Week 2: infection control and pneumonia

Class notes Week 2

8/28/07

Infection control: you’ll use it every day. Hippocratic oath.

HAI: Hosp Associated Infections

What’s infection control

Hand hygiene= washing and foams etc.

Standard Precautions

Nursing is practical application of medical principals in a healing setting

Aseptic practice

You have 1000 bugs per sq sonometer on most skin, at armpit and crotch we’re talking 100,000.

Risk stratification: hospitals are high risk areas. Nothing is dirtier than the hosp.

Standard precautions: apply to all patients. In any case when contact w/ blood and body fluids occurs.

PPE: Personal Protective Equip. Gloves, Gown, Shield/goggles, Mask

Infection Prevention and Control:

Prevention:

Immunization, TB testing

Quality improvement programs at hosps; inst. For healthcare improvement. Research based stuff to reduce risk of infections for patients.

Blood Borne Pathogens: Hep B, C, and HIV

Chain of infection:

• Pathogenic bug
• Reservoir: body fluids, injuries, wounds, surgical sites, people’s skin [staphs, diptheroid, MRSA.] Biofilm can be a reservoir; film of bacterial communities, it’s now identified on catheters and central lines—bugs live on these. Oral secretions—these are a high source of hospital pneumonia infections. All objects [sheets, dressings] that have contact are also reservoirs.
• Route of exit from reservoir: hand hygiene, covering wounds, standard precautions. Respiratory Etiquette; used to mean covering mouth when you cough, but now it’s into your elbow.
• Mode of Trans: Indirect, Direct, Airborne, Droplet. Hand hygiene is the #1 for indirect contact trans. Compliance level is about 50%--at best it gets up to 80%.

Hand Hygiene; when to use alcohol and when you use handwashing:

Handwashing: eating, bathroom, soiled hands, C Difficil. It removes the oil from the skin which can mean your hands get dry and are at risk.

Alcohol: Doesn’t remove oils from the hands, or organic material. Therefore it is preferred most of the time.

Nail care: no fake nails, preferably no polish or fresh polish. Patients in itchy scenarios should have nails clipped.

• Means of Entry: portals of entry on the natural body, portals created for patient care [IVs, lines], injuries, damaged skin
• Host susceptibility: immunocomprimised, age, diabetics, instage renal patients, chemo patients, anyone in the hospital. Interventions: immunization, nutrition, early intervention—observation of signs of infection [fever/over 38c, hypothermic in young and old, increased white blood cells—over 12,000; pain, hypotension, Low BP due to vasodilation

Epidemiology: patterns of disease in large groups.

1. Prevalence: # of cases in certain period of time
2. Incidence: # new cases in certain time period

Factor influencing microorganism’s capability to produce infection

a. Number of microorganisms present—trying to cut down on number of orgs with asepsis

b. Virulence and pathogenicity (potency of organisms)—how mean is the bug? Virulence: how many infected, untreated people die. Pathogenicity: how many infected get sick.

c. Ability to enter the body—if it needs to be airborne, get out of reservoir

d. Susceptibility of the host—can it beat the

e. Ability to live in the host’s body

History: we’re trying to use les antibiotics. In the 60’s it was required for each hosp to have an infection control person.

HAI: how do we know that it’s noso? We don’t unless we culture people when they come in the door

2. Healthcare-associated infection
1. Urinary tract infections: gender and length of stay matter! Interventions: better medical asepsis; handwashing, better technique, chemical agents.
2. Central line associated bloodstream infections (CLABSI) handwashing, better technique, chemical agents.
3. Surgical site infections: that’s a whole lecture.
4. Hospital-associated pneumonia: this one’s tonight. Get patients moving. Head of the bed up. Mouth care. Dysphagic—swallowing issues need special care.

Any invasive lines are now daily checked for necessity- we want to get these out of patients soon. Even tho it makes life easier for nurses.

3. Multi-drug resistant organisms (MDROs)

CDC: a multi-drug resistance means more than 2 drugs

1. Infection vs. colonization; you’re actually sick versus being an uneffected carrier. Where are you colonized? Nose, axilla, crotch.
2. MRSA: Meth resistant staph: Hospital strain is resistant to more antibiotics. Community acquired strain is more susceptible. Presents initially as a spider bite. Can be carried by animals—pets, and also housemates in healthcare. Janet had the normal treatment—sometimes the nostrils are treated topically.
3. VRE: Vancomycin Resistant Enterococcus: Vanc is a big gun med, so those things that are resistant to it are usually resistant to broad spectrums
4. Clostridium difficile – pseudomembranous colitis: this is a spore bearing Gr(-.) Tends to show up in patients who’ve been on antibiotics.
5. Resistance to two or more classifications of antibiotics
6. Minimum inhibitory concentration and antibiograms

You can cohort two [no-draining wound] MRSA patients, but not a VRE and MRSA patient

Norovirus, meningitis are rampant in dorms and crowd situations

Kentfield gets a lot of resistant bugs b/c the patients may be shipped in and out of MGH.

4. Standard precautions: see clean/dirty grid
1. History
2. Current recommendations
3. Use of PPE
4. Bloodborne pathogen standard – what to do for an exposure

Delineate areas of sterile and non areas in a hospital, clean/dirty areas.

Clean means infectious org’s gone. Sterile means all org’s gone. One room can have both clean and dirty areas—so long as its clearly labeled. Nursing station should be a clean area, but samples should be set somewhere else.

Dirty: commodes and bathrooms are dirty areas. This gets tricky—male patients need their urinals on the bedside table, which is also where meals and water glasses go—god forbid the patient is ill-sighted or confused? Sharps containers, linen hampers, etc.

Universal Precautions arose at time of HIV awareness. Became “blood and body fluid precautions,” now they’re “blood and body fluid precautions.” Anytime you’re likely to come into contact w/ fluids:

• Coughing
• Oral care
• Dressings, etc

You’ll wear PPE depending on what treatment you’re delivering: mask just if splashing is likely.

Contact: MRSA, VRE, C Diff, are common contact bugs. Gown and Glove when entering the room, not necessarily masking.

Droplet: Mask if within 6-10 feet of a coughing patient. Old guidelines say 3 feet. Common illnesses: flu, nisseria meningitis.

Airborne: Isolation of aerosolizable agents. These can go into the ventilation system of the hosp [that’s why the neg pressure rooms and special engineering requirements. Common with TB, chicken pox, SARS. Heavy particulate mask required by OSHA with a tight seal, etc.

Studies show that infectious patients get less hours of nursing care—shocking!

Pneumonia:

ABC’s; airway, breathing, circulation.

Pneumonia’s not that complex: Definition: respiratory disease characterized by inflammation of the lung parenchyma (excluding the bronchi) with congestion caused by viruses or bacteria or irritants.

The exudates from the immune response pool and decrease the working surface area of the lungs and therefore oxygenation. Ventilation and profusion—you don’t have surface area for the oxygen to diffuse to the blood. Ventilation [depth of breath, expansion of lungs] and profusion [oxygen transmission] create a downward cycle of inhibition.

Look for: trouble breathing, raspy, wet, sticky lung sounds [like Velcro]

1. Clinical signs:
1. Fever > 38, chills, WBC > 12,000, hypotension
2. Consolidation on Chest X-ray (air space disease, infiltrates)—clinical diagnostic sign.
3. Abnormal breath sounds: rales, rhonchi, decreased at the bases
4. Cough, purulent sputum [yellowy green lung butter], productive cough—can be effected if the patient is dehydrated.
5. Increased oxygen requirements. Decreased blood oxygenation.
6. Pleuritic pain might be present. A rubbing between the pleura of the lung.

2. Acute bacterial pneumonia – caused by an acute infectious process
1. Most common agents: strep pneumoniae, haemophilus influenzae most common community acquired. Recommendation; admin of pneumovax vaccine for seniors
2. Pseudomonas aerginosa, s. aureus, e. coli, klebsiella most common hospital associated (HAI).
3. Acute presentation: more elevated fever, WBC count, any clinical signs.
4. Empyema can result: pus pocket in the lungs; that’s the exudates from the immune system creating buildup. Treated with a chest tube. When those burst, it’s very septic.
5. Treated with antibiotics, IV fluids to prevent dehydration, oxygen, tri-flow [breathing apparatus to expand the lung—like exercise] or “cough, turn and deep breathe;” moves the fluids around. Encourage a cough. Postural drainage.
6. Often seen in acute care hospital

3. Viral pneumonia – caused by a viral process
1. Milder form of pneumonia. Not likely to see as much in the hosp. Walking pneumonia. You don’t usually need to go to the hospital for it.
2. Flu-like symptoms

4. Aspiration pneumonia
1. Caused by aspiration of stomach contents into the lung: barf and breath!
2. Causes a chemical burn from the stomach acids
3. High morbidity/mortality rate
4. Often HAI
5. Prevention - sitting patient up to drink fluid, NPO before surgery [no food so no barf], NPO before intubation, dysphagia precautions, smoker patients are a target, keeping HOB up
6. Peptic ulcer disease prophylaxis now routinely done to prevent aspiration

Careful of stroke patients, dysphagic patients

Different Pneumonias: which one do we have?

Start antibiotics w/in 4 hours of admission, and then: Sputum culture and sensitivity, CBC, chest x-ray, bronchoscopy, ABG [arterial blood gas], pulse oximetry

Prevention: walking, mobility, lungs expanding, tri-flow, airway management, assess for dysphagia, rduced conciousness levels, head of the bed up.

Adolextisis: lungs collapse at the bases b/c they don’t open all the way—comes from people laying in bed just for 12 hours sometimes. Makes people susceptible.

Sterile vs Clean;

You should see boxes of ‘clean’ gloves in patient rooms. Never be wearing gloves outside a client room! They are disposed in the client room. The end.

Clean gloves: some nurses carry gloves in their pockets, super clean would not have them carried there.

When to glove: when its warm and wet and doesn’t belong to you.

Sterile glove: have number sizes. What size am I? Probably a 6.

When do you need a sterile field?

• Anytime you have an open wound, (esp First surgical dressing change, maybe not a sutured wound that’s a few days old)

What’s sterile: anything below the waist; if your hands even go lower than your waist, not sterile anymore. Why? Tradition, and it’s out of sight. Touching unsterile stuff—like gloving and then pulling the curtain.

What’s not sterile: skin, hair. Patients. Any sterile field you’ve reached over, or turned your back on. Wet area. Inch around the boundary of the sterile field.

Supplies: experience. Take more than you need. Sometimes you need a mask, but that mask isn’t sterile, so you have to put it on first. Make sure supplies aren’t expired.

Tricks of Sterile Field procedures:

• Prep the patient
• Get supplies, including trashcan
• The goodies in the packages are sterile, but the outsides aren’t. So you have to open the packages before you glove.
• Gloving: leave room on the table. the wrapper can be a sterile field. Usually put dom hand in glove first. Don’t set hands below the waist to struggle gloves on. The sterile hand can help adjust the next hand’s glove. Don’t screw with the cuffs if they’re sloppy.
• Oops: you forgot to pour your fluid. Don’t unglove—ask the patient to press their call light, ask them to pour the goodies. Sterile gloves cost about $1.50
• If you need to cut stuff, there are sterile scissors and tweezers

• Work on the client; use either clean gloves to remove the dressing and then sterile up, or remove the dressing with your non-dom hand.

PPE: often alerted by signage at the door.

You’ll need gown, gloves, goggles, etc as determined by standard procedures, depending on what’ you’re doing

Dressing up:

Gowns; fluid resistant. Goes on first

Mask: tie over ears and under ears.

Clean gloves on

Undressing:

Gown; ties

Gown comes off and gloves go with it.

Mask goes last.

Wash hands in the patient room

Wash hands before and after:

All procedures

Meds

Bathroom

Eating

Being in patient room