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Chapter 42
Infection Control
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Infection Control
• Clients in all healthcare settings at risk for acquiring
nosocomial infections (infections acquired in the
healthcare facility, also known as hospital-acquired
infections.)
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Infection Control, cont.
• Prevention is best method of infection control.
• Control successful when the chain of infection broken
• Several types of infection control/prevention methods
used.
• Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) requires healthcare facilities to
have an effective infection control plan to qualify for
accreditation
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Infection Control Plan
• Plan must include
– An infection control committee
– Surveillance of nosocomial infections
– Employee health program
– Isolation policies
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Infection Control Plan, cont.
• Plan must include, cont.
– Infection control in-service education for employees
– Procedures for environmental sanitation
– Available microbiology laboratory
– Infection control procedures for client care
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Isolation Precaution Guidelines
• Per Centers for Disease Control and Prevention (CDC)
and the Hospital Infection Control Practices Advisory
Committee (HICPAC)
• Two tiers of precautions
– Standard Precautions
• Used for all clients
– Transmission-Based Precautions
• Used with clients with specific infections or
diagnoses
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
**Infection Control Committee
• Provide a central place for reporting infections
• Investigate cases of infection
• Determine the cause of infection
• Maintain total statistics related to the numbers and types
of infections that occur in the facility
• Serve as consultants in cases of questions or concerns by
healthcare personnel
• Work to prevent further recurrences
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Standard Precautions
• First and most important
– Care of all clients, regardless of diagnosis or
infection status
• Universal Precautions
• Designed to reduce the risk of transmission of
blood-borne pathogens
Body Substance Isolation
• Designed to reduce the transmission of pathogens
from moist body substances
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Standard Precautions, cont.
• *Precautions apply to
– Blood
– All body fluids
– Secretions
– Excretions (except sweat)
– Nonintact skin
– Mucous membranes
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Occupational Safety and Health
Administration (OSHA) Regulations:
Blood-Borne Pathogens (BBP)
• Requires and enforces
– Implementation of policies, procedures, and control
measures
– Prevention of employee exposure to the blood and
body fluids of clients
– Provide free hepatitis B immunizations to staff who
might be exposed to blood/body fluids.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Alert
• You must report unusual exposure to potential infection
(eg, a needle stick) immediately.
• OSHA requires initial screening and follow-up care.
• KEY CONCEPT
• *Blood and body fluids flushed , if the amount of fluid or
tissue is too large or bulky to be flushed, it must be
bagged in a biohazard bag
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Transmission-Based Precautions
• Implemented when caring for clients with a suspected or
known infectious disease, based on the disease’s route of
transmission
• Three types
– Airborne precautions
– Droplet precautions
– Contact precautions
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Transmission-Based Precautions, cont.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Airborne Precautions
• *Tiny microorganisms from evaporated droplets remain suspended in
the air or are carried on dust particles
• Air currents disperse the microorganisms; susceptible host can easily
inhale
• *Special air handling and ventilation required to prevent disease
transmission
–
TB
–
Measles
–
Chickenpox
• *Private room with monitored negative airflow pressure
–
6-12 air changes occur/her with air being discharged to the
outdoors or specially filtered before circulating to other areas of
the healthcare facility
• Doors to rooms with airborne precautions kept closed
• Respiratory protection necessary-special mask!!
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Droplet Precautions
• *Droplets containing microorganisms are propelled
through the air from an infected person and deposited on
the host’s eyes, nose, or mouth.
• Transmission
– Sneezing
– Coughing
– Talking
– During procedures such as suctioning
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Droplet Precautions, cont.
• Private room or may share a room with another client with the
same infectious disease
• Room door may remain open
• Wear a mask when working within 3 feet of the client.
• Client wears mask if he/she must be transported to an area
outside the room
• **Examples of diseases on droplet precautions:
– Strept. Pharyngitis
– Pertussis
– Influenza
– Mumps
– rubella
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Contact Precautions
• Most frequent mode of disease transmission in healthcare
facilities*
• Transmission occurs as a result of direct contact between
a susceptible host’s body surface and an infected or
colonized person
• Colonization
– Occurs when a microorganism is present in a client,
but he or she shows no clinical signs or symptoms of
infection
• Indirect contact
– Occurs when a susceptible host comes into contact
with an intermediate contaminated object
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Contact Precautions, cont.
• **Examples include: gastroenterititis and respiratory,
skin and wound infections
• May be placed in a room with other clients who are
infected with the same microorganism if a private room
is unavailable
• Door may remain open
• Wear gloves when entering the room and remove them
before leaving.
• Change your gloves after contact with a client’s infective
material.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Contact Precautions, cont.
• Wash your hands with an antimicrobial agent or
waterless antiseptic agent.
• Wear a gown, gloves, and mask into the room if you
anticipate contact with infectious matter, and remove
them before leaving the room.
• Try to restrict the use of noncritical equipment to one
client only.
• Clean and disinfect equipment before using it for other
clients.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Isolation
• Standard Precautions and Transmission-Based
Precautions are isolation guidelines.
• Two primary types of isolation systems
1. Category-specific isolation
2. Disease-specific isolation
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Category-Specific Isolation
• Specific categories of isolation identified, based on
client’s diagnosis
• Color-coded cards posted outside client’s room
• Visitors check with nurses before entering.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Disease-Specific Isolation
• Single all-purpose sign
• Select the items on the card that are appropriate for the
specific disease that is causing isolation.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Measures in Isolation
• Setting up a client’s room for isolation
– Client must stay in his/her own room
– Follow facility’s policy and procedure for isolation.
– Items to be placed outside the room or in the anteroom
include a stand or cabinet stocked with PPE’s required for
the clients type of isolation*
– Use PPE.
• Education and preparation
– Explain the reasons for the isolation precautions to the
client and family.
– Client may become lonely
• Make every effort to visit!
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Nursing Alert
• If you will be working in a pediatric unit, determine your
immune status regarding the communicable diseases of
childhood.
– Young children may not understand good
handwashing and need supervision
– Keep surfaces clean
– Shared toys must have cleanable surfaces, don’t
share stuffed animals and dolls
• You may require immunization to prevent exposure and
infection.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Administering Medications in Isolation
• Follow Standard Precautions.
• Suggestions for clients in isolation
– *Unwrap medications before going into the client’s
room.
• Rationale: Unwrapping will be difficult to do after
you put on gloves.
– *To avoid accidental needlestick, DO NOT break or
recap needles or detach them from syringes!!
– *If you will need juice or applesauce in which to mix
medications, take it with you into the room.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Isolation: Specimen Collection
• Label container before collecting a specimen.
• Place specimen on a clean paper towel in the anteroom.
• Carefully scrub the container after you are outside the
room.
• Place the specimen into a sealable plastic bag identified
with the standard “biohazard” label.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Isolation: Specimen Collection, cont.
• Wash your hands again.
• Take the specimen to the laboratory as soon as possible.
• Use only clean hands to touch the request cards and the
outside of the bag containing the specimen.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Isolation: Taking Vital Signs
• Use the equipment in the room.
– Do not bring items in with you.
• *Wear gloves and whatever other PPE is indicated.
• *Use disposable thermometers, cuffs, and
stethoscopes if available.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Double-Bagging
• Refuse and linen are “double-bagged” outside the client’s
room.
– Procedure is no longer used in all facilities because
refuse and linen from all clients are considered
contaminated and treated as such
• Requires two nurses
• Nurse inside the room is considered “contaminated”
• Nurse outside is considered “clean”
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Transporting the Client
• When transporting a client in isolation to another area
– Wear PPE as needed.
– Make sure the client wears appropriate PPE as
indicated by his or her condition.
– Control and contain any of the client’s drainage.
– Drape the wheelchair or stretcher with a clean sheet
or bath blanket. Wrap the client with the clean
material.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Antibiotic-Resistant Organisms
• Methicillin-resistant Staphylococcus aureus (MRSA)
– Cultures are taken in nares and/or specific wound or
drainage sites.
• Vancomycin-resistant Enterococcus (VRE)
– Cultures are obtained from the perirectal (around the
rectum) area and/or an open wound or drainage site.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Protective Isolation
• Protective isolation (reverse or neutropenic isolation)
attempts to prevent harmful microorganisms from coming
into contact with the client.
• The client requires a private room or total neutropenic
unit.
• Persons with communicable diseases may not enter.
• Others entering the room must wear a mask and practice
strict handwashing.
• Special linens, scrub suits, and shoe covers may be used.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Protective Isolation (cont’d)
• The client cannot receive fresh fruit, fresh vegetables, or
flowers.
• Rectal temperatures, enemas, suppositories, intravenous
and intramuscular injections, and other invasive
procedures are to be avoided, if possible.
• The tympanic/ear probe or forehead sensor for
monitoring the client’s temperature is recommended.
• A blood culture may be necessary if any reason exists to
suspect infection.
• Special air purification measures are used.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Client on Contact Precaution
• Clients with MRSA and VRE are placed on Contact
Precautions and must have a private room.
• All people interacting with the client must use suitable
PPE, and all equipment remains in the isolated client’s
room.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hepatitis A
• o
Cause-unknown or from contaminated food and seafood
from sewage (feces: animal/human) handling of food from
infected persons who do not wash their hands
• o S/s-incubation for 4 weeks, patient is infectious for 7-10
days
• o Tx: vaccination or if you have had Hep. A, your body may
become immune to future exposures (does not produce a
carrier state)
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hepatitis B
Virus transmitted by sexual contact with infected
individuals, sharing needles with infected individuals,
tattooing, piercing, accidental needlesticks
• o
• o
Incubation period 30-180 days
• o
Tx: Vaccination
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hepatitis C
• o
Mutates rapidly, no vaccine
• o Susceptible people: health care workers, people who have
received blood prior to 1987, tattoos, piercings, multiple sexual
partners, has been detected through breast milk if mothers viral
load is high
• o Virus incubates for 14-180 days, found during bloodwork by
testing for viral RNA or antibodies
• o
Treatment combination therapy
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hepatitis D
• o
Relies on Hepatitis B proteins to reproduce; coinfection
• o
Prevention-Hep. B vaccine
• o Tx: interferon alfa-2b; if fulminant hepatitis-may need liver
transplant
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hepatitis E
• o Rarely seen in the US
• o Dx made by r/o other types of Hepatitis
• o Symptoms occur 15-60 days after exposure
• o Tx: immune globulin
• o Prevention: boiling drinking water, thoroughly cooking meat,
avoid raw foods if traveling
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hepatitis G
• o
Latest hepatitis virus
• o
Transmitted by blood and body fluids
• o
Dx. By detection of Hep. G RNA in blood or liver tissue
• o
Long-term effects unknown
• o
No vaccine, tx is focused on symptom management
•
•
•
Reference
(Durston, S. (2005). What you need to know about viral hepatitis. Nursing2005 35(8), p. 36-42).
•
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
TB
•
Caused by bacillus Mycobacterium Tuberculosis
•
Transmitted AIRBORNE!! When a patient coughs, laughs, or
sings
•
At Risk: residents and employees of LTC facilities and shelters,
prison inmates, alcoholics, IV drug users, homeless, family of TB
patients
•
Latent TB-person is infected without symptoms, healthy
immune system prevents spreading of the disease
•
Active TB-cough, NIGHT SWEATS, fever, chills, tired, weak,
hemoptysis, anorexia and weight loss
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
TB
•
TB mainly affects lungs, can also affect organs or tissues
•
Nsg. Care
•
Airborne precautions: Negative airflow room, special respirator
•
Dx: Mantoux skin test (PPD), if positive
DX confirmed by sputum specimen
•
TX: Combo drug therapy lasting months of INH, rifampin,
pyrazinamide and ethambutol
•
DOT (directly observed therapy)
•
•
(Frakes, M. & Evans. T. (2004) TB-your vigilance is vital. RN, 67(11), p. 30-36)
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
CXR,
Tetanus
•
Infection that affects CNS, produces muscle stiffness, rigidity
and convulsive muscle spasms
•
Caused by Clostridium tetani
•
Found in soil, dust, animal and human feces in dormant form
•
Spores enter body through any scratch or break in skin
•
Can occur in burn victims, patients receiving frequent IM
injdections, tattoos
•
Risk Factors
•
IV drug use, PVD, chronic wounds, DM
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Tetanus
•
•
Incubation-3-21 days
Progression of the disease leads to fixed smile and raised eyebrows,
convulsions may break bones
•
S/S: Wounds more than six hours old, appear infected
•
TX: Clean wounds with current vaccine-NO Vaccine
•
•
Clean wound-unknown vaccine history-Give tetanus booster Td
Deep or dirty wound with uncertain vaccine Hx-administer TIG
(tetanus immune globulin) in addition to tetanus booster
• (Baucom, B. (2006). Help stamp out this lingering menace. RN 69(4), p.
43-49.)
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Streptococcus Pneumonia
S. pneumoniae lives in the respiratory tract of children and adults
At risk: young, elderly, chronically ill
Vaccination offers best defense against disease (PPV); purified
protein vaccine
Vaccine usually only given once, but may be given 3-5 years after
initial vaccination to at risk individuals
• (Schweon, S. (2005). Streptococcus pneumonia. RN 68(10), p.
35-39).
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Streptococcus pharyngitis
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
SWINE FLU 2009
• Pandemic
• Combination of pig (swine), bird (avian) and human gene flu
• S/S: similar to flu (influenza virus) fever, cough, sore throat,
runny or stuffy nose, body aches, headache, chills and fatigue.
Vomiting and diarrhea may also occur
• Greatest affects on ages 5-24 and those with chronic medical
conditions
• Dx-flu swab
• TX-antiviral drugs (oseltamivir and zanamivir) with rare
exception, vaccination
•
Centers for Disease Control. (2009). 2009 H1N1 flu: Situation update. Retrieved September 3, 2009
from http://www.cdc.gov/h1n1flu/update.htm
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Epidemiological Triad
 v Communicable disease transmission depends on the
interacton of the following three factors :
• o
Agent
– Chemical, etc
• o
Host
– Employee
– Susceptible person
– children
• o
Environment
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
C. diff
• Diarrhea
• Caused by antibiotics
• Tx:
– With antibiotic  Metronidazole (Flagyl)
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hepatitis A
• o
Cause-unknown or from contaminated food and seafood
from sewage (feces: animal/human) handling of food from
infected persons who do not wash their hands
• o S/s-incubation for 4 weeks, patient is infectious for 7-10
days
• o Tx: vaccination or if you have had Hep. A, your body may
become immune to future exposures (does not produce a
carrier state)
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hepatitis B
Virus transmitted by sexual contact with infected
individuals, sharing needles with infected individuals,
tattooing, piercing, accidental needlesticks
• o
• o
Incubation period 30-180 days
• o
Tx: Vaccination
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hepatitis C
• o
Mutates rapidly, no vaccine
• o Susceptible people: health care workers, people who have
received blood prior to 1987, tattoos, piercings, multiple sexual
partners, has been detected through breast milk if mothers viral
load is high
• o Virus incubates for 14-180 days, found during bloodwork by
testing for viral RNA or antibodies
• o
Treatment combination therapy
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hepatitis D
• o
Relies on Hepatitis B proteins to reproduce; coinfection
• o
Prevention-Hep. B vaccine
• o Tx: interferon alfa-2b; if fulminant hepatitis-may need liver
transplant
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hepatitis E
• o Rarely seen in the US
• o Dx made by r/o other types of Hepatitis
• o Symptoms occur 15-60 days after exposure
• o Tx: immune globulin
• o Prevention: boiling drinking water, thoroughly cooking meat,
avoid raw foods if traveling
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Hepatitis G
• o
Latest hepatitis virus
• o
Transmitted by blood and body fluids
• o
Dx. By detection of Hep. G RNA in blood or liver tissue
• o
Long-term effects unknown
• o
No vaccine, tx is focused on symptom management
•
•
•
Reference
(Durston, S. (2005). What you need to know about viral hepatitis. Nursing2005 35(8), p. 36-42).
•
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
TB
•
Caused by bacillus Mycobacterium Tuberculosis
•
Transmitted AIRBORNE!! When a patient coughs, laughs, or
sings
•
At Risk: residents and employees of LTC facilities and shelters,
prison inmates, alcoholics, IV drug users, homeless, family of TB
patients
•
Latent TB-person is infected without symptoms, healthy
immune system prevents spreading of the disease
•
Active TB-cough, NIGHT SWEATS, fever, chills, tired, weak,
hemoptysis, anorexia and weight loss
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
TB
•
TB mainly affects lungs, can also affect organs or tissues
•
Nsg. Care
•
Airborne precautions: Negative airflow room, special respirator
•
Dx: Mantoux skin test (PPD), if positive
DX confirmed by sputum specimen
•
TX: Combo drug therapy lasting months of INH, rifampin,
pyrazinamide and ethambutol
•
DOT (directly observed therapy)
•
•
(Frakes, M. & Evans. T. (2004) TB-your vigilance is vital. RN, 67(11), p. 30-36)
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
CXR,
Tetanus
•
Infection that affects CNS, produces muscle stiffness, rigidity
and convulsive muscle spasms
•
Caused by Clostridium tetani
•
Found in soil, dust, animal and human feces in dormant form
•
Spores enter body through any scratch or break in skin
•
Can occur in burn victims, patients receiving frequent IM
injdections, tattoos
•
Risk Factors
•
IV drug use, PVD, chronic wounds, DM
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Tetanus
•
•
Incubation-3-21 days
Progression of the disease leads to fixed smile and raised eyebrows,
convulsions may break bones
•
S/S: Wounds more than six hours old, appear infected
•
TX: Clean wounds with current vaccine-NO Vaccine
•
•
Clean wound-unknown vaccine history-Give tetanus booster Td
Deep or dirty wound with uncertain vaccine Hx-administer TIG
(tetanus immune globulin) in addition to tetanus booster
• (Baucom, B. (2006). Help stamp out this lingering menace. RN 69(4), p.
43-49.)
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Streptococcus Pneumonia
S. pneumoniae lives in the respiratory tract of children and adults
At risk: young, elderly, chronically ill
Vaccination offers best defense against disease (PPV); purified
protein vaccine
Vaccine usually only given once, but may be given 3-5 years after
initial vaccination to at risk individuals
• (Schweon, S. (2005). Streptococcus pneumonia. RN 68(10), p.
35-39).
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
SWINE FLU 2009
• Pandemic
• Combination of pig (swine), bird (avian) and human gene flu
• S/S: similar to flu (influenza virus) fever, cough, sore throat,
runny or stuffy nose, body aches, headache, chills and fatigue.
Vomiting and diarrhea may also occur
• Greatest affects on ages 5-24 and those with chronic medical
conditions
• Dx-flu swab
• TX-antiviral drugs (oseltamivir and zanamivir) with rare
exception, vaccination
•
Centers for Disease Control. (2009). 2009 H1N1 flu: Situation update. Retrieved September 3, 2009
from http://www.cdc.gov/h1n1flu/update.htm
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Epidemiological Triad
 v Communicable disease transmission depends on the
interacton of the following three factors :
• o
Agent
– Chemical, etc
• o
Host
– Employee
– Susceptible person
– children
• o
Environment
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
C. diff
• Diarrhea
• Caused by antibiotics
• Tx:
– With antibiotic  Metronidazole (Flagyl)
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins