Asepsis
AsepsisMedical asepsis
- Includes all practices intended to confine a specific microorganism to a specific area
- Limits the number, growth, and transmission of microorganisms
- Objects referred to as clean or dirty (soiled, contaminated)
- Sterile technique
- Practices that keep an area or object free of all microorganisms
- Practices that destroy all microorganisms and spores
- Used for all procedures involving sterile areas of the body
Principles of Aseptic Technique
- Only sterile items are used within sterile field.
- Sterile objects become unsterile when touched by unsterile objects.
- Sterile items that are out of vision or below the waist level of the nurse are considered unsterile.
- Sterile objects can become unsterile by prolong exposure to airborne microorganisms.
- Fluids flow in the direction of gravity.
- Moisture that passes through a sterile object draws microorganism from unsterile surfaces above or below to the surface by capillary reaction.
- The edges of a sterile field are considered unsterile.
- The skin cannot be sterilized and is unsterile.
- Conscientiousness, alertness and honesty are essential qualities in maintaining surgical asepsis
Infection
Signs of Localized Infection
- Localized swelling
- Localized redness
- Pain or tenderness with palpation or movement
- Palpable heat in the infected area
- Loss of function of the body part affected, depending on the site and extent of involvement
- Fever
- Increased pulse and respiratory rate if the fever high
- Malaise and loss of energy
- Anorexia and, in some situations, nausea and vomiting
- Enlargement and tenderness of lymph nodes that drain the area of infection
- Number of microorganisms present
- Virulence and potency of the microorganisms (pathogenicity)
- Ability to enter the body
- Susceptibility of the host
- Ability to live in the host’s body
- Intact skin and mucous membranes
- Moist mucous membranes and cilia of the nasal passages
- Alveolar macrophages
- Tears
- High acidity of the stomach
- Resident flora of the large intestine
- Peristalsis
- Low pH of the vagina
- Urine flow through the urethra
- Risk for Infection
- State in which an individual is at increased risk for being invaded by pathogenic microorganisms
- Risks factors
- Inadequate primary defenses
- Inadequate secondary defenses
Related Diagnoses
- Potential Complication of Infection: Fever
- Imbalanced Nutrition: Less than Body Requirement
- Acute Pain
- Impaired Social Interaction or Social Isolation
- Anxiety
- Proper hand hygiene techniques
- Environmental controls
- Sterile technique when warranted
- Identification and management of clients at risk
Chain of Infection
- The chain of infection refers to those elements that must be present to cause an infection from a microorganism
- Basic to the principle of infection is to interrupt this chain so that an infection from a microorganism does not occur in client
- Infectious agent; microorganisms capable of causing infections are referred to as an infectious agent or pathogen
- Modes of transmission: the microorganism must have a means of transmission to get from one location to another, called direct and indirect
- Susceptible host describes a host (human or animal) not possessing enough resistance against a particular pathogen to prevent disease or infection from occurring when exposed to the pathogen; in humans this may occur if the person’s resistance is low because of poor nutrition, lack of exercise of a coexisting illness that weakens the host.
- Portal of entry: the means of a pathogen entering a host: the means of entry can be the same as one that is the portal of exit (gastrointestinal, respiratory, genitourinary tract).
- Reservoir: the environment in which the microorganism lives to ensure survival; it can be a person, animal, arthropod, plant, oil or a combination of these things; reservoirs that support organism that are pathogenic to humans are inanimate objects food and water, and other humans.
- Portal of exit: the means in which the pathogen escapes from the reservoir and can cause disease; there is usually a common escape route for each type of microorganism; on humans, common escape routes are the gastrointestinal, respiratory and the genitourinary tract.
Etiologic agent
- Correctly cleaning, disinfecting or sterilizing articles before use
- Educating clients and support persons about appropriate methods to clean, disinfect, and sterilize article
- Changing dressings and bandages when soiled or wet
- Appropriate skin and oral hygiene
- Disposing of damp, soiled linens appropriately
- Disposing of feces and urine in appropriate receptacles
- Ensuring that all fluid containers are covered or capped
- Emptying suction and drainage bottles at end of each shift or before full or according to agency policy
- Avoiding talking, coughing, or sneezing over open wounds or sterile fields
- Covering the mouth and nose when coughing or sneezing
- Proper hand hygiene
- Instructing clients and support persons to perform hand hygiene before handling food, eating, after eliminating and after touching infectious material
- Wearing gloves when handling secretions and excretions
- Wearing gowns if there is danger of soiling clothing with body substances
- Placing discarded soiled materials in moisture-proof refuse bags
- Holding used bedpans steadily to prevent spillage
- Disposing of urine and feces in appropriate receptacles
- Initiating and implementing aseptic precautions for all clients
- Wearing masks and eye protection when in close contact with clients who have infections transmitted by droplets from the respiratory tract
- Wearing masks and eye protection when sprays of body fluid are possible
- Using sterile technique for invasive procedures, when exposing open wounds or handling dressings
- Placing used disposable needles and syringes in puncture-resistant containers for disposal
- Providing all clients with own personal care items
- Maintaining the integrity of the client’s skin and mucous membranes
- Ensuring that the client receives a balanced diet
- Educating the public about the importance of immunizations
Modes of Transmission
- Direct contact: describes the way in which microorganisms are transferred from person to person through biting, touching, kissing, or sexual intercourse; droplet spread is also a form of direct contact but can occur only if the source and the host are within 3 feet from each other; transmission by droplet can occur when a person coughs, sneezes, spits, or talks.
- Indirect contact: can occur through fomites (inanimate objects or materials) or through vectors (animal or insect, flying or crawling); the fomites or vectors act as vehicle for transmission
- Air: airborne transmission involves droplets or dust; droplet nuclei can remain in the air for long periods and dust particles containing infectious agents can become airborne infecting a susceptible host generally through the respiratory tract
- Incubation: the time between initial contact with an infectious agent until the first signs of symptoms the incubation period varies from different pathogens; microorganisms are growing and multiplying during this stage
- Prodromal Stage: the time period from the onset of nonspecific symptoms to the appearance of specific symptoms related to the causative pathogen symptoms range from being fatigued to having a low-grade fever with malaise; during this phase it is still possible to transmit the pathogen to another host
- Full Stage: manifestations of specific signs & symptoms of infectious agent; referred to as the acute stage; during this stage, it may be possible to transmit the infectious agent to another, depending on the virulence of the infectious agent
- Convalescence: time period that the host takes to return to the pre-illness stage; also called the recovery period; the host defense mechanisms have responded to the infectious agent and the signs and symptoms of the disease disappear; the host, however, is more vulnerable to other pathogens at this time; an appropriate nursing diagnostic label related to this process would be Risk for Infection
Inflammation
- The protective response of the tissues of the body to injury or infection; the physiological reaction to injury or infection is the inflammatory response; it may be acute or chronic
- The “inflammatory response” begins with vasoconstriction that is followed by a brief increase in vascular permeability; the blood vessels dilate allowing plasma to escape into the injured tissue
- WBCs (neutrophils, monocytes, and macrophages) migrate to the area of injury and attack and ingest the invaders (phagocytosis); this process is responsible for the signs of inflammation
- Redness occurs when blood accumulates in the dilated capillaries; warmth occurs as a result of the heat from the increased blood in the area, swelling occurs from fluid accumulation; the pain occurs from pressure or injury to the local nerves.
- The immune response involves specific reactions in the body to antigens or foreign material
- This specific response is the body’s attempt to protect itself, the body protects itself by activating 2 types of lymphocytes, the T-lymphocytes and B-lymphocytes
- Cell mediated immunity: T-lymphocytes are responsible for cellular immunity
- When fungi , protozoa, bacteria and some viruses activate T-lymphocytes, they enter the circulation from lymph tissue and seek out the antigen
- Once the antigen is found they produce proteins (lymphokines) that increase the migration of phagocytes to the area and keep them there to kill the antigen
- After the antigen is gone, the lymphokines disappear
- Some T-lymphocytes remain and keep a memory of the antigen and are reactivated if the antigen appears again.
- Humoral response: the ability of the body to develop a specific antibody to a specific antigen (antigen-antibody response)
- B-lymphocytes provide humoral immunity by producing antibodies that convey specific resistance to many bacterial and viral infections
- Active immunity is produced when the immune system is activated either naturally or artificially.
- Natural immunity involves acquisition of immunity through developing the disease
- Active immunity can also be produced through vaccination by introducing into the body a weakened or killed antigen (artificially acquired immunity)
- Passive immunity does not require a host to develop antibodies, rather it is transferred to the individual, passive immunity occurs when a mother passes antibodies to a newborn or when a person is given antibodies from an animal or person who has had the disease in the form of immune globulins; this type of immunity only offers temporary protection from the antigen.
Types of Immunity
Active Immunity
- Host produces antibodies in response to natural antigens or artificial antigens
- Natural active immunity
- Antibodies are formed in presence of active infection in the body
- Duration lifelong
- Artificial active immunity
- Antigens administered to stimulate antibody formation
- Lasts for many years
- Reinforced by booster
- Host receives natural or artificial antibodies produced from another source
- Natural passive immunity
- Antibodies transferred naturally from an immune mother to baby through the placenta or in colostrums
- Lasts 6 months to 1 year
- Artificial passive immunity
- Occurs when immune serum (antibody) from an animal or another human is injected
- Lasts 2 to 3 weeks
Nosocomial Infection
- Nosocomial Infections: are those that are acquired as a result of a healthcare delivery system
- Iatrogenic infection: these nosocomial infections are directly related to the client’s treatment or diagnostic procedures; an example of an iatrogenic infection would be a bacterial infection that results from an intravascular line or Pseudomonas aeruginosa pneumonia as a result of respiratory suctioning
- Exogenous Infection: are a result of the healthcare facility environment or personnel; an example would be an upper respiratory infection resulting from contact with a caregiver who has an upper respiratory infection
- Endogenous Infection: can occur from clients themselves or as a reactivation of a previous dormant organism such as tuberculosis; an example of endogenous infection would be a yeast infection arising in a woman receiving antibiotic therapy; the yeast organisms are always present in the vagina, but with the elimination of the normal bacterial flora, the yeast flourish.
- Diagnostic or therapeutic procedures
- Iatrogenic infections
- Compromised host
- Insufficient hand hygiene
Factors Increasing Susceptibility to Infection
- Age: young infants & older adults are at greater risk of infection because of reduced defense mechanisms
- Young infants have reduced defenses related to immature immune systems
- In elderly people, physiological changes occur in the body that make them more susceptible to infectious disease; some of these changes are:
- Altered immune function (specifically, decreased phagocytosis by the neutrophils and by the macrophages)
- Decreased bladder muscle tone resulting in urinary retention
- Diminished cough reflex, loss of elastic recoil by the lungs leading to inability to evacuate normal secretions
- Gastrointestinal changes resulting in decreased swallowing ability and delayed gastric emptying.
- Heredity: some people have a genetic predisposition or susceptibility to some infectious diseases
- Cultural practices: healthcare beliefs and practices, as well as nutritional and hygiene practices, can influence a person’s susceptibility to infectious diseases
- Nutrition: inadequate nutrition can make a person more susceptible to infectious diseases; nutritional practices that do not supply the body with the basic components necessary to synthesized proteins affect the way the body’s immune system can respond to pathogens
- Stress: stressors, both physical and emotional, affect the body’s ability to protect against invading pathogens; stressors affect the body by elevating blood cortisone levels; if elevation of serum cortisone is prolonged, it decreases the anti-inflammatory response and depletes energy stores, thus increasing the risk of infection
- Rest, exercise and personal health habits: altered rest and exercise patterns decrease the body’s protective, mechanisms and may cause physical stress to the body resulting in an increased risk of infection; personal health habits such as poor nutrition and unhealthy lifestyle habits increase the risk of infectious over time by altering the body’s response to pathogens
- Inadequate defenses: any physiological abnormality or lifestyle habit can influence normal defense mechanisms in the body, making the client more susceptible to infection; the immune system functions throughout the body and depends on the following:
- Intact skin and mucous membranes
- Adequate blood cell production and differentiation
- A functional lymphatic system and spleen
- An ability to differentiate foreign tissue and pathogens from normal body tissue and flora; in autoimmune disease, the body has a problem with recognizing its own tissue and cells; people with autoimmune disease are at increased risk of infection related to their immune system deficiencies.
- Environmental: an environment that exposes individuals to an increased number of toxins or pathogens also increases the risk of infection; pathogens grow well in warm moist areas with oxygen (aerobic) or without oxygen (anaerobic) depending on the microorganism, an environment that increases exposure to toxic substances also increases risk
- Immunization history: inadequately immunized people have an increased risk of infection specifically for those diseases for which vaccines have been developed.
- Medications and medical therapies: examples of therapies and medications that increase clients risk for infection includes radiation treatment, anti-neo-plastic drugs, anti inflammatory drugs and surgery
- Signs and symptoms related to infections are associated with the area infected; for instance, symptoms of a local infection on the skin or mucous membranes are localized swelling, redness, pain and warmth
- Symptoms related to systemic infections include fever, increased pulse & respirations, lethargy, anorexia, and enlarged lymph nodes
- Certain diagnostic tests are ordered to confirm the presence of an infection.
Category-specific Isolation Precautions
- Strict isolation
- Contact isolation
- Respiratory isolation
- Tuberculosis isolation
- Enteric precautions
- Drainage/secretions precautions
- Blood/body fluid precautions
- Delineate practices for control of specific diseases
- Use of private rooms with special ventilation
- Cohorting clients infected with the same organism
- Gowning to prevent gross soilage of clothes
Universal Precautions (UP)
- Used with all clients
- Decrease the risk of transmitting unidentified pathogens
- Obstruct the spread of bloodborne pathogens (hepatitis B and C viruses and HIV)
- Used in conjunction with disease-specific or category-specific precautions
Body Substance Isolation (BSI)
- Employs generic infection control precautions for all clients
- Body substances include:
- Blood
- Urine
- Feces
- Wound drainage
- Oral secretions
- Any other body product or tissue
Standard Precautions
- Used in the care of all hospitalized persons regardless of their diagnosis or possible infection status
- Apply to:
- Blood
- All body fluids, secretions, and excretions except sweat (whether or not blood is present or visible)
- Nonintact skin and mucous membranes
- Combine the major features of UP and BSI
Transmission-based Precautions
- Used in addition to standard precautions
- For known or suspected infections that are spread in one of three ways:
- Airborne
- Droplet
- Contact
- May be used alone or in combination but always in addition to standard precautions
Managing Equipment Used for Isolation Clients
- Many supplied for single use only
- Disposed of after use
- Agencies have specific policies and procedures for handling soiled reusable equipment
- Nurses need to become familiar with these practices
- Report the incident immediately
- Complete injury report
- Seek appropriate evaluation and follow-up
- Identification and documentation of the source individual when feasible and legal
- Testing of the source for hepatitis B, C and HIV when feasible and consent is given
- Making results of the test available to the source individual’s health care provider
- Testing of blood exposed nurse (with consent) for hepatitis B, C, and HIV – please check these to match style used in book – fairly certain it should be caped antibodies
- Postexposure prophylaxis if medically indicated
- Medical and psychologic counseling
Puncture/Laceration
- Encourage bleeding
- Wash/clean the area with soap and water
- Initiate first aid and seek treatment if indicated
- Mucous membrane exposure (eyes, nose, mouth)
- Flush with saline or water flush for 5 to 10 minutes
Postexposure Protocol (PEP) for HIV
- Start treatment as soon as possible preferably within hours after exposure
- For “high-risk” exposure (high blood volume and source with a high HIV titer), three drug treatment is recommended
- For “increased risk” exposure (high blood volume or source with high HIV titer), three-drug treatment is recommended
- For “low risk” exposure (neither high blood volume nor source with a high HIV titer), two-drug treatment is considered
- Drug prophylaxis continues for 4 weeks
- Drug regimens vary and new drugs and regimens continuously being developed
- HIV antibody tests should be done shortly after exposure (baseline), and 6 weeks, 3 months, and 6 months afterward
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