Chapter 28: Infection Prevention and Control
Background:
- Protects patient from healthcare related infections
- Meet professional standards/guidelines
- Protect yourself and your loved ones from disease
- Help lower the cost of healthcare
- Healthcare associated infections (HAIs): hospitals, homecare, long-term care, ambulatory setting
- Nosocomial infections: hospital-acquired, specifically
Scientific Knowledge Base:
- Nature of infection:
o Infection: results when a pathogen invades tissues and begins growing within a host
o Colonization: presence and growth of microorganisms within a host and without tissue invasion
or damage
- Chain of infection:
o Infectious agent
o Reservoir: food, oxygen, water, temperature, pH,
light
o Portal of exit: skin and mucous membranes,
respiratory tract, urinary tract, gastrointestinal tract,
reproductive tract, blood
o Modes of transmission:
 Contact:
 Direct: person-to-person (fecal, oral)
physical contact between source and
susceptible host
o A healthcare provider’s hands
become contaminated by
touching germs and the healthcare worker then carries the germs on his
or her hands and spreads to a susceptible person
 Indirect: personal contact of susceptible host with contaminated inanimate
object
o Needles, soiled linen, dressings, environment
 Droplet: an infected person coughs or sneezes, creating droplets that carry germs short
distances (within approximately 6 feet)
 These germs can land on a person’s eyes, nose, or mouth and can cause infection
 Airborne: organisms are carried in droplet nuclei or residue or evaporated droplets
suspended in the air during coughing or sneezing
 Germs are aerosolized by medical equipment or by dust from a construction
zone
 Vehicles:
 Contaminated items
o Example: sharp injuries can lead to HIV infection when bloodborne
pathogens enter a person through a skin puncture by a used needle
 Water
 Drugs, solutions
 Blood
 Food (improperly handed, stored, or cooked)
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Vector:
 External mechanical transfer: flies
 Internal transmission such as parasitic conditions between vector and host:
insects
o Portal of entry
o Susceptible host
The Infectious Process
- Defenses against infection
o Normal floras
o Body system defenses
o Inflammation
 Vascular and cellular responses
 Inflammatory exudate
 Tissue repair
- Health care-associated infections (HAIs)
o Occur as the result of:
 Invasive procedures
 Antibiotic administration
 Multidrug-resistant organisms (MDROs)
 Breaks in infection prevention and control activities
Nursing Knowledge Base
- Factors influencing infection prevention and control
o Age
o Sex
o Nutritional status
o Stress
o Disease process
Nursing Process: Assessment
- Through the patient’s eyes
o Past experiences
-
o Knowledge of infection
Risk factors
Clinical appearance
Status of defense mechanisms
o Medical therapy
Travel history
Laboratory data
Assessment-Risk Factors
- Developmental Stage
- Breaks in line of defense
- Illness or injury
- Tobacco/Substance Abuse
- Multiple Sexual Partners
- Environmental Factors
- Chronic Disease
- Medications
- Nursing/Medical Procedures
Nursing Process: Nursing Diagnosis
- Nursing diagnoses for infection:
o Risk for Infection
o Impaired Nutritional Status: Deficient Food Intake
o Impaired Oral Mucous Membrane
o Social Isolation
o Impaired Tissue Integrity
Nursing Process: Planning
- Goals and outcomes
o Common goals of care often include:
 Preventing further exposure to infectious organisms
 Controlling or reducing the extent of infection
 Maintaining resistance to infection
 Verbalizing understanding of infection prevention and control
- Setting priorities
o Establish priorities for each diagnosis and for related goals of care.
- Teamwork and collaboration
o Collaborate with patients and interprofessional team
Nursing Process: Implementation
- Health promotion
o Nutrition
o Hygiene
o Immunization
o Adequate rest and regular exercise
- Acute care
o Eliminate the infectious organism
o Support the patient's defenses
- Medical asepsis
o Control or elimination of infectious agents
 Cleaning
 Disinfection and sterilization
o Protection of the susceptible host
o Control and elimination of reservoirs of infection
o Control of portals of exit/entry
 Cough etiquette
o Control of transmission
 Hand hygiene
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Isolation and isolation precautions
o Standard precautions
o Transmission-based precautions
 Airborne, Droplet, Contact, and Protective Environment
o Psychological implications of isolation
o The isolation environment
o Personal protective equipment
 Gowns, masks, eye protection, gloves
o Specimen collection
o Bagging trash or linen
o Transporting patients
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Role of the infection control professional
o Collection and analysis of infection data
o Evaluation of products and procedures
o Development and review of policies and procedures
o Consultation
o Education
o Implementation of changes
o Application of epidemiological principles
o Antimicrobial management
o Participation in research projects
o Monitoring antibiotic-resistant organisms in the institution
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Infection prevention and control for hospital personnel
o WHO's five moments for hand hygiene
Patient education
o Infection prevention and control in the home setting
Exposure issues
o Accidental needlesticks
o Blood or other potentially infectious materials
(OPIMs)
o Airborne and droplet diseases
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My Five Moments for Hand Hygiene
Surgical asepsis
o Patient preparation for a sterile procedure
o Principles of surgical asepsis
o Performing sterile procedures
o Donning and removing caps, masks, and eyewear
o Opening sterile packages
o Opening a sterile item on a flat surface
o Opening a sterile item while holding it
o Preparing a sterile field
o Pouring sterile solutions
o Surgical scrub
o Applying sterile gloves
o Donning a sterile gown
o Placing Sterile Item on Sterile Field
Opening Sterile Packages
Nursing Process: Evaluation
- See through the patient’s eyes:
o Have the patient’s expectations been met?
- Patient outcomes
o Measure the success of the infection control techniques
o Compare the patient’s actual response with expected outcomes
o If goals are not achieved, determine what steps must be taken
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Safety Guidelines for Nursing Skills
Apply Standard Precautions
Use clean gloves when you anticipate contact with body fluids and nonintact skin or mucous
membranes
Use gown, mask, and eye protection when there is a risk for splash
Keep bedside table surfaces clutter-free, clean, and dry when performing aseptic procedures.
Clean all equipment that is shared between patients
Ensure that patients cover mouth and nose when coughing or sneezing, use tissues to contain
respiratory secretions, and dispose of tissues in waste receptacle
Chapter 29: Vital Signs
What is a Vital Sign?
- Assessment of vital or critical physiological
functions
- Always evaluate in context of clinical condition:
o Temperature
o Pulse
o Respiratory rate, oxygen saturation
o Blood pressure
o Pain as the 5th vital sign
Guidelines for Measuring Vital Signs
- Measuring vital signs is your responsibility
- Assess equipment is working correctly
- Select the appropriate equipment for the patient
- Know the patient's usual range of vital signs
- Know the patient's health history, therapies, and
prescribed and over-the-counter medications
- Control environmental factors and be organized
- Verify and communicate significant changes
- Provide patient teaching about your findings
Body Temperature: Physiology
- Body temperature regulation
o Neural and vascular control
o Heat production
o Heat loss
o Skin in temperature regulation
o Behavioral control
Regulation of Body Temperature
- Heat Production:
o Neural & Vascular Control
o Basal Metabolic Rate
-
o Skeletal Muscle Movement
o Non-shivering Thermogenesis
Heat Loss:
o Radiation
o Convection
o Evaporation
o Conduction
Factors Affecting Body Temperature:
- Age
- Exercise
- Hormone level
- Circadian rhythm
- Stress
- Environment
- Temperature alterations
o Fever, hyperthermia, heatstroke, heat exhaustion, hypothermia
Hypothalamic Temperature Control
- “Hot” Terminology:
o Febrile/Pyrexia >38
o Hyperthermia
o Heatstroke > 40◦C (104◦F)
o Heat Exhaustion
- “Cold” terminology:
o Hypothermia <36◦C
 Mild 34-36◦C (93.2-96.8◦F)
 Moderate 30-34 ◦C (86-93 ◦F)
 Severe <30 (<86 ◦F)
 Deliberately Induced
 Frostbite
Nursing Process: Temperature Assessment Equipment
o Thermometers
 Electronic
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Tympanic
Temporal Artery
Chemical dot
Infrared Forehead Thermometer???
Core temperature: tympanic
o Critical Care: pulmonary artery, urinary bladder, esophageal
Surface temperature: oral, axillary, skin, temporal artery, rectal
Temperature: Tympanic Membrane
- Fast, 2-5 seconds
- Uncooperative clients
- Cerumen impaction ↓ accuracy
- Contraindicated with ear infection, ear surgery
Temperature: Oral
- Measurement affected by hot or cold drinks, cold ambient air, rapid respiratory rate
- Measurement is delayed by cigarette smoking, oxygen flow
- Must be able to follow directions
Temperature: Axillary
- Safe, Easy
- Uncooperative clients
- Underestimates core temp
Temperature: Rectal
- Clients unable to follow directions
- Risk for injury to mucosa
- Contraindicated for those with impaired rectal mucosa or immunocompromised (Chemotherapy,
Transplant, AIDS etc.)
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Diagnosis: cluster defining characteristics to form a nursing diagnosis
o Examples of nursing diagnoses for patients with body temperature alterations
 Risk for Impaired Thermoregulation
 Hyperthermia
 Hypothermia
 Impaired Thermoregulation
 Fever
Planning
o Goals and outcomes
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o Setting priorities
o Teamwork and collaboration
o Nursing Process: Temperature (4 of 5)
Implementation
o Health promotion
Acute care
o Fever
o Heatstroke
o Hypothermia
Restorative and continuing care
Nursing Intervention
- Selecting the appropriate route and device
- Taking appropriate precautions and positioning especially when taking a rectal temperature
- Consider specific client related factors that could raise or lower temperature
- Obtain temperature measurement as ordered/Needed
What is the nurse going to do?
- Assessment
o Help determine cause
o Monitor temperature and vital signs
o Observe for other signs and symptoms
- Activities
- Treat cause/Blood Cultures
- Give fluids/nutrition
- Cooling blankets
- Antipyretics
- Keep bed linens dry
- Emergency cooling if heat stroke
- Hypothermia
- Evaluation
o Get patient’s perspective, compare actual with expected outcomes, and determine whether
goals were met
Pulse
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Normal: 60-100 beats per minute
Systole: left heart ventricle contracts>blood is forced out into arteries, wave pulses through arteries
Diastole: left ventricle relaxes, arteries constrict
Cardiac Output (CO): 5-8 L/min
o The volume of blood pumped by the heart in one minute
Heart Rate (HR): 60-100 BPM
o The number of times the heart pumps in one minute
Stroke Volume (SV): 50-100 mL/beat
o the volume of blood pumped from one ventricle of the heart with each beat
CO = HR X SV
Factors that influence Pulse Rate:
- Developmental level
- Exercise
- Emotion
- Temperature
- Disease
- Hemorrhage/Blood loss
- Postural changes
- Medications/Foods
Nursing Process: Pulse
- Palpation: radial or carotid
- Auscultation via stethoscope (apical)
Assessment of Pulse
- Character of the pulse
o Rate
o Rhythm
o Strength
o Equality
- Nursing diagnosis
o Cluster defining characteristics to form a nursing diagnosis
- Examples of nursing diagnoses related to pulse assessment
o Activity Intolerance
o Dehydration
o Hypervolemia
o Impaired Cardiac Function
o Impaired Peripheral Tissue Perfusion
- Planning and Implementation
o Independent nursing interventions based on the nursing diagnosis identified and the risk
factors or related factors
o Dependent interventions that focus on the timely administration of medications and careful
management of fluid balance
- Evaluation
o Patient outcomes: evaluation of the character of the pulse in response to interventions
Respiration:
- Involves:
o Ventilation
o Diffusion
o Perfusion
- Physiological control
o Regulated via CO2 levels-respiratory center in the
brain stem
o Uses levels of CO2, O2, and hydrogen ion
concentration (pH) of the arterial blood to
regulate ventilation
o Patients with chronic lung disease are sensitive to
low levels of O2 (hypoxemia)
Factors affecting Respiration:
- Developmental level
- Exercise
- Pain/Anxiety
- Stress
- Smoking
- Fever
- Hemoglobin
- Disease/Neurologic Injury
- Medications
- Position
Nursing Process: Respiration
- Assessment of ventilation
o Respiratory rate
• 12-20 breaths per minute
• Apnea/Dyspnea/Tachypnea
o Ventilatory depth
• Volume
o Ventilatory rhythm
• Rhythm-Regular or irregular, effort
- Should be done without the patient/client being aware. Usually after taking the patient’s pulse
Respiration Assessment Tools
- Assessment of diffusion and perfusion
o Measurement of arterial oxygen saturation
o Finger
o Earlobe
o Forehead/bridge of nose
- Capnography
Assessment of Arterial Oxygen Saturation
o The pulse oximeter probe measures the O2 of arterial blood by bouncing light from
Hemoglobulin and reading its Oxygen Concentrations
- Nursing diagnosis
o Cluster defining characteristics to form a nursing diagnosis
- Examples of nursing diagnoses related to respiration
o Activity Intolerance
o Impaired Airway Clearance
o Impaired Breathing
o Impaired Gas Exchange
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Planning and implementation
o Interventions are based on the nursing diagnosis identified and the related factors
Evaluation
o Evaluate patient outcomes by evaluating the respiratory rate, ventilatory depth, rhythm, and
SpO2
o Consider the physiological changes expected from nursing interventions as you evaluate patient
outcomes
Blood Pressure
- Blood Pressure: force exerted on walls of an artery by the pulsing blood under pressure from the heart
o Systolic pressure: peak pressure as ventricles contract and eject blood
o Diastolic pressure: minimum pressure when ventricles are at rest
- Physiology of arterial blood pressure:
o Cardiac output
o Peripheral resistance
o Blood volume
o Viscosity
o Elasticity
- Factors influencing blood pressure:
o Age, stress, ethnicity and genetics, gender, daily variation, medications, activity and weight,
smoking
- Hypertension
- Hypotension
Nursing Process: Blood Pressure
- Assessment of blood pressure
o Blood pressure equipment for auscultation
o Width: 40% of upper arm circumference
o Length: 80% of upper arm (Cuff covers 2/3rds of the extremity)
Hypotension:
- Systolic blood pressure is below 90 mm Hg
- Abnormal finding when associated with an illness
- Orthostatic hypotension: occurs when the blood volume is decreased resulting in a drop in blood
pressure when changing positions from lying to sitting or standing (20 mm Hg drop in Systolic number
or 10 mm Hg drop in Diastolic)
Assessment: Blood Pressure
- Auscultation
o Orthostatic Hypotension
o Ultrasonic Stethoscope
o Palpation
- Equipment
o Manual Blood Pressure Cuff
o Automated Oscillometer Device
Nursing Process: Blood Pressure
- BP assessment in children
- Lower-extremity blood pressure
- Self-measurement of blood pressure
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Nursing diagnosis
o Cluster defining characteristics to form a nursing diagnosis
Examples of nursing diagnoses related to blood pressure
o Activity Intolerance
o Anxiety
o Impaired Cardiac Output
o Fluid Imbalance
o Acute Pain
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Planning and implementation
o Health Promotion
• Incorporate patient teaching
Evaluation
o Recording vital signs
• Documenting on a graphic
o Document any interventions initiated because of vital sign measurement