Lauren Wren

Chapter 31
Asepsis
Some microorganisms found in the intestines (e.g., enterobacteria) produce substances
called bacteriocins, which are lethal to related strains of bacteria.
resident flora (the collective vegetation in a given area) in one part of the body, yet
produce infection in another.
infection is an invasion of body tissue by microorganisms and their growth there.
Infectious Agent Microorganisms invading body
A detectable alteration in normal tissue function, however, is called disease
virulence (i.e., their ability to produce disease).
the infectious agent can be transmitted to an individual by direct or indirect contact or as an
airborne infection, the resulting condition is called a communicable disease.
Pathogenicity is the ability to produce disease; thus, a pathogen is a microorganism that
causes disease.
opportunistic pathogen causes disease only in a susceptible individual.
Asepsis is the freedom from disease-causing microorganisms.
Medical asepsis includes all practices intended to confine a specific microorganism to a
specific area, limiting the number, growth, and transmission of microorganisms.
clean, which means the absence of al- most all microorganisms
dirty (soiled, contaminated), which means likely to have microorganisms, some of which
may be capable of causing infection.
Surgical asepsis, or sterile technique, refers to those practices that keep an area or object
free of all microorganisms; it includes practices that destroy all microorganisms and spores
(microscopic dormant structures formed by some pathogens that are very hardy and often
survive common cleaning techniques). Surgical asepsis is used for all procedures involving
the sterile areas of the body.
Sepsis is the state of infection and can take many forms, including septic shock.
I. Types of Microorganisms Causing Infection
Bacteria are by far the most common infection-causing microorganisms.
Viruses consist primarily of nucleic acid and therefore must enter living cells in order to
reproduce.
Fungi include yeasts and molds
Parasites live on other living organisms. They include protozoa such as the one that causes
malaria, helminths (worms), and arthropods (mites, fleas, ticks).
II. Types of Infections
Colonization is the process by which strains of microorganisms become resident flora.
may grow and multiply but do not cause disease.
infection oc- curs when newly introduced or resident microorganisms suc- ceed in
invading a part of the body where the hosts defense mechanisms are ineffective and the
pathogen causes tissue damage.
local infection is limited to the specific part of the body where the microorganisms
remain.
systemic infection If the microorganisms spread and damage different parts of the body
bacteremia when blood cultures show bacteria in the blood
septicemia When bacteremia results in systemic infection
Acute infections generally appear suddenly or last a short time. A chronic infection may
occur slowly, over a very long period, and may last months or years.
III. Nosocomial Infections
Nosocomial infections are classified as infections that originate in the hospital.
health careassociated infections (HAIs)those that originate in any health care setting
endogenous source The microorganisms that cause nosocomial infections can originate
from the clients themselves
Most nosocomial infections appear to have endogenous sources
exogenous sources hospital environment and hospital personnel.
Iatrogenic infections are the direct result of diagnostic or therapeutic procedures. One
example of an iatrogenic infection is bacteremia that results from an intravascular line.
IV. Chain of Infection
Six links make up the chain of infection
A. Etiologic Agent
The extent to which any microorganism is capable of producing an infectious process
depends on the number of microorganisms present, the virulence and potency of the
microorganisms (pathogenicity), the ability of the microorganisms to enter the body, the
susceptibility of the host, and the ability of the microorganisms to live in the hosts
body.
B. Reservoir
reservoirs sources of microorganisms.
carrier is a person or animal reservoir of a specific infectious agent that usually does
not manifest any clinical signs of disease.
C. Portal of Exit from Reservoir
carrier is a person or animal reservoir of a specific infectious agent that usually does
not manifest any clinical signs of disease.
Before an infection can establish itself in a host, the microorganisms must leave the
reservoir. (Respiratory tract, GI, blood)
D. Method of Transmission
Direct transmission - person to person through touching, biting, kissing, or sexual
intercourse.
Droplet spread is also a form of direct transmission but can occur only if the source
and the host are within 1 m (3 ft) of each other. Sneezing, coughing, spitting,
singing, or talking can project droplet spray into the conjunctiva or onto the mucous
membranes of the eye, nose, or mouth of another person.
Indirectt ransmission. vehicle-borne or vector-borne.
Vehicle-borne transmission. A vehicle is any substance that serves as an
intermediate means to transport and introduce an infectious agent into a susceptible
host through a suitable portal of entry.
Fomites, water, food, blood, serum, and plasma
Vector-borne transmission. A vector is an animal or flying or crawling insect that
serves as an intermediate means of transporting the infectious agent.
Airborne transmission - droplets or dust.
Droplet nuclei, the residue of evaporated droplets emitted by an infected host such
as someone with tuberculosis, can remain in the air for long periods. Dust particles
containing the infectious agent
E. Portal of Entry to the Susceptible Host
The skin is a barrier to infectious agents; how- ever, any break in the skin can readily
serve as a portal of en- try. Often, microorganisms enter the body of the host by the
same route they used to leave the source.
F. Susceptible Host
compromised host is a person at increased risk, an individual who for one or more
reasons is more likely than others to ac- quire an infection.
V. Body Defenses Against Infection
Nonspecific defenses protect the person against all microorganisms, regardless of prior
exposure.
Specific (immune) defenses, by contrast, are directed against identifiable bacteria,
viruses, fungi, or other infectious agents.
A. Non Specific Defenses
1. Anatomic and Physiological barriers
Intact skin and mucous membranes are the bodys first line of defense
against microorganisms.
The dry- ness of the skin also is a deterrent to bacteria. Bacteria are most
plentiful in moist areas of the body, such as the perineum and axillae.
Resident bacteria use up the available nourishment, and the end products of
their metabolism inhibit other bacterial growth.
Normal secretions make the skin slightly acidic; acidity also inhibits bacterial
growth.
nasal passages air comes in con- tact with moist mucous membranes and
cilia. traps microorganisms, dust, and foreign materials.
lungs have alveolar macrophages (large phagocytes).
The oral cavity regularly sheds mucosal epithelium to rid the mouth of
colonizers.
flow of saliva and its partial buffering action help prevent infections.
Saliva contains microbial inhibitors, such as lactoferrin, lysozyme, and
secretory IgA.
eye is protected from infection by tears, which continually wash
microorganisms away and contain inhibiting lysozyme.
gastrointestinal tract - high acidity of the stomach normally prevents
microbial growth, resident flora of the large intestine prevent establishment
of disease-producing microorganisms. Peristalsis moves microbes out of the
body.
Vagina - lactobacilli ferment sugars in the vaginal secretions, creating a
vaginal pH of 3.5 to 4.5. This low pH inhibits the growth of many disease-
producing microorganisms.
urine flow has a flushing and bacteriostatic action that keeps the bacteria
from ascending the urethra.
2. Inflammatory Response
Inflammation is a local and nonspecific defensive response of the tissues to
an injurious or infectious agent.
characterized by five signs: (a) pain, (b) swelling, (c) redness, (d) heat, and
(e) impaired function of the part, if the injury is severe.
Injurious agents can be categorized as physical agents, chem- ical agents, and
microorganisms.
Physical agents - mechanical objects causing trauma to tissues, excessive
heat or cold, and radiation.
Chemical agents - external irritants (e.g., strong acids, alkalis, poisons, and
irritating gases) and internal irritants (substances manufactured within the
body such as excessive hydrochloric acid in the stomach).
stages of the inflammatory response:
First stage: Vascular and cellular responses
blood vessels at the site of injury constrict followed by dilation of
small blood vessels (occurring as a result of histamine released by the
injured tissues).
more blood flows to the injured area. Increase in blood supply is
referred to as hyperemia and is responsible for the characteristic
signs of redness and heat.
Vascular permeability increases at the site with dilation of the vessels
in response to cell death, the release of chemical mediators (e.g.,
bradykinin, serotonin, and prostaglandin), and the release of
histamine.
Fluid, proteins, and leukocytes leak into the interstitial spaces, and
the signs of inflammation swelling (edema) and pain appear.
Pain is caused by the pressure of accumulating fluid on nerve endings
and the irritating chemical mediators.
In response to the exit of leukocytes from the blood, the bone marrow
produces large numbers of leukocytes and releases them into the
bloodstream. This is called leukocytosis
Second stage: Exudate production
exudate is produced, consisting of fluid that escaped from the blood
vessels, dead phagocytic cells, and dead tissue cells and products that
they release. The plasma protein fibrinogen (which is converted to
fibrin when it is re- leased into the tissues), thromboplastin (released
by injured tissue cells), and platelets together form an interlacing
network to wall off the area, and prevent spread of the injurious
agent.
the injurious agent is overcome, and the exudate is cleared away
by lymphatic drainage.
The nature and amount of exudate vary according to the tis- sue
involved and the intensity and duration of the inflammation. The
major types of exudate are serous, purulent, and hemorrhagic
(sanguineous)
Third stage: Reparative phase.
regeneration or replacement with fibrous tissue (scar) formation.
Regeneration is the replacement of destroyed tissue cells by cells
that are identical or similar in structure and function.
Damaged cells are replaced one by one, but the cells are also
organized so that the architectural pattern and function of the tissue
are restored.
Tissues that have little regenerative capacity include nervous,
muscular, and elastic tissues.
Damaged tissues are replaced with the connective tissue elements of
collagen, blood capillaries, lymphatics, and other tissue-bound
substances
Early stages of regeneration - granulation tissue. It is a fragile,
gelatinous tissue, appearing pink or red because of the many newly
formed capillaries.
Later the tissue shrinks (the capillaries are constricted, even
obliterated) and the collagen fibers contract, so that a firmer fibrous
tissue re- mains. This is called cicatrix, or scar.
B. Specific Defenses
Specific defenses of the body involve the immune system.
antigen is a substance that induces a state of sensitivity or immune responsiveness
(immunity).
If the proteins originate in a persons own body, the antigen is called an autoantigen.
1. Antibody mediated Defenses -
antibody-mediated defenses is humoral (or circulating) immunity because
these defenses reside in the B lymphocytes and are mediated by antibodies
produced by B cells. Antibodies, also called immunoglobulins, are part of
the bodys plasma proteins.
Defends primarily against the extracellular phases of bacterial and viral
infections
active immunity, host produces antibodies in response to natural antigens
(e.g., infectious microorganisms) or artificial antigens (e.g., vaccines).
B cells are activated when they recognize the antigen. They then
differentiate into plasma cells, which secrete the antibodies and serum
proteins that bind specifically to the foreign substance and initiate a
variety of elimination responses. The B cell may produce antibody
molecules: IgM, IgG, IgA, IgD, and IgE
IgM in a laboratory analysis shows current infection.
Before the antibody response can become effective, the phagocytic cells
of the blood bind and ingest foreign substances.
rate of binding and phagocytosis increases if IgG antibodies (which
indicate past infection and subsequent immunity) are present.
passive (or acquired) immunity, the host receives natural (e.g., from a
nursing mother) or artificial (e.g., from an injection of immune serum)
antibodies produced by another source.
2. Cell mediated Defenses
cell-mediated defenses, or cellular immunity, occur through the T-cell
system.
On exposure to an antigen, the lymphoid tissues release large numbers of
activated T cells into the lymph system. T cells pass into the general
circulation.
There are three main groups of T cells:
(a) helper T cells, which help in the functions of the immune system
(b) cytotoxic T cells, which attack and kill microorganisms and
sometimes the bodys own cells
(c) suppressor T cells, which can suppress the functions of the helper T
cells and the cytotoxic T cells.
VI. Factors Increasing Susceptibility to Infection
One of the most important factors is host susceptibility, which is affected by age,
heredity, level of stress, nutritional status, current medical therapy, and preexisting
disease processes.
Newborns and older adults have reduced defenses against infection.
Newborns only for the first 2 or 3 months by immunoglobulins passively received
from the mother. Between 1 and 3 months of age, infants begin to synthesize their
own immunoglobulins.
annual immunization against influenza for older adults and for persons with chronic
cardiac, respiratory, metabolic, and renal disease. Pneumococcal vaccine is
recommended for older adults last vaccinated more than 5 years previously
Stressors elevate blood cortisone. Prolonged elevation of blood cortisone de- creases
anti-inflammatory responses, depletes energy stores, leads to a state of exhaustion, and
decreases resistance to infection.
antibodies are proteins, the ability to synthesize antibodies may be impaired by
inadequate nutrition, especially when protein reserves are depleted
Certain antibiotics can also induce resistance in some strains of organisms
Any disease that lessens the bodys defenses against infec- tion places the client at risk.
VII. Nursing Management
A. Assessing
1. Nursing History
nurse assesses (a) the degree to which a client is at risk of developing an
infection and (b) any client complaints suggesting the presence of an
infection.
To identify risk review the clients chart and structures the nursing
interview to collect data regarding the factors influencing the development of
infection, especially existing disease process, history of recurrent infections,
current medications and therapeutic measures, current emotional stressors,
nutritional status, and history of immunizations
2. Physical Assessment
Commonly the skin and mucous membranes are involved in a local
infectious process, resulting in the following:
Localized swelling
Localized redness
Pain or tenderness with palpation or movement
Palpable heat at the infected area
Loss of function of the body part affected, depending on the
site and extent of involvement.
Signs and Symptoms of Systemic Infection:
Fever
Increased pulse and respiratory rate if the fever is 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.
3. Laboratory Data
Elevated leukocyte (white blood cell or WBC) count (4,500 to 11,000/mL3 is
normal)
Increases in specific types of leukocytes as revealed in the differential WBC
count.
Elevated erythrocyte sedimentation rate (ESR). Red blood cells normally
settle slowly, but the rate increases in the presence of an inflammatory
process.
Urine, blood, sputum, or other drainage cultures (laboratory cultivations of
microorganisms in a special growth medium) that indicate the presence of
pathogenic microorganisms.
B. Diagnosing
Inadequate primary defenses such as broken skin, traumatized tissue, decreased
ciliary action, stasis of body fluids, change in pH of secretions, or altered peristalsis
Inadequate secondary defenses such as leukopenia, immunosuppression, decreased
hemoglobin, or suppressed inflammatory response.
Potential Complication of Infection: Fever
Imbalanced Nutrition: Less than Body Requirements if the client is too ill to eat
Acute Pain
impaired Social Interaction or Social Isolation if the client is required to be
separated from others during a contagious episode
Anxiety
C. Planning
major goals for clients susceptible to infection are to
Maintain or restore defenses.
Avoid the spread of infectious organisms.
Reduce or alleviate problems associated with the infection.
1. Planning for the Home
nurse needs to know the clients and familys risks, needs, strengths, and
resources.
D. Implementing
nurse implements strategies to prevent infection. If infection cannot be prevented,
the nurses goal is to prevent the spread of the infection and to treat the existing
infection.
1. Preventing Nosocomial Infections
prevented by using proper hand hygiene techniques, environmental controls,
sterile technique when war- ranted, and identification and management of
clients at risk for infections.
2. Hand Hygiene
one of the most effective infection control measures
both the nurses and the clients hands be cleansed before eating, after using
the bedpan or toilet, and after the hands have come in contact with any body
sub- stances, such as sputum or drainage from a wound.
CDC - vigorous hand washing under a stream of water for at least 20 seconds
using granular soap, soap-filled sheets, or liquid soap at the beginning of the
nurses shift
CDC recommends antimicrobial hand hygiene agents:
When there are known multiple resistant bacteria
Before invasive procedures
In special care units, such as nurseries and intensive care units (ICUs)
Before caring for severely immunocompromised clients.
CDC recommends the use of alcohol-based antiseptic hand rubs (rinses, gels,
or foams) before and after each direct client contact. visible dirt or matter, or
if C. difficile may be present, alcohol- based rubs will not be sufficient, and
soap and water washing is necessary
Proper use of alcohol-based products includes following these steps:
Apply a palmful of product into cupped handenough to cover all
surfaces of both hands.
Rub palms against palms.
Interlace fingers palm to palm.
Rub palms to back of hands.
Rub all surfaces of each finger with opposite hand.
Continue until product is dryabout 20 to 30 seconds.
E. Supporting Defenses of a Susceptible Host
Susceptibility is the degree to which an individual can be affected, that is, the likelihood
of an organism causing an infection in that person.
reduce a persons susceptibility:
Hygiene
Nutrition
Fluid
Sleep
Stress
Immunization
F. DISINFECTING AND STERILIZING
antiseptics (agents that inhibit the growth of some microorganisms)
disinfectants (agents that destroy pathogens other than spores), and by sterilization.
1. Disinfecting.
A disinfectant is a chemical preparation, such as phenol or iodine
compounds, used on inanimate objects. Disinfectants are frequently caustic
and toxic to tissues
disinfectant is a more concentrated solution
A bactericidal preparation destroys bacteria, whereas a bacteriostatic
preparation prevents the growth and reproduction of some bacteria
2. Sterilizing. Sterilization
is a process that destroys all microorganisms, including spores and viruses.
Moist Heat To sterilize with moist heat (such as with an auto- clave), steam
under pressure is used because it attains tempera- tures higher than the
boiling point.
Gas Ethylene oxide gas destroys microorganisms by interfering with their
metabolic processes. It is also effective against spores. Advantages are good
penetration and effectiveness for heat- sensitive items. Its major disadvantage
is its toxicity to humans.
BoilingWater This is the most practical and inexpensive method for
sterilizing in the home. The main disadvantage is that spores and some
viruses are not killed by this method. Boil a minimum of 15 minutes
Radiation Both ionizing (such as alpha, beta, and x-rays) and nonionizing
(ultraviolet light) radiation are used for disinfection and sterilization. The
main drawback to ultraviolet light is that the rays do not penetrate deeply.
effective for items difficult to sterilize; its chief disadvantage is that the
equipment is very expensive.
VIII. INFECTION CONTROL PRECAUTIONS
Tier 1 is standard precautions (SP) all client care situations.
respiratory hygiene/cough etiquette that calls for covering the mouth and nose when
sneezing or coughing, proper disposal of tissues, and separating potentially infected
persons from others by at least 1 m (3 ft) or having them wear a surgical mask.
If the client is known to have an infection - the CDCs Tier 2 precautions, transmission-
based precautions, are used to protect the nurse and others from acquiring the infectious
organ- ism. These precautions are used in addition to SP when those precautions do not
completely block the chain of infection and the infections are spread in one of three
ways: by airborne or droplet transmission or by contact.
Isolation - Category-specific isolation precautions use seven categories: strict
isolation, contact isolation, respiratory isolation, tuberculosis isolation, enteric
precautions, drainage/secretions precautions, and blood/body fluid precautions.
Disease-specific isolation precautions provide precautions for specific diseases. These
precautions delineate use of private rooms with special ventilation, having the client
share a room with other clients infected with the same organism, and gowning to
prevent gross soilage of clothes for specific infectious diseases.
1. Standard precautions -used in the care of all hospitalized persons regardless of their
diagnosis or possible infection status. They apply to blood, all body fluids, secretions,
and excretions except sweat (whether or not blood is present or visible), nonintact skin,
and mucous membranes.
2. Transmission-Based Precautions. Transmission-based pre- cautions are used in
addition to standard precautions for clients with known or suspected infections that
are spread in one of three ways: by airborne or droplet transmission, or by contact.
3. Airborne precautions are used for clients known to have or suspected of having
serious illnesses transmitted by airborne droplet nuclei smaller than 5 microns.
Examples of such illnesses include measles (rubeola), varicella (including
disseminated zoster), and tuberculosis.
4. Droplet precautions are used for clients known or suspected to have serious
illnesses transmitted by particle droplets larger than 5 microns. Examples of such
illnesses are diphtheria (pharyngeal); mycoplasma pneumonia; pertussis; mumps;
rubella; streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young
children; and pneumonic plague.
5. Contact precautions are used for clients known or suspected to have serious
illnesses easily transmitted by direct client con- tact or by contact with items in the
clients environment gastrointestinal, respira- tory, skin, or wound infections or
colonization with multidrug- resistant bacteria; specific enteric infections such as C.
difficile and enterohemorrhagic E. coli O157:H7, Shigella, and hepatitis A,
special contact precautions are used for vancomycin-resistant enterococci (VRE)
infections.
antimicrobial soap for hand washing
no sharing of equipment.
private room (or a room with other clients who have VRE)
isolation should continue until at least three cultures taken 1 week apart are
negative
B. Compromised Clients. - Clients who are severely compromised include those who:
Have diseases, such as leukemia, or treatments such as chemo- therapy, that depress the
clients resistance to infectious organisms.
Have extensive skin impairments, such as severe dermatitis or major burns, which
cannot be effectively covered with dressings.
IX. ISOLATION PRACTICES
In all client situations, nurses must cleanse their hands before and after giving
care.
A. Personal Protective Equipment. All healthcare providers must apply PPE (clean or sterile
gloves, gowns, masks, and protective eyewear) according to the risk of exposure to potentially
infective materials.
Gloves Gloves are worn for three reasons:
protect the hands when the nurse is likely blood, urine, feces, sputum, and nonintact
skin.
reduce the likelihood of nurses transmitting their own microorganisms to individuals
receiving care.
reduce the chance that the nurses hands will transmit microorganisms from one
client or an object to another client.
In all situations, gloves are changed between client contacts.
Hands are cleansed each time gloves are removed for two primary reasons:
(a) the gloves may have imperfections or be damaged during wearing so that they
could allow microorganism entry
(b) the hands may become contaminated during glove removal
Gowns Clean or disposable impervious (water-resistant) gowns or plastic aprons are
worn during procedures when the nurses uniform is likely to become soiled. Sterile
gowns may be indicated when the nurse changes the dressings of a client with extensive
wounds (e.g., burns)
FaceMasks The CDC recommends that masks be worn:
By those close to the client if the infection (e.g., measles, mumps, or acute
respiratory diseases in children) is transmitted by large-particle aerosols (droplets).
Large-particle aerosols are transmitted by close contact and generally travel short
distances (about 1 m, or 3 ft)
Anyone entering the room if the infection (e.g., TB, SARS) is transmitted by small-
particle aerosols (droplet nuclei). Small-particle aerosols remain suspended in the air
and thus travel greater distances by air. Special masks that provide a tighter face seal
and better filtration may be used for these infections.
the cate- gory N respirator at 95% efficiency (referred to as an N95 respirator)
meets tuberculosis, SARS, and influenza control criteria.
Eyewear for when fluids might splash face
Sterile Field. A sterile field is a microorganism-free area. Nurses often establish a
sterile field by using the innermost side of a sterile wrapper or by using a sterile drape.
When the field is established, sterile supplies and sterile solutions can be placed on it.
Sterile forceps are used in many instances to handle and transfer sterile supplies.
All objects used in a sterile field must be sterile.
Sterile objects become unsterile when touched by unsterile objects.
Sterile objects that are out of sight or below the waist or table level are considered
unsterile.
Sterile objects can become unsterile by prolonged exposure to airborne
microorganisms.
Fluids flow in the direction of gravity.
Moisture that passes through a sterile object draws micro- organisms from unsterile
surfaces above or below to the sterile surface by capillary action.
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.
X. INFECTION CONTROL FOR HEALTH CARE WORKERS
Occupational exposure is de- fined as skin, eye, mucous membrane, or parenteral
contact with blood or other potentially infectious materials that may re- sult from the
performance of an employees duties.
three major modes of transmission of infectious materials in the clinical setting:
Puncture wounds from contaminated needles or other sharps
Skin contact, which allows infectious fluids to enter through
wounds and broken or damaged skin
Mucous membrane contact, which allows infectious fluids to
enter through mucous membranes of the eyes, mouth, or nose.