Lecture 1B
Disease transmission/ prevention
1st line of Defense
• Skin 
– Barrier
• Mucus 
– Traps and removes
Inflammation
• “Non-specific”
response to injury
• WHY?
– Destroy pathogens
– Limit spread
– Begin to heal
Pathophysiology of Inflammation
• 3 step process
1. Vascular response
2. Cellular response
3. Healing
1. Vascular response
Injury 
Chemicals released 
• Histamine
• Bradykinin
• Prostaglandins
1. Vascular response
• Histamine 
• Dilate
–Vasodilation
•  h blood flow
•  h pressure
 Redness
1. Vascular response
• Bradykinin 
• h permeability
– capillaries leak
fluid into
surrounding tissue
• swelling
1. Vascular response
• Prostaglandins 
– h Pain
– h Temperature
• Pain
• Heat
• Loss of function
2. Cellular response
• h blood flow 
• h WBC
– Neutrophils:
• First responders!
• Move from blood
vessel  the
injured tissue
2. Cellular response (cont.)
• 2nd responders
– Monocytes 
(mature) 
MACROPHAGES
2. Cellular response (cont.)
• Neutrophils +
Macrophages
– Ingest
• bacteria and
• dead tissue
– PHAGOCYTOSIS
Cellular response (cont.)
• Neutrophils &
Macrophages eat
then die
•  Pus Formation
• “purulent
drainage”
3. Healing & Tissue repair
• Minor injury:
–Inflammatory
process heals
• Major injury
–New cells are
produced 
–Scar tissue
Classic Signs & Symptoms of
inflammation
•
•
•
•
•
Heat
Redness
Swelling
Pain
Loss of function
Geriatric Inflammation
Older adult
•
•
•
•
•
Thin skin
i blood flow
i macrophages
i phagocytosis
Med interference
Geriatric Inflammation
• Results
–
–
–
h risk of injury
i wound healing
i S&S
Geriatric Inflammation
• In 25% of the
elderly, they do
not have an
elevated fever
even with a
serious infection
Geriatric Inflammation
• Best indicator of
serious infection in
the elderly…
–Delirium
–Change in
mental
function
Small Group Questions
1. Define inflammation in your own words and
describe the pathophysiology of the inflammatory
response.
2. What are the cardinal signs of inflammation and
what causes each one of them?
3. What is phagocytosis? What cells “do it”?
4. Why are the elderly more susceptible to
inflammation, or are they?
5. How do the elderly typically manifest infection?
Acute vs. Chronic
Acute inflammation
• Short-term reaction
• Immediate response
• Duration
– < 2 weeks
Chronic inflammation
• Slower onset
• Lasts weeks - months
Diabetes mellitus & Inflammation
• DM 
– h risk of poor wound
healing and infection
• High blood glucose
levels
– i phagocytosis
– Damages capillaries
Systemic manifestations
• Enlarges lymph
nodes
• Appetite
–i
• Fatigue
• Heart rate
– Tachycardia
Systemic manifestations
• Respiratory rate
–Tachypnea
• Leukocytosis
–h WBC
• Fever
Interdisciplinary Care: Diagnostic Tests
• WBC c differential
• Erythrocyte
sedimentation rate
(ESR)
• C-reactive protein
(CRP)
• Cultures
WBC c differential
• 5 leukocytes
–Neurtophils
–Eosinophils
–Basophils
–Monocytes
–Lymphocytes
WBC c differential
• Normal TOTAL WBC
– 4,500 – 10,000 mm3
• > 10,000 mm3 
– Leukocytosis =
– Bacterial infection
• < 4,500 mm3 
– Leukopenia =
– Viral infection
WBC c\ differential
Type of leukocyte (normal
value)
Increased
Decreased
TOTAL WBC
4,500 – 10,000 mm3
Leukocytosis: acute
infection, stress
Leukopenia: Anemia, viral
infection
Neutrophils
50-70%
Acute infection, leukemia,
Viral diseases
Eosinophils
1-3%
Allergies, parasitic
diseases, cancer
Burns, Cushing’s syndrome
Basophils
0.4 – 1%
Inflammation, leukemia
Stress, hypersensitity
reactions
Monocytes
4 - 6%
Viral disease, parasitic
diseases
Bone marrow depression
Lymphocytes
25-35%
Leukemia
Cancer
Erythrocyte Sedimentation Rate (ESR)
• Detects
generalized
inflammation
•h=
–Inflammation
C-reactive Protein (CRP)
• Produces by the
liver during acute
inflammation
• +=
– inflammation
Cultures
• Used to identify
bacterial
infection.
Small Group Questions
1. Differentiate between acute and chronic.
2. What affect does Diabetes Mellitus have on
wound healing?
3. What are the systemic manifestations of
infection? (use medical terms AMAP)
4. What will the following lab tests indicate?
– WBC c/ differential; ESR; CRP; wound culture
Medications
• Antibiotics
• Acetaminophen
• Antiinflammatory
agents
Antibiotics: Indications
• Treat infection caused by bacteria
• Prevent infection:
–Prophylactic
Antibiotics: Rule
• Culture done
first!
Antibiotics: Patient Education
• Teach client to
FINSH all of the
antibiotics
Acetaminophen
• Is NOT an antiinflammatory
• Analgesic
–i pain
• Antipyretic
–i
fever
Anti-inflammatory agents
• 4 classification
• When
– Salicylates
inflammation 
– Other Non-steroidal
harm  antianti-inflammatory
inflammatory
drugs (NSAID)
drugs
– Corticosteroids
– Cyclooxygenase-2
(COX-2) inhibitors
Salicylates
• Aspirin
–Acetylsalicylic
Acid (ASA)
WARNING!!!
• Do not give
Aspirin to kids
– chickenpox’s
– influenza
Aspirin WARNING!!!
• Aspirin + kids
•  Reye’s syndrome
– h intracranial
pressure
–Seizures
NSAIDS
• Non-steroidal anti-inflammatory
drugs
• Action:
1. Anti-inflammatory
2. Anti-pyretic
3. Analgesic
Salicylates & NSAIDS
• S/E
–GI irritation
–Bleeding
Corticosteroids
• Action:
–Anti-inflammatory
–Anti-allergy
–Anti-immunity
Corticosteroids
• Indication:
–Acute hypersensitivity reactions
–Chronic inflammatory diseases
Corticosteroids
• S/E
–Delayed healing
–Na+ & H2O
retention
Corticosteroids
• Rules:
–Smallest effective
dose
–Never stop abruptly
• Taper the dose
Small Group Questions
1. What 3 classification of medications are used to
treat a patient with inflammation?
2. Give an example by name of each classification
of medication.
3. What are the indications for each medication?
4. What are the actions of each type of
medication?
5. What are the side-effects of each medication?
6. What are the Nursing Management (RULES) for
each classification of medication?
Can you fill this out?
Medications used to treat inflammation
Class
Example
Action
Indication
S/E
Rules
Keys to wound healing
• Healing requires
–Adequate circulation
–Adequate oxygenation
–Adequate nutrition
Healing Nutrition
•
•
•
•
Carbohydrates
Protein
Vitamins
Minerals
– Vitamin A
• Capillary formation &
tissue growth
– B-complex
• Wound healing
– Vitamin C
• Collagen synthesis
– Vitamin K
• Blood clotting
– Zinc
• Immune health
Nursing Process for Inflammation:
Assessment
• Subjective Data
– General health
– Change in appetite
– Frequent infections
– Medication use (3 A’s)
• Anti-inflammatory meds
• Antibiotics
• Acetaminophen
Nursing Process for Inflammation:
Assessment
• Objective data
– Vital signs
• Pulse
–h
•T
–h
• BP
–h
•R
–h
–S&S
–Circulation
–Skin / wound
–Edema
–Palpate lymph
nodes
–Lab values
Nrs Diagnosis: Pain
•
•
•
•
•
•
•
Assess
Elevate
Enc. Rest
Distraction
Apply cold or heat (per Rx)
Give anti-inflammatory agents (per Rx)
Give mild analgesics (per Rx)
Nrs Diagnosis: Impaired Tissue Integrity
•
•
•
•
•
Protect & Clean
Dressing
Enc. Rest
Enc. Movement
Enc. Well-balanced diet
Nrs. Diagnosis: Risk for infection
• Monitor vital signs
–Labs
• Culture drainage
• Enc. Fluids
–2,500 mL per day
• Infection Control measures
Small Group Questions
1. Define leukocytosis & leukopenia. How do you know if you
have it?
2. Mr. Jones is prescribed an antibiotic for a thumb infection.
What would you teach him about taking his antibiotic?
3. What are some of the side effects of taking corticosteroids?
What might the IDT do to decrease these risks?
4. 8 year old Mary got her fingers crushed in a car door. What
would be your priority nursing diagnosis and interventions?
5. Following surgery, George has a 3 inch incision on his
abdomen. What might be a priority nursing diagnosis &
interventions related to this incision?
Infection
• Microorganisms
–Normal Flora 
• Beneficial
–Infection 
• Growth and invasion of
microorganisms that leads to disease
Chain of Infection
1. Pathogen
• Microorganism
capable of
causing disease
Chain of Infection
1. Pathogen
• Virulence
– Power of
microorganism to
cause infection
• Invasiveness
– Ability to get into
the body
Chain of Infection
1. Pathogen
2. Reservoir
3. A portal of exit
• Reservoir
– Where the
pathogen lives
• Portal of Exit
– A way to get out
of the reservoir
Chain of Infection
1. Pathogen
2. Reservoir
3. Portal of exit from the
reservoir
4. Mode of
Transmission
• Pathogens move
from the reservoir 
host
Mode of Transmission
• Direct contact
– Person to person
– Contact with
inflected fluids
• Indirect contact
– Infectious agent is
carried on an
inanimate object
or vector
Direct: Mode of Transmission
• Droplet
– Large, moist droplets
• Airborne
– Small particles are
carried by air-currents
and then inhaled
Mode of Transmission
• Vectors
–Insects and animals that act an
intermediate hosts between reservoir
and host
Chain of Infection
1. Pathogen
2. Reservoir
3. Portal of exit from the
reservoir
4. Mode of Transmission
5. Portal of entry
• Entrance into host
– Eyes
– Mouth
– Respiratory
– GI
– GU
– Broken skin
– Blood
Chain of Infection
1. Pathogen
2. Reservoir
3. Portal of exit from the
reservoir
4. Mode of Transmission
5. Portal of entry
Susceptible host
Stages of the Infectious Process
1. Initial stage
• Incubation period
• Pathogen is active
but no symptoms
Stages of the Infectious Process
1. Initial stage
2. Prodromal
stage
• Symptoms begin to
appear
– Vague
– General malaise
– Fatigue
– Fever
– Muscle aches
Stages of the Infectious Process
1. Initial stage
2. Prodromal stage
3. Acute stage
• Pathogens h
• Obvious S&S
– Fever
– Chills
– Tachycardia
– Tachypenia
Stages of the Infectious Process
1. Initial stage
2. Prodromal stage
3. Acute stage
4. Convalescent
stage
• Infection contained
• Tissue repair
• Symptoms i
Stages of the Infectious Process
1.
2.
3.
4.
Initial stage
Prodromal stage
Acute stage
Convalescent stage
5. Resolution
• Infection totally
eliminated
• No S&S
Healthcare-Associate Infection
• AKA: Nosocomial infections
Who is more likely to get a nosocomial
infection?
LEFT ⏪
• Acute disease
⏩ RIGHT
• Chronic disease
Who is more likely to get a
nosocomial
infection?
LEFT ⏪
Thin
⏩ RIGHT
Obese
Who is more likely to get a
nosocomial
infection?
LEFT ⏪
 Foley catheter
⏩ RIGHT
 Incontinent
Who is more likely to get a
nosocomial
infection?
LEFT ⏪
 Short-term
hospital stay
⏩ RIGHT
 Long-term
hospital stay
Who is more likely to get a
nosocomial
infection?
LEFT ⏪
 8 week old
enfant
⏩ RIGHT
 8 year old
child
Who is more likely to get a
nosocomial
infection?
LEFT ⏪
 40 year old
man
⏩ RIGHT
 90 year old
woman
Who is more likely to get a
nosocomial
infection?
LEFT ⏪
 Corticosteroid
⏩ RIGHT
 Chemotherapy
Who is more likely to get a
nosocomial
infection?
LEFT ⏪
 Acute disease
⏩ RIGHT
 Chronic disease
Who is more likely to get a
nosocomial
infection?
LEFT ⏪
 Acute disease
⏩ RIGHT
 Chronic disease
Healthcare-associated infections
• Mode of Transportation
– Healthcare professionals
– Visitors
– Therapeutic devices
Healthcare-associated infections
• Common sites
–UTI - #1
–Post-op wound infections
–Respiratory
–Bloodstream
Healthcare-associated infections
• Most frequently pathogens
– Escherichia coli
– Staphylococcus aureus
– Group A streptococci
– Enterococcus
Resistant pathogens
• Causes
– Inappropriate use of antibiotics
• Result
– Resistance
– Mutation
Methicillin-Resistant Staphylococcus Aureus
(MRSA)
• Reservoir
– Mucous membranes
– Resp. Tract
• Hospital & community acquired
• Isolation
– Contact Precautions
Vancomycin-Resistant Enterococcus
(VRE)
• Reservoir
– GI
– Female genital tract
• Isolation
– Contact Precautions
Other Resistant Strains
• Penicillin-resistant
streptococcus
pneumoniae
• Clostridiumdifficile
• TB
Small Group Questions
1. Describe the chain of infection and how it
relates to infection control.
2. What are the stages of the infectious process?
What are the typical S&S in each stage?
3. What is the #1 nosocomial infection?
4. How do you create a “Super-Bug”? What makes
it “super”? Give an example of a “super-bug”.
5. BONUS: Can you come up with an acronym for
the stages of the infectious process?
Diagnostic Tests
• WBC – differential
• Culture & Sensitivity
Culture & Sensitivity
• Culture
–Collect
– lab
–Incubator:
• 24-36 hours
–Identified
• via microscope
Culture & Sensitivity
• Sensitivity
– Determine which antibiotics are most
effective
– Duration: 24-72 hours
Medications
• Antimicrobials
– Drugs able to destroy pathogens
– Types
• Antibiotics
• Antifungal
• Antiviral
• Antiparasitic
Medications: Antibiotics
• Narrow-spectrum antibiotics
–Act against limited number of
pathogens
• Broad-spectrum antibiotics
–Inhibit a wide variety of pathogens
Terms to know
• Prophylactic
–Preventative
• Super-infection
–A new infection due to destruction of
normal flora
Infection Control & Prevention
• Hand washing
• Personal hygiene
• Immunization
REMEMBER!!!
• Alcohol based hand rub is recommended by
the CDC as the preferred method of hand
hygiene. A soap and water wash is
recommended for visibly soiled hands.
Wearing gloves does not eliminate the need
for hand washing.
Standard Precaution
• Do not touch
–
–
–
–
Blood
Body fluids (except sweat)
Non-intact skin
Mucous membranes
Hand washing
• After
–Touching body fluids
–Removing gloves
–Between patients
Gloves
• When touching
–Body fluids
–Mucous membranes
–Non-intact skin
Gown
• During procedures when contact with
body fluids is anticipated.
Mask
• When body fluids are likely to splash
or spray.
–Suctioning
–Endotracheal intubation
Equipment
• Wash hands
after handling
• Cleaning routine
Laundry/textiles
• Cover
• Don’t hug
Needles / sharps
• Do not recap
• 1-handed scoop
• Punctureresistant
container
CDC Confirms Las Vegas Hepatitis
Outbreak Stemmed From Needle Reuse
Monday, May 19, 2008
• The CDC has confirmed that a Las Vegas hepatitis C outbreak was
caused by clinic workers improperly reusing syringes and medicine
vials.
• The Centers for Disease Control and Prevention was contacted by
state health officials earlier this year after two people treated at the
now-closed Endoscopy Center of Southern Nevada were diagnosed
with hepatitis C.
• Officials have linked 84 cases of the liver disease to the clinic after
notifying 50,000 patients of the clinic to be tested.
• CDC investigators said in a report to the Nevada State Health Division
that during visits to the clinic, they saw employees reusing syringes to
give a sedative and that interviews suggested it was common practice.
• "This was considered the most likely mode of transmission," the
report said.
Patient resuscitation
• Use a barrier or
bag
Respiratory hygiene
(cough etiquette)
•
•
•
•
Cover
Turn
Toss
Wash
Airborne Precaution
• Private room
• Negative pressure
room
• Door closed
• Mask
• Mask client (out of
room)
Droplet precaution
• Private room
• Mask
• Mask client (out of
room)
Contact Precaution
•
•
•
•
•
•
Private room
Enter with Gloves
Change gloves after contact
Gown & gloves when giving direct care
Leave equipment in the room
Wash hands after removing gloves
Nursing Process - Infection:
Assessment
Subjective
Objective
•
•
•
•
•
•
•
•
•
Weak
Appetite
Pain
Medication history
– Antipyretics
– Antimicrobials
– Immunization
Vital signs
Ht & Wt
S&S
Palpate (lymphs)
Labs
– WBC
– C&S
How does the infectious process affect
weight?
•h
– Edema
•i
– Appetite i
Nrs Diagnosis: Risk for infection
•
•
•
•
Precautions
Explain isolation
Collect C&S
Administer antimicrobials
Nrs. Diagnosis: Imbalanced nutrition
• Calories
–h
• Protein
–h
• Liquids
–h
• Appealing
• i offensive odors
Nrs. Diagnosis: Ineffective thermal
regulation
•
•
•
•
•
h fluids
I&O
Administer antipyretic (per Rx)
Cool
Clean linens
How to study for this class
1. Tonight!
2. Small group question
3. Flash cards
4. Study groups
5. Understand not just memorize!