34 Infection Prevention and Control O B JE CT IVE S Mastery of content in this chapter will enable the student to: • Explain the relationship between the chain of infection and transmission of infection. • Give an example for preventing infection for each element of the infection chain. • Identify the body’s normal defenses against infection. • Discuss the events in the inflammatory response. • Identify clients most at risk for infection. • Describe the signs/symptoms of a localized infection and those of a systemic infection. • Explain conditions that promote the transmission of health care–associated infection. • Explain the difference between medical and surgical asepsis. • Explain the rationale for standard precautions. • Perform proper procedures for hand hygiene. • Explain how infection control measures may differ in the home versus the hospital. • Properly don a surgical mask, sterile gown, and sterile gloves. • Explain procedures for each isolation category. • Understand the definition of occupational exposure. • Explain the postexposure process. MEDIA RESOURCES Companion CD • NCLEX®-Style Review Questions • Audio Glossary • Interactive Learning Activities • English/Spanish Glossary Website ® • NCLEX -Style Review Questions • Audio Glossary • English/Spanish Glossary • Interactive Learning Activities • Weblinks • Audio Summaries • Video Clips • Nursing Skills Online KE Y T E RMS Aerobic, p. 643 Anaerobic, p. 643 Asepsis, p. 654 Asymptomatic, p. 642 Bactericidal, p. 644 Bacteriostasis, p. 644 Broad-spectrum antibiotics, p. 646 Carriers, p. 643 Colonization, p. 642 Communicable disease, p. 642 Contaminated, p. 644 Cough etiquette, p. 661 Disinfection, p. 658 Dose, p. 643 Edema, p. 647 Endogenous infection, p. 648 Epidemiology, p. 668 Exogenous infection, p. 648 Exudates, p. 647 Granulation tissue, p. 648 Hand hygiene, p. 655 Hand washing, p. 655 Health care–acquired infections, p. 648 Health care–associated infections, p. 648 Host resistance, p. 643 Iatrogenic infections, p. 648 Immunocompromised, p. 643 Infectious, p. 642 Inflammatory response, p. 646 Invasive, p. 642 Leukocytosis, p. 648 Localized, p. 645 Medical asepsis, p. 655 Microorganisms, p. 642 Necrotic, p. 646 Normal flora, p. 646 Nosocomial infections, p. 648 Pathogen, p. 642 Pathogenicity, p. 645 Phagocytosis, p. 648 Purulent, p. 648 Sanguineous, p. 648 Serous, p. 648 Standard precautions, p. 655 Sterile field, p. 671 Sterilization, p. 659 Suprainfection, p. 646 Surgical asepsis, p. 668 Susceptibility, p. 645 Suppurative, p. 651 Symptomatic, p. 642 Systemic, p. 645 Vector, p. 644 Virulence, p. 643 T he incident rate of clients developing infections as the direct result of hospital stay and hospital pro- cedures is increasing. Several states have passed legislation requiring hospitals to report their infection rates and specific type of infections. This reporting permits clients to see infection rates for facilities and select their point of care. The Joint Commission (TJC) (2007) is viewing this as a client safety issue. In- fection prevention and control are essential for creating a safe health care environment for clients and staff. As a nurse, you play a primary role in infection prevention and control in all health care settings. Clients in all health care settings are at risk for acquiring infections because of lower resistance to infec- tious microorganisms, increased exposure to numbers and types of disease-causing microorganisms, and invasive procedures. Staff are at risk for exposure to infections as the result of contact with client blood, body fluids, and contaminated equipment and surfaces. In acute care or ambulatory care facilities, clients can be exposed to pathogens, some of which may be resistant to most antibiotics. By practicing basic infection prevention and control techniques, you can avoid spreading microorganisms to clients and sustaining an exposure when providing direct care. In all settings, clients and their families need to be able to recognize sources of infections and institute protective measures. Client teaching needs to include basic information on infection, the various modes of transmission, and methods of prevention appropriate to their care needs. Health care workers protect themselves from contact with infectious material, sharps injury and/or ex- posure to a communicable disease by using knowledge of the infectious process and appropriate person- al protective equipment (PPE). Diseases such as hepatitis B and C, human immunodeficiency virus (HIV) infection, acquired immunodeficiency syndrome (AIDS), tuberculosis (TB), and multidrug-resistant organ- isms require a greater emphasis on infection prevention and control techniques. Nature of Infection Infection is the entry and multiplication of an organism (infectious agent) in a host. If an infectious agent (pathogen) is merely present in a host, it does not mean that infection will occur. If a microorganism is present or invades a host, grows and/or multiplies but does not cause infection, this is referred to as co- lonization. Infections are infectious or communicable. An infectious disease may not pose a risk for transmission. Illness such as viral meningitis or pneumonia are infectious. The illness, although possibly serious for the client, does not pose a risk to others, including caregivers. If the infectious disease can be transmitted directly from one person to another, it is termed a commu- nicable disease. If the pathogens multiply and cause clinical signs and symptoms, the infection is symp- tomatic. If clinical signs and symptoms are not present, the illness is termed asymptomatic. Hepatitis C is 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 client is asymptomatic (Centers for Disease Control and Prevention [CDC], 2001). 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 portal of exit from the reservoir • A mode of transmission • A portal of entry to a host • A susceptible host Infection can develop if this chain remains uninterrupted (Figure 34-1). It is imperative that nurses fol- low infection prevention and control practices to break the chain so that infection will not develop. Infectious Agent. Microorganisms include bacteria, viruses, fungi, and protozoa (Table 34-1). Microor- ganisms on the skin are either resident or transient flora. Resident organisms (normal flora) are perm a- nent residents of the skin, where they survive and multiply without causing illness. It fact, they serve as a major part of the body’s protection. Resident flora on the skin covers the entire exterior of the body and protects against pathogens. It is important to retain and maintain resident flora (CDC, 2002b). Transient microorganisms attach to the skin when a person has contact with another person or object during normal activities. For example, when a nurse touches a bedpan or a contaminated dressing, tran- sient bacteria adhere to the nurse’s skin. The organisms attach loosely to the skin in dirt and grease or under fingernails. These organisms may be readily transmitted unless removed using hand hygiene (Lar- son, 2005). If hands are visibly soiled with proteinaceous material, soap and water is the preferred prac- tice. If hands are not visibly soiled, use of an alcohol-based hand product or hand washing with soap and water is acceptable for disinfecting hands of health care workers (CDC, 2002). The potential for microorganisms or parasites to cause disease depends on the following factors: • Sufficient number of organisms (dose) • Virulence, or ability to survive in the host or outside the body • Ability to enter and survive in the host • Susceptibility of the host (host resistance) Resident skin microorganisms are not virulent. However, they can cause serious infection when sur- gery or other invasive procedures allow them to enter deep tissues or when a client is severely immuno- compromised (has an impaired immune system). Reservoir. A reservoir is a place where a pathogen can survive but may or may not multiply. For exam- ple, hepatitis A virus survives in shellfish but does not multiply; Pseudomonas organisms may survive and multiply in nebulizer reservoirs used in the care of clients with respiratory problems. The most common reservoir is the human body. A variety of microorganisms live on the skin and within the body cavities, fluids, and discharges. The presence of microorganisms does not always cause a person to become ill. Carriers are persons who show no symptoms of illness but who have pathogens on or in their bodies that can be transferred to others. For example, a person can be a carrier of hepatitis B virus without having signs or symptoms of infection. These persons transmit the disease to others through their blood or through sexual contact. Animals, food, water, insects, and inanimate objects can also be reservoirs for infectious organisms. Clostridium botulinum toxin, which causes botulism, survives in improperly processed foods (e.g., home-canned green beans and infant formulas). The bacterium Legionella pneu- mophila, which causes legionnaires’ disease, survives in contaminated water and water systems. To thrive, organisms require a proper environment, including appropriate food, oxygen, water, temperature, pH, and light. Food. Microorganisms require nourishment. Some, such as Clostridium perfringens, the microbe that causes gas gangrene, thrive on organic matter. Others, such as Escherichia coli, consume undigested foodstuff in the bowel. Carbon dioxide and inorganic material such as soil provide nourishment for other organisms. Oxygen. Aerobic bacteria require oxygen for survival and for multiplication sufficient to cause disease. Aerobic organisms cause more infections in humans, when compared with anaerobic organisms. Examples of aerobic organisms are Staphylococcus aureus and strains of Streptococcus organisms. Anaerobic bacte- ria 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. Bacteria that cause tetanus, gas gangrene, and botul- ism are anaerobes. An example of an anaerobic organism is Clostridium difficile, an organism that causes antibiotic-induced diarrhea. Water. Most organisms require water or moisture for survival. For example, a frequent place for mi- croorganisms is the moist drainage from a surgical wound. Some bacteria assume a form, called a spore, that is resistant to drying. Spore-forming bacteria include organisms such as those that cause anthrax, botulism, and tetanus. These can live without water. 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 77° to 108° F (Ritter, 2005). However, some can survive temperature extremes that would be fatal to humans. Cold temperatures tend to prevent growth and reproduction of bacteria (bacteriostasis). A temperature or chemical that destroys bacteria is bactericidal. pH. The acidity of an environment determines the viability of microorganisms. Most microorganisms prefer an environment within a pH range of 5 to 7. Bacteria in particular thrive in urine with an alkaline pH. Most organisms cannot survive the acid environment of the stomach. Acid-reducing medications (e.g., an- tacids and H2 blockers) may cause an overgrowth of gastrointestinal organisms, which can contribute to health care–associated pneumonia in a client receiving these medications (CDC, 2005b). Light. Microorganisms thrive in dark environments such as those under dressings and within body cavities. Portal of Exit. After microorganisms find a site to grow and multiply, they must find a portal of exit if they are to enter another host and cause disease. Portals of exit include sites such as blood, skin and muc- ous membranes, respiratory tract, genitourinary tract, gastrointestinal tract, and transplacental (mother to fetus). Skin and Mucous Membranes. The skin may be considered a portal of exit because any break in the in- tegrity of the skin and mucous membranes may allow pathogens to exit the body. This may be exhibited by the creation of purulent drainage. For example, S. aureus causes a characteristic yellow, creamy drai- nage, and infection with Pseudomonas aeruginosa causes a greenish, creamy drainage. The presence of purulent drainage is a potential portal of exit. Respiratory Tract. Pathogens that infect the respiratory tract, such as Mycobacterium tuberculosis or influenza virus, can be released from the body when an infected person sneezes or coughs. The act of coughing or sneezing allows for organisms to exit the respiratory tract. In clients with artificial airways such as tracheostomy or endotracheal tubes, organisms easily exit the respiratory tract through these devices when the device is manipulated or suctioned (see Chapter 40). Urinary Tract. Normally urine is sterile. However, when a client has a urinary tract infection (UTI), mi- croorganisms exit during urination or through urinary diversions such as ileostomies and suprapubic drains (see Chapter 45). Gastrointestinal Tract. The mouth is one of the most bacterially contaminated sites of the human body, but most of the organisms are normal flora. Organisms that are normal flora in one person can be patho- gens in another. Organisms, for example, exit when a person expectorates saliva. Kissing can also pro- vide a means of exit. For example, Neisseria, the organism responsible for meningitis in young adults, is normal flora in the mouth and is transmitted to another person via kissing. In addition, gastrointestinal por- tals of exit include bowel elimination, drainage of bile via surgical wounds, or drainage tubes. Reproductive Tract. Organisms such as Neisseria gonorrhoeae and HIV may exit through a man’s urethral meatus or a woman’s vaginal canal during sexual contact. HIV is present in much higher num- bers in semen than in female vaginal secretions. Blood. The blood is normally a sterile body fluid, but in the case of communicable diseases such as hepatitis B or C or HIV it becomes a reservoir for pathogens. Caregivers may become exposed during activities such as blood drawing, starting an intravenous (IV) line, or giving an injection unless standard precautions are taken and needle-safe devices are used. A blood-borne pathogen exposure involves be- ing stuck with a sharp contaminated with infected blood. Modes of Transmission. Each disease has a specific mode of transmission. For example, some types of encephalitis are transmitted by infected mosquitoes. The mosquito serves as a vector, transmitting the virus when it bites the host. Table 34-2 summarizes the most common modes of transmission. However, some microorganisms may be transmitted by more than one route. For example, varicella zoster (chick- enpox) may be spread by the airborne route in droplet nuclei or by direct contact. The major route of transmission for pathogens identified in the health care setting is the unwashed hands of the health care worker (CDC, 2002b; Cipriano, 2007). Equipment used within the environment (e.g., a stethoscope, blood pressure cuff, bedside commode, or shower chair) can become a source for the transmission of pathogens. All hospital personnel providing direct care (e.g., nurses, physical therap- ists, and physicians) and persons performing diagnostic and support services (e.g., laboratory techni- cians, respiratory therapists, and dietary workers) must follow infection prevention and control practices to minimize the spread of infection. Each group follows procedures for handling and cleaning equipment and supplies used by a client. For example, respiratory therapists perform hand hygiene before working with each client and dispose of or clean contaminated therapy equipment according to established infection prevention and control procedures. Medical devices and the performance of diagnostic procedures pro- vide a mode of entry for pathogens. For example, starting a line for IV infusion introduces bacteria if the skin is not properly cleansed. Invasive procedures such as cystoscopy (visualization of the bladder) also increase the risk of introducing infection. Because so many factors promote the spread of infection to a client, all health care workers must be diligent in using infection prevention and control practices, such as proper hand hygiene and ensuring that shared equipment is adequately cleaned, disinfected, and/or steri- lized before it is used again. Portal of Entry. Organisms enter the body through the same routes they use for exiting. For example, when a needle pierces a client’s skin, organisms enter the body if a proper skin preparation is not per- formed. Any obstruction to the flow of urine from a urinary catheter allows organisms to migrate up the urethra. Factors that reduce the body’s defenses enhance the chances of pathogens entering the body. Susceptible Host. Whether a person acquires an infection depends on susceptibility to an infectious agent. Susceptibility depends on the individual degree of resistance to a pathogen (immune response). Although everyone is constantly in contact with large numbers of microorganisms, an infection does not develop until an individual becomes susceptible to the strength and numbers of microorganisms (dose) capable of producing infection. The more virulent an organism, the greater the dose, the more likely a person will develop an infection. Some of the factors that influence a person’s susceptibility (resistance) include age, nutritional status, presence of chronic disease, trauma, and smoking. Organisms with resis- tance to key antibiotics are becoming more common in all health care settings, but especially acute care. This is associated with the frequent and sometimes inappropriate use of antibiotics over the years in all settings (i.e., acute care, ambulatory care, clinics, and long-term care). The Infectious Process By understanding the chain of infection, you are vital in preventing infections. When the client acquires an infection, observe for signs and symptoms of infection and take appropriate actions to prevent its spread. Infections follow a progressive course (Box 34-1). The severity of the client’s illness depends on the extent of the infection, the pathogenicity of the microorganisms, dose of the organism, and the sus- ceptibility of the host. If an infection is localized (e.g., a wound infection), the client usually experiences localized symptoms, such as pain and 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 will block the spread of infection to other sites or clients. 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. The course of an infection influences the level of nursing care provided. The nurse is responsible for properly administering antibiotics, monitoring the response to drug therapy (see Chapter 35), and using proper hand hygiene and standard precautions. Supportive therapy includes providing adequate nutr i- tion and rest to bolster defenses against the infectious process. The course of care for the client may have additional effects on body systems affected by the infection. The nurse plays a vital role in the control of infection whether infection is localized or systemic. For example, if the nurse uses improper hand hygiene and skin preparation technique, the organism cau s- ing wound infection can be transferred to that same client’s IV site. Infection from one client’s wound infection can transfer to another clients’ tracheostomy site. Nurses who have breaks in their own skin are at risk for infections from blood or tissues if proper infection prevention and control practices, such as gloves and proper hand hygiene, are not used. However, if the nurse has an open area too large to be covered with a dressing, the nurse should not perform client care procedures (CDC, 2002b; Occ u- pational Safety and Health Administration [OSHA], 2001). Defenses Against Infection The body has normal defenses, which protect against infection. Normal body flora that reside inside and outside of the body protect a person against pathogens. Intact skin protects from pathogens, and linings of the nasal passageways act to prevent organisms from entering the lungs. Each organ system has de- fense mechanisms that work to prevent exposure to infection. The inflammatory response is a protec- tive reaction that serves to neutralize pathogens and repair body cells. Normal flora, body system de- fenses, and inflammation are all nonspecific defenses that protect against microorganisms regardless of prior exposure. The immune system is composed of separate cells that help the body resist disease. Cer- tain responses of the immune system are nonspecific, whereas others are specific defenses against spe- cific pathogens. If any of the body’s defenses fail, an infection can occur. This infection may lead to a se- rious health problem. Normal Flora. 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 flora do not usually cause disease when residing in their usual area of the body but instead participate in maintaining health. Normal flora of the large intestine exist in large numbers without causing illness. Normal flora also se- crete antibacterial substances within the intestine’s walls. The skin’s normal flora exert a protective, bacte- ricidal action that kills organisms landing on the skin. The mouth and pharynx are also protected by flora that impair growth of invading microbes. Normal flora maintain a sensitive balance with other microorgan- isms to prevent infection. Any factor that disrupts this balance places a person at increased risk for acquir- ing 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 flora are eliminated, the body’s defenses are reduced, which allows for disease-producing microorganisms to multiply, causing ill- ness. Body System Defenses. A number of the body’s organ systems have unique defenses against infection (Table 34-3). The skin, respiratory tract, and gastrointestinal tract are easily accessible to microorgan- isms. Pathogenic organisms can adhere to the skin’s surface, be inhaled into the lungs, or be ingested with food. Each organ system has defense mechanisms physiologically suited to its specific structure and function. For example, the lungs cannot completely control the entrance of microorganisms. However, the airways are lined with moist mucous membranes and with hairlike projections, or cilia, that rhythmically beat to move mucus or cellular debris up to the pharynx to be expelled. Inflammation. The body’s cellular response to injury, infection, or irritation is termed inflammation. In- flammation 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 may include swelling, redness, heat, pain or tenderness, and loss of function in the affected body part. When inflammation becomes sys- temic, other signs and symptoms develop, including fever, leukocytosis, malaise, anorexia, nausea, vo- miting, lymph node enlargement, or organ failure. The inflammatory response may be triggered by physical agents, chemical agents, or microorganisms. 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. Microorganisms may also trigger this response. After tissues are injured, a series of well-coordinated events occurs. The inflammatory response in- cludes 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 Vascular and Cellular Responses. Acute inflammation is an immediate response to cellular injury. When this occurs, rapid vasodilatation occurs, which allows more blood near the location of the injury. The in- crease in local blood flow causes the redness at the site of inflammation. The localized warmth at the site is also the result of a greater volume of blood. Local vasodilatation delivers blood and white blood cells (WBCs) to injured tissues. Serum proteins play a major role in inflammation. These include kinins, va- soactive amines, prostaglandins, and certain complement components. These serve to increase vasodila- tation. Neutrophils present at the site of infection serve as the first line of defense from microorganisms. If this does not occur, then chronic inflammation will result. Injury causes tissue damage and possibly necrosis, and as a result the body releases chemical media- tors that increase the permeability of small blood vessels. As a result, fluid, protein, and cells enter inters- titial spaces. The accumulation of fluid appears as localized swelling (edema). Another sign of inflamma- tion 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 undergo a tempo- rary loss of function. For example, a localized infection of the hand causes the fingers to become swollen, painful, and discolored. Joints may become stiff as a result of swelling, but function of the fingers returns when inflammation subsides. The cellular response of inflammation involves 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 3 body’s response to WBCs leaving blood vessels. A serum WBC count is normally 5000 to 10,000/mm 3 but may rise to 15,000 to 20,000/mm and higher during inflammation. Fever is caused by phagocytic re- lease of pyrogens from bacterial cells that cause a rise in the hypothalamic set point (see Chapter 32). 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 lymphat- ic drainage. Platelets and plasma proteins such as fibrinogen form a meshlike matrix at the site of inflam- mation to prevent its spread. 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 appear- ance as the previous cells. If inflammation is chronic, tissue defects may fill with fragile granulation tis- sue. Granulation tissue is not as strong as tissue collagen and assumes the form of scar tissue. Health Care–Associated Infections Clients in health care settings may have an increased risk of acquiring infections. Health care– associated infections (HAIs), formerly called nosocomial or health care–acquired infections, result from delivery of health services in a health care facility. They can occur as the result of invasive proce- dures, antibiotic administration, the presence of multidrug-resistant organisms, and breaks in infection prevention and control activities. Iatrogenic infections are a type of HAI from a diagnostic or therapeutic procedure. For example, fol- lowing a gastrointestinal endoscopy the client developed a P. aeruginosa infection. Use critical thinking when practicing aseptic techniques and following basic infection prevention and control policies and pro- cedures to reduce the incidence of HAIs. Always consider the client’s risks for infection, and anticipate how the approach to care may increase or decrease the risk. Health care–associated infections are exogenous or endogenous. An exogenous organism is one that is present outside the client. For example, a postoperative infection is an exogenous infection. Endo- genous organisms are part of normal flora or virulent organisms residing that could cause infection. An endogenous infection can occur when part of the client’s flora becomes altered and an overgrowth re- sults. For example, a client is placed on several antibiotics in the hospital setting and develops C. difficile infection as a result. The number of health care employees having direct contact with a client, the type and number of inva- sive procedures, the therapy received, and the length of hospitalization influence the risk of infection. Ma- jor sites for HAIs include surgical or traumatic wounds, urinary and respiratory tracts, and the bloodstream (Box 34-2). Health care–associated infections significantly increase costs of health care. Older adults have increased susceptibility to these infections because of their affinity to chronic disease and the aging process itself (Box 34-3). Extended stays in health care institutions, increased disability, increased costs of antibiotics, and pro- longed recovery times add to the expenses of the client, as well as the expenses of the health care institution and funding bodies (e.g., Medicare). Often costs for HAIs are not reimbursed; as a result, prevention has a beneficial financial impact and is an important part of managed care. TJC has listed several national safety goals focusing on the care of older adults, for example, ensuring that older adults receive influenza and pneumonia vaccine or preventing health care–associated pressure ulcers (TJC, 2007). The Nursing Process in Infection Control Assessment Assess the client’s defense mechanisms, susceptibility, and knowledge of how infections are transmitted (Table 34-4). Conduct a review of disease and travel history with the client and family to reveal an expo- sure to a communicable disease. Immunization and vaccination history is also very useful. Conduct a tho- rough review of the client’s clinical condition to identify signs and symptoms of actual infection or a risk for infection. An analysis of laboratory findings provides information about a client’s defense against infec- tion. By knowing the factors that increase susceptibility or risk for infection and recognizing early signs and symptoms, you are able to plan appropriate interventions. Status of Defense Mechanisms. Review physical assessment findings and the client’s medical condition to determine the status of normal defense mechanisms against infection. For example, any break in the skin, such as an ulcer on the foot of a client who has diabetes, is a potential site for infection. Similarly, a client who smokes is at greater risk for acquiring a respiratory tract infection after general surgery be- cause respiratory cilia are less likely to propel retained mucus from the client’s airways. Any reduction in the body’s primary or secondary defenses against infection places a client at increased risk. Client Susceptibility. Many factors influence susceptibility to infection. Gather information about each factor through the client’s and family’s history. Age. Throughout life, susceptibility to infection changes. For example, an infant has immature de- fenses against infection. Born with only the antibodies provided by the mother, the infant’s immune sys- tem is incapable of producing the necessary immunoglobulins and WBCs to adequately fight some infec- tions. However, breast-fed infants may have greater immunity than bottle-fed infants, because they re- ceive the mother’s antibodies through the breast milk. As the child grows, the immune system matures, but the child is still susceptible to organisms that cause the common cold, intestinal infections, and infec- tious diseases such as mumps, measles, and chickenpox if not vaccinated. The young or middle-age adult has refined defenses against infection. Normal flora, body system de- fenses, inflammation, and the immune response provide protection against invading microorganisms. Vi- ruses are the most common cause of communicable illness in young or middle-age adults. Since 2000, there has been a major effort to vaccinate all children against all diseases for which vaccine is available. The result is a significant decline in the number of cases occurring. For example, hepatitis B infection in children and adolescents has decreased by 89% (CDC, 2005b). Defenses against infection change with aging (Lesser, Paiusi, and Leips, 2006). The immune response, particularly cell-mediated immunity, declines. Older adults also undergo alterations in the structure and func- tion of the skin, urinary tract, and lungs. For example, the skin loses its turgor, and the epithelium thins. As a result, it is easier to tear or abrade the skin, and this increases the potential for invasion by pathogens. Nutritional Status. When protein intake is inadequate as a result of poor diet or debilitating disease, the rate of protein breakdown exceeds that of tissue synthesis (see Chapter 44). A reduction in the intake of protein and other nutrients such as carbohydrates and fats reduces the body’s defenses against infec- tion and impairs wound healing (see Chapter 48). Clients with illnesses or problems that increase protein requirements are at further risk. These prob- lems include traumatic injury, extensive burns, and conditions causing fever. Clients who have had sur- gery also require increased protein. The nurse assesses clients’ dietary intakes and abilities to tolerate solid foods. C lients who have dif- ficulty with swallowing, who experience alterations in digestion, or who are too confused or weak to feed themselves are at risk for inadequate dietary intake. Obese clients will benefit from dietary a s- sessment. Confer with a dietitian to assist in calculating the calorie count of foods ingested. Stress. The body responds to emotional or physical stress by the general adaptation syndrome (see Chapter 31). During the alarm stage the basal metabolic rate increases as the body uses energy stores. Adrenocorticotropic hormone (ACTH) acts to increase serum glucose levels and decrease unnecessary antiinflammatory responses through the release of cortisone. If stress continues or becomes intense, ele- vated cortisone levels result in decreased resistance to infection. Continued stress leads to exhaustion, in which energy stores are depleted and the body has no resistance to invading organisms. The same con- ditions that increase nutritional requirements, such as surgery or trauma, also increase physiological stress. For example, meningitis is a seasonal disease commonly occurring in high schools and colleges around examination time. Students are under stress, not eating properly, and not getting enough sleep. Their resistance is lowered, and they are more prone to illness. Disease Process. Clients with diseases of the immune system are at particular risk for infection. Leukemia, AIDS, lymphoma, and aplastic anemia are conditions that compromise a host by weakening defenses against infectious organisms. For example, clients with leukemia are unable to produce enough WBCs to ward off infection. Clients with HIV are often unable to ward off simple infections and are prone to opportu- nistic infections. Clients with chronic diseases such as diabetes mellitus and multiple sclerosis are also more susceptible to infection because of general debilitation and nutritional impairment. Diseases that impair body system defenses, such as emphysema and bronchitis (which impair ciliary action and thicken mucus), cancer (which alters the immune response), and peripheral vascular disease (which reduces blood flow to injured tissues), increase susceptibility to infection. Clients with burns have a very high susceptibility to infection because of the damage to skin surfaces. The greater the depth and extent of the burns, the higher the risk for infection. Medical Therapy. Some drugs and medical therapies compromise immunity to infection. The nurse assesses the client’s history to determine whether the client takes medications at home that increase in- fection susceptibility. The medication assessment includes any over-the-counter medications and herbal medications. A review of therapies received within the health care setting further reveals risks. Adrenal corticosteroids, prescribed for several conditions, are antiinflammatory drugs that cause protein break- down and impair the inflammatory response against bacteria and other pathogens. Cytotoxic or antineop- lastic drugs attack cancer cells but cause side effects of bone marrow depression and normal cell toxicity. With bone marrow depression the body is unable to produce lymphocytes and sufficient WBCs. When normal cells become altered by antineoplastic agents, cellular defenses against infection fail. Cyclospo- rine and other immunosuppressant drugs, which decrease the body’s immune response, are commonly taken by clients who receive organ transplants. The immunosuppressants prevent organ and tissue rejec- tion, but they also increase susceptibility to infection. 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 the area for redness and swelling caused by in- flammation. 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 secre- tions may indicate a sinus infection. Ask the client about pain or tenderness around the site. Some clients may complain of tightness and pain caused by edema. If the infected area is large enough, movement may be restricted. Gentle palpation of an infected area usually results in some degree of tenderness. In addition to gloves, wear a surgical mask to prevent additional contamination of the wound. Wear protec- tive eyewear when there is a risk for splash or spray with blood or body fluids. Systemic infections cause more generalized symptoms than local infection. They usually result in fev- er, fatigue, nausea/vomiting, and malaise. Lymph nodes that drain the area of infection often become en- larged, swollen, and tender during palpation. For example, an abscess in the peritoneal cavity may cause enlargement of lymph nodes in the groin. An infection of the upper respiratory tract may cause cervical lymph node enlargement. If an infection is serious and widespread, all major lymph nodes may enlarge. Systemic infections can develop after treatment for localized infection has failed. Be alert for changes in the client’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. In- volvement of major body systems produces specific symptoms. For example, a pulmonary infection may result in a productive cough with purulent sputum. A urinary tract infection may result in cloudy, foul- smelling urine. An infection does not always present with typical signs and symptoms in all clients. It is not unusual to find that older adults have an advanced infection before it is identified. This is because due to age there is a reduced inflammatory and immune response. Older adults have increased fatigue and diminished pain sensitivity. A reduced or absent fever response can occur from chronic use of aspirin or nonsteroid- al antiinflammatory drugs. Atypical symptoms such as confusion, incontinence, or agitation may be the only symptoms of an infectious illness (Gantz, 2005). For example, as many as 20% of older adults with pneumonia do not have the typical signs and symptoms of fever, shaking, chills, and rusty productive sputum. The only symptoms are often an increased, unexplained heart rate, confusion, or generalized fatigue. A pneumonia vaccine is available and recommended for all persons with respiratory problems and those over 65 years of age. This will greatly assist in the decline of pneumonia in the older adult population. Laboratory Data. A review of laboratory test results may reveal infection (Table 34-5). Laboratory val- ues, however, are not enough to detect infection. You need to assess other clinical signs. Factors other than infection may alter test values. For example, trauma and physical stress can cause an elevation in the number of neutrophils. A culture result may show growth of an organism in the absence of infection. It is also important to note that laboratory values may vary from laboratory to laboratory. Be sure to know the standard range of laboratory values for the laboratory in your facility. Clients With Infection. Some clients with infection have a variety of problems. It is important to ask spe- cific questions to assesses the client’s and family’s needs related to disease status (Box 34-4). These needs are physical, psychological, social, or economic. For example, a client with a chronic disease such as HIV/AIDS may experience serious psychological problems as a result of self-imposed isolation or re- jection by family and friends. Clients or their families may not be able to afford the cost of medical care. Using a case management approach, the nurse determines the client’s and family’s ability to adjust to the disease and identifies available resources needed for managing health care challenges, such as referrals to area group meetings that may assist a client with acceptance of the illness or referral to local agency resources for assistance with prescription drug expenses. Nursing Diagnosis During assessment gather objective data, such as an open incision or a reduced caloric intake, and sub- jective data, such as a client’s complaint of tenderness over a surgical wound site. Then review the data carefully, looking for clusters of characteristics or risk factors that create a pattern. This pattern may sug- gest a specific nursing diagnosis (Box 34-5). The following are examples of nursing diagnoses: • Risk for infection • Imbalanced nutrition: less than body requirements • Impaired oral mucous membrane • Risk for impaired skin integrity • Social isolation • Impaired tissue integrity It is necessary to validate data, such as inspecting the integrity of a wound more carefully, and to re- view laboratory findings as needed. Success in planning appropriate nursing interventions depends on the accuracy of the diagnosis and the ability to meet the client’s needs. For example, minimizing the risk for infection related to broken skin requires proper hygiene measures, wound care, and use of standard precautions. Minimizing the risk for infection related to malnutrition requires good nutritional support and fluid balance. Planning Goals and Outcomes. The client’s care plan is based on each nursing diagnosis and related factor (see Care Plan). Develop a plan that sets realistic outcomes so that interventions are purposeful and directed. When you care for a client with the nursing diagnosis of risk for infection related to broken skin, imple- ment skin and wound care measures to promote healing. The expected outcomes of ―reduction in wound size by 1 cm‖ and ―absence of drainage‖ set targets for measuring the client’s improvement. Common goals of care applicable to clients with infection often include the following: • Preventing exposure to infectious organisms • Controlling or reducing the extent of infection • Maintaining resistance to infection • Verbalizing understanding of infection prevention and control techniques (e.g., hand hygiene) Setting Priorities. Establish priorities for each goal of care. For example, your client developed an open wound, suffers a debilitating disease such as cancer, and is unable to tolerate solid foods. The priority of administering therapies to promote wound healing overrides the goal of educating the client to assume self-care therapies at home. When the client’s condition improves, the priorities will change, and client education becomes an essential intervention. Collaborative Care. The development of a care plan includes prevention and infection control practi c- es from multiple disciplines. Select interventions in collaboration with the client, the family, and others on the health care team such as the dietitian or respiratory therapist. In addition, the infection preven- tion and control professional (IPCP) or home care nurses collaborate in the client’s care. When care continues into the client’s home, the home care nurse plans to ensure that the home environment su p- ports good infection prevention and control practices. For example, if a client does not have running water yet requires wound care, even simple hand hygiene with soap and water is difficult to achieve. The nurse will need to bring a waterless alcohol product during visits to ensure adequate hand hygiene. Use bottled water if hands are visibly soiled. Instruct the client to use hand hygiene with either bottled water and soap or alcohol-based hand products. Implementation By identifying and assessing a client’s risk factors and implementing appropriate measures, the nurse re- duces the risk of infection. Health Promotion. Use your critical thinking skills to prevent an infection from developing or spreading. Implement procedures to minimize the numbers and kinds of organisms that could be possibly transmit- ted. Eliminating reservoirs of infection, controlling portals of exit and entry, and avoiding actions that transmit microorganisms prevent bacteria from finding a new site in which to grow. Proper use of sterile supplies, barrier precautions, standard precautions, transmission-based precautions, and proper hand hygiene are examples of methods to control the spread of microorganisms. A final preventive measure is to strengthen a potential host’s defenses against infection. Nutritional support, rest, maintenance of phy- siological protective mechanisms, and recommended immunizations protect a client. For example, annual vaccination to protect against influenza is an important element of risk reduction. NURSING CARE PLAN Risk for Infection Assessment Mr. Huntly is a 32-year-old married father of two admitted to the medical nursing unit 5 days ago with a diagnosis of HIV infec- tion. He received his first doses of antiretroviral drugs. Before his admission he lost interest in food and noticed that his intake decreased. His children are school aged and attend public school. Both children have stayed home from school twice in the last 2 months for colds and sore throats. Sara Jones is the nursing student caring for Mr. Huntly. She begins her shift of care by con- ducting a focused assessment. Assessment Activities Findings/Defining Characteristics Review client’s chart for laboratory data reflecting im- The number of CD4 cells is low. mune function (e.g., WBC count; CD4 count; viral load). Ask client to describe appetite and review food intake for Client reports a decreased interest in eating for a couple of weeks. He last 24 hours. lost approximately 8 pounds in 3 weeks. His food intake yesterday con- sisted of a small cup of applesauce, one-half bowl of soup, some crack- ers, and two glasses of juice. Weigh client. Measure height. His current weight is 155 pounds; height is 5 feet 10 inches. Palpate client’s cervical and clavicular lymph nodes. Lymph nodes are enlarged and pain free. Assess client’s complete medication history. Client receiving multiagent chemotherapy. Nursing Diagnosis: Risk for infection related to immunosuppression and reduced food intake. Planning Goal Expected Outcomes (NOC)* Immune Status Client will remain free of infection. Client will remain afebrile. Client will have no signs or symptoms of local infection (e.g., remains free of cough, cloudy or foul-smelling urine, oral lesions). Knowledge: Infection Management Client describes risks for infection in 2 weeks. Client will identify routines to follow in the home that reduce risk for infection. Client will identify signs and symptoms to report to health care provider indicating infection. †Outcome classification labels from Moorhead S and others: Nursing outcomes classification (NOC), ed 4, St. Louis, 2008, Mosby. Interventions† Rationale Infection Protection • Monitor client’s body temperature routinely, inspect oral Interventions help prevent and ensure early detection of infection in a cavity for lesions, inspect urine for odor, inspect IV access client at risk (Fauerbach, 2005). site for drainage, and observe client for evidence of cough. • Consult with dietitian in providing a high-calorie, high- Maintaining calorie and protein intake will prevent weight loss. protein, low-bacteria diet. Minimize intake of salads, raw Foods high in fat should be avoided. Excessive amounts of omega fruits and vegetables and undercooked meat, pepper, and pa- fatty acids are immunosuppressive (Gantz, 2005). prika. Offer small frequent meals. Infection Control • Teach client and family how to perform hand hygiene cor- Client can easily come in contact with organisms in the environment rectly. that can cause infection. Rigorous hand hygiene reduces Me- taOT-NormalItalic bacterial counts on the hands (Larson, 2005). • Instruct client to report the following to his caregiver: tem- Signs and symptoms are indicative of local or systemic infection. perature greater than 100° F (38° C), persistent cough with or without sputum, urine that is cloudy or foul smelling, or burning on urination. • Teach client and family the following: These measures are designed to prevent infection in those clients • Avoid crowds and large gatherings of people. with impaired immune function (Gantz, 2005). • Do not share personal toilet items (toothbrush, washcloth, deodorant stick) with family. • Take temperature twice daily. • Do not drink water that has been standing for longer than 15 minutes. • Do not reuse cups or glasses without washing; whenever possible, use the dishwasher. • Use of condoms during intercourse. Do not pass or receive body fluids, particularly blood, semen, or vaginal secretions. Evaluation Nursing Actions Client Response/Finding Achievement of Outcome Compare client’s body temperature and Client remains afebrile and denies having Client has no active infection at this time. other physical findings with baseline da- cough or burning on urination. No sign of ta. oral lesions Ask client to describe signs and symptoms Client able to identify temperature range to Client has partial understanding of signs to report to health care provider. report. Was able to describe cough. Una- and symptoms to report. Will require ad- ble to identify signs of urinary infection or ditional instruction. Offer information local discharge. sheet. Ask client to explain the measures to take Client able to discuss need to avoid sharing Client has partial understanding of restric- at home to reduce exposure to infectious personal hygiene articles and to wash fresh tions. Will obtain printed guidelines and agents. produce. Asked for a listing of other pre- include wife in discussion this evening. cautions and requested that his wife be in- cluded in discussion. †Intervention classification labels from Bulechek GM, Butcher HK, and Dochterman JM: Nursing interventions classification (NIC), ed 5, St. Louis, 2008, Mosby. Having an infection prevention and control conscience helps you apply principles of medical-surgical asepsis. When a client develops an infection, implement techniques and procedures to reduce the oppor- tunity for health care personnel and other clients to be exposed to the infection. Clients with communica- ble diseases may require specific isolation precautions to break the chain of infection. Acute Care. Treatment of an infectious process includes eliminating the infectious organisms and sup- porting the client’s defenses. To identify the causative organism, the nurse collects specimens of body fluids such as sputum or drainage from infected body sites for cultures. When the disease process or causative organism is identified, the health care provider prescribes the most effective treatment. Systemic infections require measures to prevent complications of fever (see Chapter 32). Maintaining intake of fluids prevents dehydration resulting from diaphoresis. The client’s increased metabolic rate re- quires an adequate nutritional intake. Rest preserves energy for the healing process. Localized infections often require measures to assist removal of debris to promote healing. The nurse applies principles of wound care to remove infected drainage from wound sites and support the integrity of healing wounds. When changing a dressing, wear a mask and goggles or a mask with a face shield if splashing or spraying with blood or body fluids is anticipated. Apply gloves to reduce the transmission of microorganisms into the wound (CDC, 2007). Apply special dressings to facilitate removal of drainage and promote healing of wound margins. Sometimes drainage tubes are inserted to remove infected drai- nage from body cavities. Use medical and surgical aseptic techniques to manage wounds and ensure correct handling of all drainage or body fluids (see Chapter 48). During the course of infection the nurse supports the client’s body defense mechanisms. For example, if a client has diarrhea, the nurse needs to maintain skin integrity to prevent breakdown and the entrance of additional microorganisms. Other routine hygiene measures such as cleansing the oral cavity and bath- ing protect the skin and mucous membranes from invasion and overgrowth of organisms. Asepsis. Base efforts to minimize the onset and spread of infection on the principles of aseptic tec h- nique. Asepsis is the absence of pathogenic (disease-producing) microorganisms. Aseptic technique refers to practices/procedures that assist in reducing the risk for infection. The two types of aseptic technique are medical and surgical asepsis. Medical asepsis, or clean technique, includes procedures used to reduce the number of organisms present and prevent the transfer of organisms. Hand hygiene, using clean gloves to prevent the transfer of organisms from one client to another or to prevent direct contact with client blood or body fluids, and cleaning the environment routinely are examples of medical asepsis. Principles of medical asepsis are also commonly followed in the home; hand hygiene with soap and water before preparing food is an ex- ample. After an object becomes unsterile or unclean, it is considered contaminated. In medical asepsis an area or object is considered contaminated if it contains or is suspected of containing pathogens. For ex- ample, a used bedpan, the over-bed table, and a used dressing are considered to be contaminated items. The nurse follows certain principles and procedures, including standard precautions, to prevent and control infection and its spread. During daily routine care the nurse uses basic medical aseptic techniques to break the infection chain. For example, use gloves and a mask during a dressing change to break the mode of entry for pathogens. Eyewear is indicated whenever there is the possibility for splash or splatter. The term standard precautions applies to all blood and body fluids except sweat even if blood is not present. Standard precautions apply to contact with blood, body fluid, nonintact skin, and mucous mem- branes from all clients. These precautions protect the client and provide protection of the health care staff as directed by the Occupational Safety and Health Administration (OSHA) (2001). A major component of client and worker protection is hand hygiene (Skill 34-1). Hand hygiene in- cludes using an instant alcohol hand antiseptic before and after providing client care, hand washing with soap and water when hands are visibly soiled, and performing a surgical scrub. Hand washing is the act of washing hands with soap and water, followed by rinsing under a stream of water for 15 seconds (CDC, 2002b). The friction used removes soil and transient organisms from the hands. Contaminated hands of health care workers are a primary source of infection transmission in the health care settings For example, you are performing a dressing change, and the client’s roommate asks for as- sistance with a blocked IV line. If you fail to perform hand hygiene before handling the IV line, organisms from the client’s wound could be transferred to the roommate’s IV site. TJC has identified compliance with proper hand hygiene as a National Patient Safety Goal (TJC, 2007). The use of alcohol-based hand rubs is recommended by the Centers for Disease Control and Preven- tion (CDC) (2002b) to improve hand hygiene practices, protect health care worker’s hands, and reduce transmission of pathogens to clients and personnel in health care settings. Alcohols have excellent ger- micidal activity and are as effective than either soap and water. The CDC (2002b) recommends the following: 1. Wash hands with a non-antimicrobial soap or antimicrobial soap and water when hands are visibly soiled. 2. If hands are not visibly soiled, use an alcohol-based waterless antiseptic agent for routinely deconta- minating hands in all other clinical situations: a. After contact with a client’s intact skin (as in taking a pulse or blood pressure or lifting a client) b. Before eating c. After contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings as long as hands are not visibly soiled d. When moving from a contaminated body site to a clean body site during client care e. After contact with inanimate objects (including medical equipment) in the immediate area of the client f. Before caring for clients with severe neutropenia or other forms of severe immune suppression g. Before inserting indwelling urinary catheters or other invasive devices h. After removing gloves Instruct clients and visitors about the proper technique and times for hand hygiene. Teaching hand hy- giene is particularly important if health care is to continue at home. Clients need to wash their hands be- fore eating or handling food; after handling contaminated equipment, linen, or organic material; and after elimination. Encourage visitors to wash their hands before eating or handling food, after coming in contact with infected clients, and after handling contaminated equipment, client furniture, or organic material. You are responsible for providing the client with a safe environment. The effectiveness of infection con- trol practices depends on your conscientiousness and consistency in using effective aseptic technique. It is human nature to forget key procedural steps or, when hurried, to take shortcuts that break aseptic pro- cedures. However, failure to comply with basic procedures places the client at risk for an infection that can seriously impair recovery or lead to death. Cleaning, Disinfection, and Sterilization. Proper cleansing, disinfection, and sterilization of contami- nated objects significantly reduce and often eliminate microorganisms. In health care facilities, a sterile processing department is responsible for the disinfection and sterilizing of reusable supplies and equip- ment. However, in the home care setting, sometimes the nurse has to perform these functions. Many principles of cleaning and disinfection also apply to the home. Cleaning. Cleaning is the removal of all soil (e.g., organic and inorganic material) from objects and surfaces (Rutala and Weber, 2005). Generally cleaning involves use of water and mechanical action with detergents or enzymatic products. Detergents should have natural pH. When an object comes in contact with an infectious or potentially infectious material, the object is contaminated. If the object is disposable, it is discarded. Clean reusable objects must be cleaned thoroughly before reuse and then either disinfected or sterilized according to the manufacturer’s recommendations. Failure to follow the manufacturer’s recommendations transfers liability from the manufacturer to the health care facility or agency if an infection results from improper processing. When cleaning equipment that is soiled by organic material such as blood, fecal matter, mucus, or pus, apply protective eyewear (or a face shield) and utility (dishwashing style) gloves. These barriers provide protection from potentially infectious organisms. A brush and detergent or soap are necessary for clean- ing. The following steps ensure that an object is clean: 1. Rinse contaminated object or article with cold running water to remove organic material. Hot water causes the protein in organic material to coagulate and stick to objects, making removal difficult. 2. After rinsing, wash the object with soap and warm water. Soap or detergent reduces the surface ten- sion of water and emulsifies dirt or remaining material. Rinse the object thoroughly. 3. Use a brush to remove dirt or material in grooves or seams. Friction dislodges contaminated material for easy removal. Open any hinged items for cleaning. 4. Rinse the object in warm water. 5. Dry the object and prepare it for disinfection or sterilization if indicated by classification of the item— critical, semicritical, or noncritical. 6. The brush, gloves, and sink used to clean the equipment are considered contaminated and should be cleaned and dried according to policy. Disinfection and Sterilization. Disinfection describes a process that eliminates many or all microorgan- isms, with the exception of bacterial spores, from inanimate objects (Rutala and Weber, 2005). There are two types of disinfection: the disinfection of surfaces and high-level disinfection, which is required for some client 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 have been shown to pose a potential health risk. Sterilization is the complete elimina- tion 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 po- tential health risk to staff processing with this agent, and exposure must be monitored. The decision to clean, or clean and disinfect or sterilize, depends on the intended use of the item. There are three categories of device classification (Box 34-7). Be familiar with the health care facility or agency policy and procedures for cleaning, handling, and delivering care items for eventual disinfection and sterilization. Workers in the central processing area who are specially trained in disinfection and steri- lization should perform most of the procedures. The following factors influence the efficacy of the disin- fecting or sterilizing method: • Concentration of solution and duration of contact. A weakened concentration or shortened exposure time lessens its effectiveness. • Type and number of pathogens. The greater the number of pathogens on an object, the longer the re- quired disinfecting time. • Surface areas to treat. All dirty surfaces and areas must be fully exposed to disinfecting and sterilizing agents. The type of surface is an important factor. Is the surface porous or nonporous? • Temperature of the environment. Disinfectants tend to work best at room temperature. • Presence of soap. Soap cause certain disinfectants to be ineffective. Thorough rinsing of an object is necessary before disinfecting. • Presence of organic materials. Disinfectants become inactivated unless blood, saliva, pus, or body ex- cretions are washed off. Table 34-6 lists processes for disinfection and sterilization and their characteristics. It should be noted that some delicate instruments requiring sterilization cannot tolerate steam and must be processed using gas or plasma. Infection Prevention and Control—Client Safety. Effective prevention and control of infection requires you to remain aware of the modes of transmission and ways to control them (Box 34-8). In the hospital, home, or extended care facility a client should have a personal set of care items. Sharing bedpans, urinals, bath basins, and eating utensils can easily lead to cross infection. In facilities where health care–associated di- arrhea occurs, electronic thermometers are not recommended for rectal temperatures. Do not use the same electronic thermometer for clients on contact isolation. Always be careful when handling exudate, such as urine, feces, emesis, and blood. Contaminated flu- ids can easily splash while being discarded in toilets or hoppers. These containers need to be emptied at water level to reduce the risk of splash or splatter, and gloves and protective eyewear are worn. The nurse appropriately disposes of disposable soiled items in trash bags. Items contaminated with large amounts of blood are to be disposed of in biohazard bags. Check the location of the biohazard bags be- cause their location may vary depending on the health care facility. Handle laboratory specimens from all clients as if they were infectious and place them in designated biohazard containers or bags for transport or disposal. Even though there is no science to show that medical waste poses a health risk, the nurse must also be aware of the state regulations for the handling and disposal of medical (infectious) waste. The updated version of OSHA’s regulations address the handling and disposal of blood and body fluids that potentially pose a risk for the transmission of blood-borne pathogens. These regulations defer to the state laws and regulations (OSHA, 1991). To control organisms exiting via the respiratory tract, cover your mouth or nose when coughing or sneezing. The nurse should also teach clients respiratory hygiene or cough etiquette (see Table 34-7). Cough etiquette has become more important due to concerns for transmission of respiratory infections such as M. tuberculosis and influenza (CDC, 2007). The elements of a respiratory hygiene or cough eti- quette include (1) education of health care facility staff, clients’ families, and visitors; (2) posters and writ- ten material for health care facility or agency staff, clients, families, and visitors; (3) education on how to cover your nose/mouth when you cough, using a tissue, and the prompt disposal of the contaminated tis- sue; (4) placing a surgical mask on the client if it will not compromise respiratory function or is applicable, which may not be feasible in pediatric populations; (5) hand hygiene after contact with contaminated res- piratory secretions; and (6) spatial separation greater than 3 feet away from persons with respiratory in- fections (CDC, 2007). A nurse who has an upper respiratory tract infection should be placed on work restriction. Working when ill poses an additional risk to clients and co-workers. OSHA is enforcing the CDC guidelines for work restriction published in 1998. Work restriction for non–work-related illness requires the use of sick time. Work-related illness or exposures are covered by workers’ compensation. Employee health and in- fection control services may become responsible to ensure compliance with these guidelines. To prevent transmission of microorganisms through indirect contact, soiled items and equipment must be kept from touching your clothing. A common error is to carry dirty linen in the arms against the uniform. Use fluid-resistant linen bags, or carry soiled linen with hands held out from the body. Laundry hampers should be covered and emptied before becoming overloaded. Many measures that control the exit of microorganisms likewise control the entrance of pathogens. Maintaining the integrity of skin and mucous membranes reduces the chances of microorganisms reach- ing a host. Keep the client’s skin well lubricated by using lotion as appropriate. Immobilized and debili- tated clients are particularly susceptible to skin breakdown. Do not position clients on tubes or objects that might cause breaks in the skin. Dry, wrinkle-free linen also reduces the chances of skin breakdown. It is important to turn and position clients before their skin becomes reddened. Frequent oral hygiene pre- vents drying of mucous membranes. A water-soluble ointment keeps the client’s lips well lubricated. After elimination, a woman should clean the rectum and perineum by wiping from the urinary meatus toward the rectum. Cleansing in a direction from the least to the most contaminated area helps reduce genitourinary infections. Meticulous and frequent perineal care is especially important in older adult wom- en who wear disposable incontinent pads Another cause for entrance of microorganisms into a host is improper handling and management of urinary catheters and drainage sets (see Chapter 45). The point of connection between a catheter and drainage tube should remain closed and intact. As long as such systems are closed, their contents are considered sterile. Outflow spigots on drainage bags should also remain closed to prevent entrance of bacteria. Minimize movement of the catheter at the urethra by stabilizing the catheter with tape to reduce chances of microorganisms ascending the urethra into the bladder. Do not share urine-measuring con- tainers between clients. Performing hand hygiene is an important intervention when caring for urinary drainage systems. Sometimes you will care for clients with closed drainage systems that collect wound drainage, bile, or other body fluids. Make sure the site from which a drainage tube exits remains clear of excess moisture or accumulated drainage. All tubing should remain connected throughout use. You only open drainage re- ceptacles when it is necessary to discard or measure the volume of drainage. As a nurse, you will at times obtain specimens from drainage tubes or IV tubing ports. Disinfect tubes and ports by wiping the surface outward with alcohol or a chlorhexidine solution before entering the sys- tem. Temporarily placing squares of sterile gauze around the ends of an open drainage tube, such as a urinary catheter, adds further protection against bacteria. However, keeping drainage tubes closed and secure is the best practice. A final method for reducing the entry of microorganisms is the technique for wound cleansing. The sur- gical wound is considered to be sterile. To prevent entry of microorganisms into the wound, always clean outward from a wound site. When applying an antiseptic or cleaning with soap and water, wipe around the wound edge first and then clean outward away from the wound (see Chapter 48). Use clean gauze for each revolution around the wound’s circumference. A client’s resistance to infection improves as the nurse protects normal body defenses against infection. The nurse intervenes to maintain the body’s nor- mal reparative processes (Box 34-9). Nurses also protect themselves and others through the use of isola- tion precautions. The risk of transmitting HAIs or infectious disease among clients is high especially with an organism such as methicillin- resistant S. aureus (MRSA). When a client has a suspected or known infection, health care workers become alerted and follow infection prevention and control practices. However, in some cases, health care workers are not always aware that clients have an infection. Body substances such as feces, saliva, mucus, and wound drainage always contain potentially infectious organisms. Isolation and Isolation Precautions. Isolation is the separation and restriction of movement of ill persons with contagious diseases. Health care facilities are required to have the capability of isolating clients. For example, facilities are required to have special negative-pressure rooms for clients suspected of or diag- nosed with active pulmonary TB. However, not all communicable diseases require the placement of a client in a special private room (OSHA, 1996). You can conduct many isolation practices in standard rooms using barrier precautions. Barrier precautions includes the appropriate use of gowns, gloves, masks, eyewear, and other protective devices or clothing. The choice of barriers depends on the task being performed. Barrier protection, using gloves for example, is for use with all clients because every client has the potential to transmit infection via blood and body fluids, and the risk for infection transmission is unknown. Because of the increased attention to the prevention of blood-borne pathogens and tuberculosis, the CDC and OSHA have stressed the impor- tance of using barrier protection (OSHA, 2001). The CDC issued new isolation guidelines in 2007 that build on the two-tiered approach established in the 1996 guidelines. The first and most important tier is standard precautions. The second tier addresses isolation precau- tions, which are based on the mode of transmission of the disease (Table 34-7). Isolation precautions are termed airborne, droplet, contact, and a new category, protective environment. The precautions are for clients with highly transmissible pathogens. The new category, protective environment, is designed for clients who have undergone transplants and gene therapy (CDC, 2007). Contact transmission—Is divided into two subcategories, direct and indirect. Direct contact transmis- sion is applied to the care and handling of contaminated body fluids. An example includes blood or other bloody body fluids from an infected client that enters the health care worker’s body through direct contact with compromised skin or mucous membranes. Indirect contact transmission in- volves the transfer of an infectious agent through a contaminated intermediate object such as con- taminated instruments or hands of health care workers. The health care worker may transmit mi- croorganisms from one client site to another if hand hygiene is not performed between clients (CDC, 2007). Droplet Precautions—Focus on diseases that are transmitted by large droplets that are expelled into the air 3 to 6 feet. Droplet precautions require the wearing of a surgical mask when within 3 feet of the client, proper hand hygiene, and some dedicated-care equipment. An example would be a client with influenza. Airborne precautions—Focus on diseases that are transmitted by smaller droplets that remain in the air for long periods of time. This requires a specially equipped room with a negative air flow. The air ex- changes in the room are set at a lower rate and are exhausted directly to the outside. Air is not re- turned to the inside ventilation system and is filtered though a high-efficiency particulate air (HEPA) filter. Protective environment—Focuses on a very limited client 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. Clients are not allowed to have dried and fresh flowers and potted plants in these rooms (CDC, 2007). When using the CDC’s isolation guidelines also refer to additional CDC documents to prevent health care–associated aspergillosis and legionnaires’ disease in immunocompromised clients and the spread of multidrug-resistant organisms (CDC, 1995, 2002a, 2006b). Regardless of the type of isolation system, follow the following basic principles: • Use thorough hand hygiene before entering and leaving the room of a client in isolation. • Dispose of contaminated supplies and equipment in a manner that prevents spread of microorganisms to other persons as indicated by the mode of transmission of the organism. • Apply knowledge of a disease process and the mode of infection transmission when using protective barriers. • Protect all persons who might be exposed during transport of a client outside the isolation room. Psychological Implications of Isolation. When a client requires isolation in a private room, a sense of lo- neliness may develop because normal social relationships become disrupted. This situation can be psy- chologically harmful, especially for children. As a result of the infectious process, clients’ body images are altered. Some feel unclean, rejected, lonely, or guilty. Infection prevention and control practices further intensify these beliefs of difference or undesirability. Isolation in a private room limits sensory contact. Unless the nurse acts to minimize feel- ings of psychological and physical isolation, clients’ emotional states can interfere with recovery. Another factor to consider is your attitude and body language when caring for clients in isolation. If you are un- comfortable, the client will sense this, and this will further impair the client’s emotional status. Before you institute isolation measures, the client and family need to understand the nature of the dis- ease or condition, the purposes of isolation, and steps for carrying out specific precautions. If they are able to participate in maintaining infection prevention and control practices, the chances of reducing the spread of infection increase. Teach the client and family to perform hand hygiene and use barrier protec- tion if appropriate. Demonstrate each procedure, and give the client and family an opportunity for prac- tice. It is also important to explain how infectious organisms are transmitted so that the client and family understand the difference between contaminated and clean objects. Take measures to improve the client’s sensory stimulation during isolation. Make sure the room envi- ronment is clean and pleasant. Open drapes or shades, and remove excess supplies and equipment. Lis- ten to the client’s concerns or interests. If the nurse rushes through care or shows a lack of interest, the client will feel rejected and even more isolated. Mealtime is a particularly good opportunity for conversa- tion. Providing comfort measures such as repositioning, a back massage, or a warm sponge bath in- creases physical stimulation. Depending on the client’s condition, encourage the client to walk around the room or sit up in a chair. Recreational activities such as board games or cards are an option to keep the client mentally stimulated. Explain to the family the client’s risk for depression or loneliness. Encourage visiting family members to avoid expressions or actions that convey revulsion or disgust related to infection prevention and control practices. Discuss ways to provide meaningful stimulation. The Isolation Environment. Private rooms used for isolation sometimes provide negative-pressure air- flow to prevent infectious particles from flowing out of the room to other rooms and the air handling system. There are also special rooms with positive- pressure airflow that are used for highly susceptible immuno- compromised clients 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 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 personal protective equipment supplies. Soap and antiseptic (antimicrobial) solutions need to be available. Personnel and visitors perform hand hygiene before approaching the client’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 client care rooms, including those used for isolation, contain an impervious bag for soiled or conta- minated linen, as well as 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 clients in protected environments. The nurse should feel comfortable performing all procedures and yet remain conscious of infection prevention and control principles. Depending on the microorganism and the mode of transmis- sion, evaluate what articles or equipment to take into an isolation room. For example, the CDC (1995, 2007) recommends the dedicated use of articles such as stethoscopes, sphygmomanometers, or rectal thermometers in the isolation room of a client infected or colonized with vancomycin-resistant enterococci (VRE). Do not use these devices on other clients unless they are first adequately cleaned and disinfected. Box 34-10 describes the procedures commonly performed when shared equipment is used. Personal Protective Equipment. Personal protective equipment (gowns, masks or respirators, protec- tive eyewear, and gloves) should be readily available for personnel performing client care. The equipment to be used is task based. Gowns. The primary reason for gowning is to prevent soiling clothes during contact with the client. Gowns or cover-ups protect health care personnel and visitors from coming in contact with infected ma- terial and blood or body fluid. Gowns are often required for contact precautions, depending on the ex- pected 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. Depending on health care facility policy, isolation gowns can be 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. There is no special technique required for applying clean gowns as long as they are fastened securely. However, carefully remove gowns to minimize contamina- tion of the hands and uniform, and then discard them after removal. Respiratory Protection. Wear full-face protection (with eyes, nose, and mouth covered) when you an- ticipate splashing or spraying of blood or body fluid into the face. Also wear masks when working with a client placed on airborne or droplet precautions. If the client is on airborne precautions for TB, then apply an OSHA-approved respirator-style mask. The mask protects the nurse from inhaling microorganisms from a client’s respiratory tract and prevents transmission of pathogens from the nurse’s respiratory tract to the client. The surgical mask protects a wearer from inhaling large-particle aerosols that travel short distances (3 feet) and small-particle droplet nuclei that remain suspended in the air and travel longer distances. When caring for clients on droplet precautions apply a surgical mask when entering the isolation room. At times a client who is susceptible to infection wears a mask to prevent inhalation of pathogens. Clients on droplet or airborne precautions who are transported outside of their rooms need to wear a sur- gical mask to protect other clients and personnel. Masks prevent transmission of infection by direct con- tact with mucous membranes (CDC, 2005a). A mask discourages the wearer from touching the eyes, nose, or mouth (Box 34-11). A properly applied mask fits snugly over the mouth and nose so that 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 that they will 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 microor- ganisms and is ineffective. You will need to discard it. Never reuse a disposable mask. Warn clients and family members that a mask can cause a sensation of smothering. If family members become uncomfort- able, they should leave the room and discard the mask. Specially fitted respiratory protective devices (N95 respirator masks) are required when caring for a client with known or suspected TB (Figure 34-2) (CDC, 2005a). The mask must have a higher filtration rating than the regular surgical mask 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 wears this type of mask (OSHA, 1995). Eye Protection. Use either special glasses or goggles when performing procedures that generate splash or splatter. Examples of such procedures include irrigation of a large abdominal wound or insertion of an arterial catheter in which the nurse assists a health care provider. A nurse who wears prescription glasses will use removable reusable or disposable side shields over prescription glasses (OSHA, 2001). Eyewear is available in the form of plastic glasses or goggles. The eyewear needs to fit snugly around the face so that fluids cannot enter between the face and the glasses. Gloves. Gloves help to prevent the transmission of pathogens by direct and indirect contact. The CDC notes that you should wear clean gloves when touching blood, body fluid, secretions, excretions, (except sweat), moist mucous membranes, nonintact skin, and contaminated items or surfaces. Change gloves between tasks and procedures on the same client after contact with material that contains a high concentration of microorganisms. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another client. Perform hand hygiene immediate- ly to avoid transfer of microorganisms to other clients or environments. Because of allergy or sensitivity to latex gloves, facilities provide nonlatex gloves. This is to reduce the incidence of health care providers developing latex allergy or sensitivity. Most facilities are working to become latex free to protect health care providers and clients. When full PPE is necessary, first perform hand hygiene, then apply a gown, apply mask and eyewear or goggles (as needed), and end with applying gloves. Clean gloves are easy to apply and will fit either hand. The glove cuffs should be pulled up over the wrists or over the cuffs of the gown. If you notice a break or tear in a glove while providing care, change gloves. If the nurse does not plan to have more con- tact with the client, reapplying gloves is unnecessary. Perform hand hygiene when gloves are removed. Instruct family members visiting clients on isolation precautions in how to apply gloves properly. Dem- onstrate application of gloves to family members and explain the reason for the use of gloves. Emphasize the importance of performing hand hygiene after removing gloves. Specimen Collection. Many laboratory studies are often necessary when a client is suspected of having an infectious or communicable disease (Box 34-12). You will collect body fluids and secretions suspected of containing infectious organisms for culture and sensitivity tests. Place the specimen in a medium that promotes growth of organisms. After the specimen is sent to the laboratory, the laboratory technologist then identifies the microorganisms growing in the culture. Additional test results indicate antibiotics to which the organisms are resistant or sensitive. Sensitivity reports determine the antibiotics used in treat- ment. The nurse obtains all culture specimens using clean gloves and sterile equipment. Collecting fresh ma- terial from the site of infection, such as wound drainage, ensures that neighboring microbes do not con- taminate the specimen. Seal all specimen containers tightly to prevent spillage and contamination of the outside of the container. Bagging Trash or Linen. Nurses use special bagging procedures for removing contaminated items from the client’s environment. Bagging contaminated items prevents accidental exposure of personnel and prevents contamination of the surrounding environment. The CDC recommends a single bag for discarding items if the bag is impervious and sturdy and if you are able to place the article in the bag without contaminating the outside of the bag. You need to place soiled linen in an impervious laundry bag in the client’s room (OSHA, 2001). The CDC recommends double bagging if it is impossible to prevent contamination of the bag’s outer surface. Double bagging is not otherwise recommended. Studies have shown that this procedure is not necessary to prevent and control infection (CDC, 2007). Use of one standard-size linen bag that is not overfilled, that is tied securely, and that is intact is adequate to prevent infection transmission. Check the color code of bag that your facility uses for bagging these items. Transporting Clients. Before transferring clients to wheelchairs or stretchers, the nurse gives them clean gowns to serve as robes. Clients infected with organisms transmitted by the airborne route normally leave their rooms only for essential purposes, such as diagnostic procedures or surgery. These clients must also wear surgical masks. Personnel transporting these clients should also wear barrier protection as needed. Notify personnel in diagnostic or procedural areas or the operating room of the type of isolation precau- tions the client requires. Some clients being transported drain body fluids onto a stretcher or wheelchair. Use an extra layer of sheets to cover the stretcher or seat of the wheelchair. When this occurs, be sure to clean the equipment after client use and before another client uses the shared equipment. Role of the Infection Control Professional. An infection prevention and control professional is a valua- ble resource for assisting nurses in controlling health care–associated infections. These professionals are specially trained in infection prevention and control. They are responsible for advising health care per- sonnel regarding infection prevention and control practices and for monitoring infections within the hospit- al. An infection prevention and control professional may do the following: • Provide staff and client education on infection prevention and control • Develop and review infection prevention and control policies and procedures • Recommend appropriate isolation procedures • Screen client records for community-acquired infections that are reportable to the public health depart- ment • Consult with employee health departments concerning recommendations to prevent and control the spread of infection among personnel, such as TB testing • Gather statistics regarding the epidemiology (cause and effect) of health care–associated infections • Notify the public health department of incidences of communicable diseases within the facility • Consult with all hospital departments to investigate unusual events or clusters of infection • Monitor antibiotic-resistant organisms in the institution Infection Prevention and Control for Hospital Personnel. Health care workers are continually at risk for exposure to infectious microorganisms. OSHA (2001) publishes rules and regulations to protect em- ployees from blood-borne pathogens in the workplace. The OSHA regulations and CDC guidelines are incorporated into the policies and procedures of health care institutions and are part of regularly sche- duled staff education programs. Client Education. Often clients must learn to use infection prevention and control practices at home (Box 34-13). Preventive technique becomes almost second nature to the nurse who practices it daily. However, the client is less aware of factors that promote the spread of infection or ways to prevent its transmission. The home environment does not always lend itself to infection prevention and control. Often you will help a client adapt according to the resources available to maintain hygienic techniques. General- ly clients in a home care setting have a decreased risk of infection because of decreased exposure to resistant organisms such as those found in a health care facility and because of fewer invasive proce- dures. However, it is important to educate clients about infection prevention and control techniques. 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 sur- gery. Surgical asepsis includes procedures used to eliminate all microorganisms, including pathogens and spores, from an object or area. In surgical asepsis an area or object is considered contaminated if touched by any object that is not sterile. For example, a tear in a surgical glove exposes the outside of the glove to the skin surface, thus contaminating it. The nurse working with a sterile field or with sterile equipment needs to understand that the slightest break in technique results in contamination. Use surgic- al asepsis in the following situations: • During procedures that require intentional perforation of the client’s skin, such as insertion of IV cathe- ters or central lines • When the skin’s integrity 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 diagnos- tic areas, you will also use surgical aseptic techniques at the client’s bedside. This includes, for example, 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 client’s bedside only performs hand hygiene and ap- plies sterile gloves. Client Preparation. Because surgical asepsis requires exact techniques, you need to have the client’s cooperation. Certain clients fear moving or touching objects during a sterile procedure, whereas others try to assist. Explain how you will perform a procedure and what the client can do to avoid contaminating ste- rile items, including the following: • Avoid sudden movements of body parts covered by sterile drapes • Refrain from touching sterile supplies, drapes, or the nurse’s gloves and gown • Avoid coughing, sneezing, or talking over a sterile area Certain sterile procedures last an extended time. The nurse assesses the client’s needs and antic- ipates factors that may disrupt a procedure. If a client is in pain, you need to administer analgesics no more than half an hour before a sterile procedure begins. Ask the client if he or she needs to use the bathroom or a bedpan. Often clients have to assume relatively uncomfortable positions during sterile pro- cedures. The nurse helps the client to assume the most comfortable position possible. Finally, the client’s condition sometimes results in actions or events that contaminate a sterile field. For example, a client with a respiratory infection transmits organisms by coughing or talking. Anticipate such a problem and place a surgical mask on the client before the procedure begins. Principles of Surgical Asepsis. When beginning a surgically aseptic procedure, the nurse follows certain principles to ensure maintenance of asepsis. Failure to follow these principles places clients at risk for infec- tion. The following principles are important: 1. A sterile object remains sterile only when touched by another sterile object. This principle guides the nurse in placement of sterile objects and how to handle them. a. Sterile touching sterile remains sterile; for example, sterile gloves or sterile forceps are used to han- dle objects on a sterile field. b. Sterile touching clean becomes contaminated; for example, if the tip of a syringe or other sterile ob- ject touches the surface of a clean disposable glove, the object is contaminated. c. Sterile touching contaminated becomes contaminated; for example, when the nurse touches a ste- rile object with an ungloved hand, the object is contaminated. d. Sterile state is questionable, for example, when you find a tear or break in the covering of a sterile object. Discard it regardless of whether the object itself appears untouched. 2. Only sterile objects may be placed on a sterile field. All items are properly sterilized before use. Sterile objects are kept in clean, dry storage areas. The package or container holding a sterile object must be intact and dry. A package that is torn, punctured, wet, or open is considered unsterile. 3. A sterile object or field out of the range of vision or an object held below a person’s waist is contami- nated. Nurses never turn their backs on a sterile field or a sterile tray or leave it unattended. Contami- nation can occur accidentally by a dangling piece of clothing, falling hair, or an unknowing client touch- ing a sterile object. Any object held below waist level is considered contaminated because it cannot be viewed at all times. Keep sterile objects in front with the hands as close together as possible. 4. A sterile object or field becomes contaminated by prolonged exposure to air. Avoid activities that may create air currents, such as excessive movements or rearranging linen after a sterile object or field be- comes exposed. When you are opening sterile packages, it is important to minimize the number of people walking into the area. Microorganisms also travel by droplet through the air. No one should talk, laugh, sneeze, or cough over a sterile field or when gathering and using sterile equipment. When open- ing sterile packages, the nurse holds the item or piece of equipment as close as possible to the sterile field without touching the sterile surface. 5. When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action. If moisture leaks through a sterile package’s protective covering, microorganisms travel to the sterile object. When stored sterile packages become wet, dis- card the objects immediately or send the equipment for resterilization. When working with a sterile field or tray, you may have to pour sterile solutions. Any spill is a source of contamination unless on a sterile surface that moisture cannot penetrate. Urinary catheterization trays contain sterile supplies that rest in a sterile, plastic container. In contrast, if a nurse places a piece of sterile gauze in its wrapper on a client’s bedside table and the table surface is wet, the gauze is considered contami- nated. 6. Fluid flows in the direction of gravity. A sterile object becomes contaminated if gravity causes a conta- minated liquid to flow over the object’s surface. To avoid contamination during a surgical hand scrub, hold your hands above your elbows. This allows water to flow downward without contaminating the nurse’s hands and fingers. The principle of water flow by gravity is also the reason for drying from fin- gers to elbows, with hands held up, after the scrub. 7. The edges of a sterile field or container are considered to be contaminated. Frequently you will place sterile objects on a sterile towel, drape, or tray (Figure 34-3). Because the edge of the drape touches an unsterile surface, such as a table or bed linen, a 2.5-cm (1-inch) border around the drape is consi- dered contaminated. Objects placed on the sterile field must be inside this border. The edges of ste- rile containers become exposed to air after they are open and are thus contaminated. After you re- move a sterile needle from its protective cap or after you remove forceps from a container, the objects must not touch the container’s edge. Performing Sterile Procedures. Assemble all of the equipment that will be needed before a procedure. Have a few extra supplies available in case objects accidentally become contaminated. The nurse should not leave the sterile area. Before the sterile procedure, each step should be explained so that the client can cooperate fully. If an object becomes contaminated during the procedure, do not hesitate to discard it immediately. Donning and Removing Caps, Masks, and Eyewear. For sterile procedures on a general nursing unit, wear a surgical mask and eyewear without a cap. Eyewear is worn as a part of standard precautions if there is a risk of fluid or blood splashing into the nurse’s eyes. For sterile surgical procedures, the nurse first applies a clean cap that covers all of the hair and then the surgical mask and eyewear. A mask should fit snugly around the face and nose. After wearing a mask for several hours, the area over the mouth and nose often becomes moist. Because moisture promotes the growth of microorganisms, change the mask if it becomes moist. Protective glasses or goggles should fit snugly around the forehead and face to fully protect the eyes. Wear eyewear only for procedures that create the risk of body fluids splashing into the eyes. Remove PPE in the following order: gloves, face shield or goggles, gown, and then mask or respirator (CDC, 2005b). After removing all PPE, perform hand hygiene. Opening Sterile Packages. Sterile items such as syringes, gauze dressings, or catheters are packaged in paper or plastic containers and are impervious to microorganisms as long as they are dry and intact. Some institutions wrap reusable supplies in a double thickness of paper, linen, or muslin. These pack- ages are permeable to steam and thus allow for steam autoclaving. Sterile items are kept in clean, en- closed storage cabinets and are separated from dirty equipment. Sterile supplies have chemical tapes indicating that a sterilization process has taken place. The tapes change color during the sterilization process. Failure of the tapes to change color means that the item is not sterile. Never use a sterile item if the packaging is outdated, open, or soiled. Health care facilities apply the date processed and a lot number to the item after processing (―event-related expiration‖), or they may apply an expiration date (―date-related expiration‖) to the item. With either system it is important for the nurse to check the packaging of the item before use. Before opening a sterile item, perform hand hygiene. Inspect the supplies for package integrity and ste- rility, and assemble the supplies in the work area, such as the bedside table or treatment room, before opening packages. A bedside table or countertop provides a large, clean working area for opening items. The work area should be above waist level. Do not open sterile supplies in a confined space where con- tamination might occur. Opening a Sterile Item on a Flat Surface. You must open sterile packages without contaminating the contents. Commercially packaged items are usually designed so that the nurse only has to tear away or separate the paper or plastic cover. Hold the item in one hand while pulling the wrapper away with the other (Figure 34-4). Take care to keep the inner contents sterile before use. When opening items processed by the facility and packed in paper or linen, use the following steps: 1. Place the item flat in the center of the work surface. 2. Remove the sterilization tape or seal. 3. Grasp the outer surface of the tip of the outermost flap. 4. Open the outer flap away from the body, keeping the arm outstretched and away from the sterile field (Figure 34-5, A). 5. Grasp the outside surface of the first side flap. 6. Open the side flap, allowing it to lie flat on the table surface. Keep the arm to the side and not over the sterile surface (Figure 34-5, B). Do not allow the flaps to spring back over the sterile contents. 7. Grasp the outside surface of the second side flap and allow it to lie flat on the table surface (Figure 34-5, C). 8. Grasp the outside surface of the last and innermost flap. 9. Stand away from the sterile package and pull the flap back, allowing it to fall flat on the surface (Fig- ure 34-5, D). 10. Use the inner surface of the package (except for the 1-inch border around the edges) as a sterile field to add additional sterile items. Grasp the 1-inch border to maneuver the field on the table surface. If you will not be using the sterile supplies immediately, close the sterile package. In this case the nurse should touch only the wrapper’s outside surface. To close the package, the order of unwrapping is reversed, and the nurse does not touch the inside contents or reach over the field. Opening a Sterile Item While Holding It. To open a small sterile item, hold the package in the nondominant hand while opening the top flap and pulling it away from the nurse. Using the dominant hand, the nurse care- fully opens the sides and innermost flap away from the enclosed sterile item in the same order previously mentioned. You open the item in a hand so that you can pass the item to a person wearing sterile gloves or transfer to a sterile field. Preparing a Sterile Field. When performing sterile procedures, the nurse needs a sterile work area that provides room for handling and placing of sterile items. A sterile field is an area free of microorganisms and prepared to receive sterile items. You prepare the field by using the inner surface of a sterile wrapper as the work surface or by using a sterile drape or dressing tray. After creating the surface for the field (Skill 34-2), the nurse adds sterile items by placing them directly on the field or by transferring them with a sterile forceps. Discard an object that comes in contact with the 1-inch border Sometimes you may wear sterile gloves while preparing items in the field. If you do this, you can touch the entire drape, but sterile items must be handed over by an assistant. The nurse’s gloves cannot touch the wrappers of sterile items. Pouring Sterile Solutions. Often you will have to pour sterile solutions into sterile containers. A bottle containing a sterile solution is sterile on the inside and contaminated on the outside; the bottle’s neck is also contaminated, but the inside of the bottle cap is considered sterile. After you remove the cap or lid, you hold it in your hand or place it sterile side (inside) up on a clean surface. This means t hat you are able to see the inside of the lid as it rests on the table surface. Never rest a bottle cap or lid on a sterile surface, even though the inside of the cap is sterile. The outer edge of the cap is unsterile and will co n- taminate the surface. Placing a sterile cap down on an unsterile surface increases the chances of the inside of the cap becoming contaminated. Hold the bottle with its label in the palm of the hand to prevent the possibility of the solution wetting and fading the label. Before pouring the solution into the container, the nurse pours a small amount (1 to 2 mL) into a disposable cap or plastic-lined waste receptacle. The discarded solution cleans the lip of the bottle. Keep the edge of the bottle away from the edge or inside of the receiving container. Pour the solu- tion slowly to avoid splashing the underlying drape or field. Never hold the bottle so high above the con- tainer that even slow pouring will cause splashing. Hold the bottle outside the edge of the sterile field. Surgical Scrub. Clients undergoing operative procedures are at an increased risk for infection. Nurses working in operating rooms perform surgical hand antisepsis (Skill 34-3) to decrease and suppress the growth of skin microorganisms in case of glove tears (Association of Perioperative Nurses [AORN], 2005). For maximum elimination of bacteria, remove all jewelry and keep the nails clean and short. Do not wear artificial nails because they often hold a greater number of bacteria (AORN 2005; CDC, 2002b). Nurses who have active skin infections, open lesions or cuts, or respiratory infections should be excluded from the surgical team. During surgical hand antisepsis the nurse scrubs from fingertips to elbows with an antiseptic soap be- fore each operation. The optimum duration of the surgical hand scrub is unclear, although research indi- cates that it may be dependent on the type of antimicrobial product (CDC, 2002b). The traditional scrub time in the United States for both the initial and the subsequent scrub has been 5 minutes. Follow the manufacturer’s recommendation for scrub solutions. For many years, preoperative hand washing proto- cols required nurses to scrub with a brush. However, this practice can damage the skin. Scrubbing with a disposable sponge or combination sponge-brush reduces bacterial counts on the hands as effectively as scrubbing with a brush. However, several studies suggest that neither a brush nor a sponge is necessary to reduce bacterial counts on the hands, especially when using an alcohol-based product (CDC, 2002b). Applying Sterile Gloves. Sterile gloves are an additional barrier to bacterial transfer. There are two gloving methods: open and closed. Nurses who work on general nursing units use open gloving before procedures such as dressing changes or urinary catheter insertions. The closed gloving method, which you perform after applying sterile gowns, is practiced in operating rooms and special treatment areas. Skills 34-4, p. 678, and 34-5, p. 681 review the steps of each sterile gloving technique. Make sure to se- lect the proper glove size; the glove should not stretch so tightly that it can easily tear, yet it should be tight enough that you can pick up objects easily. Donning a Sterile Gown. Nurses wear sterile gowns when assisting at the sterile field in the operating room, delivery room, and special treatment areas. Wearing a sterile gown allows the nurse to handle ste- rile objects and also be comfortable with less risk of contamination. The circulating nurse does not gener- ally wear a sterile gown. The sterile gown acts as a barrier to decrease shedding of microorganisms from skin surfaces into the air and thus prevents wound contamination. Nurses caring for clients with large open wounds or assisting physicians during major invasive procedures (e.g., inserting an arterial cathe- ter) will also wear sterile gowns. The nurse does not apply a sterile gown until after applying a mask and surgical cap and performing surgical hand washing. The nurse picks up the gown from a sterile pack, or an assistant hands the gown to the nurse. Only a certain portion of the gown—the area from the anterior waist to, but not including, the collar and the anterior surface of the sleeves—is considered sterile. The back of the gown, the area under the arms, the collar, the area below the waist, and the underside of the sleeves are not sterile because the nurse cannot keep these areas in constant view and ensure their sterility. Skill 34-4 reviews the steps for applying a sterile gown. Evaluation Measure the success of infection prevention and control techniques by determining whether you achieved the goals for reducing or preventing infection. A comparison of the client’s response, such as absence of fever or wound infection are examples of expected outcomes for measuring the success of nursing inter- ventions. If the goals were not achieved, make a determination about whether you need to revise or elim- inate interventions. The ability to correctly assess wounds for healing and the ability to conduct a physical assessment of body systems (see Chapter 33) are important skills in the evaluation process. During this process, the nurse closely monitors clients, especially those at risk, for signs and symptoms of infection. For example, a client who has undergone a surgical procedure is at risk for infection at the surgical site, as well as at other invasive sites, such as the venipuncture site or central line sites. In addition, the client is at risk for a respiratory tract infection as a result of decreased mobility and for a urinary tract infection if an indwelling catheter is present. The nurse closely monitors all invasive and surgical sites for swelling, erythema, or purulent drainage. Monitor breath sounds for changes, and observe sputum character for change in color or consistency. Review laboratory test results for leukocytes. For example, leukocytosis in the urine may indicate a urinary tract infection. The absence of signs or symptoms of infection is the ex- pected outcome of infection prevention and control. The client at risk for infection needs to understand the measures needed to reduce or prevent microor- ganism growth and spread. Providing clients or family members the opportunity to discuss infection preven- tion and control measures or to demonstrate procedures will reveal their ability to comply with therapy. Sometimes you will determine that clients require new information or that previously instructed information needs reinforcement. Document the client’s response to therapies for infection control. A clear description of any signs and symptoms of systemic or local infection is necessary to give all nurses a baseline for comparative evalua- tion. You also need to report the efficacy of any intervention in reducing infection. Exposure Issues. Clients and health care personnel, which includes housekeepers and maintenance personnel, are at risk for acquiring infections from accidental needle sticks. After administering an injec- tion or inserting an IV catheter, place the used needle safety device in a puncture-resistant box (see Chapter 35). Sharps boxes must be at the site of use; this is an OSHA requirement. With the passage of the Needlestick Safety and Prevention Act in 2000, the incidence rate of sharps injuries decreased by 50% (Jagger, 2003). All sharps must now be either needle safe or needleless. In the past a stray needle lying in bed linen or carelessly thrown into a wastebasket served as a prime source for exposure to blood- borne pathogens. Hepatitis B and hepatitis C are the infections most commonly transmitted by contami- nated needles (Box 34-14). Report any contaminated needle stick immediately. Additional criteria for ex- posure reporting includes blood or other potentially infectious materials (OPIM) in direct contact with an open area of the skin, blood or OPIM that is splashed into the nurse’s eye, mouth or up the nose, and cuts with a sharp object that is covered with blood or OPIM. Follow-up for risk for acquiring infection will begin with source client testing, Access to testing the client (source) is stated in the testing law for each state. Some states have deemed consent, which means the state has granted the clients consent to be tested. Other states require that the client consent to testing for the presence of blood-borne pathogens. Nurses should know the testing laws in the state where they are employed. Health care facilities, agen- cies, and workers’ compensation require the exposed employee to complete an injury report and seek appropriate treatment if needed. The need for treatment is linked to the results of the testing of the client. The client should be tested for HIV, hepatitis B virus (HBV) and hepatitis C virus (HCV). If positive for HIV or HCV, then testing for syphilis may be indicated because of the incidence of coinfection (CDC, 2005b) It is required that an exposed employee be given the client’s testing results. This is not a violation of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Both the CDC and OSHA state that this information must be given to the exposed health care worker. Testing the exposed employee at the time of the exposure is not needed immediately unless required by the state testing law. Testing of the exposed employee is dependent on the results of the testing of the client. If the client tests positive for a blood-borne pathogen, then testing and treatment will be started for the employee. Exposures also occur involving non–blood-borne pathogens. Airborne and droplet diseases also pose a risk to the nonimmune nurse. The CDC has published a list of recommended immunizations and vacci- nations for health care workers, and OSHA is enforcing them. The recommended vaccinations and im- munizations include hepatitis B vaccine; TB testing; annual influenza vaccine; measles, mumps, rubella (MMR); chickenpox vaccine; and tetanus, diphtheria, and pertussis. Employee health should review your health history and offer appropriate prevention. Declination forms are needed if these are declined (OSHA, 2001). Key Concepts • Hand hygiene is the most important technique to use in preventing and controlling transmission of infection. • The potential for microorganisms to cause disease depends on the number of organisms, virulence, ability to enter and survive in a host, and susceptibility of the host. • Normal body flora help to resist infection by releasing antibacterial substances and inhibiting multiplication of patho- genic microorganisms. • The signs of local inflammation and infection are identical. • An infection can develop as long as the six elements composing the infection chain are uninterrupted. • Microorganisms are transmitted by direct and indirect contact, by airborne spread, and by vectors and contaminated articles. • Increasing age, poor nutrition, stress, inherited conditions, chronic disease, and treatments or conditions that com- promise the immune response increase susceptibility to infection. • The major sites for health care–associated infections include the urinary and respiratory tracts, bloodstream, and surgical or traumatic wounds. • The Centers for Disease Control and Prevention now recommend use of alcohol-based waterless antiseptics as an alter- native to hand washing. • Invasive procedures, medical therapies, long hospitalization, and contact with health care personnel increase a hospita- lized client’s risk for acquiring a health care–associated infection. • Isolation practices may prevent personnel and clients from acquiring infections and may prevent transmission of micro- organisms to other persons. • Standard precautions use generic barrier techniques when caring for all clients. • Proper cleansing requires mechanical removal of all soil from an object or area. • A client in isolation is subject to sensory deprivation because of the restricted environment. • An infection prevention and control professional monitors the incidence of infection within an institution and provides educational and consultative services to maintain infection prevention and control. • Surgical asepsis requires more stringent techniques than medical asepsis and is directed at eliminating microorganisms. • If the skin is broken, or if an invasive procedure into a body cavity normally free of microorganisms is performed, follow surgical aseptic practices. Critical Thinking Exercises 1. Mrs. Jaycock had an indwelling urethral catheter for 1 week. The catheter has now been out for 24 hours. She com- plains of frequency and pain on urination. Mrs. Jaycock suggests reinsertion of the catheter because of the need to get up frequently. What can frequency or pain on urination be an indication of? Should the catheter be reinserted? Why or why not? Describe at least one appropriate assessment measure and independent nursing action for Mrs. Jaycock. 2. You are caring for Mr. Huang, who has a large, open, and draining abdominal wound. You notice another health care worker changing Mr. Huang’s dressing without wearing gloves or using sterile supplies or sterile technique. When you question the health care worker regarding his or her practice, this person says, ―Don’t worry, the wound is al- ready infected, and the antibiotics and draining will take care of any contaminants.‖ How would you respond to this comment? What would your next steps be in following up on this incident? 3. Mrs. Niles is 83 years of age and lives alone. She has difficulty walking and relies on a church volunteer group to deliver lunches during the week. Her fixed income limits her ability to buy food. Last week, Mrs. Niles’s 79-year-old sister died. The two sisters had been very close. As a home care nurse, explain the factors that might increase Mrs. Niles’s risk for infection. 4. Mr. Vargas is admitted to the facility with a history of recent weight loss, a cough that has persisted for 2 months, and hemoptysis. His chest x-ray film shows a cavitary lesion in one lung, and his physician suspects tuberculosis. What type of isolation precautions would you use for Mr. Vargas? What protection would you use to provide care? What education would you provide for the client and his family? NCLEX®-Style Review Questions 1. If the infectious disease can be transmitted directly from one person to another, it is a: 1. Susceptible host 2. Communicable disease 3. Portal of entry to a host 4. Portal of exit from the reservoir 2. Infectious diseases such as hepatitis B or C become a reservoir for pathogens in: 1. Blood 2. The urinary tract 3. The respiratory tract 4. The reproductive tract 3. The interval when a client manifests signs and symptoms specific to a type of infection is the: 1. Illness stage 2. Convalescence 3. Prodromal stage 4. Incubation period 4. The most effective way to break the chain of infection is by: 1. Hand hygiene 2. Wearing gloves 3. Placing clients in isolation 4. Providing private rooms for clients 5. After coming in contact with infected clients, and after handling contaminated equipment or organic material, visitors are encouraged to: 1. Wear gloves before eating or handling food 2. Use a private room to talk with family members 3. Leave the facility to prevent contamination of others 4. Perform hand hygiene before eating or handling food 6. A client is isolated for pulmonary tuberculosis. The nurse notes the client seems to be angry, but he knows this is a normal response to isolation. The best intervention is to: 1. Provide a dark, quiet room to calm the client 2. Reduce the level of precautions to keep the client from becoming angry 3. Explain the reasons for isolation procedures and provide meaningful stimulation 4. Limit family and other caregiver visits to reduce the risk of spreading the infection 7. A gown should be worn when: 1. The client’s hygiene is poor 2. The nurse is assisting with medication administration 3. The client has acquired immunodeficiency syndrome (AIDS) or hepatitis 4. Blood or body fluids may get on the nurse’s clothing from a task the nurse plans to perform 8. The nurse has redressed a client’s wound and now plans to administer a medication to the client. It is important to: 1. Leave the gloves on to administer the medication 2. Remove gloves and perform hand hygiene before leaving the room 3. Remove gloves and perform hand hygiene before administering the medication 4. Leave the medication on the bedside table to avoid having to remove gloves before leaving the client’s room 9. When a nurse is performing surgical hand asepsis, the nurse must keep hands: 1. Below elbows 2. Above elbows 3. At a 45-degree angle 4. In a comfortable position 10. To sterilize surgical instruments, parenteral solutions, and surgical dressings: 1. An autoclave is used 2. Soap and water is used 3. Ethylene oxide gas is used 4. Chemicals are used for disinfection SKILL 34-1 HAND HYGIENE Delegation Considerations The skills of hand hygiene is performed by all caregivers. Instruct all caregivers to use proper hand hygiene. Equipment • Antiseptic hand rub • Alcohol-based waterless hand products containing emollient • Hand washing • Easy-to-reach sink with warm running water • Antimicrobial or non-antimicrobial soap • Paper towels or air dryer • Clean orangewood stick (optional) STEPS RATIONALE 1. Inspect surface of hands for breaks or cuts in skin or Open cuts or wounds can harbor high concentrations of cuticles. Cover any skin lesions with a dressing be- microorganisms. Health care facility or agency policy fore providing care. If lesions are too large to cover, often prevents nurses from caring for high-risk clients you may be restricted from direct client care (CDC, if open lesions are present on hands. 2002b). 2. Inspect hands for visible soiling. If hands are visibly soiled, use soap and water until soil is removed. 3. Inspect condition of nails. Natural tips should be 1⁄4 Subungual areas of hand harbor high concentrations of inch from fingertip and smooth. DO NOT WEAR ar- bacteria. Long nails and chipped or old polish in- tificial nails or extensions. crease the number of bacteria residing on hands. Ar- tificial applications increase microbial load on hands (CDC, 2002b) (Box 34-6). 4. Push wristwatch and long uniform sleeves above Provides complete access to fingers, hands, and wrists. wrists. Avoid wearing rings; however, there is not Some studies do show that the skin underneath rings definitive evidence that rings increase microbial load is more heavily colonized. Gram-negative bacilli and on the hands (CDC, 2002b). Staphylococcus aureus are more common under rings (Boyce and Pitter, 2001). 5. Antiseptic hand rub a. Apply an ample amount of product to palm of Enough product is needed to thoroughly cover the hands. one hand (see illustration). b. Rub hands together, covering all surfaces of Covering all aspects of the hands will kill bacteria that hands and fingers with antiseptic (see illustra- can be transmitted to the client. tion). c. Rub hands together for several seconds until Drying ensures full antiseptic effect. alcohol is dry. Allow hands to dry before apply- ing gloves. 6. Hand washing using antiseptic soap a. Stand in front of sink, keeping hands and uniform Inside of sink is a contaminated area. Reaching over sink away from sink surface. (If hands touch sink dur- increases risk of touching edge, which is contami- ing hand washing, repeat.) nated. b. Turn on water. Turn faucet on or push knee ped- Knee pads within the operating room and treatment areas als laterally or press pedals with foot to regulate are preferred to prevent hand contact with faucet. flow and temperature (see illustration). Faucet handles are likely to be contaminated with or- ganic debris and microorganisms (Griffith and others, 2003). c. Avoid splashing water against uniform. Microorganisms travel and grow in moisture. d. Regulate flow of water so that temperature is Warm water removes less of the protective oils than hot warm. water. e. Wet hands and wrists thoroughly under running Hands are the most contaminated parts to be washed. water. Keep hands and forearms lower than elbows Water flows from least to most contaminated area, during washing. rinsing microorganisms into the sink. f. Apply 3 to 5 mL of antiseptic soap, and rub Ensures that all surface areas of the hands and fingers are hands together vigorously, lathering thoroughly cleansed. (see illustration). Soap granules and leaflet prepa- rations may be used. Critical Decision Point: The decision whether to use a non-antimicrobial soap, antimicrobial soap, or alcohol-based hand antiseptic is not dependent on the procedure and the client’s immune status. However, acute care hospitals usually have only antiseptic soap. g. Wash hands using plenty of lather and friction for Soap cleanses by emulsifying fat and oil and lowering at least 15 seconds. Interlace fingers, and rub surface tension. Friction and rubbing mechanically palms and back of hands with circular motion at loosen and remove dirt and transient bacteria. Inter- least 5 times each. Keep fingertips down to faci- lacing fingers and thumbs ensures that all surfaces litate removal of microorganisms. are cleansed. Adequate time is needed to expose skin surfaces to antimicrobial agent h. Areas under fingernails are often soiled. Clean Areas under nails are often highly contaminated, which them with fingernails of other hand and additional will increase the risk of infection for the nurse or the soap with an orangewood stick (optional). client. Critical Decision Point: Do not tear or cut skin under or around nail. i. Rinse hands and wrists thoroughly, keeping Rinsing mechanically washes away dirt and microorgan- hands down and elbows up (see illustration). isms. j. Dry hands thoroughly from fingers to wrists and Drying from cleanest (fingertips) to least clean (fo- forearms with paper towel, single-use cloth, or rearms) area avoids contamination. Drying hands warm air dryer. prevents chapping and roughened skin. Critical Decision Point: Paper towels should dispense cleanly without hand or paper towel contact with other sur- faces. Reaching into the dispenser cabinet and touching the paper slot increases the risk of contamination (Harrison and others, 2003). k. If used, discard paper towel in proper receptacle. Prevents transfer of microorganisms. l. Turn off water with foot or knee pedals. To turn Wet towel and hands allow transfer of pathogens from off hand faucet, use clean, dry paper towel; avoid faucet to hands. Faucet handles are contaminated touching handles with hands (see illustration). (Griffiths and others, 2003). Home Care Considerations • Evaluate the hand-washing facilities in the home to determine the possibility of contamination, how close the facili- ties are to the client, and available supplies in the area. • Evaluate the availability of warm running water and soap when conducting home visits, and anticipate the need for alternative hand-washing products such as alcohol-based hand rubs and/or detergent-containing towels. • Instruct the client and primary caregiver in proper techniques and situations for hand washing. STEP 5a Apply waterless antiseptic to hands. STEP 5b Rub hands thoroughly. STEP 6b Turning on water. STEP 6i Rinsing hands. STEP 6f Lathering hands thoroughly. STEP 6l Turning off faucet. SKILL 34-2 PREPARATION OF STERILE FIELD Delegation Considerations The skill of preparation of a sterile field cannot be delegated. A surgical technician may prepare a sterile field as indi- cated by health care facility policy. Equipment • Sterile gloves • Sterile drape or kit that is used as a sterile field • Sterile gown (see health care facility policy) • Disposable cap, mask, and/or eyewear (see health care facility policy) • Sterile equipment and solutions specific to the procedure • Waist-high table or surface • Protective eyewear STEPS RATIONALE 1. Apply personal protective equipment as needed (consult agency policy) 2. Select clean work surface above waist level. Sterile object held below waist is contaminated. 3. Assemble necessary equipment, and check dates or Preparation of equipment in advance prevents break in labels on supplies for sterility of equipment. technique. Equipment stored beyond expiration date is considered unsterile. 4. Perform hand hygiene. Reduces transmission of microorganisms. 5. Prepare sterile field. a. Sterile commercial kit or tray containing ste- rile items (1) Place sterile kit or pack containing sterile Ensures sterility of packaged drape. items on work surface. (2) Open outside cover, and remove kit from Inner kit remains sterile. dust cover. Place on work surface. (3) Grasp outer edge of tip of outermost flap. Outer surface of package is considered unsterile. There is a 2.5-cm (1-inch) border around any sterile drape or wrap that is considered unsterile. (4) Open outermost flap away from body, keep- Reaching over sterile field contaminates it. ing arm outstretched and away from the ste- rile field. (5) Grasp outer edge of first side of flap. Outer border is considered unsterile. (6) Open side flap, pulling to side and allowing Drape or flap should lie flat so it will not accidentally it to lie flat on table surface. Keep arm to the rise up and contaminate inner surface or the sterile side, and do not extend it over the sterile sur- items placed on its surface. face. (7) Grasp outer edge of second side flap. Repeat for opening second side of package. (8) Grasp outer edge of last and innermost flap. (9) Stand away from sterile package, and pull Reaching over sterile filed contaminates it. flap back, allowing it to fall flat on work sur- face. b. Sterile linen-wrapped package (1) Place package on work surface. (2) Remove tape and seal, and unwrap both layers, following steps 5a(1) to (9) as with sterile kit. (3) Use opened package wrapper as a sterile Inner surface of wrapper is considered sterile. field. c. Sterile drape (1) Place pack containing the sterile drape on Ensures sterility of packaged drape. work surface. (2) Apply sterile gloves. (NOTE: This is an option depending on health care facility policy. You may touch outer 1- inch border of drape without wearing gloves.) (3) Grasp folded top edge of drape with finger- If sterile object touches any nonsterile object, it becomes tips of one hand. Gently lift drape up from its contaminated. wrapper without touching any object. (4) Allow drape to unfold, keeping it above Object held below person’s waist or above chest is conta- waist and the work surface and away from minated. the body. (Carefully discard outer wrapper with other hand.) (5) With other hand, grasp the adjacent corner of Drape can now be properly placed with two hands. drape. Hold drape straight over work surface (see illustration). (6) Holding drape, first position the bottom half Prevents nurse from reaching over sterile filed. over top half of the intended work surface (see illustration). (7) Allow top half of drape to be placed over A flat sterile surface is now available for placement of bottom half of work surface (see illustra- sterile items. tion). 6. Adding sterile items a. Open sterile item (following package directions) Frees dominant hand for unwrapping outer wrapper. while holding outside wrapper in nondominant hand. b. Carefully peel wrapper onto nondominant hand. Item remains sterile. Inner surface of wrapper covers hand, making it sterile. c. Being sure wrapper does not fall down on sterile Prevents reaching over field and contaminating its sur- field, place item onto field at angle. Do not hold face. arm over sterile field (see illustration). d. Dispose of outer wrapper. Prevents accidental contamination of sterile field. 7. Perform procedure using sterile technique. Prevents transmission of infection to client. Recording and Reporting • It is not necessary to record or report this procedure. STEP 5c(5) Hold drape straight up and away from body. STEP 5c(6) Lay bottom half over work surface. STEP 5c(7) Place top half of drape over work surface. STEP 6c Adding item to sterile field. SKILL 34-3 SURGICAL HAND ASEPSIS Delegation Considerations The skill of surgical hand asepsis can be delegated to properly trained surgical technicians (know State’s Nurse Practice Act). Equipment • Deep sink with foot or knee controls for dispensing water and soap (faucets should be high enough for hands and forearms to fit comfortably) • Antimicrobial agent approved by the health care facility • Surgical scrub sponge with plastic nail pick • Paper face mask, cap or hood, surgical shoe covers • Sterile towel • Sterile pack containing sterile gown • Protective eyewear (glasses or goggles) STEPS RATIONALE 1. Consult manufacturer’s policy regarding required Guidelines vary regarding ideal time needed and antisep- length of time and antiseptic to use for hand antisepsis. tic to use for surgical scrub. 2. Remove bracelets, rings, and watches. Jewelry may harbor or protect microorganisms from removal. Allergic skin reactions may occur as a result of scrub agent or glove powder accumulating under jewelry. 3. Be sure fingernails are short, clean, and healthy. Long nails and chipped or old polish increase number of Artificial nails should be removed. Natural nails bacteria residing on nails. Long fingernails can punc- 1 should be less than ⁄4 inch long. ture gloves, causing contamination. Artificial nails are known to harbor gram-negative microorganisms and fungus (AORN, 2005; AORN, 2007; CDC, 2002b). Critical Decision Point: Remove nail polish if chipped or worn longer than 4 days because it may harbor microor- ganisms (AORN, 2005). 4. Inspect condition of cuticles, hands, and forearms These conditions increase likelihood of more microor- for abrasions, cuts, or open lesions. ganisms residing on skin surfaces. Broken skin per- mits microorganisms to enter layers of the skin pro- viding deeper microbial breeding grounds (AORN, 2005). 5. Apply surgical shoe covers, cap or hood, face mask, Mask prevents escape into air of microorganisms that and protective eyewear. can contaminate hands. Other protective wear pre- vents exposure to blood and body fluid splashes dur- ing the procedure. 6. Turn on water using knee or foot controls, and ad- Knee or foot controls prevent contamination of hands just to comfortable temperature. after scrub. 7. Prescrub wash/rinse: Wet hands and arms under Water runs by gravity from fingertips to elbows. Hands running lukewarm water, and lather with detergent become cleanest part of upper extremity. Keeping to 5 cm (2 inches) above elbows. (Hands need to be hands elevated allows water to flow from least to above elbows at all times.) most contaminated areas. Washing a wide area reduc- es risk of contaminating overlying gown that the nurse later applies. 8. Rinse hands and arms thoroughly under running Rinsing removes transient bacteria from fingers, hands, water. Remember to keep hands above elbows. and forearms. 9. Under running water, clean under nails of both Removes dirt and organic material that harbor large hands with nail pick. Discard after use (see illustra- numbers of microorganisms. tion). 10. Surgical hand scrub (with brush). a. Wet clean sponge, and apply antimicrobial Friction loosens resident bacteria that adhere to skin agent. Visualize each finger, hand, and arm as surfaces. Ensures coverage of all surfaces. Scrubbing having four sides. Wash all four sides effective- is performed from cleanest area (hands) to marginal ly. Scrub the nails of one hand with 15 strokes. area (upper arms). Scrub the palm, each side of thumb and fingers, and posterior side of hand with 10 strokes each (see illustration). b. Divide the arm mentally into thirds: scrub each Eliminates transient microorganisms and reduces resi- third 10 times (AORN, 2005) (see illustration). dent hand flora. Some health care facility policies require scrub by time rather than 10 strokes. Rinse brush, and repeat the sequence for the other arm. A two- brush method may be substituted (check health care facility policy). c. Discard brush. Flex arms, and rinse from fin- Hands remain the cleanest part of upper extremities. gertips to elbows in one continuous motion, al- lowing water to run off at elbow (see illustra- tion). d. Turn off water with foot or knee control, with Keeps hands free of microorganisms. hands elevated in front of and away from body. Enter operating room suite by backing into room. e. Approach sterile setup; grasp sterile towel, Water contaminates sterile setup. taking care not to drip water onto the sterile se- tup. f. Bending slightly at waist, keeping hands and Avoids sterile towel from contacting unsterile scrub at- arms above the waist and outstretched, grasp tire and transferring contamination to hands. Dry skin one end of the sterile towel and dry one hand from cleanest (hands) to least clean (elbows). moving from fingers to elbow in a rotating mo- tion (see illustration). g. Repeat drying method for other hand by care- Prevents accidental contamination. fully reversing towel or using a new sterile to- wel. h. Drop town into linen hamper or into circulating Prevents accidental contamination. nurse’s hand. 11. Optional: Brushless antiseptic hand rub a. After prescrub wash, dry hands and forearms Promotes reduction in microorganisms on all surfaces of thoroughly with a paper towel. hands and arms. b. Dispense 2 mL of antimicrobial agent hand preparation into the palm of one hand. Dip the fingertips of the opposite hand into the hand preparation and work it under the nails. Spread the remaining hand prep over the hand and up to just above the elbow, covering all surfaces (see illustration). c. Using another 2 mL of hand preparation, repeat with other hand. d. Dispense another 2 mL of hand preparation into either hand, and reapply to all aspects of both hands up to the wrist. Allow to dry before don- ning gloves. 12. Proceed with sterile gowning (see Skill 34-4). Recording and Reporting • It is not necessary to record or report this procedure. • Report any dermatitis to employee health or infection control per agency policy. STEP 9 Cleaning under fingernails. STEP 10a Scrubbing side of fingers. STEP 10b Scrubbing forearms. STEP 10c Rinsing arms. STEP 10f A, Grasping sterile towel. B, Drying sequence. STEP 11b Application of an antimicrobial agent for brushless hand scrub. Nurse using 3M Avagard. (Photo courtesy of 3M Health Care.) SKILL 34-4 APPLYING A STERILE GOWN AND PERFORMING CLOSED GLOVING Delegation Considerations Applying a sterile gown and closed gloving can be delegated to a properly trained surgical technician (know State’s Nurse Practice Act). Equipment • Package of proper-size sterile gloves (latex free if nurse or client has sensitivity or allergy) • Sterile pack containing sterile gown • Clean, flat, dry surface • Paper face masks, cap or hood, surgical shoe covers • Protective eyewear/face shield STEPS RATIONALE Gowning 1. Before entering operating room or treatment area, Prevents hair and air droplet nuclei from contaminating apply cap, face mask, and eyewear. Foot covers are sterile work areas. Eyewear protects mucous mem- also required in operating room. branes of eye. Foot covers are paper or cloth and fit over work shoes. 2. Perform thorough surgical hand wash (see Skill 34- Removes transient and resident bacteria from fingers, 3). hands, and forearms. 3. Circulating nurse assists by opening sterile pack Gown’s outer surface remains sterile. containing sterile gown (folded inside out). 4. Circulating nurse prepares glove package by peeling Keeps gloves sterile and allows nurse who has scrubbed outer wrapper open while keeping inner contents to handle sterile items. sterile. Places inner glove package on sterile field created by sterile outer wrapper. 5. Reach down to sterile gown package; lift folded Provides wide margin of safety, avoiding contamination gown directly upward and step back away from ta- of gown. ble. 6. Holding folded gown, locate neckband. With both Clean hands can touch inside of gown without contami- hands, grasp inside front of gown just below neck- nating outer surface. band. 7. Allow gown to unfold, keeping inside of gown to- Outside of gown will be sterile surface. ward body. Do not touch outside of gown with bare hands. 8. With hands at shoulder level, slip both arms into Careful application prevents contamination. Gown cov- armholes simultaneously (see illustration). Ask cir- ers hands to prepare for closed gloving. culating nurse to bring gown over shoulders by reaching inside to arm seams and pulling gown on, leaving sleeves covering hands. 9. Have circulating nurse securely tie back of gown at Gown must completely enclose underlying garments. neck and waist (see illustration). (If gown is a wra- paround style, do not touch sterile flap to cover gown until you are gloved.) 10. Closed gloving a. With hands covered by gown sleeves, open Hands remain clean. Sterile gown cuff will touch sterile inner sterile glove package (see illustration). glove surface. b. With dominant hand inside gown cuff, pick up Sterile gown touches sterile glove. glove for nondominant hand by grasping folded cuff. c. Extend nondominant forearm with palm up and Positions glove for application over cuffed hand, keep- place palm of glove against palm of nondomi- ing glove sterile. nant hand. Glove fingers will point toward el- bow. d. Grasp back of glove cuff with covered dominant Seal created by glove cuff over gown prevents exit of hand, and turn glove cuff over end of nondomi- microorganisms over operative sterile field. nant hand and gown cuff (see illustration). e. Grasp top of glove and underlying gown sleeve with covered dominant hand. Carefully extend fingers into glove, being sure glove’s cuff cov- ers gown’s cuff. f. Glove dominant hand in same manner, revers- Sterile touches sterile. ing hands (see illustration). Use gloved nondo- minant hand to pull on glove. Keep hand inside sleeve (see illustration). g. Be sure fingers are fully extended into both Ensures that nurse has full dexterity while using gloved gloves. hand. 11. For wraparound sterile gowns: take gloved hand Front of gown is sterile. and release fastener or ties in front of gown. 12. Hand tie to sterile team member who stands still Contact with team member could contaminate gown and (see illustration). Allowing margin of safety, turn gloves. Gown must enclose undergarments. around to the left, covering back with extended gown flap. Take back tie from team member, and secure tie to gown. Recording and Reporting • It is not necessary to record or report this procedure. STEP 8 Placing arms in sleeves. STEP 9 Circulating nurse ties scrub gown. STEP 10a Scrub nurse opens glove package. STEP 10d Glove applied to left hand as right hand remains inside cuff. STEP 10f Second glove applied. STEP 12 Handing tie to sterile team member. SKILL 34-5 OPEN GLOVING Delegation Considerations The skill of open gloving can be delegated when personnel are trained to perform a sterile procedure. Equipment • Sterile gloves (proper size) STEPS RATIONALE 1. Perform thorough hand hygiene. Removes bacteria from skin surfaces and reduces trans- mission of infection. 2. Remove outer glove package wrapper by carefully Prevents inner glove package from accidentally opening separating and peeling apart sides. and touching contaminated objects. 3. Grasp inner package, and lay it on clean, flat sur- Sterile object held below waist is contaminated. Inner face just above waist level. Open package, keeping surface of glove package is sterile. gloves on wrapper’s inside surface (see illustra- tion). 4. If gloves are not prepowdered, take packet of Powder allows gloves to slip on easily. (Some staff mem- powder and apply lightly to hands over sink or was- bers do not use powder for fear of promoting growth tebasket. of microorganisms.) 5. Identify right and left glove. Each glove has cuff Proper identification of gloves prevents contamination approximately 5 cm (2 inches) wide. Glove domi- by improper fit. Gloving of dominant hand first im- nant hand first. proves dexterity. 6. With thumb and first two fingers of nondominant Inner edge of cuff will lie against skin and thus is not hand, grasp edge of cuff of glove for dominant sterile. hand. Touch only glove’s inside surface. 7. Carefully pull glove over dominant hand, leaving If glove’s outer surface touches hand or wrist, then it is cuff and being sure cuff does not roll up wrist. Be contaminated. sure thumb and fingers are in proper spaces (see il- lustration). 8. With gloved dominant hand, slip fingers underneath Cuff protects gloved fingers. Sterile touching sterile second glove’s cuff (see illustration). prevents glove contamination. 9. Carefully pull second glove over nondominant Contact of gloved hand with exposed hand results in hand. Do not allow fingers and thumb of gloved contamination. dominant hand to touch any part of exposed non- dominant hand. Keep thumb of dominant hand ab- ducted back (see illustration). 10. After second glove is on, interlock hands. The cuffs Ensures smooth fit over fingers. usually fall down after application. Be sure to touch only sterile sides (see illustration). Glove Disposal 11. Grasp outside of one cuff with other gloved hand; Minimizes contamination of underlying skin. avoid touching wrist. Pull half way down palm of hand. Take thumb of half-ungloved hand, and place under cuff of the other glove 12. Pull glove off, turning it inside out. Discard in re- Outside of glove does not touch skin surface. ceptacle. 13. Take fingers of bare hand, and tuck inside remain- ing glove cuff. Peel glove off, inside out. Discard in receptacle. Recording and Reporting • It is not necessary to record or report this procedure. STEP 3 Opening package. STEP 7 Pulling glove over dominant hand. STEP 8 Slipping fingers underneath second glove’s cuff. STEP 9 Pulling second glove over nondominant hand. STEP 10 Hands interlocked. B O X 34 -1 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 post exposure; common cold, 1 to 2 days; influenza, 1 to 5 days; mumps, 12 to 26 days). Prodromal Stage Interval from onset of nonspecific signs and symptoms (malaise, low-grade fever, fatigue) to more specific symp- toms. (During this time, microorganisms grow and multiply, and client may be capable of spreading disease to oth- ers.) For example, herpes simplex begins with itching and tingling at the site before the lesion appears. Illness Stage Interval when client manifests signs and symptoms specific to type of infection. (For example, strep throat is mani- fested by sore throat, pain, and swelling; mumps is manifested by high fever, parotid and salivary gland swelling.) Convalescence Interval when acute symptoms of infection disappear. (Length of recovery depends on severity of infection and client’s host resistance; recovery may take several days to months.) B O X 34 -2 Sites for and Causes of Health Care–Associated Infections Improperly performing hand hygiene increases client risk for all types of health care–associated infections. Urinary Tract Unsterile insertion of urinary catheter Improper positioning of the drainage tubing Open drainage system Catheter and tube becoming disconnected Drainage bag port touching contaminated surface Improper specimen collection technique Obstruction or interference with urinary drainage Urine in catheter or drainage tube being allowed to reenter bladder (reflux) Repeated catheter irrigations Surgical or Traumatic Wounds Improper skin preparation before surgery (i.e., shaving verses clipping hair; not performing a preoperative bath or shower) Failure to cleanse skin surface properly Failure to use aseptic technique during dressing changes Use of contaminated antiseptic solutions Respiratory Tract Contaminated respiratory therapy equipment Failure to use aseptic technique while suctioning airway Improper disposal of secretions Bloodstream Contamination of intravenous (IV) fluids by tubing Insertion of drug additives to IV fluid Addition of connecting tube or stopcocks to IV system Improper care of needle insertion site Contaminated needles or catheters Failure to change IV access site when inflammation first appears Improper technique during administration of multiple blood products Improper care of peritoneal or hemodialysis shunts Improperly accessing an IV port BOX 34-3 F OCUS ON O LDER A D ULTS Risks for Infection • An age-related decline in immune system function, termed immune senescence, increases the body’s suscep- tibility to infection and slows overall immune response (Lesser and others, 2006). • Older adults are less capable of producing lymphocytes to combat challenges to the immune system. When antibodies are produced, the duration of their response is shorter and fewer cells are produced (Burns, 2001). • Risks associated with the development of health care– associated infections in older clients include poor nutrition, unintentional weight loss, and low serum albumin levels (Meiner and Lueckenotte, 2006). • After age 70, older adults appear likely to produce autoantibodies that attack parts of the body itself instead of infections (Burns, 2001). • Older adults experience loss and stress along with suppressed immunity related to bereavement, depression, and poor social support (Burns, 2001). BOX 34-4 NURSING ASSESSMENT QUESTIONS Risk Factors • Do you have any recent cuts or lacerations? • Have you been diagnosed with any chronic illnesses? • Have you had any recent diagnostic testing, such as cystoscopy, performed? Possible Existing Infections • Do you have or feel like you have a fever? • Do you have any pain/burning during urination? Medication History • Are you taking any medication that could affect your immune system (e.g., cancer chemotherapy, rheumatoid arthritis medications, steroids)? • Are you taking any antiviral medications? Stressors • Is there any major lifestyle change occurring, such as the loss of employment or place of residence, divorce, or disability? BOX 34-5 NURSING DIAGNOSTIC PROCESS Risk for Infection Related to Impaired Immunity Assessment Activities Defining Characteristics Check results of laboratory WBC count ,5000/mm3 tests. Review current medications. Client receiving azathioprine (Imuran), an immunosuppressant Identify potential sites of in- IV catheter in right forearm, in place for 3 fection. days Foley catheter draining cloudy amber- colored urine WBC, White blood cell; IV, intravenous. BOX 34-6 E VIDENCE -B ASED P R ACTICE Pathogens and Artificial Fingernails Evidence Summary Female health care workers (HCWs) frequently have artificial or manicured nails. Researchers posed the question as to whether bacteria reside in higher than normal numbers on artificial nail material. In three separate studies the identity and quantity of microbial flora from HCWs wearing artificial nails were compared with those from HCWs with normal nails. In both studies, nail surfaces were swabbed and subungual (area under nails) debris was collected to obtain material for culture. In the first study, 12 HCWs who did not normally wear artificial nails wore polished artificial nails on their nondo- minant hand for 15 days. Identity and quantity of microflora were compared between the artificial nails and the polished normal nails of the other hand. Potential pathogens were isolated from more samples obtained from artificial nails than normal nails. Colonization of artificial nails increased over time. More organisms were found on the surface of artificial nails than normal nails. In the second study the flora of the nails of 30 HCWs who wore permanent acrylic artificial nails were compared with that of HCWs who do not wear artificial nails. HCWs wearing artificial nails were more likely to have a pathogen isolated than the other group. In this study, artificial nails were more likely to harbor pathogens, especially gram-negative bacilli and yeasts, than normal nails. The longer artificial nails were worn, the more likely that a pathogen was isolated. The third study examined an outbreak of Pseudomonas aeruginosa in a neonatal intensive care unit. This outbreak was attributed to two nurses. One nurse had long artificial nails, and another nurse had long natural nails. Both nurses carried on their hands the implicated strain of P. aeruginosa. The investigation found that the neonates were more likely to have been cared for by the two nurses during the exposure period. This indicated that the artificial and long natural nails may have contributed to causing this outbreak. Evidence-Based Practice • Nurses should not wear artificial nails or extenders when performing client care (CDC, 2002). • Natural nails should be kept well manicured at 1⁄4 inch long and free of nail gels and acrylic products. Reference Boyce JM, Pittet D: HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force and the CDC Healthcare Con- trol Practices Advisory Committee draft guidelines for hand hygiene in healthcare settings, 2001. B O X 34 -7 Categories for Sterilization, Disinfection, and Cleaning Critical Items Items that enter sterile tissue or the vascular system present a high risk of infection if the items are con- taminated with microorganisms, especially bacterial spores. Critical items must be sterile. Some of these items include: • Surgical instruments • Cardiac or intravascular catheters • Urinary catheters • Implants Semicritical Items Items that come in contact with mucous membranes or nonintact skin also present a risk. These objects must be free of all microorganisms (except bacterial spores). Semicritical items must be high-level disinfected (HLD) or sterilized. Some of these items include: • Respiratory and anesthesia equipment • Endoscopes • Endotracheal tubes • Gastrointestinal endoscopes • Diaphragm fitting rings After rinsing, dry items and store in a manner to protect from damage and contamination. Noncritical Items Items that come in contact with intact skin but not mucous membranes must be clean. Noncritical items must be disinfected. Some of these items include: • Bedpans • Blood pressure cuffs • Bed rails • Linens • Stethoscopes • Bedside trays and client furniture • Food utensils B O X 34 -8 Infection Prevention and Control to Reduce Reservoirs of Infection Bathing Use soap and water to remove drainage, dried secretions, or excess perspiration. Dressing Changes Change dressings that become wet and/or soiled (see Chapter 48). Contaminated Articles Place tissues, soiled dressings, or soiled linen in fluid-resistant bags for proper disposal. Contaminated Sharps Place all needles, safety needles, and needleless systems into puncture-proof containers, which should be located at the site of use. Federal law requires the use of needle-safe technology. Blood tube holders are single use only (OSHA: Needlestick Safety Prevention Act of 2000, 2001). Bedside Unit Keep table surfaces clean and dry. Bottled Solutions Do not leave bottled solutions open. Keep solutions tightly capped. Date bottles when opened, and discard in 24 hours. Surgical Wounds Keep drainage tubes and collection bags patent to prevent accumulation of serous fluid under the skin surface. Drainage Bottles and Bags Wear gloves and protective eyewear if splashing or spraying with contaminated blood or body fluids is antic- ipated. Empty and dispose of drainage suction bottles according to facility policy. Empty all drainage systems on each shift unless otherwise ordered by a physician. Never raise a drainage system (e.g., urinary drainage bag) above the level of the site being drained unless it is clamped off. OSHA, Occupational Safety and Health Administration. B O X 34 -9 Infection Prevention and Control: Protecting the Susceptible Host Protecting Normal Defense Mechanisms Regular bathing removes transient microorganisms from the skin’s surface. Lubrication helps keep the skin hydrated and intact. Regular oral hygiene. Saliva contains enzymes that promote digestion and has a bactericidal action to maintain control of bacteria. Flossing removes tartar and plaque that cause germ infection. Maintenance of adequate fluid intake promotes normal urine formation and a resultant outflow of urine to flush the bladder and urethral lining of microorganisms. For physically dependent or immobilized clients, encourage routine coughing and deep breathing to keep lower airways clear of mucus. The nurse encourages proper immunization of children or adult clients who become exposed to certain infectious microor- ganisms. Children are vaccinated for measles, mumps, rubella, chickenpox, diphtheria, and other vaccine-preventable dis- eases. Adults should receive one booster of tetanus- diphtheria-acellular pertussis (Tdap), annual flu vaccine, and others as recommended by the CDC. Older adults should receive pneumococcal vaccine and annual influenza vaccine. Maintaining Healing Processes Promote intake of adequate fluids and a well-balanced diet containing essential proteins, vitamins, carbohydrates, and fats. The nurse also uses measures to increase the client’s appetite. Promote a client’s comfort and sleep so that energy stores are replaced daily. Assist the client in learning techniques to reduce stress. BOX 34-10 P ROCE DURAL G UIDE LINES Caring for a Client on Isolation Precautions Delegation Considerations: The skill of caring for a client on isolation precautions can be delegated. However, it is the nurse who assesses the client’s status and isolation indications. Instruct nursing assistive personnel about special precautions regarding individual client needs, such as transportation to diagnostic tests. Equipment: Barrier protection determined by type of isolation—gowns, protective eyewear, or face shield may be needed; supplies depend on procedures performed in room; sharps container; disposable blood pres- sure (BP) cuff 1. Assess isolation indications (e.g., client’s medical history for exposure, laboratory tests, wound drainage). 2. Review agency policies and precautions necessary for the specific isolation system, and consider care measures you will perform while in client’s room. 3. Review nurses’ notes or speak with colleagues regarding client’s emotional state and adjustment to isolation. 4. Perform hand hygiene, and prepare all equipment you will need to take into client’s room. In some cases, equipment may remain in the room (stethoscope or BP cuff). Decide which isolation equip- ment is necessary before entering the client’s room. For example, decide if you will need a gown and gloves for a client in contact precautions or if you will need a special respirator mask for a client on airborne precautions. 5. Prepare for entrance into isolation room: a. Apply cover gown, being sure it covers all outer garments. Pull sleeves down to wrist. Tie se- curely at neck and waist (see illustration). b. Apply either surgical mask or respirator around mouth and nose. (Type will depend on type of precautions and facility policy.) The nurse must have a medical evaluation and be fit tested be- fore using a respirator (OSHA, 1996). c. If needed, apply eyewear or goggles snugly around face and eyes. If prescription glasses are worn, side shield may be used. d. Apply clean gloves. (NOTE: Wear unpowdered, latex-free gloves.) Wear gloves within gown, bring glove cuffs over edge of gown sleeves. 6. Enter client’s room. Arrange supplies and equipment. (If equipment will be removed from room for reuse, place on clean paper towel.) 7. Explain purpose of isolation and necessary precautions to client and family. Offer opportunity to ask questions. Assess for evidence of emotional problems that can occur from isolation. 8. Assess vital signs. a. If client is infected or colonized with a resistant organism (e.g., vancomycin-resistant enterococcus [VRE], methicillin-resistant Staphylococcus aureus [MRSA]), equipment remains in room. This in- cludes the stethoscope and blood pressure cuff. b. If stethoscope is to be reused, clean diaphragm or bell with alcohol. Set aside on clean surface. c. Use individual electronic or disposable thermometer. Critical Decision Point: If disposable thermometer indicates a fever, assess for other signs/symptoms. Confirm fever using an electronic thermometer (Potter, 2003). 9. Administer medications (see Chapter 35). a. Give oral medication in wrapper or cup. b. Dispose of wrapper or cup in plastic-lined receptacle. c. Administer injection. d. Discard safety needle and syringe or needle into the sharps container. e. If you are not wearing gloves and hands come into contact with contaminated article or body flu- ids, perform hand hygiene as soon as possible. 10. Administer hygiene, encouraging the client to discuss questions or concerns about isolation. Use informal teaching at this time. a. Avoid allowing gown to become wet. Carry washbasin out away from gown; avoid leaning against any wet surface. b. Remove linen from bed; avoid contact with gown. Place in leakproof linen bag. c. Change gloves, and perform hand hygiene if hands become excessively soiled and further care is necessary. 11. Collect specimens. a. Place specimen containers on clean paper towel in client’s bathroom. Follow procedure for col- lecting specimen of body fluids. b. Transfer specimen to container without soiling outside of container. Place container in plastic bag, and place label on outside of bag or as per facility policy. Perform hand hygiene, and reglove if additional procedures are needed. 12. Dispose of linen and trash bags as they become full. a. Use sturdy, moisture-resistant single bags to contain soiled articles. Use double bag if outside of bag is contaminated. b. Tie bags securely at top in knot (see illustration). 13. Remove all reusable equipment. Clean any contaminated surfaces (see health care facility or agency policy). 14. Resupply room as needed. Have a staff member outside the isolation room hand you new supplies. 15. Explain to client when you plan to return to room. Ask whether client requires any personal care items, books, or magazines. 16. Leave isolation room. The order for removing PPE depends on what was needed for the type of isolation. The sequence listed is based on full PPE being required. a. Remove gloves. Remove one glove by grasping cuff and pulling glove inside out over hand. Discard glove. With ungloved hand, tuck finger inside cuff of remaining glove and pull it off, inside out (see illustration). b. Remove eyewear/face shield or goggles. c. Untie waist and neck strings of gown. Allow gown to fall from shoulders. Remove hands from sleeves without touching outside of gown. Hold gown inside at shoulder seams, and fold inside out. Discard in laundry bag if fabric or in trash can if gown is disposable. d. Remove mask: If mask loops over your ears, remove from ears and pull away from face. For a tie-on mask, untie top mask strings, hold strings, and then untie bottom strings, pull mask away from face, and drop it into trash receptacle. Do not touch outer surface of mask. e. Perform hand hygiene. f. Leave room, and close door, if necessary. (Make sure door is closed if client is on airborne pre- cautions.) g. Dispose of all contaminated supplies and equipment in a manner that prevents spread of micro- organisms to other persons (see health care facility or agency policy). STEP 5a Tying gown at waist. STEP 5d Applying gloves over gown sleeves. STEP 12b Tie trash bag securely. STEP 16a Removing glove. OSHA, Occupational Safety and Health Administration; PPE, personal protective equipment. BOX 34-11 P ROCE DURAL G UIDE LINES Applying a Surgical Type of Mask 1. Find top edge of mask (some have a thin metal strip along edge). Pliable metal fits snugly against bridge of nose. Others offer an occlusive fit that does not require an adjustment. 2. Hold mask by top two strings or loops. Tie two top ties at top of back of head (see illustration), with ties above ears. (Alternative: Slip loops over each ear.) 3. Tie two lower ties snugly around neck with mask well under chin (see illustration). 4. Gently pinch upper metal band around bridge of nose. NOTE: Change mask if wet, moist, or contaminated. B O X 34 -1 2 Specimen Collection Techniques* Ensure that all specimen containers used have the biohazard symbol on the outside. Wound Specimen Clean site with sterile water or saline before wound specimen collection (see Chapter 48). Apply gloves and use cotton-tipped swab or syringe to collect as much drainage as possible. Have clean test tube or culture tube on clean paper towel. After swabbing center of wound site, grasp collection tube with a paper towel. Carefully insert swab without touching outside of tube. After securing tube’s top, transfer tube into biohazard bag for transport and perform hand hygiene. Blood Specimen (This procedure is usually performed by the laboratory technician.) Wearing gloves, use a needle-safe syringe and culture media bottles to collect up to 10 mL of blood per culture bottle (check health care facility or agency policy). After prepping, perform venipuncture at two different sites to decrease likelihood of both specimens being contaminated with skin flora. Place blood culture bottles on a clean paper towel on bedside table or other surface; swab off bottle tops with alcohol. Inject appropriate amount of blood into each bottle. Transfer specimen into clean, labeled biohazard bag for transport. Remove gloves and perform hand hygiene. Stool Specimen Wearing gloves, use clean cup with seal top (need not be sterile) and tongue blade to collect small amount of stool, approximately 2 to 3 cm. Place cup on clean paper towel in client’s bathroom. Using tongue blade, collect needed amount of feces from client’s bedpan. Transfer feces to cup without touching cup’s outside surface. Dispose of tongue blade, and place seal on cup. Transfer specimen into clean biohazard bag for transport. Remove gloves and perform hand hygiene. Urine Specimen Apply gloves and use sterile cup to collect 1 to 5 mL of urine. Place cup or tube on clean towel in client’s bathroom. If client has a urinary catheter, use a needleless safety syringe to collect spec i- men from the sampling port on the catheter (see manufacturer’s instructions). Have client follow procedure to obtain a clean voided specimen (see Chapter 45) if not catheterized. Secure top of transfer container, label for transport, and place in a biohazard bag. Remove gloves and perform hand hygiene. From Pagana KD, Pagana TJ: Mosby’s diagnostic and laboratory test reference, ed 7, St. Louis, 2005, Mosby. * Health care facility or agency policies may differ on type of containers and amount of specimen material required. BOX 34-13 C LIENT T EACHIN G Infection Prevention and Control Objective • Client will assume self-care using proper infection prevention and control techniques. Teaching Strategies • Instruct client about cleaning equipment using soap and water and disinfecting with an appropriate disinfec- tant, such as diluted bleach. • Demonstrate proper hand hygiene, explaining that the client should perform before and after all treatments and when infected body fluids are contacted. • Instruct client in the signs and symptoms of wound infection and when to notify the health care provider. • For clients who receive tube feedings at home, explain the importance of preparing enough formula for only 8 hours (commercially prepared) or 4 hours (home prepared). Tell client that contaminated enteral feeding sometimes causes infections. Rinse feeding bag and tubing with mild soap and water daily and dry. • Instruct client to place contaminated dressings and other disposable items containing infectious body fluids in impervious plastic or brown paper bags. Place needles in metal or hard plastic containers such as coffee cans or laundry detergent bottles, and tape the openings shut. Some states have specific requirements for sharps disposal. Check local regulations. • Clean noticeably soiled linen separate from other laundry. Wash in warm water with detergent. There are no special recommendations for setting dryer temperature (CDC, 2007). Evaluation • Ask client or family member to describe techniques used to reduce transmission of infection. • Have client demonstrate select techniques. • Ask client to explain the risks for infection based on the condition. CDC, Centers for Disease Control and Prevention. B O X 34 -1 4 Hepatitis B Vaccination and Follow-Up After Exposure 1. Health care employers shall make available the hepatitis B vaccine and vaccination series to all employees who may have occupational exposures. If an employee declines the vaccine, the employee must sign a declination form. Evaluation and follow-up care will be available to all employees who have been exposed. 2. Hepatitis B vaccinations will be made available to employees within 10 working days of assignment. This means before starting to provide client care and after receiving education and training on the vaccine. 3. A blood test (titer) is offered in some facilities 1-2 months after completing the 3 dose vaccine series (check the health care facility or agency policy). 4. Vaccine is offered at no cost to employees. Vaccine does not require any boosters. 5. After exposure, no treatment is needed if there is a positive blood titer on file. If no positive titer is on file, the CDC guidelines must be followed. Exposure to Hepatitis C (HCV) 1. If the source client is positive for HCV, the employee will receive a baseline test. 2. At 4 weeks after exposure, the employee should be offered a HCV-RNA test to determine if the employee con- tracted HCV. 3. If positive, the employee is started on treatment. 4. There is no prophylactic treatment for HCV after exposure. 5. Early treatment for infection can prevent chronic infection. Exposure to HIV 1. If the client is positive for HIV infection, a viral load study should be performed to determine the amount of virus present in the blood. 2. If the exposure meets the CDC criteria for HIV prophylactic treatment (PEP), it should be started as soon as possible, preferably within 24 hours after the exposure (CDC, 2005b). All medical evaluations and procedures, including the vaccine and vaccination series and evaluation after expo- sure (prophylaxis), are made available at no cost to at-risk employees. A confidential written medical evaluation will be available to employees with exposure incidents. From Occupational Safety and Health Administration: Occupational Safety and Health Act of 2001, 2001, 2005, http://www.cdc.gov. T AB L E 3 4 -1 Common Pathogens and Some Infections or Diseases They Produce ORGANISM M AJOR RESERVOIR ( S) M AJOR INFECTIONS /DISEASES Bacteria Escherichia coli Colon Gastroenteritis, urinary tract infection Staphylococcus aureus Skin, hair, anterior nares, mouth Wound infection, pneumonia, food poisoning, cellulitis Streptococcus (beta-hemolytic Oropharynx, skin, perianal area ―Strep throat,‖ rheumatic fever, scarlet fever, im- group A) organisms petigo, wound infection Streptococcus (beta-hemolytic Adult genitalia Urinary tract infection, wound infection, postpar- group B) organisms tum sepsis, neonatal sepsis Mycobacterium tuberculosis Droplet nuclei from lungs, larynx Tuberculosis Neisseria gonorrhoeae Genitourinary tract, rectum, mouth Gonorrhea, pelvic inflammatory disease, infec- tious arthritis, conjunctivitis Rickettsia rickettsii Wood tick Rocky Mountain spotted fever Staphylococcus epidermidis Skin Wound infection, bacteremia Viruses Hepatitis A virus Feces Hepatitis A Hepatitis B virus Blood and certain body fluids, sexual contact Hepatitis B Hepatitis C virus Blood, certain body fluids, sexual contact Hepatitis C Herpes simplex virus (type 1) Lesions of mouth or skin, saliva, genitalia Cold sores, aseptic meningitis, sexually transmit- ted disease, herpetic whitlow Human immunodeficiency vi- Blood, semen, vaginal secretions via sexual Acquired immunodeficiency syndrome (AIDS) rus (HIV) contact Fungi Aspergillus organisms Soil, dust, mouth, skin, colon, genital tract Aspergillosis, pneumonia, sepsis Candida albicans Mouth, skin, colon, genital tract Candidiasis, pneumonia, sepsis Protozoa Plasmodium falciparum Blood Malaria Modified from Ritter H: Clinical microbiology. In Carrico R, editor: APIC text of infection control and epidemiology, Washington, DC, 2005, Association for Professionals in Infection Control and Epidemiology. T AB L E 3 4 -2 Modes of Transmission ROUTES AND M EANS EXAMPLES OF ORGANISMS Contact DIRECT Person-to-person (fecal, oral) Physical contact between source and susceptible host (e.g., touching client Hepatitis A virus, Shigella, Staphylococcus feces and then touching your inner mouth or consuming contaminated food) INDIRECT Personal contact of susceptible host with contaminated inanimate object Hepatitis B virus, hepatitis C virus, human immunodefi- (e.g., needles or sharp objects, dressings, environment) ciency virus (HIV), Staphylococcus, respiratory syncy- tial virus (RSV), Pseudomonas, methicillin-resistant Staphylococcus aureus (MRSA) DROPLET Large particles that travel up to 3 feet and come in contact with suscepti- Influenza virus, rubella virus, bacterial meningitis ble host (e.g., coughing, sneezing, or talking) Airborne Droplet nuclei, or residue or evaporated droplets suspended in air (e.g., Mycobacterium tuberculosis (tuberculosis), varicella zos- coughing, sneezing) or carried on dust particles ter virus (chickenpox), Aspergillus, measles virus Vehicles Contaminated items Vibrio cholerae, MRSA Water Pseudomonas, Legionella Drugs, solutions Pseudomonas Blood Hepatitis B virus, hepatitis C virus, HIV, syphilis Food (improperly handled, stored, or cooked; fresh or thawed meats) Salmonella, Escherichia coli, Clostridium botulinum Vector External mechanical transfer (flies) V. cholerae Internal transmission such as parasitic conditions between vector and host, such as: Mosquito Plasmodium falciparum (malaria), West Nile virus Louse Rickettsia typhi Flea Yersinia pestis (plague) Tick Borrelia burgdorferi (Lyme disease) T AB L E 3 4 -3 Normal Defense Mechanisms Against Infection FACTORS THAT M AY ALTER DEFENSE DEFENSE M ECHANISMS ACTION M ECHANISMS Skin Intact multilayered surface (body’s first Provides barrier to microorganisms and anti- Cuts, abrasions, puncture wounds, areas line of defense against infection) bacterial activity of maceration Shedding of outer layer of skin cells Removes organisms that adhere to skin’s Failure to bathe regularly, improper outer layers hand-washing technique Sebum Contains fatty acid that kills some bacteria Excessive bathing Mouth Intact multilayered mucosa Provides mechanical barrier to microorgan- Lacerations, trauma, extracted teeth isms Saliva Washes away particles containing microor- Poor oral hygiene, dehydration ganisms Contains microbial inhibitors (e.g., lyso- zyme) Eye Tearing and blinking Provides mechanisms to reduce entry (blink- Injury, exposure—splash/splatter of ing) or to assist in washing away (tearing) blood or other potentially infectious particles containing pathogens, thus reduc- material into the eye ing dose of organisms Respiratory Tract Cilia lining upper airway, coated by mu- Trap inhaled microbes and sweep them out- Smoking, high concentration of oxygen cus ward in mucus to be expectorated or swal- and carbon dioxide, decreased humidi- lowed ty, cold air Macrophages Engulf and destroy microorganisms that Smoking reach lung’s alveoli Urinary Tract Flushing action of urine flow Washes away microorganisms on lining of Obstruction to normal flow by urinary bladder and urethra catheter placement, obstruction from growth or tumor, delayed micturition Intact multilayered epithelium Provides barrier to microorganisms Introduction of urinary catheter, conti- nual movement of catheter in urethra Gastrointestinal Tract Acidity of gastric secretions Administration of antacids Administration of antacids Rapid peristalsis in small intestine Prevents retention of bacterial contents Delayed motility resulting from impac- tion of fecal contents in large bowel or mechanical obstruction by masses Vagina At puberty, normal flora causing vaginal Inhibit growth of many microorganisms Antibiotics and oral contraceptives dis- secretions to achieve low pH rupting normal flora T AB L E 3 4 -4 Assessing the Risk of Infection in Adults COMPONENT CAUSES OUTCOME Age COPD, heart disease, diabetes Pneumonia, skin breakdown, venous stasis ulcers Lifestyle—high-risk Exposure to communicable/infectious disease- STDs, HIV, HBV, HCV, opportunistic infections, behaviors sUse of IV drugsUse of other drugs/substances viral infections, yeast infections, liver failure Occupation Miner, unemployed, homeless Black lung disease, pneumonia, TB, poor nutritional intake, lack of access to medical care, stress Diagnostic procedures Invasive radiology, transplant Multiple IV lines, immunosuppressive drugs Heredity Sickle cell disease, diabetes Anemia, delayed healing Travel history West Nile virus, SARS, avian flu, Hantavirus Meningitis, acute respiratory distress Trauma Fractures, internal bleeding Sepsis, secondary infection Nutrition Obesity, anorexia Impaired immune response Modified from Tweeten SM: General principles of epidemiology. In Carrico R, editor: APIC text of infection control and epidemiology, Washington, DC, 2005, Association for Professionals in Infection Control and Epidemiology. COPD, Chronic obstructive pulmonary disease; HBV, hepatitis B virus; HCV, hepatitis C virus; HIV, human immunodeficiency virus; IV, intravenous; SARS, severe acute respiratory syndrome; STDs, sexually transmitted diseases; TB, tuberculosis. T AB L E 3 4 -5 Laboratory Tests to Screen for Infection LABORATORY VALUE NORMAL (ADULT ) VALUES INDICATION OF INFECTION WBC count 5000-10,000/mm3 Increased in acute infection, decreased in certain viral or over- whelming infections Erythrocyte sedimentation rate Up to 15 mm/hr for men and Elevated in presence of inflammatory process 20 mm/hr for women Iron level 60-90 g/100 mL Decreased in chronic infection Cultures of urine and blood Normally sterile, without Presence of infectious microorganism growth microorganism growth Cultures and Gram stain of No WBCs on Gram stain, Presence of infectious microorganism growth and WBCs on Gram wound, sputum, and throat possible normal flora stain Differential Count (Percentage of Each Type of WBC) Neutrophils 55%-70% Increased in acute suppurative (pus-forming) infection, decreased in overwhelming bacterial infection (older adult) Lymphocytes 20%-40% Increased in chronic bacterial and viral infection, decreased in sep- sis Monocytes 5%-10% Increased in protozoan, rickettsial, and tuberculosis infections Eosinophils 1%-4% Increased in parasitic infection Basophils 0.5%-1.5% Normal during infection WBC, White blood cell. T AB L E 3 4 -6 Examples of Disinfection and Sterilization Processes CHARACTERISTICS EXAMPLES OF USE Moist Heat Steam is moist heat under pressure. When exposed to high pressure, water vapor Autoclave sterilizes heat-tolerant surgical instru- can attain temperature above boiling point to kill pathogens and spores. ments and semicritical client care items. Chemical Sterilants—High-Level Disinfection (HLD) A number of chemical disinfectants are used in health care. These include alcohols, Chemicals disinfect heat-sensitive instruments and chlorines, formaldehyde, glutaraldehyde, hydrogen peroxide, iodophors, phenol- equipment, such as endoscopes, respiratory ther- ics, and quaternary ammonium compounds. Each product performs in a unique apy equipment. manner and is used for a specific purpose. Ethylene Oxide (ETO) Gas This gas destroys spores and microorganisms by altering cells’ metabolic This gas sterilizes most medical materials. processes. Fumes are released within an autoclave-like chamber. Ethylene oxide gas is toxic to humans, and aeration time varies with products. Boiling Water Boiling is least expensive for use in home. Bacterial spores and some viruses resist Items in home care. boiling. It is not used in health care facilities. T AB L E 3 4 -7 Centers for Disease Control and Prevention Isolation Guidelines Standard Precautions—Tier 1 Standard precautions apply to all blood, all body fluids (except sweat), nonintact skin, and mucous membranes. Perform hand hygiene between client contact; after contact with blood, body fluids, secretions, and excretions and after contact with equipment or articles contaminated by them; and immediately after gloves are removed. Wear gloves when touching blood, body fluids, secretions, excretions (except sweat) nonintact skin, mucous mem- branes, or contaminated items or surfaces. Gloves should be removed and hand hygiene performed between client care encounters. Wear masks, eye protection, or face shields if client care activities generate actual or risk of splashes or sprays of blood or body fluids. Wear gowns if soiling of clothing is likely from blood and/or body fluids. Perform hand hygiene after gown removal. Client care equipment is properly cleaned and disinfected. Single-use items are discarded (see health care facility or agency policy). Place contaminated linen in leakproof bags and handle so as to prevent skin and mucous membrane exposure. Discard all contaminated sharp instruments and needles in a puncture-resistant container. Health care facilities must make available needleless devices. Any needle should be disposed of uncapped, or a mechanical safety device is activated for recapping. A private room is unnecessary unless the client’s hygiene is unacceptable. Check with an infection prevention and control professional. Respiratory hygiene/cough etiquette. Have clients cover the nose/mouth when coughing or sneezing; use tissues to contain respiratory secretions and dispose in nearest waste container; perform hand hygiene after contacting respiratory secre- tions and contaminated objects; contain respiratory secretions with procedure or surgical masks; sit at least 3 feet away from others if coughing. Transmission Categories (Tier Two) CATEGORY DISEASE B ARRIER PROTECTION Airborne precau- Droplet nuclei smaller than 5 mcg; Private room, negative-pressure airflow of tions measles; chickenpox (varicella); disse- at least 6-12 air exchanges per hour via minated varicella zoster; pulmonary or HEPA filtration; mask or respiratory pro- laryngeal TB tection device Droplet precautions Droplets larger than 5 mcg; being within 3 Private room or cohort clients; refer to the feet of the client; diphtheria (pharyn- facility policy for cohorting clientsMask geal); rubella; streptococcal pharyngitis, or respirator is required; refer to facility pneumonia, or scarlet fever in infants policy and young children; pertussis; mumps; mycoplasmal pneumonia; meningococ- cal pneumonia or sepsis; pneumonic plague Contact precautions Direct client or environmental contact; Private room or cohort clients; refer to the colonization or infection with multidrug- facility policy for cohorting clients; resistant organism (MDRO) such as gloves, gowns VRE and MRSA, Clostridium difficile, or respiratory syncytial virus (RSV); draining wounds where secretions are not contained; scabies Protective environ- Allogeneic hematopoietic stem cell trans- Private room, positive-pressure room with ment plants 12 or more air exchanges per hour, HEPA filtration for incoming air, respirator mask, gloves, and gowns TB, Tuberculosis; HEPA, high-efficiency particulate air; VRE, vancomycin-resistant enterococci; MRSA, methicillin-resistant Staphylococcus aureus. Figure 34-1 Chain of infection. Figure 34-2 N95 respirator mask with protective eyewear. (Courtesy Kimberly-Clark Health Care, Roswell, Ga.) Figure 34-3 Placing sterile item on sterile field. Figure 34-4 Nurse opens sterile package on work area above waist level. Figure 34-5 Opening sterile packaged items on a flat surface. A, The nurse opens the top flap away from the body. B, The nurse’s arm is kept out away from the sterile field while opening a side flap. C, The second side flap is opened. D, The back flap is opened.