NCM CD

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Nursing Care Management of Clients with Infectious/Communicable Disease – Dean Josephine De La Serna RN MN

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Infectious and Communicable Disease Nursing

Infection and Communicable Disease – brought about by a pathogenic microorganism

Communicable Disease – can be spread in the same way as a n infectious disease

***can be interchanged

General Objectives

- To recognize the physiologic interaction between man and a microorganism that lead to a degree of

subsequent pathology

- To help identify, prevent, and control communicable diseases

Specific Objectives

- Descriptive the infectious process with its complete chain of events

- Identify microorganism that serve as causative agents

- Use the biologic report as a primary source of information and tool to be used in the care of clients, along

with clinical indications to determine whether a client is colonized , infected , or diseased .

- Play an active role in infection control and prevention in the hospital and the community

- Discuss changing patterns if infectious diseases in our present time

- Utilize the nursing process in the care of a client with an infectious disease

- Utilize statistical date to identify responses to problem presented by clients with infectious/communicable

disease

Course Content

- See Copy on separate sheet

Evaluation Criteria

- Q – 50% (60% Passing)

- TE – 40%

- CP – 10%

Why study CD/ID?

- Despite improve methods for treating and preventing infection, infection remains the most common cause

of human disease and death.

- Potent antibiotics – up to 4th generation

- Complex immunizations

- Modern sanitation

CD/ID can be

1. Mild – person can go about with routine activities with little limitation

- E.g. Common colds

2. Debilitating – stays for a long time, chronic

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- E.g. Chronic Hepatitis

3. Fatal – there is no definitive treatment, tx is only supportive

- E.g. AIDs

Infection

- Invasion and multiplication of microbes in or on body tissues, resulting in signs and symptoms as well as

immunologic response.- The more numerous, the higher degree of infection

- Immunologic process – mechanism of the body to act and respond

Microbial reproduction injures the patient by:

1. Competing with the host metabolism

2. Causing cellular damage from toxins produced by the microbes or from intracellular multiplications

The severity of infection varies with:

1. Disease – producing ability of microbes (determines the virulence of the microbe)

2. Number of the invading microbes (directly proportional to the severity of infection)

3. Strength of the host defences (hosts capacity to fight the infection/microorganism)

Communicable Disease

- Transmitted form one person to another

- Eg. Chickenpox

Contagious Disease

- Communicable disease that is easily transmitted from one person to another

- Easily transmitted; takes lesser time to be transmitted from one person to another

- Eg. Influenza

***in terms of transfer, shorter time of transmission (contagious) compared to communicable

Why outbreaks occur despite antibiotics and other effective therapies:

1. Some bacteria develop a resistance to antibiotics

- Unnecessary use of antibiotics

- Inappropriate prescribing of antibiotics

- Patient failure to complete the full course of antibiotic treatment (Usually 1week tid)

***once level of accumulation is reached in the blood, body is now responding to antibiotics, and so

- Use of antibiotics in animal feed

- Hereditary drug resistance – extra chromosomal genetic elements with cell resistance (R) factors

- Effects of hospitalization – special risk for drug-resistant infections

Very old

Very young

Seriously ill

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Those patients on invasive procedures (using of an instrument to go into a body part;

something sharp) – ventilatory support

NGT – non invasive

- Those already taking antibiotics – antibiotics kill susceptible microbes allowing resistant strains to

take hold

2. Some microbes such as influenza virus have so many different strains that a single vaccine can’t protectthem all

3. Most viruses resist antiviral drugs (viral infections take a natural course)

4. Some microbes localize in areas of the body that make treatment difficult including bone and CNS

5. Opportunistic microbes can cause infections in immunocompromised patients – leukemia, AIDS patient,

cancer patients undergoing chemotherapy and radiation which destroy WBC

6. Much of the world ever increasing population has not received immunizations

7. Increasing air travel by the world population

8. The use of biological warfare and bioterrorism

9. The expanded use of immunosuppressive drugs and invasive procedures – immunosuppressive drugs to

prevent tissue rejection for transplants; wide variety of diagnostic tests

Terminologies

- Pathogens – disease causing microorganism, microbes, germs

- Pathology – scientific study of disease

Pathos – suffering

Logos – science

***Pathology is macro (or wider) so as epidemiology is under pathology

- Pathogenesis – manner in which a disease develops

- Epidemiology – study and investigation of diseases, esp its

cause, transmission, occurrence, prevention and control (under pathologist)

- Etiology – cause of disease (microorganisms)

- Communicable – able to spread and pass on, transmitted

- Infectious – may spread quickly

- Contagious – may spread easily/directly form person to person

- Communicable Disease

- Any disease that spreads from one host to another directly or indirectly (Smeltzer and Bare)

- Any infectious disease that comes either directly or indirectly from another host (Bauman)

***direct – immediate coming together of a surface to another

***indirect – not directly in contact

- Non-communicable Disease

- A disease which does not spread from one person to another, only when introduced into a body

(Tortora)

- An infectious disease that arises from outside of host or from (N) microbiota (Bauman)

- Contamination – mere presence of pathogens in the skin

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- Colonization – process by which strains of bacteria become resident flora, grows and reproduce but doesn’t

produce disease

***colonized person can transmit disease to another without own self getting the disease

- Infection

- Invasion or colonization of the body by microbes

- Condition in which the host interacts physiologically and immunologically with a microorganism

- Presence of a microbe in a part of the body where it’s not normally found

- Virulence – disease producing power of microbes

- Resistance – sum total of the body’s defenses which fro barriers to the progress of invasion or

multiplication of infectious agents (capacity of the body to fight an infection)

- Pathogenicity – ability to produce pathologic changes or disease

- Susceptibility – degree of resistance an individual has to pathogens

- Contact – a person or animal who is in close ass’n with an infected person, animal or thing

- Carrier – one who harbours microbes in his body without manifesting the disease

- Frank case – one actually sick of a particular disease

- Fomites (Sing. Fomes) – inanimate objects and materials on which disease-producing agents may be

conveyed

A. Historical Perspectives

Significant Persons

1. Antonie van Leeuwenhock

- Father of Microbiology

- First to describe microorganisms: Bacteria Protozoa

- Dutch Trade Man

- Animalcules

2. Louise Pasteur

- Discovered the Germ Theory of Disease

-

Created the first vaccines for rabies (100% mortality from Rabies)- Invented pasteurization (sterilizing milk and other food products)

3. Joseph Lister

- Pioneer of antiseptic surgery

- Use of antiseptic to control infections

- He used carbolic acid (Phenol)

4. Robert Koch

- Isolated Bacillus anthracis, TB bacillus, Vibrio cholera

- Developed the Koch’s postulate

5. Edward Jenner

- Pioneer of smallpox vaccine (almost similar to chicken pox but more contagious)- Father of Immunology

6. Alexander Fleming

- Discovered Penicillin

7. Ignaz Semmelweis

- From Vienna, Austria discovered that handwashing decrease the incidence of death due to

infection following childbirth

8. Linnaeus - nomenclature

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Microbiologists

Pathologists – one that examine tissues so that a more definitive can be given based on the report

Medical Technologist

Medical Practitioner Specializing in Infectious Disease

B. Factors that contribute to the emergence/incidence of CD

1. Societal Changes

- War

Crowded living conditions

Delivery of health care services is delayed

- Population growth – esp third world countries

- Urban deterioration

- Unemployment

- Poverty

- Slum areas

- Migrant workers

2. Health Care System

- Use and abuse of antimicrobial agents – OTC in the Philippines

- Reduce funding for CD control

3. Environmental/Ecological Changes

- Deforestation (environmental destruction)

- Housing/Village construction

- Mining

4. Technological Advancement

- Technology – Good effect: people everywhere in the world can warn that there is an ongoing

epidemic

-

Bad effect – exposure to radiation and chemicals5. Human Behaviors

- Global travel (population movements)

- Sexual promiscuity (may be linked to poverty)

- Drug use

- Globalization of food supply

Trends in Infection

- Deaths from infectious diseases have declined greatly in industrialized nations

- Infectious diseases continue to be a major cause of death in developing countries

- “New” and “emerging” infectious diseases plague both industrialize and developing nations – A(H1N1)

Swine flu

General Characteristics and Nature of Infectious Diseases

1. According to Occurrence

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- Sporadic – occurs throughout the year (E.g. Typhoid fever); occurs throughout the year but very

few or rare; very occasional and irregular in a certain population over a period of time, E.g. Flu and

Typhoid; has the possibility to become endemic

- Endemic – regular and constant, affects a certain population; present in a population regularly

number is not as great; (E.g. PTB); specific population (slum areas, crowded living conditions)

- Epidemic – number of cases of endemic course of illness will increase; definite increase over its

expected endemic pattern E.g. A(H1N1)

- Pandemic – affects several countries worldwide

Incidence and Prevalence

Incidence – number of new cases

Prevalence – a combination of new cases and old cases; fraction of the population having the disease at a particular

time

2. According to Severity/Duration- Acute – onset is sudden

Shorter span of time (2 weeks or less)

- Subacute

midway between acute and chronic

3 months, 2 months for the disease conditions to be solved

- Chronic – gradual onset

Longer span of time

Extend up to months or years

- Latent

Microorganism is in the body but waits for an opportunity for the resistance to go downand brings about a disease condition

3. According to Extent of Host Involvement

a. Local – affects a small area of the body (boils and abscesses)

5 Cardinal S/Sx of Local Infection

i. Rubor – normal inflammatory response in case of infections causes vasodilation

ii. Calor – heat on the part that is inflamed or infected (vasodilatation of blood vessels)

iii. Tumor – swelling; production of exudates

Pus – product of exudation

iv. Dolor – pain; brought about by compression of nerve ending brought about by the

swollen part; also caused by different toxins produced by the process of infection

v. Loss of function – due to pain

b. Systemic – spread throughout the body via the circulation (measles)

c. Inapparent or subclinical – does not cause any noticeable signs of the disease in the host (Hep

A, Polio virus)

Manifestations usually show after febrile stage

d. Focal – when infectious agents of a local infection enter a blood or lymph vessel and spread to

other specify parts of the body (those arising from infections in teeth, tonsils or sinuses)

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4. According to its acquisition

a. Primary – an acute infection that causes initial illness

b. Secondary

c. Nosocomial – healthcare acquired

i. Hospital Acquired

ii. Community Acquired

d. Iatrogenic – one that is acquired as a result of diagnostic and treatment procedure

E.g. Urinary Catheterization – UTI, Phlebitis due to IV insertion

Chain of Infection

Causative Agent – bacteria, virus, fungi, algae, protozoa

Reservoir – place where microorganism stay; person, animal, soil, water

Portal of exit – a way by which causative agent goes out and readies to be delivered to susceptible host (nose,

mouth, GI tract)

Mode of transmission

Portal of entry – may also be a portal of exit

***break the chain of infection

What is the significance of Chain of Infection to Prevention of Disease?

See to it that we break the chain of infection to avoid occurrence of infection

***autoclaving, sterilization, environmental sanitation, hand washing, early recognition of microorganism =

CAUSATIVE AGENT

***= MODE OF TRANSMISSION

HAND WASHING

PERSONAL PROTECTIVE EQUIPMENT – cap, mask, goggles, face shield, gowns, gloves

ENVIRONMENTAL SANITATION

IMMUNIZATION

HEALTHY LIFESTYLE --- balanced nutritious food, rest, exercise

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***typhoid fever = mask, gloves (fecal-oral route)

Course of Infection

a. Incubation Period – period from the entry of a microorganism until the development of the signs and

symptoms of the disease; time interval between the initial infection and the first appearance of any signs

and symptoms

- Host does not know that he will be sick

- Capable of transmitting the microorganism

- Rabies has incubation period of up to 20 years

b. Prodromal – period in which the patient feels that there is something wrong, feels mild signs and symptoms

of disease; not know the kind of disease; a relatively short period characterized by early, mild symptoms of

the disease, such as general aches and malaise

- Capable of transmitting the microorganism

c. Period of Illness – person exhibits S/Sx of the disease and the infectious agent (Full Stage); person can serve

as reservoir of disease

d. Period of Decline - <24 hours to days, S/Sx subside, person is vulnerable to 2ndary infection

e. Period of Convalescence – recovery has occurred and the person regains strength and the body returned to

its pre-diseased state; person can serve as reservoirs for months or years

Relationship between Microbes and Host

- Symbiosis – dissimilar organisms live an intimate and mutually advantageous partnership (most favorable)

- Mutualism – when 2 organism interact, both benefit; may be similar organism (man and man)

- Commensalism – one member of the relationship benefits without significantly affecting the other

- Parasitism – one benefits and the other is either harmed, (some with slight damage) or killed, in the

process, the parasite destroys its own home (Hookworms and tapeworm)

Defenses vs. Infections

1. Normal Flora – permanent residents of certain body sites; non pathogenic in usual places; constitute

protective host defense mechanism, limit growth of pathogens (E. Coli – UTI)

2. Body System Defenses – intact skin and mucous membranes of the RT, GIT, GUT, Repro Tract etc.

3. Inflammation – process that neutralizes and eliminates pathogens or necrotic tissues; establishes a mean o

repairing body cells and tissues

Inflammatory Response (InR) – the physiological reaction to injury or infection

4. Complement – “completes” the killing of bacteria; a complex of at least 20 serum enzymatic CHONs that

mediate InR and amplify specific ImR

5. Interferons – CHONs that acts to prevent multiplication of viruses in cells

6. Immune Response (ImR) – the body’s mechanism to protect itself

First Line of Defenses

I. Normal Flora

A. Resident – all the time

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B. Transient - here and now

- A variety of microbes on and inside our body

- Permanent residents of certain body sites: non-pathogens in usual places

- Does no harm and in some cases actually benefit us

- Under some circumstances they can make us sick or infect people we contact (can even kill us)

- Interferes with the establishment of pathogens from occupying a body surface by offering stiff

competition for space and nutrition (microbial antagonism – do not allow certain microorganism to

come in)

- No (N) Microbiota in – blood, bone, brain, heart, vascular system, lungs, esophagus, empty

stomach, eyes, amniotic membranes, bag of water, uterus (Axenic environments)

How does (N) Microbiota cause disease?

- When they are outside where they are supposed to be

- Increase in usual number

1. Immune Suppression

- Radiation/CA chemotherapy- Malnutrition, disease

- Emotional/physical stress

- Extremes of age

- Use of steroids to transplant patients

2. Changes in the microbiota

- Changes in the diet

- Hormonal changes

- Stress

- Long term antibiotic therapy

- Exposure to an overwhelming number of pathogens- Introduction of a member of (N) microbiota into an unusual site in the body

II. Body System Defenses

A. External Barriers

1. Intact skin and mucous membranes

Impervious to most pathogens

2. Body secretions provide an inhospitable environment

Maintain ph that discourages colonization

“Washing” the area to keep organism from accumulating

3. Secrete germicidal substances

4. Stimulate the development of the immune system

B. Components of the Internal Defenses

1. Lymphatic system: Lymph, lymph nodes

Filtration/sensitization), thymus, spleen, tonsils, Peyer’s patches (In GI tract)

Provides for the components of teh internal defenses to circulate thought the body

Designed to capture and destroy invading microbes

Function both in InR and ImR

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2. Leukocytes – play an active roles in InR and ImR

3. Lymphocytes in ImR only; intercept antigens; circulate to lymph nodes, spleen, tonsils,

lymph nodes, lymph tissue (Primary players: T-cells and Beta Cells)

***antigen – foreign substances that stimulate production of antibodies

4. Mediators – chemicals, CHONs (Chemotaxis, Leukotaxis, Opsonization)

Second Line of Defense (InR)

- Process that neutralizes and eliminates pathogens or necrotic tissues and establishes a means of repairing

body cells and tissues

3 Interdependent Stages

a. Cellular response – the same regardless of type of injury

b. Vascular response – the arterioles, venules, capillaries dilate and become permeable

c. Phagocytosis – engulfing, digesting, destroying infectious agents, cells debris and other small particles by

circulating macrophages (neutrophils and monocytes)

Components of the 2nd

Line of Defense

1. Phagocytosis

5 Stages of Phagocytosis

i. Chemotaxis – attraction of phagocytic cells to an area (+ Chemotaxis, - Chemotaxis)

Bacteria will follow or draw towards chemical environment of greatest concentration

ii. Adherence – adhere to membrane

iii. Ingestions – of bacteria and debris

iv. Digestion

v. Elimination – where the inflammatory process is completed and resolution (healing process)2. Extracellular killing by WBC (Eosinophils and natural killer (NK) cells)

o Aka leukotaxis

3. Non specific Chemical Defenses vs. Pathogens

o Lysozyme, Complement, Interferons, defensins

4. Inflammation

5. Fever (by Pyrogens and Interleukin 1)

o If patient develops fever, it means he is protected

Third Line of Defense (ImR)

- Produces antibodies

I. Cell-mediated Response

o Acts vs. Intracellular antigens

o Triggered after foreign materials have been cleared from the area of inflammation

o T- cells are activated, enter the circulation from lymph tissue and seek out the antigen

II. Humoral Response

o “Antigen antibody response” (ability of the body to develop a specific antibody to a specific

antigen

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o Acts vs circulating antigens

o Beta cells are activated

o Antibody mediated

III. Acquired Immunity

- Resistance developed by a host as a result of a previous exposure to a disease

- Protection an animal develops vs certain types of microbes

- Or foreign

- Produces when the immune system is activated either naturally or artificially

Types of Acquired Immunity

Natural Acquired Active

- Antigens enters body naturally

- Body produces antibodies and specified

lymphocytes

Artificially Acquired Active

- Body produces anti-bodies and specialized

lymphocytes upon vaccination

- Body takes an active role (compared to passive)

- Patient develops mild signs and symptoms of

disease (compared to passive)

Natural Passive

- Antibodies pass from mother to fetus viaplacenta or milk

Artificially Acquired Passive

- Antibodies in immune serum introduced intothe body by injection

IV. Immunoglobulin

- Specialized CHONs;

- Form of antibodies given to a person, coming from an animal or person who has had the disease

(passive immunity)

- Given to pregnant women to prevent congenital abnormalities to babies

Principles and Procedures in Preventing CDs and Controlling Transmission

3 Principal Approaches

1. Elimination or containment of the sources of infection – kill breeding grounds of mosquitoes

2. Interruption in the important mechanism of transmission

3. Protection of the susceptible host – isolation, quarantine, barrier precautions, increase immune system

through healthy lifestyle

Control Measure Geared On:

1. Killing or altering virulence of pathogens (Chemoprophylaxis) – by use of drugs, antiviral, antimicrobial

2. Destroying non-human reservoirs and vectors (Physical/Chemical Methods)3. Isolating and segregating infected persons

4. Using precaution with infected body fluids/contaminated objects – body secretion, precaution and drainage

precaution

5. Development of vaccines

6. Education

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Principles of Basic Infection Control

- Microorganisms move on air currents

- Avoid shaking or tossing linens

- Doors leading to rooms used as a respiratory isolation are kept closed to stop air currents

- Ventilation system:

a. TB negative pressure (door opened -> air from the corridor moves)

b. Operating room: + pressure (door opened -> air doesn’t move in to contaminate)

- Microorganisms are transferred from one surface to another whenever objects touch

- Clean item -> less clean item = dirty microorganisms transferred to it

- Keep hands away from own face and hair

- Keep linens away from your uniform

- Separate clean and dirty linens

- If you drop anything on the floor, consider it dirty

- Microorganisms are released into the air on droplet nuclei whenever a person breathes or sp eaks

- Safe distance = 3 feet away

- Coughing and sneezing dramatically increases the # of microbes released from the mouth

and nose (forceful)

a. Avoid having a patient breath directly to your face

b. Avoid breathing directly into a patients face

- Microorganisms move slowly on dry surfaces but quickly through moisture

- Used dry paper towel to turn off faucet

- Don’t use moistened towel

- Dry bath basin before returning to a bedside stand and storage

- Proper hand washing removes many microorganism that can be transferred by the hands

from one item to another

a. Before patient contact

b. Before sterile task

c. After blood or body fluid exposure (obviously soiled)

d. After patient contact

e. After contact with patient’s surroundings

Control and Elimination of Infectious Agents

Isolation – segregation/separation of a person with infectious disease from other persons to prevent the spread of

infections or potentially infectious microorganism to health personnel, clients and visitor

***One person per room in isolation

***Group together patients with same diagnosis and infection

Rationale for Isolation

1. To prevent the spread of infection

a. From client to client

b. From client to health care worker

c. From health care worker to client

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d. From client to visitor

e. From visitor to client

2. To lessen the risk of infection in immunocompromised clients

Isolation Based Theory

- It is appropriate to isolate persona presumed contagious when more specific preventive measure are

unknown or unfeasible (Wehrle and Top)- In case of doubt, isolate the patient

***If unsure/doubt if patient is infectious, isolate the patient

Isolation Categories

- See handouts

STRICT

- Purpose: prevents transmission of highly contagious or virulent infections spread by air and contact

- Eg. chickenpox, diphtheria

- Room: Private room with door closed

- Gown: required of all persons entering room

- Gloves: required of all persons entering room

- Mask: required of all persons entering room

- Precautions: discard or bag and label articles contaminated with infective material. Send reusable articles for

disinfection and sterilization

- NEED MASK, GLOVES, GOWN

CONTACT

- Purpose: prevents transmission of highly transmissible infections spread by close or direct contact, which not

warrant strict precautions

- Eg. acute respiratory infections in infants and young children; impetigo; herpes simples; infections by multiple

resistant bacteria

- Private room: clients infected with same organsism amy share room

- Gown: indicated if soiling or contact likely

- Gloves: indicated for persons touching infective material

- Mask: INDICATED FOR PERSONS COMING CLOSE TO CLIENT

- Precautions: discard or bag and label articles contaminated with infective material. Send reusable items for

disinfection and sterilization- SUCTIONING: GLOVES AND MASK

- ASK PATIENT: DO NOT NEED ANYTHING UNLESS STAY CLOSE TO PATIENT

RESPIRATORY

- Purpose: prevents transmission of infectious diseases over short distances by air droplets

- Eg. measles, meningitis, mumps, pneumonia, haemophilus influenza (in children)

- Room: private room: clients infected with same organisms may share room

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- Gown: not indicated

- Gloves: not indicated

- Mask: indicated for persons who come close to client

- Precautions: discard or bag and label articles contaminated with infective material. Send reusable items for

disinfection and sterilization. Bathroom should not be shared with clients.

ACID-FAST BACILLUS ISOLATION- Purpose: is special category for clients with pulmonary tuberculosis who have positive results on sputum or

chest xray examination indicating active disease

- Eg. pulmonary or laryngeal tuberculosis

- Room: Private room with special ventilation (air from adjacent rooms and corridors must flow into, not out of

isolation room). Exhaust air must not be recirculated; door closed

- Gown: indicated only if needed to prevent gross contamination of clothing

- Gloves: not indicated

- Mask: well-fitting, high filtration mask. Ordinary surgical masks offer little protection.

- Precautions: articles are rarely involved. In transmissions of tuberculosis. Articles should be thoroughly

cleansed, disinfected or discarded

- MOST NEED PPE EQUIP: MASK (HIGH FILTRATION MASK = N95)

ENTERIC PRECAUTIONS

- Purpose: prevents infections transmitted by direct or indirect contact with feces

- PPE MOST NEEDED: GLOVES, and mask (for odor)

DRAINAGE/SECRETION PRECAUTIONS

- Purpose: prevents infections transmitted by direct or indirect contact with purulent material or drainage from

infected body site

- Eg. abscess; burn infection; infected wound; minor infection snot included in contact isolation

- Room: private room not indicated

- Gown: indicated if soiling or contact with infective material is likely

- Gloves: indicated when touching infective material

- Mask: not indicated

- Precautions: Discard or bag and label articles contaminated with infective material. Send reusable articles for

disinfection and sterilization.

UNIVERSAL PRECAUTIONS

- Purpose: prevents transmission of blood-borne pathogens by direct ofr indirect contact; must be practiced

with all clients as a minimum standard

- Eg. AIDS, hepatitis E, syphilis

- Room: Private room indicated if client’s hygiene is poor

- Gown: indicated during procedures likely to generate splashes of blood or body fluids

- Gloves: indicated for touching blood or body fluids containing visible blood, mucous membranes or nonintact

skin of all clients; indicated for touching soiled items

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- Mask: indicated during procedures likely to generate droplets of blood

- Precautions: Discard or bag and label articles contaminated with blood or body fluids. Disinfect and sterilize

articles. Avoid needle stick injuries. Dispose used needles in properly labeled, puncture-resistant container.

Clean blood spills with 5.25% solution of sodium hydrochloride diluted 1:10 with water.

- SPECIAL PRECAUTION TO TAKE: CARE OF BLOOD AND BODY FLUIDS (NEEDLES, DISCHARGES) PLACED ON

SPECIAL PLASTIC BAGS

NEUTROPENIC PRECAUTIONS or REVERSE ISOLATION

- Purpose: protects uninfected client with lowered immunity and resistance from acquiring infectious organisms

- Eg. leukemia, lymphoma, aplastic anemia (with blood problems)

- Room: private room with door closed

- Gown: required of all persons entering room

- Gloves: required of all persons entering room

- Mask: Indicated for persons coming in contact with client

- Precautions: for open wounds or burns, use sterile gloves

What type of PPE Would You Wear?

1. Giving a bed bath? None (will need gloves if there are discharges from any openings esp skin; will need

mask when patient is having disease condition where droplet nuclei is source of contamination)

2. Suctioning oral secretions? Gloves = will likely touch patient’s secretions; Mask if not skillful in handling

catheter

3. Transporting a patient in a wheel chair? None

4. Responding to an emergency where blood is spurting? Gloves, mask, gown, face shield

5. Drawing blood from a vein? Gloves

6. Cleaning an incontinent patient with diarrhea? Gloves, gown

7. Irrigating a wound? Gloves, gown, mask 8. Taking vital signs? None

How often do you clean your hands after touching a patient’s intact skin? ALWAYS

Remember to your part for patient safety: FOLLOW good hand hygiene practices.

Definitions

Hand hygiene – performing hand washing, antiseptic hand wash, alcohol-based hand rub, surgical hand

hygiene/antisepsis (BETTER THAN HAND WASHING)

Hand washing

Use gloves – blood and body fluids, soiled patient care equipment or used linenMask/eye protection and gown – when splashing of blood or body fluid

Sequencing for Donning PPE

1. Gown first

2. Mask or respirator

3. Goggles or face shield

4. Gloves

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How to Don a Gown?

- Select appropriate type and size

- Opening is in the back

- Secure at neck and waist

- If gown is too small, use two gowns (gown #1 ties in front, gown #2 ties in back ==== put on the one in back first

then in front)

How to Don a Mask?- Place over nose, mouth and chin

- Fit flexible nose piece over nose bridge

- Secure on head with ties or elastic

- Adjust to fit

How to Don Gloves

- Don gloves last

- Select correct type and size

- Insert hands into gloves

- Extend gloves over isolation gown cuffs --- beyond radial area

Sequence for Removing PPE

1. Gloves

2. Face shield or goggles

3. Gown

4. Mask or respirator

How to Remove Gloves ---- GLOVE-TO-GLOVE TECHNIQUE

- Grasp outside edge near wrist

- Peel away from hand, turning glove inside-out

- Hold in opposite gloved hand

- SKIN-TO-SKIN TECHNIQUE

Removing Eye Shield

- Grasp ear or head pieces with ungloved hands

- Lift away from face

- Remove on two sides

Removing Isolation Gown

- Unfasten ties

- Peel gown away from neck and shoulder

- Turn contaminated side inward

- Roll the gown

Quarantine

- Is the limitation of the freedom of movement of persons with infectious diseases, for a period equivalent to

the period of the communicability of the disease

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Quarantine-Based Theory

- A CD suspect is isolated for 40 days until infectivity should theoretically have ended (Wehrle and Top).

- Chemoprophylaxis – use of pharmacologic agents to control infection

- Antisepsis – reduction in teh number of microorganism and viruses, particularly potential pathogens, on

living tissue

***sterility: all microbes (pathogenic or nonpathogenic) are removed including their spores

***antiseptics: reduce to a minimum

- Degerming – removal of microbes by mechanical means (eg. dusting, mopping, washing, taking a bath)

- Disinfection – destruction of most microorganisms and viruses on non living tissue

***disinfection and antiseptics are used interchangeably. Antisepsis coupled with antiseptic solution

(Zonrox, mouth wash, Cidex)

- Sterilization – destruction of all microorganisms and viruses in, or on, an object (including spores) –

autoclave

- Sanitization – removal of pathogens from objects to meet public standards – handwashing with safeguard

- Cleaning – reduces growth of microbes but do not totally remove them – for soiled equipment at home

1. Rinse with cold H20

2. Wash with warm, soapy water

3. Rinse to remove soap

4. Use a stiff brush to clean equipments with grooves and corners

***hot water effect on secretions: secretions contain CHON -> coagulate if with hot water -> stick to

instrument :::: thus rinse with cold water first

- Pasteurization – use of moderate heat to destroy pathogens and reduce the number of spoilage

microorganisms in foods and beverages (15seconds @ 72 degrees Celsius)

Dairy

Fruit Juices

BeerWine

- Autoclaving

- Steam under pressure

- Usually operated @ 121Degrees Celsius

- 15lbs pressure/square inch

- Time needed for procedure depends on materials being sterilized

- Laboratory/medical supplies that can tolerate heat and moisture

- Boiling

- denatures CHONs and destroys membranes

- 10 minutes @100Degrees Celsius

- Sterilization of restaurant cookware and tableware

- Ultra High Temperature Sterilization

- 1-3 seconds @ 140Degrees Celsius

- Sterilization of dairy products

- Dry Heat Hot Air Oven

- 2 hours @ 160Dec Celsius or 1 hour @ 171Deg Celsius

- Denatures CHONs, destroys membranes

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- Oxidize metabolic compounds

- Sterilization of H30 Sensitive materials: Powders, oils and metals

- Incineration

- 1 sec @ >1000Deg Celsius

- Sterilization of inoculating loops, flammable contaminated medical wastes, disease

carcasses

- Same as cremation of the dead

- Radiation – all types of radiation injurious to microbes

a. Ionizing radiation – destroys DNA

Ex. Electron beams, gamma and x-rays

Sterilization of medical and laboratory equipment, preservation

b. Non-ionizing radiation (UV light)

- Inhibits DNA transcription and replication

- OR, nurseries, labs, schools, food establishments

- Refrigeration

- 0-7Deg Celsius inhibits metabolism and microbial multiplication; preservation of food

- Environmental Sanitation

- Is the study of all factors in man’s physical environment which may exercise a deleterious

effect on his well-being and survival (Public Health Nursing in the Philippines NLPGN Inc.,

10th edition, p.311)

Water Sanitation

Food sanitation

Refuse and Garbage disposal

Air pollution

Noise

Radiological protection

Institutional sanitation

Stream pollution

Chemical Methods of Microbial Control – for body and inanimate objects

- Antiseptic – inhibits microbial growth

- Disinfectant – destroys pathogenic microbes and inhibits microbial growth (more concentrated)

- Germicide – destroys pathogenic microbes

- Bactericide – destroys bacteria

- Fungicide – destroys fungi

- Varicide – destroys viruses

***disinfectant (alcohol, Zonrox) is more concentrated than antiseptic (Listerine, mouth wash)

Commonly Used Chemical Agents

1. Ethyl Alcohol (70%)

2. Isopropyl Alcohol (80%)

3. Benzalkonium Chloride 1:1000 Zephiran

4. Hydrogen Peroxide (3%)

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5. Silver nitrate (1%)

6. Iodine and iodine releasing compounds

7. Substituted phenols

8. Ethylene oxide – OR for anesthetic machine

Protecting the Host and Improving Susceptibility

- Use hygienic practices to maintain skin and mucous membranes as 1st

line of defense- Reinforce or maintain natural protective mechanisms such as coughing, pH of secretions, resident flora

- Promote./maintain proper and good nutrition and encourage rest and sleep to promote tissues repair and

production of lymphocytes and antibodies

- Educates client about immunization and on teh availability of health services

Notifiable/Reportable Disease

- Refers to a disease that, by legal requirements, must be reported to a public health – or other authority, in

the pertinent jurisdiction when the diagnosis was made (DOH AO 2007-0036), (DOH AO 2008-0009) Ferb

12, 2008, RA 3573

Immediately Notifiable Disease/Syndrome/events and conditions (Category I)

- Immediate notification is required for the epidemic-prone diseases that newly appear in a population or

have existed but are rapidly increasing in incidence. This also includes epidemic-prone diseases targeted

for eradication and elimination. The Disease Reporting Unit (DRU) shall notify simultaneously the PHO,

CHD, and NEC within 24 hours of detection by the fastest means possible even a single cause of such

disease. A case-based investigation report shall be submitted to the above-mentioned offices by facsimile

or e-mail.

1. Acute flaccid paralysis --- in polio

2. Adverse event following immunization (AEFI)

3. Anthrax4. Human avian influenza

5. Measles

6. Meningococcal disease

7. Neonatal tetanus

8. Paralytic shellfish poisoning --- red tide

9. Rabies

10. Severe acute respiratory syndrome (SARS)

11. Outbreaks

12. Clusters of diseases

13. Unusual diseases or threats

Category 2 – reported weekly

Acute bloody diarrhea syndrome

Acute encephalitis syndrome

Acute hemorrhagic fever syndrome

Acute viral hepatitis

Bacterial meningitis

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Cholera

Dengue

Diphtheria

Influenza –like illness

Leptospirosis

Malaria

Non-neonatal tetanus

Pertussis

Typhoid and paratyphoid fever

Nursing Care and Management

Involves the ff:

- Self protection

- Prevention of spread (medical asepsis and concurrent disinfection)

- Physical care

- Emotional support

- Spiritual support

***Nurses’ responsibility extends beyond the immediate care

Nurses must be knowledgeable in:

- Nature of specific microbes

- Most effective methods of destruction

- How pathogens invade host, routes of escape

- Incubation period, prodromata, length of communicability

- How a specific drug alters the clinical signs and the infectious course of the disease

- Most recent methods and concepts of prophylaxis for CD

- Rationale of control measures, isolation techniques

4 Aspects of Care

- Preventive

- Health Education

- Immunization

- Environmental Sanitation

- Control System- Isolation (8categories)

- Quarantine

- Disinfection(Concurrent and terminal)

- Disinfestations(Physical/chemical means)

- Fumigation(Disinfectant fogging)

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- Curative

- Medical Management

- Nursing Management

- Rehabilitative

- Activity

- Nutrition

Potassium Manganese Crystal – for fumigation

Assessment

Challenges to the Nurse

o Infectious agent cause a wide range of disease

o Symptoms vary from highly specific (Pathognomonic sign) to a generalized feeling of illness

o Susceptibility to infection increases with poor nutrition, chronic disease, stress, fatigue,

immunosuppression

o Many infectious diseases follow a reasonably predictable risk pattern in which they occur more commonlyin certain individuals

o Certain behaviors put persons at risk

Parts of Assessment: Nursing history, Physical Assessment, Laboratory and Diagnostic Exam

Nursing Health History

Factors relating to infectious diseases

1. Potential exposure to infectious agents

2. Risk factors that alter host resistance to the disease3. Medical history related to increased risk of infections (Leukemia)

4. Previous infections

5. Immunization history

6. Present complaint for visit

Diagnostic Tests to Screen and Confirm Certain Infection/Ids

1. Based on manifestations: local/systemic

2. Hematologic Test

3. Skin Tests

4. Microscopic Exams

5. Antibiotic Sensitivity Testing

6. Cultures

7. Immunologic Tests

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Manifestations of Infection

Local

1. Pain – Dolor

2. Redness – Rubor

3. Swelling – tumor

4. Warmth – Calor

Systemic

1. Fever – increased metabolic rate (inc in PR and RR); as we breath, we give off heat

2. Increased PR and RR

3. Lethargy – sleepy, drowsy

4. Anorexia

5. Enlarged Lymph Nodes – lymphadenopathy

II. Hematologic Tests

1. WBC

- 4500-11000/mm3;

- provides info on client’s response to disease and treatment

- Critical values: <2500mm3, >30000mm3

2. WBC Differential – identifies and enumerates N L M E B, also bands and segmenters

Total Neutrophils: 50-70%

Bands 0-5% - bacterial infections

Lymphocytes 25-35% - viral/chronic

Monocytes 4-6% - viral/chronic inflammation

Eosinophils 1-3% - allergic/parasitic

Basophils .4-1.0% – acute or sever infection

3. ESR

- M – 40-50% F – 38-47%; assists in the diagnosis of acute/chronic infection acute InR,

Rheumatoid/autoimmune disorders, Temporal arthritis, Polymyalgia rheumatica, course of an

infectious process and client’s response to treatment; acute/severe bacterial infection (Wintrobe

Westergren)

- Increase in case of infections

4. C-Reactive Protein

- 6.8-820micrograms/dL

-

Detect the increase or exacerbation of inflammatory process- Ii 4-6 hours after onset, decreases rapidly as InR begins to resolve

5. Intracellular Enzymes – ca be detected in serum following inflammation/injury

- ALT – Alanine Aminotransferase (SGPT)

o Produced by teh liver

o To track course of liver disease

o To monitor liver damage due to hepatotoxic drugs

o To monitor response to liver disease treatment’

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o Routine screen for hepatitis (donor blood samples rejected if levels are >1.5x the upper

limits of normal (F: 7-35 U/L) *M:10-40U/L)

- AST – Aspartate Aminotranspeptidase

o Rises when there is cellular damage to tissues where the enzyme is found: liver, myocardia

cells, skeletal muscle, kidneys, pancreas, brain

- LDH – Lactate Dehydrogenase (313-618 U/L)

o Non specific indicator of cellular damage because LDH is found in every tissue of the body

6. Lactic Acid Levels – increases in teh + of bacteria but not virtues (E.g. CSF: Bacterial vs viral meningitis)

7. Ig Ratio – aids in differentiating current/past infection/immunization

Serum IgM – Inc levels = current infection

- Levels generally peak 1-2 weeks after antigen is introduced (active infection) and

- Decrease during the convalescence period

Serum IgG – Inc levels = previous infection

- Placental transfer of maternal antibodies

- Previous active or passive immunization

- Peaks during convalescence

***A 4 fold rise in antibody titer during convalescence indicates concurrent infection

III. Skin Tests

- Based on the principle that an intradermal injection of either certain antigens or toxins produces a loca

(cell mediated) reaction if a person has recently been infected with a particular antigen

- Y Antibody Test – TB (Mantoux Test, PPD, Tine test <leaves a scar>)

- Y Toxin Tests – Diphtheria (Schick Test)

- Scarlet Fever (Dick Test)

IV. Microscopic Exams

- Only method of identifying parasites/ova

- Distinguishes tissue cells from microorganisms

- Permits a presumptive diagnosis

V. Antibiotic Sensitivity Testing

- Adding antimicrobials to a culture to determine whether an organism is inhibits from growing or is dead

VI. Culture Test

-

Use liquid/solid medium- Positively identifies organism depending on:

- Type of Microorganism (Pneumococcus)

- Type of Specimen (E.g. S. Typhosa)

- Stage of Illness (E.g. TB)

VII. Immunologic Test – measures antibody titers

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I. Agglutination Tests

- Demonstrates ability of antibodies and antigens to bind together (clumping)

- Used in blood typing

- Used in identifying antibodies vs many bacterial, fungal, parasite nad a few viral infections

2 Types

1. DAT – antibodies attach directly to antigens

2. IAT – antigens must 1st be coated with chemicals that attract antibodies

Enzyme-Linked Immunoabsorbent Assay (ELISA) – more sensitive than CIE in detecting antigens and

antibodies associated with B, F, V, P infections: HIV, Hepa A and B, Rubella

Radioimmunoassay (RIA) – highly sensitive, can detect small mounts of antigen or antibody; useful

in diagnosis of Hepa B

Immunofluorescent Antibody Assay (IFA) – antigen-antibody binding can be observe under a

fluorescent microscope when either antigens or antibodies are tagged with a fluorescent dye

VIII. Other Immunologic Tests

Limulus Lysate Assay – detects endotoxins in CSF produced by gram negative bacteria (N. Meningitidis,

E.Coli, H. Influenzae)

Antigen-Antibody reactions that can be observed microscopically: Immobilization, opsonization, and

phagocytosis, and capsular swelling (quelling reaction)

o Ex. TPI (Treponema Pallidum Immobilization) test detects capsular swelling; diagnosis of syphilis

Neutralization tests – uses the principle that if neutralizing antibodies or antitoxins are +, tissue destruction

is prevented

Nursing Process – refer to hand out10 Leading Causes of Mortality

2007 2004

1. Heart Disease

2. Diseases of the Vascular System

3. Pneumonias

4. Malignant neoplasm/cancers

5. All forms of Tuberculosis

6. Accidents

7. COPD and allied conditions

8. Diseases of Respiratory system9. Diabetes mellitus

10. Nephritis/nephrotic Syndrome

1. Heart Disease

2. Diseases of the vascular System

3. Malignant neoplasm/cancers

4. Accidents

5. Pneumonias

6. All forms of TB

7. COPD and allied condition

8. Respi diseases9. DM

10. Nephritis/Nephrotic Syndrome

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Emerging Infectious Diseases (CDC 1994)

What?

- Infections that have newly appeared in a population or have existed but are rapidly increasing in incidence

or geographic change (Kwan-Gett p.1-5)

- Diseases of infectious origin with human incidence that have increased within the past 2 decades

- That are likely to increase the near future (Smeltzer and Bare, pp. 2125)

Why?

- Human actions in the environment

- Social forces worsened by war and economic disparity

3 Categories of EIDs

- Diseases that have not previously occurred in human (SARS)

- Diseases that have occurred previously but affected only small #’s of persons in isolated locations (Ebola

AIDS)

- Diseases that have occurred thought history bust have only been recently recognized as distinct disease

caused by an infectious agent (Lyme Disease, Gastric Ulcers)

Diseases Surveillance and Response Network: to control the spread of infectious disease, draw statistical data….

- GOARN – Global Outbreak and Response Network – to control the spread of communicable disease, make a

study, draw statistical data and inform one another of the situation in various area)

- 122 member countries involve in GOARN

- PIDSR – Philippines Integrated Disease Surveillance and Response – main office at Manila

- NOCHESS – Negros Occidental Health Epidemiology and Surveillance System- CDCS – Community-based Disease Surveillance System

NCM CD

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