Infection, Risk for Universal Precautions; Standard Precautions;
CDC Guidelines; OSHA
Audrey Klopp, RN, PhD, ET, CS,
NANDA: The state in which an individual is at increased risk for
being invaded by pathogenic organisms
Persons at risk for infection are those whose natural defense
mechanisms are inadequate to protect them from the inevitable injuries and
exposures that occur throughout the course of living. Infections occur when an
organism (bacterium, virus, fungus, or other parasite) invades a susceptible
host. Breaks in the integument, the body's first line of defense, and/or the
mucous membranes allow invasion by pathogens. If the host's (patient's) immune
system cannot combat the invading organism adequately, an infection occurs.
Open wounds, traumatic or surgical, can be sites for infection; soft tissues
(cells, fat, muscle) and organs (kidneys, lungs) can also be sites for
infection either after trauma, invasive procedures, or by invasion of pathogens
carried through the bloodstream or lymphatic system. Infections can be
transmitted, either by contact or through airborne transmission, sexual
contact, or sharing of intravenous (IV) drug paraphernalia. Being malnourished,
having inadequate resources for sanitary living conditions, and lacking
knowledge about disease transmission place individuals at risk for infection.
Health care workers, to protect themselves and others from disease
transmission, must understand how to take precautions to prevent transmission.
Because identification of infected individuals is not always apparent, standard
precautions recommended by the Centers for Disease Control and Prevention (CDC)
are widely practiced. In addition, the Occupational Safety and Health
Administration (OSHA) has set forth the Blood Borne Pathogens Standard,
developed to protect workers and the public from infection. Ease and increase
in world travel has also increased opportunities for transmission of disease
from abroad. Infections prolong healing, and can result in dealth if untreated.
Antimicrobials are used to treat infections when susceptibility is present.
Organisms may become resistant to antimicrobials, requiring multiple
antimicrobial therapy. There are organisms for which no antimicrobial is
effective, such as the human immunodeficiency virus (HIV).
- Inadequate primary defenses: broken skin, injured tissue, body
- Inadequate secondary defenses: immunosuppression, leukopenia
- Indwelling catheters, drains
- Intravenous (IV) devices
- Invasive procedures
- Rupture of amniotic membranes
- Chronic disease
- Failure to avoid pathogens (exposure)
- Inadequate acquired immunity
- Patient remains free of infection, as evidenced by normal
vital signs, and absence of purulent drainage from wounds, incisions, and
- Infection is recognized early to allow for prompt
- (i) independent
- (i) Assess for presence, existence of, and
history of risk factors such as open wounds and abrasions; indwelling catheters
(Foley, peritoneal); wound drainage tubes (T-tubes, Penrose, Jackson-Pratt);
endotracheal or tracheostomy tubes; venous or arterial access devices; and
orthopedic fixator pins.
- Each of these examples represent a break in the body's
normal first lines of defense.
- (c) Monitor white blood count (WBC).
- Rising WBC indicates body's efforts to combat pathogens;
normal values: 4000 to 11,000. Very low WBC (neutropenia <1000) indicates
severe risk for infection because patient does not have sufficient WBCs to
fight infection. NOTE: In the elderly,
infection may be present without an increased WBC.
- (i) Monitor for the following signs of
- Redness, swelling, increased pain, or purulent drainage at
incisions, injured sites, exit sites of tubes, drains, or catheters.
- Any suspicious drainage should be cultured; antibiotic
therapy is determined by pathogens identified at culture.
- Elevated temperature.
- Fever of up to 38 degrees C (100.4 degrees F) for 48
hours after surgery is related to surgical stress; after 48 hours, fever above
37.7 degrees C (99.8 degrees F) suggests infection; fever spikes that occur and
subside are indicative of wound infection; very high fever accompanied by
sweating and chills may indicate septicemia.
- Color of respiratory secretions.
- Yellow or yellow-green sputum is indicative of
- Appearance of urine.
- Cloudy, foul-smelling urine with visible sediment is
indicative of urinary tract or bladder infection.
- (i) Assess nutritional status, including
weight, history of weight loss, and serum albumin.
- Patients with poor nutritional status may be anergic, or
unable to muster a cellular immune response to pathogens and are therefore more
susceptible to infection.
- (i) In pregnant patients, assess intactness
of amniotic membranes.
- Prolonged rupture of amniotic membranes before delivery
places the mother and infant at increased risk for infection.
- (i) Assess for exposure to individuals with
- (i) Assess for history of drug use or
treatment modalities that may cause immunosuppression.
- Antineoplastic agents and corticosteroids reduce
- (i) Assess immunization status.
- Elderly patients and those not raised in the United States
may not have completed immunizations, and therefore not have sufficient
- (i) independent
- (i) Maintain or teach asepsis for dressing
changes and wound care, catheter care and handling, and peripheral IV and
central venous access management.
- (i) Wash hands and teach other caregivers to
wash hands before contact with patient, and between procedures with
- Friction and running water effectively remove
microorganisms from hands. Washing between procedures reduces the risk of
transmitting pathogens from one area of the body to another (e.g., perineal
care or central line care). Use of disposable gloves does not reduce the need
- (i) Limit visitors.
- To reduce the number of organisms in patient's environment
and restrict visitation by individuals with any type of infection to reduce the
transmission of pathogens to the patient at risk for infection. The most common
modes of transmission are by direct contact (touching) and by droplet
- (i) Encourage intake of protein- and
- To maintain optimal nutritional status.
- (i) Encourage fluid intake of 2000 ml to 3000
ml of water per day (unless contraindicated).
- To promote diluted urine and frequent emptying of bladder;
reducing stasis of urine in turn reduces risk of bladder infection or urinary
tract infection (UTI).
- (i) Encourage coughing and deep breathing;
consider use of incentive spirometer.
- These measures reduce stasis of secretions in the lungs and
bronchial tree. When stasis occurs, pathogens can cause upper respiratory
infections, including pneumonia.
- (c) Administer or teach use of antimicrobial
(antibiotic) drugs as ordered.
- Antimicrobial drugs include antibacterial, antifungal,
antiparasitic, and antiviral agents. Ideally, the selection of the drug is
based on cultures from the infected area; this is often impossible or
impractical, and in these cases, empirical management usually with a
broad-spectrum drug is undertaken. All of these agents are either toxic to the
pathogen or retard the pathogen's growth.
- (c) Place patient in protective isolation if
patient is at very high risk.
- Protective isolation is established to protect the person
at risk from pathogens.
- (i) Recommend the use of soft-bristled
toothbrushes and stool softeners to protect mucous membranes.
Education/Continuity of Care
- (i) independent
- (i) Teach patient or caregiver to wash hands
often, especially after toileting, before meals, and before and after
- Patients and caregivers can spread infection from one part
of the body to another, as well as pick up surface pathogens; handwashing
reduces these risks.
- (i) Teach patient the importance of avoiding
contact with those who have infections, colds, or other things.
- (i) Teach family members and caregivers about
protecting susceptible patient from themselves and others with infections or
- (i) Teach patient, family, and caregivers the
purpose and proper technique for maintaining isolation.
- (i) Teach patient to take antibiotics as
- Most antibiotics work best when a constant blood level is
maintained; a constant blood level is maintained when medications are taken as
prescribed. The absorption of some antibiotics is hindered by certain foods;
patient should be instructed accordingly.
- (i) Teach patient and caregiver the signs and
symptoms of infection, and when to report these to the physician or nurse.
- (i) Demonstrate and allow return
demonstration of all high-risk procedures that patient or caregiver will do
after discharge, such as dressing changes, peripheral or central IV site care,
peritoneal dialysis, self-catheterization (may use clean technique).
- Bladder infection more related to overdistended bladder
resulting from infrequent catheterization than to use of clean versus sterile
Infection Control; Infection Protection
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