Kozier - Chapter 31 - Asepsis

Chapter

Asepsis

Kozier & Erb's Fundamentals of Nursing, 8e Berman, Snyder, Kozier, Erb Copyright 2008 by Pearson Education, Inc.

31

Question 1 The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or health care providers, the nurse emphasizes interventions that do which of the following? 3. 4. 5. 6.

Eliminate the reservoir Block the portal of exit from the reservoir Block the portal of entry into the host Decrease the susceptibility of the host Copyright 2008 by Pearson Education, Inc.

Rationales 1 • • •

•

Since the carrier person is the reservoir and the condition is chronic, it is not possible to eliminate the reservoir. Correct. Blocking the movement of the organism from the reservoir will succeed in preventing the infection of any other persons. Blocking the entry into a host will be effective for only that one single individual and, thus, is not as effective as blocking exit from the reservoir. Decreasing the susceptibility of the host will be effective for only that one single individual and, thus, is not as effective as blocking exit from the reservoir. Copyright 2008 by Pearson Education, Inc.

Question 2 The most effective nursing action for controlling the spread of infection includes which of the following? 3. Thorough hand cleansing 4. Wearing gloves and masks when providing direct client care 5. Implementing appropriate isolation precautions 6. Administering broad-spectrum prophylactic antibiotics Copyright 2008 by Pearson Education, Inc.

Rationales 2 •

• • •

Correct. Since the hands are frequently in contact with clients and equipment, they are the most obvious source of transmission. Regular and routine hand cleansing is the most effective way to prevent movement of potentially infective materials. PPE (gloves and masks) is indicated for situations requiring Standard Precautions. Isolation precautions are used for clients with known communicable diseases. Routine use of antibiotics is not effective and can be harmful due to the incidence of superinfection and development of resistant organisms. Copyright 2008 by Pearson Education, Inc.

Question 3 When caring for a single client during one shift, it is appropriate for the nurse to reuse which of the following personal protective equipment? 3. 4. 5. 6.

Goggles Gown Surgical mask Clean gloves

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Rationales 3 •

•

• •

Correct. Unless overly contaminated by material that has splashed in the nurse’s face and cannot be effectively rinsed off, goggles may be worn repeatedly. Since gowns are at high risk for contamination, they should be used only once and then discarded or washed. Surgical masks are never washed or reused. Gloves are never washed or reused. Copyright 2008 by Pearson Education, Inc.

Question 4 After evaluating the client’s chart, the nurse concludes a 65-year-old client’s immunizations are current. What evidence supports this conclusion? (Select all that apply.) 3. 4. 5. 6.

Last tetanus booster was at age 50 Receives a flu shot every year Has not received the hepatitis B vaccine Has not received the hepatitis A vaccine Copyright 2008 by Pearson Education, Inc.

Rationales 4 • All adults should receive a tetanus booster every 10 years (or sooner if injured). • Correct. Flu shots are recommended for all adults over age 50. • Correct. Only persons at risk need to receive hepatitis B vaccine. • Correct. Only persons at risk need to receive hepatitis A vaccine. Copyright 2008 by Pearson Education, Inc.

Question 5 The nurse determines that a field remains sterile if which of the following conditions exist? 4. 5. 6. 7.

Tips of wet forceps are held upward when held in ungloved hands. The field was set up 1 hour before the procedure. Sterile items are kept at least 2 inches from the edge of the field. The nurse reaches over the field rather than around the edges. Copyright 2008 by Pearson Education, Inc.

Rationales 5 •

• •

•

When hands are ungloved, forceps tips are to be held downward to prevent fluid from becoming contaminated by the hands and then returned to the sterile field. Fields should be established immediately before use to prevent accidental contamination when not observed closely. Correct. All items within 1 inch of the edge of the sterile field are considered contaminated because the edge of the field is in contact with unsterile areas. Reaching over a sterile field increases the chances of dropping an unsterile item onto or touching the sterile field. Copyright 2008 by Pearson Education, Inc.

Asepsis • Medical asepsis – Includes all practices intended to confine a specific microorganism to a specific area – Limits the number, growth, and transmission of microorganisms – Objects referred to as clean or dirty (soiled, contaminated)

• Surgical asepsis – Sterile technique – Practices that keep an area or object free of all microorganisms – Practices that destroy all microorganisms and spores – Used for all procedures involving sterile areas body Copyright of 2008the by Pearson Education, Inc.

Signs of Localized Infection • Localized swelling • Localized redness • Pain or tenderness with palpation or movement • Palpable heat in the infected area • Loss of function of the body part affected, depending on the site and extent of involvement Copyright 2008 by Pearson Education, Inc.

Signs of Systemic Infection • Fever • Increased pulse and respiratory rate if the fever high • Malaise and loss of energy • Anorexia and, in some situations, nausea and vomiting • Enlargement and tenderness of lymph nodes that drain the area of infection

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Signs of Infection • Laboratory data – – – –

Elevated WBC count Increase in specific WBC types Elevated ESR Cultures of urine, blood, sputum, or other drainage

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Risks for Nosocomial Infections • Diagnostic or therapeutic procedures – Iatrogenic infections

• Compromised host • Insufficient hand hygiene

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Factors Influencing Microorganism’s Capability to Produce Infection

• Number of microorganisms present • Virulence and potency of the microorganisms (pathogenicity) • Ability to enter the body • Susceptibility of the host • Ability to live in the host’s body

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Anatomic and Physiologic Barriers Defend Against Infection

• Intact skin and mucous membranes • Moist mucous membranes and cilia of the nasal passages • Alveolar macrophages • Tears • High acidity of the stomach • Resident flora of the large intestine • Peristalsis • Low pH of the vagina • Urine flow through the urethra Copyright 2008 by Pearson Education, Inc.

Active Immunity • Host produces antibodies in response to natural antigens or artificial antigens • Natural active immunity – Antibodies are formed in presence of active infection in the body – Duration lifelong

• Artificial active immunity – Antigens administered to stimulate antibody formation – Lasts for many years – Reinforced by booster Copyright 2008 by Pearson Education, Inc.

Passive Immunity • Host receives natural or artificial antibodies produced from another source • Natural passive immunity – Antibodies transferred naturally from an immune mother to baby through the placenta or in colostrums – Lasts 6 months to 1 year

• Artificial passive immunity – Occurs when immune serum (antibody) from an animal or another human is injected – Lasts 2 to 3 weeks Copyright 2008 by Pearson Education, Inc.

NANDA Diagnosis • Risk for Infection – State in which an individual is at increased risk for being invaded by pathogenic microorganisms

• Risks factors – Inadequate primary defenses – Inadequate secondary defenses

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Related Diagnoses • Potential Complication of Infection: Fever • Imbalanced Nutrition: Less than Body Requirement • Acute Pain • Impaired Social Interaction or Social Isolation • Anxiety Copyright 2008 by Pearson Education, Inc.

Interventions to Reduce Risk for Infection • Proper hand hygiene techniques • Environmental controls • Sterile technique when warranted • Identification and management of clients at risk

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The Chain of Infection

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Breaking the Chain of Infection • Etiologic agent – Correctly cleaning, disinfecting or sterilizing articles before use – Educating clients and support persons about appropriate methods to clean, disinfect, and sterilize article

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Breaking the Chain of Infection • Reservoir (source) – Changing dressings and bandages when soiled or wet – Appropriate skin and oral hygiene – Disposing of damp, soiled linens appropriately – Disposing of feces and urine in appropriate receptacles – Ensuring that all fluid containers are covered or capped – Emptying suction and drainage bottles at end of each shift or before full or according to agency policy Copyright 2008 by Pearson Education, Inc.

Breaking the Chain of Infection • Portal of exit – Avoiding talking, coughing, or sneezing over open wounds or sterile fields – Covering the mouth and nose when coughing or sneezing

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Breaking the Chain of Infection • Method of transmission – Proper hand hygiene – Instructing clients and support persons to perform hand hygiene before handling food, eating, after eliminating and after touching infectious material – Wearing gloves when handling secretions and excretions – Wearing gowns if there is danger of soiling clothing with body substances Copyright 2008 by Pearson Education, Inc.

Breaking the Chain of Infection • Method of transmission – Placing discarded soiled materials in moistureproof refuse bags – Holding used bedpans steadily to prevent spillage – Disposing of urine and feces in appropriate receptacles – Initiating and implementing aseptic precautions for all clients – Wearing masks and eye protection when in close contact with clients who have infections transmitted by droplets from the respiratory tract – Wearing masks and eye protection when sprays of body fluid are possible Copyright 2008 by Pearson Education, Inc.

Breaking the Chain of Infection • Portal of entry – Using sterile technique for invasive procedures, when exposing open wounds or handling dressings – Placing used disposable needles and syringes in puncture-resistant containers for disposal – Providing all clients with own personal care items Copyright 2008 by Pearson Education, Inc.

Breaking the Chain of Infection • Susceptible host – Maintaining the integrity of the client’s skin and mucous membranes – Ensuring that the client receives a balanced diet – Educating the public about the importance of immunizations

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Category-specific Isolation Precautions • Strict isolation • Contact isolation • Respiratory isolation • Tuberculosis isolation • Enteric precautions • Drainage/secretions precautions • Blood/body fluid precautions Copyright 2008 by Pearson Education, Inc.

Disease-specific Isolation Precautions • Delineate practices for control of specific diseases – Use of private rooms with special ventilation – Cohorting clients infected with the same organism – Gowning to prevent gross soilage of clothes

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Universal Precautions (UP) • Used with all clients • Decrease the risk of transmitting unidentified pathogens • Obstruct the spread of bloodborne pathogens (hepatitis B and C viruses and HIV) • Used in conjunction with diseasespecific or category-specific precautions Copyright 2008 by Pearson Education, Inc.

Body Substance Isolation (BSI) • Employs generic infection control precautions for all clients • Body substances include: – – – – – –

Blood Urine Feces Wound drainage Oral secretions Any other body product or tissue Copyright 2008 by Pearson Education, Inc.

Standard Precautions • Used in the care of all hospitalized persons regardless of their diagnosis or possible infection status • Apply to – Blood – All body fluids, secretions, and excretions except sweat (whether or not blood is present or visible) – Nonintact skin and mucous membranes

• Combine the major features of UP and BSI Copyright 2008 by Pearson Education, Inc.

Transmission-based Precautions • Used in addition to standard precautions • For known or suspected infections that are spread in one of three ways: – Airborne – Droplet – Contact

• May be used alone or in combination but always in addition to standard precautions

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Handwashing and Gloving Video

Click here to view a video on handwashing and gloving. Back to Directory Copyright 2008 by Pearson Education, Inc.

Hand Hygiene: Skill 31-3

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Hand Hygiene: Skill 31-1

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Donning and Removing PPE: Skill 31-2

Gowns

Masks

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Donning and Removing PPE: Skill 31-2

Gloves Copyright 2008 by Pearson Education, Inc.

Establishing and Maintaining a Sterile Field: Skill 31-3

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Establishing and Maintaining a Sterile Field: Skill 31-3

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Establishing and Maintaining a Sterile Field: Skill 31-3

Copyright 2008 by Pearson Education, Inc.

Establishing and Maintaining a Sterile Field: Skill 31-3

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Managing Equipment Used for Isolation Clients • Many supplied for single use only • Disposed of after use • Agencies have specific policies and procedures for handling soiled reusable equipment • Nurses need to become familiar with these practices Copyright 2008 by Pearson Education, Inc.

Bloodborne Pathogen Exposure • Report the incident immediately • Complete injury report • Seek appropriate evaluation and follow-up

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Bloodborne Pathogen Exposure • Identification and documentation of the source individual when feasible and legal • Testing of the source for hepatitis B, C and HIV when feasible and consent is given • Making results of the test available to the source individual’s health care provider • Testing of blood exposed nurse (with consent) for hepatitis B, C, and HIV – please check these to match style used in book – fairly certain it should be caped antibodies • Postexposure prophylaxis if medically indicated • Medical and psychologic counseling Copyright 2008 by Pearson Education, Inc.

Puncture/Laceration • Encourage bleeding • Wash/clean the area with soap and water • Initiate first aid and seek treatment if indicated • Mucous membrane exposure (eyes, nose, mouth) • Flush with saline or water flush for 5 to 10 minutes

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Postexposure Protocol (PEP) for HIV • Start treatment as soon as possible preferably within hours after exposure • For “high-risk” exposure (high blood volume and source with a high HIV titer), three drug treatment is recommended • For “increased risk” exposure (high blood volume or source with high HIV titer), three-drug treatment is recommended • For “low risk” exposure (neither high blood volume nor source with a high HIV titer), two-drug treatment is considered Copyright 2008 by Pearson Education, Inc.

Postexposure Protocol (PEP) for HIV • Drug prophylaxis continues for 4 weeks • Drug regimens vary and new drugs and regimens continuously being developed • HIV antibody tests should be done shortly after exposure (baseline), and 6 weeks, 3 months, and 6 months afterward Copyright 2008 by Pearson Education, Inc.

Postexposure Protocol (PEP) for Hepatitis B • Anti-HBs testing 1 to 2 months after last vaccine dose • HBIG and/or hepatitis B vaccine within 1 to 7 days following exposure for nonimmune workers

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Postexposure Protocol (PEP) for Hepatitis C • Anti-HCV and ALT at baseline and 4 to 6 months after exposure

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Question 1 The client is a chronic carrier of infection. To prevent the spread of the infection to other clients or health care providers, the nurse emphasizes interventions that do which of the following? 3. 4. 5. 6.

Eliminate the reservoir Block the portal of exit from the reservoir Block the portal of entry into the host Decrease the susceptibility of the host Copyright 2008 by Pearson Education, Inc.

Rationales 1 • • •

•

Since the carrier person is the reservoir and the condition is chronic, it is not possible to eliminate the reservoir. Correct. Blocking the movement of the organism from the reservoir will succeed in preventing the infection of any other persons. Blocking the entry into a host will be effective for only that one single individual and, thus, is not as effective as blocking exit from the reservoir. Decreasing the susceptibility of the host will be effective for only that one single individual and, thus, is not as effective as blocking exit from the reservoir. Copyright 2008 by Pearson Education, Inc.

Question 2 The most effective nursing action for controlling the spread of infection includes which of the following? 3. Thorough hand cleansing 4. Wearing gloves and masks when providing direct client care 5. Implementing appropriate isolation precautions 6. Administering broad-spectrum prophylactic antibiotics Copyright 2008 by Pearson Education, Inc.

Rationales 2 •

• • •

Correct. Since the hands are frequently in contact with clients and equipment, they are the most obvious source of transmission. Regular and routine hand cleansing is the most effective way to prevent movement of potentially infective materials. PPE (gloves and masks) is indicated for situations requiring Standard Precautions. Isolation precautions are used for clients with known communicable diseases. Routine use of antibiotics is not effective and can be harmful due to the incidence of superinfection and development of resistant organisms. Copyright 2008 by Pearson Education, Inc.

Question 3 When caring for a single client during one shift, it is appropriate for the nurse to reuse which of the following personal protective equipment? 3. 4. 5. 6.

Goggles Gown Surgical mask Clean gloves

Copyright 2008 by Pearson Education, Inc.

Rationales 3 •

•

• •

Correct. Unless overly contaminated by material that has splashed in the nurse’s face and cannot be effectively rinsed off, goggles may be worn repeatedly. Since gowns are at high risk for contamination, they should be used only once and then discarded or washed. Surgical masks are never washed or reused. Gloves are never washed or reused. Copyright 2008 by Pearson Education, Inc.

Question 4 After evaluating the client’s chart, the nurse concludes a 65-year-old client’s immunizations are current. What evidence supports this conclusion? (Select all that apply.) 3. 4. 5. 6.

Last tetanus booster was at age 50 Receives a flu shot every year Has not received the hepatitis B vaccine Has not received the hepatitis A vaccine Copyright 2008 by Pearson Education, Inc.

Rationales 4 • All adults should receive a tetanus booster every 10 years (or sooner if injured). • Correct. Flu shots are recommended for all adults over age 50. • Correct. Only persons at risk need to receive hepatitis B vaccine. • Correct. Only persons at risk need to receive hepatitis A vaccine. Copyright 2008 by Pearson Education, Inc.

Question 5 The nurse determines that a field remains sterile if which of the following conditions exist? 4. 5. 6. 7.

Tips of wet forceps are held upward when held in ungloved hands. The field was set up 1 hour before the procedure. Sterile items are kept at least 2 inches from the edge of the field. The nurse reaches over the field rather than around the edges. Copyright 2008 by Pearson Education, Inc.

Rationales 5 •

• •

•

When hands are ungloved, forceps tips are to be held downward to prevent fluid from becoming contaminated by the hands and then returned to the sterile field. Fields should be established immediately before use to prevent accidental contamination when not observed closely. Correct. All items within 1 inch of the edge of the sterile field are considered contaminated because the edge of the field is in contact with unsterile areas. Reaching over a sterile field increases the chances of dropping an unsterile item onto or touching the sterile field. Copyright 2008 by Pearson Education, Inc.

Resources • Audio Glossary • Canadian Centre for Occupational Health and Safety Defines universal precautions, personal protective equipment, and how to prevent and control hazards of the job • Biological Safety--Universal Precautions Describes universal precautions: protective equipment and when to use • BBC World Service--Asepsis Gives developments and milestones of asepsis • CDC Bloodborne Pathogens Provides general information, guidelines, and scientific publications for bloodborne diseases Copyright 2008 by Pearson Education, Inc.

Resources • Occupational Safety and Health Administration Home page for OSHA. Wonderful source for information regarding how workers can stay healthy and prevent on the job injuries. • Association for Professionals in Infection Control and Epidemiology Has many articles on prevention and control of infections • National Safety Council Protects life and promotes health by offering information on safety in the workplace, home/community, and environment • Infection Control Today Monthly journal that addresses many aspects of infection control, including advice, guidelines, and news • Infection Control Provides many resources for infection control on the Internet. Numerous sites listed.

Copyright 2008 by Pearson Education, Inc.