Unit 5 Microbiological Safety

Infection:

Definition: invasion of body tissues by microorganisms that increase and grow, causing infection.

• Sources

  • Endogenous: within patient (from normal flora)- Healthy microorganisms

    • Ex; Candida — yeast infection, thrush

  • Exogenous: from the environment / transmitted from person to person

• Sites

  • Local: specific/confined area

    • Ex; UTI — confined to the bladder/urinary region/inflammation

  • Systemic: organism spreads to multiple systems

    • Ex; Bacteria, sepsis, MODS (multiple organ dysfunctional syndrome)

• Nosocomial/Healthcare Acquired (HAI): Hospital Aquired Infection

• Iatrogenic: Physician induced

  • Therapeutic or diagnostic procedure (can cause infection)

    • Ex; CAUTI, CLABSI, VAP

• Opportunistic: disruption of body defenses, and then normal microorganisms that are present in the body proliferate

  • Ex; Antibiotics causing normal flora disruption and causing a yeast infection

Defenses against Infection

• Nonspecific (No questions but need to know)

  • Barriers- First line of defenses

    • Anatomic (ex. skin, mucous membranes) — dust particles

    • Physiologic (ex. phagocytosis - engulfs foreign pathogen, saliva, sweat)

  • Inflammatory Response (LAS)

    • GAS - how body defends itself

      » By confining the injury to the smallest part of body as possible

• Specific - GAS

  • Antibody-Mediated (humoral) Immunity

    • Active immunity (immunization)

    • Natural vs. artificial immunity (nurses are exposed to many organisms, hospital workers are more immune to some diseases because of this - natural) — develops only through deliberate actions of exposure

  • Cell-Mediated (Cellular) Immunity

    • Killer T cells

    • Lymphatic system

• Why is this important » older adults are immunocompromised — all body systems decrease in function, including the immune system!

Contributing Factors (Infection)

• Increasing Risk

  • Chemical

    • Ex; anesthesia - slow BMR (Basal metabolic rate)

    • Ex; harsh soap - can decrease essential oils in the skin causing skin tears

    • Ex; antimicrobials (antibiotics) - build immunity because we don’t complete treatment (antibiotics should be the last mode of intervention)

  • Developmental

    • The very old and very young are more susceptible

  • Iatrogenic

    • Procedures that can cause infections (CAUTI, etc.)

  • Physical

    • Ex; Radiation

    • Ex; hot water can cause burns and damage skin

    • Ex; Sheering forces — pulling patients up in bed can cause tears

  • Physiological

    • Those immunocompromised individuals - easily susceptible compared to those who aren’t

      • Malnourised, pregnant, neutropenic precautions (decrease in WBC count - seen often in oncology patients)

    • Interference of urine flow - stasis - urine isn’t being excreted = UTI

    • Changes in G.I.

  • Psycho-socio-cultural

    • Stress, other cultural factors/anxiety

• Microbiological etiologic agents

  • Bacteria, fungus, virus

    • Pathogenic in nature

  • C-Diff — spore-forming organism- (No Gel, wash hands)

    • Hard to get rid of

    • Chief cause = diarrhea

    • Yellow/watery stool

    • Must get stool culture to test

  • E.coli — this is a normal flora found in the G.I. tract

    • Within 40 hours after birth it is seen in our stomachs

    • When it gets into other systems other than the G.I., is when it causes infection (always wipe front to back)

  • MRSA / VRE - found on the skin - make sure not to spread it

Clinical Manifestations

• Inflammation (LAS) — Abbreviation (HELPE)

  • Heat

  • Erythema

  • Loss of function

  • Pain

  • Edema (swelling)

    » you can think of the last E as swelling it HELPS

• Exudate (Drainage) — Characteristic of infection

  • Serous

    • Clear/Yellow (drainage from wounds)

    • This occurs when in the healing process

    • Occurs in abrasions (other breaks in the skin that are not as deep)

  • Purulent (Pus)

    • Contains bacteria — makes it cloudy

    • Can range in color depending on what organism is in the exudate

  • Sanguineous (blood)

    • Would see this kind of exudate when there is a tear in the tissue

  • Serosanguineous (serous and bloody)

    • Pinkish in nature

    • Would see this kind of exudate in thee healing process (looks like cran juice)

Systemic Manifestations

• Fever

• Leukocytosis

• Malaise

• Anorexia

• Nausea, vommiting

  • Organism is in the G.I. tract — body wants to expel it (stomach virus)

• Headache

• Lymphadenopathy

• Other manifestations related to specific infection

Modes of Transmission

• Direct Transmission — if host is susceptible, it can be transmitted through touching

  • Touching- Contact— Gloves and gown as barriers

    » Ex; MRSA, C.Diff (contact-plus)

  • Droplet — Respiratory infection (Mucous membrane)

    » Ex; Through coughing, sneezing directly from one person to another (within 3 ft)

• Airborne Transmission- Very small particles (N-95)

  • Inhalation of droplet/dust particles

  • Can remain in the air for longer periods of times (cough and sneezes)

    » Ex; TB, RSV, Legions disease

• Indirect Transmission

  • Vehicle-borne

    » Ex; soiled linens, soiled furniture

  • Vector-borne- animals or insects

    • Ex; animal/insect transporting/transmitting disease

    • Live host- either bitten, or scratched (ticks, mosquitos)

Asepsis

Definition: Absence of infection

Try to reduce as many microorganisms in the patient’s environment as possible

Contaminated = contain disease-producing organism

• Historical Perspective - Germ theory

• 2 Types

  • Medical (“Clean” technique)

    • Decrease the amount of microorganisms by elimination of gross contamination

    • confine organisms to the smallest area possible to prevent the spread

  • Surgical (“Sterile” technique)

    • Specific process to keep area free of microorganisms

    • IV, Foley, OR, Dressing, Trac care

Principles of Surgical Asepsis

• All objects in a sterile field must be sterile

• Sterile objects become unsterile when touched by unsterile objects

• Sterile objects become unsterile when below waist or out of sight

• Prolonged exposure can lead to contamination

• Fluids flow by gravity

• Moisture increases conduction of microbes

• Edges of sterile field (1 inch) are contaminated

• Skin cannot be sterilized

  • Anything touched with your hands + contaminated

  • Use a scalp to cut skin

NEVER TURN BACK, NEVER TALK OVER STERILE OBJECTS

Nursing Diagnoses and Goals

Ex; Risk for contamination

Methods to Decrease Numbers of Microorganisms

• Simple Cleaning (Clean Environment)

  • Limit food at the bedside

  • Report any bugs that are on the unit

• Physical Methods

  • Opening shades/blinds — UV light can kill some microorganisms

• Antiseptics

  • Alcohol, chlorhexidine, showers

• Disinfection

  • Sani-wipes (different color tops kill different microorganisms)

• Sterilization

  • More in the OR/surgical setting

  • Destroying of all microorganisms

    » Ex; Autoclaving (under heat), boiling equipment, chemicals, radiation, ethylene gas

• Antimicrobial agents- stops growth of infection

Precautions

Tier 1 (Standard Precaution)

• Hand Hygiene: wash vs gel; nails

  • Washing is more effective than gel

  • No artificial nails! — they can chip and harbor bacteria under the polish

• PPE (Protective Personal Equipment)- gown, gloves, mask, etc.

• Patient Care Materials — linens

• Cleaning Equipment

• Needle disposal (sharps container)

• Patient placement

  • Isolate a patient if they have an infectious disease, cohort them if possible, etc.

Tier 2 (Transmission Based Precautions)

• Airborne

• Droplet- (respiratory infection)

• Contact- (approach a patient)

• Protective

• Combination / Strict — (Droplet/Contact)

Decrease Host Susceptibility

• Immunizations

  • Increase immunity when you decrease your susceptibility (active immunity- artificial)

• Nutrition

  • Increase protein (WBC production, tissue maintenance)

  • Increase vitamin C

  • Zinc (boosts energy)

• Fluids (Keep skin moist, can’t be dry)

  • Thins secretions, flushes out microorganisms in the urinary tract

• Smoking cessation- smoking destroys passageways

• Control stress levels

  • Stress wears the immune system — inflammatory response

• Chronic disease management

• Maintaining non-specific defenses

  • Skin integrity

    • Breaks in the skin = easy for microbes to enter

Hygiene (Personal Hygiene)

Science of health and its maintenance/preservation of health and cleanliness

• Those who need help with hygiene:

  • Blind

  • Morbidly obese

  • Those who have ROM issues

    • Stroke patients

    • Paralysis

• Purposes

  • Interpersonal relationships with patient

  • Assess the patient’s skin and whole body

  • Stimulates circulation (**DO NOT massage calves — could dislodge thrombus)

  • Promotes health

  • Improves self-image

  • Promotes cleanliness

  • Conditions skin

• Clinical manifestations indicating increased need

  • Smegma

    • White cheesy like build up in the perineum

• Categorization

  • Timing

  • Extent

    • Can patient assist in their hygiene at all? (if so allow them to)

  • Types

    • Shower, bathing

    • Always must have MD order!!

Eye Care

• Cleanse with clean water

• Clean with a washcloth or cotton balls

• Clean from inner canthus outwards (prevents infection spread)

• Check for care of contact lenses, prosthetic eyes

  • Contacts should be taken out every so often

  • Prosthetics should be taken out daily and cleaned

Hair Care

• Combing and brushing

  • Should do this daily if possible

  • Redistributes the natural oils (sebum) from scalp to the ends

    • Prevent tangling

• Styling

• Shampoo- may need an MD order in some facilities

  • Ask what people prefer when washing hair or face

  • Make sure they are afebrile before washing hair

• Facial hair care

  • Shaving beards

    • Always use an electric shaver!

    • Manual ones can cause cuts - dangerous for patients on anticoagulants

Nail Care

• Epidermal appendages or extensions

• No cutting but can file carefully

• Soak fingers before cleaning under nails

• Gently push cuticles back with a washcloth

• Assess the shape, angle, color of nail beds, texture, markings, and condition of surrounding tissue

  • Nails can be a big indicator of a patient’s nutritional status and habits (nail biting)

Oral Care

• Purposes

  • The mouth is very important to keep clean

    • Many microbes can enter and proliferate here

• Candidates

  • Everyone

  • Those with NG tube

  • Altered mental status

  • Fever

  • Older adult (lack of saliva production)

  • Patients on O2 (can cause dry mouth)

• Equipment

  • Kidney basin, tooth brush, gloves, toothpaste, floss

• Methods

  • Place patient in lateral position if they have an altered level of consciousness

    • Helps with excreting mucous by gravity

  • NEVER put fingers in patient’s mouth

    • They can bite you!

Maintaining Hygienic Environment

• Bedmaking- make sure sheets are taut (wrinkles can cause irritation on the skin - skin breakdown!)

  • Unoccupied

  • Occupied

• Cleaning

  • Use of disinfectant wipes

  • Disposal of possible contaminants

    • Do not save food (can spoil)

    • Keep food fresh - refrigerate

    • Get rid of excess debris (tissues, garbage, etc.)

• Using barriers

Principles of bathing

• Privacy

  • Super important - always maintain patient’s dignity

  • Pull curtain and drape patient’s body that isn’t being washed

• Involvement of patient

  • Always explain the procedure and what it entails (have a conversation)

• Maintenance of autonomy

  • Have the patient help you as much as possible

• Components

  • Washing

  • Rinsing

  • Drying

• Control of Heat Loss

  • Prevent evaporation

    • Don’t leave skin wet - pat dry

  • Radiation

    • Cover all parts that aren’t being used (maintain body temperature)

  • Conduction- heat transfer from warm objects to cooler objects

    • Use ideal water temperature (around 105)

  • Convection

    • Control air movement by closing doors, windows, etc.

      » Ex; Covering a patient w/ both blanket limits heat loss

Peri-care for the Male

• Wash and dry the penis using firm strokes

• Start at the glans and work in a circular motion away from the glans and along the shaft of the penis towards the body away from the urinary meatus

• Wash and dry the scrotum

• Uncircumcised males: the foreskin or prepuce needs to be retracted to clean the glands and then put back

• Anus area last

Peri-care for the Female

• Clean labia majora, the spread labia to wash and rinse between the folds of the labia majora and minora

• Patients may find it embarrassing at first - but it needs to be done properly

• Work efficiently to expose patients as little as possible (no harsh chemicals, most for older adults)

• Pat dry

(Foley clean away from entry)