Learning Objectives
1. Describe basic procedures of Standard Precautions; state why they are used.
2. Differentiate between endogenous and exogenous organisms.
3. Identify the factors that predispose clients to nosocomial infections.
4. Describe the elements of medical asepsis. Explain how antimicrobial agents and environmental controls contribute to medical asepsis.
5. State the single most effective nursing measure in preventing spread of disease.
6. In the laboratory, demonstrate proper handwashing technique after routine client care, before contact with a severely immunocompromised client, and after performing an invasive procedure. State when hand sanitizers may safely be used.
7. List the most commonly used personal protective equipment.
8. In the skills laboratory, demonstrate the use of barrier techniques.
9. In the skills laboratory, demonstrate teaching of infection control to a client or family member.
10. Describe the nurse’s role in disposal of biohazardous waste and in cleaning up biohazardous materials.
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IMPORTANT TERMINOLOGY |
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antimicrobial agent endogenous |
medical asepsis |
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asepsis exogenous |
Standard Precautions |
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bacteremia invasive |
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Acronym
PPE
Preventing infections is vital to any healthcare facility’s operation and to the provision of healthcare in the community and in the home. Practicing techniques of medical asepsis will help protect you, your clients, and your coworkers from infection.
STANDARD PRECAUTIONS
Because it is impossible to know which clients may be carrying communicable diseases, the Centers for Disease Control and Prevention (CDC) established a set of guidelines to be used in the delivery of all healthcare. These guidelines are called Standard Precautions (Fig. 41-1). Standard Precautions are to be followed at all times by nurses and all other healthcare personnel when delivering any care or performing any procedures. This includes healthcare workers outside the hospital, such as dentists, acupuncturists, home care nurses, and clinic nurses. Because we can never be sure of a client’s infectious status, all clients are treated as though they are infectious. Clients may not know they have an infection or they may not divulge the fact. All exposures to blood or other body fluids have the potential to cause infection. It is vital to protect the nurse and other clients.
If you have any questions, consult the procedures in your facility. It is every nurse’s responsibility to be thoroughly familiar with these guidelines (In Practice: Nursing Care Guidelines 41-1).
Standard Precautions include:
• Maintenance of the nurse’s personal immunizations
• Thorough handwashing (with soap and water or antibacterial solution)
• Wearing gloves and other protective equipment as needed
FIGURE 41-1 · Signs reminding all healthcare personnel to use Standard Precautions are posted in prominent places throughout any healthcare facility. All personnel are expected to follow these guidelines when giving any client care.
• Handling all sharps safely (never recap or break off a needle; dispose of all sharps in the designated container)
• Proper disposal/cleanup of all linens, used equipment, medication packages, and biohazardous materials
• Surface disinfection as needed
• Maintenance of sterility of needles, catheters, and so forth
• Use of mouthpieces for resuscitation
These topics are introduced in this and the next topic and will be referred to throughout this topic.
MEDICAL ASEPSIS
Asepsis refers to practices that minimize or eliminate pathogenic organisms. There are two kinds of asepsis: medical and surgical. Medical asepsis (clean technique) is discussed in this topic; surgical asepsis.Medical asepsis refers to the practice of reducing the number of microorganisms. The goal is to prevent reinfection of the client and prevent or reduce transmission of microorganisms from one person (or
IN PRACTICE: NURSING CARE GUIDELINES 41-1
IMPLEMENTING STANDARD PRECAUTIONS
• Wear gloves when in contact with blood, body fluids containing blood, secretions, excretions, nonintact skin, mucous membranes, or contaminated items and when performing any invasive procedure, including administering injections or checking blood sugar levels. Rationale: Body substances can carry diseases. You may be at risk or you could spread disease.
• Change gloves after each contact with a client or if gloves become perforated or soiled. Double gloves may be worn in certain circumstances. Rationale: Replace gloves if they could be contaminated.
• Wash hands and skin surfaces immediately and thoroughly if they become contaminated with blood or body fluids; after each client contact; and after removing gloves. Rationale: This helps prevent transfer of microorganisms between clients or between clients and the environment. Proper handwashing helps stop the spread of infection.
• Wear a gown or apron when your clothing could become soiled. Rationale: This helps prevent spreading infection to yourself or others.
• Wear a mask, eye protection, and face shield if splashing or spraying of blood or body fluids is possible. Healthcare facility protocol determines the type of eye protection required. Rationale: Infection could enter your body through the mucous membranes of your mouth or nose or through your eyes.
• Do not recap or break needles. Place needles and sharp objects in a special, puncture-resistant container after use. Never put your
hands into the sharps container Use the needleless system, or safety syringes, if available. If not available, use special protective cap to cover needle after use.Rationale: Recapping or breaking a needle poses a possibility of accidental finger stick. Protect yourself and housekeeping personnel.
• Report any exposure to blood or body fluids to your supervisor immediately Rationale: Occupational Safety and Health Administration (OSHA) requires initial screening and follow-up of the accident. Reporting protects your safety as well.
• Clean or process equipment after use with a client. Discard disposable, single-use items. Discard appropriate items in red biohazard disposal bags or bins. Rationale: Proper cleaning and disposal help prevent transmission of infectious microorganisms.
• Place contaminated linen in a leak-proof bag. Rationale: This helps prevent skin and mucous membrane exposure.
• Wipe down all surfaces (e.g., tables, chairs, telephones) frequently with an antimicrobial agent. Rationale: Even if soil is not visible, it is important to provide as clean an environment as possible.
• If any items are used by multiple clients, such as a blood pressure cuff, it must be disinfected between uses. Rationale: This helps prevent cross-contamination.
• Assume all clients have an infectious disease and act accordingly Rationale: It is not possible to determine all sources of infection or contamination. Standard Precautions apply to care of ALL clients.
source) to another. Medical asepsis (clean technique) is used in care of all clients. Surgical asepsis, on the other hand, aims to destroy all organisms and is used only in certain situations.
They are infections that clients acquire while in the facility. A person’s risk of acquiring an infection in a healthcare facility is high for several reasons, which are discussed throughout this and the previous topic.
Nurses and Nosocomial Infections
Healthcare personnel may contribute to development of a nosocomial infection. For example:
• They may fail to use appropriate prevention techniques; the chain of infection is not interrupted.
• Multiple personnel provide care for a client, thus increasing the client’s possibility of exposure to pathogens.
• Healthcare personnel care for multiple clients, thus presenting the possibility of cross-contamination.
• Healthcare personnel may not follow Standard Precautions.
Key Concept Nosocomial infections can lengthen the person’s stay in the healthcare facility increase the cost of treatment, and even cause death.
It has been said that more than one-third of (nosocomial) infections are easily preventable (Miller-Keane & O’Toole, 2005).
NCLEX Alert Infection prevention and client teaching are common NCLEX concepts. You may be given situations in which nurses could contribute to or prevent the spread of nosocomial infections.
Common Nosocomial Infections
According to CDC, the most common nosocomial infections include:
• Genitourinary infections—about 40%
• Bacteremias (generalized bacterial infection)—approximately 14%
• Surgical site infections—approximately 17%
• Respiratory infections (may be secondary to ventilator use or emergency intubation)—approximately 13%
• Gastrointestinal infections
In some cases, endogenous (present within the person’s body) microorganisms cause infection (Table 41-1). In other cases, exogenous (from outside the body) microorganisms are responsible. Salmonella, Clostridium tetani, and Aspergillus species are examples of common exogenous microorganisms that cause nosocomial infections. Gram-negative organisms cause most of today’s nosocomial infections. However, it is predicted that lesser-known pathogens and new strains will cause more infections in the future. It is also predicted that the number of antibiotic-resistant pathogens will increase.
Clients and Nosocomial Infections
NCLEX Alert First or priority actions are common correct NCLEX responses to a clinical scenario. Actions such as "wash your hands," "provide for privacy," or "put on gloves" may be the correct response. The nurse is responsible for protecting the client from complications.
Infections can occur when a person’s resistance (ability to fight off pathogens) is lowered. Several factors can contribute to this:
• Trauma. Injury or illness lowers the body’s resistance as it tries to rebuild itself. Trauma can cause breaks in skin, providing avenues for infection. Examples include burns, compound fractures (bone exposed), stab wounds, and lacerations (cuts).
• Pre-existing disease, generally poor health, or frequent illness. The client may have an infection or condition that has lowered body defenses.
• Age. The very young and the very old have reduced defenses. Immunity that breast-fed newborns receive from their mothers does not protect them against all diseases. Older adults may be poorly nourished, have fragile skin, or be inactive, causing impaired resistance.
• Inactivity. The person who is ill usually does not get much exercise, which leaves the body weakened.
• Poor nutrition/inadequate hydration. The ill person may be malnourished, dehydrated (not enough fluid in tissues or circulation), or overhydrated (too much fluid, fluid retention). Lack of protein hinders the immune system in tissue repair and in making antibodies. Impaired skin integrity is often present, as well as inadequate circulation. Homeless people and people with substance abuse disorders are often in this group.
• Stress or emotional shock. Increased stress increases the body’s cortisone levels, reducing resistance to disease. Prolonged stress may result in exhaustion. Examples include physical stress caused by trauma, such as a motor vehicle accident, or emotional stress, such as the death of a spouse or divorce.
• Fatigue. The person who is extremely tired cannot effectively fight off disease. Those who are fighting illness or injury or who have had surgery are often sleep-deprived.
• Invasive therapy. The term invasive means any therapy that enters or invades the body (by a means other than normal), either through a skin break or incision or through an instrument that enters an otherwise sterile area. Examples of invasive therapy include surgery, injections, intravenous therapy, urinary catheterization, and tracheostomies (a tube inserted into the trachea to open an airway).
• Frequent use of broad-spectrum antibiotics. Microorganisms that the person is harboring may develop resistance to antibiotic therapy after repeated exposure to the same antibiotic. In this case, those antibiotics are later ineffective against the resistant pathogen.
• Inappropriate use of antibiotics. This leads to development of resistant strains of pathogens. For example, the client may stop taking an antibiotic before the full course of therapy is completed, or antibiotics may be prescribed and taken when they are not needed.
• Inadequate primary and secondary defenses. The body’s primary defenses may be altered because of a break in the skin, low white blood cell count, an autoimmune disorder, or diminished lung function.
TABLE 41-1. Examples of Endogenous Microorganisms
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SITE OF NORMAL GROWTH |
ENDOGENOUS ORGANISM |
POSSIBLE INFECTION |
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Skin |
Staphylococcus aureus |
Impetigo, wound infection |
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Staphylococcus epidermidis |
Acne |
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Respiratory tract |
Streptococcus pneumoniae |
Bacterial pneumonia |
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Neisseria species |
Meningitis (inflammation of meninges of nervous system) |
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Colon |
Escherichia coli |
Urinary tract infection |
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Pseudomonas species |
Wound infection |
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Vagina |
Clostridium perfringens |
Diarrhea, gas gangrene |
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Yeasts |
Moniliasis, pneumonia |
• Immunosuppressive situations. The client’s immune system may be inadequate as a result of chemotherapy for cancer or bone marrow transplant, administration of high doses of steroids to reduce inflammation, radiation, or an autoimmune disorder such as AIDS or agammaglobulinemia.
Breaking the Chain of Infection
The use of Standard Precautions in all nursing care is an important factor in controlling the spread of infection. In addition, many nursing procedures are aimed at breaking the chain of infection.Following is a review of this material and ways in which the nurse can help break this chain and reduce the possibility of infection.
• Causative agent. The nurse helps to reduce the number and/or virulence of pathogens. (Administering antibiotic medications; following agency protocols for delivery of care; and careful handwashing or sanitization.)
• Reservoir for growth of pathogens. The nurse helps eliminate areas for pathogens to grow and multiply. (Properly disposing of contaminated dressings or body fluids; disposing of outdated IV solutions and medications; proper cleanup of spills; keeping personal immunizations up to date; using disposable equipment and materials; discarding broken sterile packages; not wearing jewelry, artificial fingernails, or nail polish; and proper handwashing or sanitization.)
• Portal of exit. The nurse gives special attention to respiratory and gastrointestinal tracts and body fluids. (Keeping wounds covered, encouraging safer sex, following correct isolation techniques, and proper handwashing or sanitization.)
• Vehicle of transmission. Careful nursing care eliminates transmission of pathogens between people. (Correctly using masks and gloves; properly disposing of wound drainage, urine, feces, soiled dressings, diapers, or tubing; proper catheterization and injection techniques; keeping urinary drainage equipment sterile; correct handling of body fluids, using waterproof bags for soiled or wet linens; and careful handwashing or sanitization before and after all nursing procedures.)
• Portal of entry. Correct nursing procedures help prevent pathogens from entering a client’s system. (Following protective isolation protocol; cleansing from clean to dirty when giving perineal care; using correct sterile technique; and careful handwashing or sanitization.)
• Susceptible host. Nursing actions are aimed at increasing client resistance to disease. (Promoting adequate nutrition,hydration, and rest; careful monitoring and maintenance of skin integrity; following protocol for administration of antibiotics; administering prescribed medications; giving particular attention to the immunocompromised client’s care; and assisting the client to obtain exercise.)
Key Concept Careful handwashing or sanitization is the most important nursing action in preventing the spread of disease.
• Client history. The nurse obtains a careful history when a client is admitted to the healthcare facility. (Inquire about recent surgery or major illness; new conditions, such as diabetes; any undiagnosed conditions; knowledge of current infection; past related infections; and immunization status.)
Key Concept Nurses are urged not to wear artificial nails because they can harbor infection and conceal soil. Nail polish is also contraindicated because it conceals soil. Many facilities have policies prohibiting anyone giving direct client care from using these products.
Nursing Alert Maintenance of intact skin is of utmost importance because the skin is the first and best barrier to pathogens.
