA) filter and exhausted directly to the outside. All health care personnel wear an N95 respirator every time they enter the room.

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Protective environment:

Protective environment: Focuses on a very limited patient population. This form of isolation requires a specialized room with positive airflow. The airflow rate is set at greater than 12 air exchanges per hour, and all air is filtered through a HEPA filter. Patients are not allowed to have dried or fresh flowers or potted plants in these rooms

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The Isolation Environment

Private rooms used for isolation sometimes provide negative-pressure airflow to prevent infectious particles from flowing out of a room to other rooms and the air handling system. Special rooms with positive-pressure airflow are also used for highly susceptible immunocompromised patients such as recipients of transplanted organs. On the door or wall outside the room the nurse posts a card listing precautions for the isolation category in use according to health care facility policy. The card is a handy reference for health care personnel and visitors and alerts anyone who might enter the room accidentally that special precautions must be followed.

The isolation room or an adjoining anteroom needs to contain hand hygiene and PPE supplies. Soap and antiseptic (antimicrobial) solutions need to be available. Personnel and visitors perform hand hygiene before approaching the patient's bedside and again before leaving the room. If toilet facilities are unavailable, there are special procedures for handling portable commodes, bedpans, or urinals.

All patient care rooms, including those used for isolation; contain an impervious bag for soiled or contaminated linen and a trash container with plastic liners. Impervious receptacles prevent transmission of microorganisms by preventing leaking and soiling of the outside surface. A disposable rigid container needs to be available in the room to discard used sharps such as safety needles and syringes.

Remain aware of infection prevention and control techniques while working with patients in protected environments. You need to feel comfortable performing all procedures and yet remain conscious of infection prevention and control principles. Depending on the microorganism and mode of transmission, evaluate which articles or equipment to take into an isolation room. For example, the CDC (2007) recommends the dedicated use of articles such as stethoscopes, sphygmomanometers, or rectal thermometers in the isolation room of a patient infected or colonized with vancomycin-resistant enterococci. Do not use these devices on other patients unless they are first adequately cleaned and disinfected. Box 28-12 describes the procedures to perform when using shared equipment.

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Personal Protective Equipment

PPE, specialized clothing or equipment worn by a health care worker for protection against infectious materials (gowns, masks or respirators, protective eyewear, and gloves), should be readily available for personnel performing patient care (CDC, 2004). The equipment to be used is task based.

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Gowns

The primary reason for gowning is to prevent soiling clothes during contact with a patient. Gowns or cover-ups protect health care personnel and visitors from coming in contact with infected material and blood or body fluids. Gowns are often required depending on the expected amount of exposure to infectious material. Gowns used for barrier protection are made of a fluid-resistant material. Change gowns immediately if damaged or heavily contaminated. Isolation gowns are disposable or reusable.

Isolation gowns usually open at the back and have ties or snaps at the neck and waist to keep the gown closed and secure. Gowns need to be long enough to cover all outer garments. Long sleeves with tight-fitting cuffs provide added protection. No special technique is required for applying clean gowns as long as they are fastened securely. However, carefully remove gowns to minimize contamination of the hands and uniform and discard them after removal.

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Respiratory Protection

Wear full-face protection (with eyes, nose, and mouth covered) when you anticipate splashing or spraying of blood or body fluid into the face. Also wear masks when working with a patient placed on airborne or droplet precautions. If the patient is on airborne precautions for TB, apply an OSHA-approved respirator-style mask. The mask protects the nurse from inhaling microorganisms and small-particle droplet nuclei that remain suspended in the air from a patient's respiratory tract. The surgical mask protects a wearer from inhaling large-particle aerosols that travel short distances (3 feet). When caring for patients on droplet or airborne precautions, apply a mask (surgical or respirator) when entering the isolation room.

At times a patient who is susceptible to infection wears a mask to prevent inhalation of pathogens. Patients on droplet or airborne precautions who are transported outside of their rooms need to wear a surgical mask to protect other patients and personnel. Masks prevent transmission of infection by direct contact with mucous membranes (CDC, 2005a). A mask discourages the wearer from touching the eyes, nose, or mouth (Box 28-13).

A properly applied mask fits snugly over the mouth and nose so pathogens and body fluids cannot enter or escape through the sides. If a person wears glasses, the top edge of the mask fits below the glasses so they do not cloud over as the person exhales. Keep talking to a minimum while wearing a mask to reduce respiratory airflow. A mask that has become moist does not provide a barrier to microorganisms and is ineffective. You need to discard it. Never reuse a disposable mask. Warn patients and family members that a mask can cause a sensation of smothering. If family members become uncomfortable, they should leave the room and discard the mask.

Specially fitted respiratory protective devices (N95 respirator masks) are required when caring for patients on airborne precautions, such as patients with known or suspected TB (Fig. 28-3) (CDC, 2005a). The mask must have a higher filtration rating than regular surgical masks and be fitted snugly to prevent leakage around the sides. Be aware of health care facility policy regarding the type of respiratory protective device required. Special fit testing is required to establish the size and ability of the nurse to wear this type of mask (CDC, 2005a).

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Surgical Asepsis

Surgical asepsis or sterile technique prevents contamination of an open wound, serves to isolate the operative area from the unsterile environment, and maintains a sterile field for surgery. Surgical asepsis includes procedures used to eliminate all microorganisms, including pathogens and spores, from an object or area (Rutala and Weber, 2008, 2009). In surgical asepsis an area or object is considered contaminated if touched by any object that is not sterile. It demands the highest level of aseptic technique and requires that all areas be kept free of infectious microorganisms.

Use surgical asepsis in the following situations:

•During procedures that require intentional perforation of the patient's skin such as insertion of IV catheters or central lines
•When the integrity of the skin is broken as a result of trauma, surgical incision, or burns
•During procedures that involve insertion of catheters or surgical instruments into sterile body cavities such as insertion of a urinary catheter
Although surgical asepsis is common in the operating room, labor and delivery area, and major diagnostic areas, you also use surgical aseptic techniques at the patient's bedside (e.g., when inserting IV or urinary catheters, suctioning the tracheobronchial airway, and reapplying sterile dressings). A nurse in an operating room follows a series of steps to maintain sterile technique, including applying a mask, protective eyewear, and a cap; performing a surgical hand scrub; and applying a sterile gown and gloves. In contrast, a nurse performing a dressing change at a patient's bedside only performs hand hygiene and applies sterile gloves. For certain procedures (e.g., changing a central line dressing) the nurse also uses a mask. Regardless of the procedures followed or the setting, the nurse always recognizes the importance of strict adherence to aseptic principles

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Implementation

The fourth step of the nursing process,(formally begins after the nurse develops a plan of care) the nurse initiates the interventions that are most likely to achieve the goals and expected outcomes needed to support or improve the client's health status.

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Nursing intervention

Is any treatment, based on clinical judgment and knowledge, that a nurse performs to enhance client outcomes. Ideally the interventions a nurse uses are evidenced based, providing the most current, up-to-date, and effective approaches for managing patient problems. Interventions include direct and indirect care aimed at individuals, families, and/or the community.

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Direct care (interventions)

Are treatments performed through interactions with patient's. Ex: Medication administration, insertion of an intravenous (IV) infusion, or counseling during a time of grief.

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Indirect care (interventions)

Are treatments performed away from the patient but on behalf of the patient or group of patient's. Ex: Actions for managing patient's environment (e.g. safety and infection control), documentation, and interdisciplinary collaboration.

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Critical Thinking in Implementation

Critical thinking is necessary to consider the complexity of interventions, including the number of alternatives approaches and the amount of time available to act. Before implementing a planned intervention, use critical thinking to confirm whether the intervention is correct and still appropriate for the patient's clinical situation.

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Identify the factors that should be considered when making decisions about implementation

a. Review the set of all possible interventions for the patient's problem b. Review all of the possible consequences associated with each possible nursing action c. Determine the probability of all possible consequences d. Make a judgment of the value of that consequence to the patient

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Standard nursing interventions

Many patients have common health care problems; thus standardized interventions for these health problems make it quicker and easier for nurses to intervene. ->Nurse/Physician initiated standardized interventions- Clinical guidelines or protocols, Preprinted (standing) orders, and Nursing Interventions Classification (NIC) interventions. ->Professional level- The American Nurses Association (ANA) defines standards of professional nursing practice, which include standards for the implementation step of the nursing process.

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Clinical practice guideline

Or protocol is a document that guides decisions and interventions for specific health care problems or conditions. (or protocol) Is a systematically developed set of statements that helps nurses, physicians, and other health care providers make decisions about appropriate health care for specific clinical situations.

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Standing orders

Is a preprinted document containing orders for the conduct of routine therapies, monitoring guidelines, and/or diagnostic procedures for patients with identified clinical problems.

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Nursing Interventions Classification (NIC) interventions

Offer a level of standardization to enhance communication of nursing care across settings and to compare outcomes

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What are the five preparatory activites for implementation of safe and effective nursing care.

1. Reassessing the patient 2. Reviewing & Revising the existing nurse care plan 3. Organizing resources and care delivery 4. Anticipating and preventing complications 5. Implementation nursing interventions

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1. "Reassessing the patient"

Reassessing the patient is a continuous process that occurs each time you interact with a patient; you collect new data, identify a new patient need, and modify the care plan

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2. " Reviewing & Revising the existing nurse care plan"

If the patient's status has changed and the nursing diagnosis and related nursing interventions are no longer appropriate, modify the nursing care plan

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3. "Organizing resources and care delivery"

Organizing resources and care delivery involves organization of equipment, skilled personnel, and the environment. This makes timely, efficient, skilled patient care possible.

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4. "Anticipating and preventing complications"

Risks to patients come from both the illness and the treatments

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5. "Implementation skills"

Implementation skills includes cognitive (application of critical thinking in the nursing process), interpersonal (trusting relationship, level of caring and communication) and psychomotor skills (integration of cognitive and motor activities).

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Activities of daily living (ADLs)

Activities usually performed in the course of a normal day (ambulation, eating, dressing, bathing, grooming)

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Instrumental activities of daily living include (IADL's)

Skills such as shopping, preparing meals, writing checks, taking medications

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Physical care techniques include

Involve the safe and competent administration of nursing procedures. Common methods for administering physical care techniques appropriately include protecting you and the patient from injury, using safe patient handling techniques, using proper infection control practices, staying organized, and following applicable practice guidelines.

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Counseling

Is a direct care method that helps a patient use a problem-solving process to recognize and manage stress and to facilitate interpersonal relationships

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The focus of teaching is

is the intellectual growth or the acquisition of new knowledge or psychomotor skills

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Adverse reaction

Is a harmful or unintended effect of a medication, diagnostic test, or therapeutic intervention

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Preventive nursing actions

Promote health and prevent illness to avoid the need for acute or rehabilitative health care.

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-Primary prevention

aimed at health promotion and illness prevention.

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-Secondary prevention focuses on

people who are experiencing health problems or illnesses and who are at risk for developing complications or worsening conditions.

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-Tertiary prevention involves

minimizing the effects of long-term illness or disability, including rehabilitation measures.

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Interdisciplinary care plan

Represents the contributions of all disciplines caring for the client.

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The record entry usually includes

a brief description of pertinent assessment findings, the specific intervention, and the patient's response.

81

Briefly describe the responsibility of the nurse for delegating and supervising others

Noninvasive and frequently repetitive interventions can be assigned to nursing assistive personnel (NAP). The nurse is responsible for ensuring that each task is appropriately assigned and is completed according to the standard of care. (Indirect care activity) When performed correctly, delegation ensures that the right care provider performs the right tasks so the nurse and the NAP work most efficiently together for the patient's benefit.

82

Patient adherence

Patients and families invest time in carrying out required treatments to achieve patient goals

83

(T or F) With standing orders, the nurse relies on the health care provider's judgment to determine if the intervention is appropriate?

True

84

The nursing care plan calls for the patient, a 300-pound woman, to be turned every 2 hours. The client is unable to assist with turning. The nurse knows. that she may hurt her back if she attempts to turn the client by herself. The nurse should

Ask another nurse to help her turn the client

85

Mrs. Kay comes to the family clinic for birth control. The nurse obtains a health history and performs a pelvic examination and Pap smear. The Nurse is functioning according to

Protocol

86

Mary Jones is a newly diagnosed diabetic client. The nurse shows Mary how to administer an injection. This intervention activity is:

Teaching

87

Implementation is the step of the nursing process in which nurses provides

Direct and indirect nursing care interventions to clients.

88

During the initial phase of implementation you should

Reassess the client to determine whether the proposed nursing action is still appropriate for the client's level of wellness.

89

The implementation of nursing care often requires

Additional knowledge, nursing skills, and personnel resources.

90

Before beginning to perform interventions, be sure the client is

As physically and psychologically comfortable as possible.

91

To anticipate and prevent complications, a nurse

identifies risks to the client, adapts interventions to the situation, evaluates the relative benefit of a treatment versus the risk, and initiates risk prevention measures.

92

• • Successful implementation of nursing interventions requires you to use appropriate

cognitive, interpersonal, and psychomotor skills

93

The methods used to ensure that you administer physical care techniques appropriately include

protecting the nurse and client from injury, using proper infection control practices, staying organized, and following applicable practice guidelines

94

Counseling is a direct care method that helps clients use

problem solving to recognize and manage stress and to facilitate interpersonal relationships.

95

To complete any nursing procedure, you need to

know the procedure, its frequency, the steps, and the expected outcomes.