Lecture 1B

Disease transmission/ prevention

1st line of Defense

• Skin – Barrier

• Mucus – Traps and removes

Inflammation• “Non-specific”

response to injury• WHY?–Destroy pathogens– Limit spread–Begin to heal

Pathophysiology of Inflammation• 3 step process1. Vascular response2. Cellular response3. Healing

1. Vascular responseInjury Chemicals released • Histamine• Bradykinin• Prostaglandins

1. Vascular response• Histamine • Dilate–Vasodilation• h blood flow• h pressure

Redness

1. Vascular response

• Bradykinin • h permeability – capillaries leak

fluid into surrounding tissue • swelling

1. Vascular response• Prostaglandins –h Pain–h Temperature

• Pain• Heat• Loss of function

2. Cellular response• h blood flow • h WBC–Neutrophils:• First responders!•Move from blood

vessel the injured tissue

2. Cellular response (cont.)• 2nd responders–Monocytes

(mature) MACROPHAGES

2. Cellular response (cont.)• Neutrophils +

Macrophages – Ingest • bacteria and • dead tissue

–PHAGOCYTOSIS

Cellular response (cont.)

• Neutrophils & Macrophages eat then die

• Pus Formation• “purulent

drainage”

3. Healing & Tissue repair

• Minor injury:–Inflammatory

process heals• Major injury –New cells are

produced –Scar tissue

Classic Signs & Symptoms of inflammation

• Heat• Redness• Swelling• Pain• Loss of function

Geriatric Inflammation

Older adult• Thin skin• i blood flow• i macrophages • i phagocytosis• Med interference

Geriatric Inflammation • Results– h risk of injury– i wound healing– i S&S

Geriatric Inflammation

• In 25% of the elderly, they do not have an elevated fever even with a serious infection

Geriatric Inflammation

• Best indicator of serious infection in the elderly…–Delirium–Change in

mental function

Small Group Questions1. Define inflammation in your own words and

describe the pathophysiology of the inflammatory response.

2. What are the cardinal signs of inflammation and what causes each one of them?

3. What is phagocytosis? What cells “do it”?4. Why are the elderly more susceptible to

inflammation, or are they?5. How do the elderly typically manifest infection?

Acute vs. Chronic

Acute inflammation• Short-term reaction • Immediate response• Duration–< 2 weeks

Chronic inflammation• Slower onset• Lasts weeks - months

Diabetes mellitus & Inflammation

• DM – h risk of poor wound

healing and infection• High blood glucose

levels – i phagocytosis– Damages capillaries

Systemic manifestations• Enlarges lymph

nodes• Appetite– i

• Fatigue• Heart rate– Tachycardia

Systemic manifestations

• Respiratory rate–Tachypnea

• Leukocytosis –h WBC

• Fever

Interdisciplinary Care: Diagnostic Tests

• WBC c differential• Erythrocyte

sedimentation rate (ESR)

• C-reactive protein (CRP)

• Cultures

WBC c differential

• 5 leukocytes–Neurtophils–Eosinophils–Basophils–Monocytes–Lymphocytes

WBC c differential • Normal TOTAL WBC– 4,500 – 10,000 mm3

• > 10,000 mm3 – Leukocytosis = – Bacterial infection

• < 4,500 mm3 – Leukopenia = – Viral infection

WBC c\ differential Type of leukocyte (normal

value)Increased Decreased

TOTAL WBC4,500 – 10,000 mm3

Leukocytosis: acute infection, stress

Leukopenia: Anemia, viral infection

Neutrophils50-70%

Acute infection, leukemia, Viral diseases

Eosinophils1-3%

Allergies, parasitic diseases, cancer

Burns, Cushing’s syndrome

Basophils0.4 – 1%

Inflammation, leukemia Stress, hypersensitity reactions

Monocytes4 - 6%

Viral disease, parasitic diseases

Bone marrow depression

Lymphocytes25-35%

Leukemia Cancer

Erythrocyte Sedimentation Rate (ESR)

• Detects generalized inflammation• h =–Inflammation

C-reactive Protein (CRP)• Produces by the

liver during acute inflammation

• + =– inflammation

Cultures

• Used to identify bacterial infection.

Small Group Questions

1. Differentiate between acute and chronic. 2. What affect does Diabetes Mellitus have on

wound healing? 3. What are the systemic manifestations of

infection? (use medical terms AMAP)4. What will the following lab tests indicate?– WBC c/ differential; ESR; CRP; wound culture

Medications

• Antibiotics• Acetaminophen• Anti-

inflammatory agents

Antibiotics: Indications

• Treat infection caused by bacteria • Prevent infection:–Prophylactic

Antibiotics: Rule

• Culture done first!

Antibiotics: Patient Education• Teach client to

FINSH all of the antibiotics

Acetaminophen

• Is NOT an anti-inflammatory• Analgesic –i pain

• Antipyretic–i fever

Anti-inflammatory agents• When

inflammation harm anti-inflammatory drugs

• 4 classification – Salicylates–Other Non-steroidal

anti-inflammatory drugs (NSAID)–Corticosteroids–Cyclooxygenase-2

(COX-2) inhibitors

Salicylates

• Aspirin –Acetylsalicylic

Acid (ASA)

WARNING!!!• Do not give

Aspirin to kids– chickenpox’s – influenza

Aspirin WARNING!!!• Aspirin + kids• Reye’s syndrome– h intracranial

pressure–Seizures

NSAIDS

• Non-steroidal anti-inflammatory drugs• Action:

1. Anti-inflammatory2. Anti-pyretic3. Analgesic

Salicylates & NSAIDS

• S/E–GI irritation–Bleeding

Corticosteroids

• Action:–Anti-inflammatory–Anti-allergy–Anti-immunity

Corticosteroids

• Indication:–Acute hypersensitivity reactions–Chronic inflammatory diseases

Corticosteroids

• S/E–Delayed healing–Na+ & H2O

retention

Corticosteroids

• Rules:–Smallest effective

dose–Never stop abruptly• Taper the dose

Small Group Questions

1. What 3 classification of medications are used to treat a patient with inflammation?

2. Give an example by name of each classification of medication.

3. What are the indications for each medication?4. What are the actions of each type of medication?5. What are the side-effects of each medication?6. What are the Nursing Management (RULES) for

each classification of medication?

Can you fill this out?

Class Example Action Indication S/E RulesMedications used to treat inflammation

Keys to wound healing

• Healing requires–Adequate circulation–Adequate oxygenation–Adequate nutrition

Healing Nutrition

• Carbohydrates• Protein• Vitamins• Minerals

– Vitamin A• Capillary formation &

tissue growth– B-complex • Wound healing

– Vitamin C• Collagen synthesis

– Vitamin K• Blood clotting

– Zinc• Immune health

Nursing Process for Inflammation: Assessment

• Subjective Data–General health–Change in appetite– Frequent infections–Medication use (3 A’s)• Anti-inflammatory meds• Antibiotics• Acetaminophen

Nursing Process for Inflammation: Assessment

• Objective data– Vital signs• Pulse–h

• T–h

• BP–h

• R–h

–S&S–Circulation–Skin / wound–Edema –Palpate lymph

nodes–Lab values

Nrs Diagnosis: Pain

• Assess • Elevate• Enc. Rest• Distraction• Apply cold or heat (per Rx) • Give anti-inflammatory agents (per Rx)• Give mild analgesics (per Rx)

Nrs Diagnosis: Impaired Tissue Integrity

• Protect & Clean • Dressing• Enc. Rest • Enc. Movement• Enc. Well-balanced diet

Nrs. Diagnosis: Risk for infection

• Monitor vital signs–Labs

• Culture drainage• Enc. Fluids –2,500 mL per day

• Infection Control measures

Small Group Questions1. Define leukocytosis & leukopenia. How do you know if you

have it?2. Mr. Jones is prescribed an antibiotic for a thumb infection.

What would you teach him about taking his antibiotic?3. What are some of the side effects of taking corticosteroids?

What might the IDT do to decrease these risks?4. 8 year old Mary got her fingers crushed in a car door. What

would be your priority nursing diagnosis and interventions?5. Following surgery, George has a 3 inch incision on his

abdomen. What might be a priority nursing diagnosis & interventions related to this incision?

Infection

• Microorganisms –Normal Flora •Beneficial

–Infection •Growth and invasion of

microorganisms that leads to disease

Chain of Infection

1. Pathogen • Microorganism capable of causing disease

Chain of Infection

1. Pathogen • Virulence–Power of

microorganism to cause infection

• Invasiveness–Ability to get into

the body

Chain of Infection

1. Pathogen

2. Reservoir3. A portal of exit

• Reservoir–Where the

pathogen lives

• Portal of Exit–A way to get out

of the reservoir

Chain of Infection

1. Pathogen2. Reservoir3. Portal of exit from the

reservoir

4. Mode of Transmission

• Pathogens move from the reservoir host

Mode of Transmission

• Direct contact–Person to person–Contact with

inflected fluids

• Indirect contact– Infectious agent is

carried on an inanimate object or vector

Direct: Mode of Transmission• Droplet – Large, moist droplets

• Airborne– Small particles are

carried by air-currents and then inhaled

Mode of Transmission

• Vectors–Insects and animals that act an

intermediate hosts between reservoir and host

Chain of Infection

1. Pathogen2. Reservoir3. Portal of exit from the

reservoir4. Mode of Transmission

5. Portal of entry

• Entrance into host – Eyes–Mouth–Respiratory–GI–GU–Broken skin–Blood

Chain of Infection

1. Pathogen2. Reservoir3. Portal of exit from the

reservoir4. Mode of Transmission5. Portal of entry

Susceptible host

Stages of the Infectious Process

1. Initial stage • Incubation period• Pathogen is active

but no symptoms

Stages of the Infectious Process

1. Initial stage

2. Prodromal stage

• Symptoms begin to appear– Vague– General malaise– Fatigue– Fever–Muscle aches

Stages of the Infectious Process

1. Initial stage2. Prodromal stage

3. Acute stage

• Pathogens h• Obvious S&S– Fever– Chills– Tachycardia– Tachypenia

Stages of the Infectious Process

1. Initial stage2. Prodromal stage3. Acute stage

4. Convalescent stage

• Infection contained• Tissue repair• Symptoms i

Stages of the Infectious Process

1. Initial stage2. Prodromal stage3. Acute stage4. Convalescent stage

5. Resolution

• Infection totally eliminated

• No S&S

Healthcare-Associate Infection

• AKA: Nosocomial infections

Who is more likely to get a nosocomial infection?

LEFT ⏪• Acute disease

⏩ RIGHT• Chronic disease

LEFT ⏪ ⏩ RIGHTThin Obese

Who is more likely to get a nosocomial infection?

LEFT ⏪ ⏩ RIGHTFoley catheter

Incontinent

Who is more likely to get a nosocomial infection?

LEFT ⏪ ⏩ RIGHTShort-term hospital stay

Long-term hospital stay

Who is more likely to get a nosocomial infection?

LEFT ⏪ ⏩ RIGHT8 week old enfant

8 year old child

Who is more likely to get a nosocomial infection?

LEFT ⏪ ⏩ RIGHT40 year old man

90 year old woman

Who is more likely to get a nosocomial infection?

LEFT ⏪ ⏩ RIGHTCorticosteroid

Chemotherapy

Who is more likely to get a nosocomial infection?

LEFT ⏪ ⏩ RIGHTAcute disease

Chronic disease

Who is more likely to get a nosocomial infection?

LEFT ⏪ ⏩ RIGHTAcute disease

Chronic disease

Who is more likely to get a nosocomial infection?

Healthcare-associated infections• Mode of Transportation– Healthcare professionals– Visitors– Therapeutic devices

Healthcare-associated infections

• Common sites –UTI - #1–Post-op wound infections–Respiratory –Bloodstream

Healthcare-associated infections

• Most frequently pathogens– Escherichia coli– Staphylococcus aureus–Group A streptococci– Enterococcus

Resistant pathogens

• Causes– Inappropriate use of antibiotics

• Result– Resistance– Mutation

Methicillin-Resistant Staphylococcus Aureus (MRSA)

• Reservoir–Mucous membranes–Resp. Tract

• Hospital & community acquired• Isolation–Contact Precautions

Vancomycin-Resistant Enterococcus (VRE)• Reservoir–GI – Female genital tract

• Isolation–Contact Precautions

Other Resistant Strains• Penicillin-resistant

streptococcus pneumoniae

• Clostridium-difficile

• TB

Small Group Questions

1. Describe the chain of infection and how it relates to infection control.

2. What are the stages of the infectious process? What are the typical S&S in each stage?

3. What is the #1 nosocomial infection?4. How do you create a “Super-Bug”? What makes

it “super”? Give an example of a “super-bug”.5. BONUS: Can you come up with an acronym for

the stages of the infectious process?

Diagnostic Tests

• WBC – differential• Culture & Sensitivity

Culture & Sensitivity

• Culture–Collect – lab–Incubator:•24-36 hours

–Identified • via microscope

Culture & Sensitivity

• Sensitivity–Determine which antibiotics are most

effective –Duration: 24-72 hours

Medications

• Antimicrobials–Drugs able to destroy pathogens– Types• Antibiotics• Antifungal• Antiviral• Antiparasitic

Medications: Antibiotics

• Narrow-spectrum antibiotics–Act against limited number of

pathogens• Broad-spectrum antibiotics–Inhibit a wide variety of pathogens

Terms to know

• Prophylactic–Preventative

• Super-infection–A new infection due to destruction of

normal flora

Infection Control & Prevention

• Hand washing• Personal hygiene• Immunization

REMEMBER!!!

• Alcohol based hand rub is recommended by the CDC as the preferred method of hand hygiene. A soap and water wash is recommended for visibly soiled hands. Wearing gloves does not eliminate the need for hand washing.

Standard Precaution

• Do not touch– Blood – Body fluids (except sweat)– Non-intact skin– Mucous membranes

Hand washing

• After–Touching body fluids–Removing gloves–Between patients

Gloves

• When touching –Body fluids–Mucous membranes–Non-intact skin

Gown

• During procedures when contact with body fluids is anticipated.

Mask

• When body fluids are likely to splash or spray.–Suctioning–Endotracheal intubation

Equipment

• Wash hands after handling • Cleaning routine

Laundry/textiles• Cover• Don’t hug

Needles / sharps

• Do not recap• 1-handed scoop• Puncture-

resistant container

CDC Confirms Las Vegas Hepatitis Outbreak Stemmed From Needle ReuseMonday, May 19, 2008

• The CDC has confirmed that a Las Vegas hepatitis C outbreak was caused by clinic workers improperly reusing syringes and medicine vials.

• The Centers for Disease Control and Prevention was contacted by state health officials earlier this year after two people treated at the now-closed Endoscopy Center of Southern Nevada were diagnosed with hepatitis C.

• Officials have linked 84 cases of the liver disease to the clinic after notifying 50,000 patients of the clinic to be tested.

• CDC investigators said in a report to the Nevada State Health Division that during visits to the clinic, they saw employees reusing syringes to give a sedative and that interviews suggested it was common practice.

• "This was considered the most likely mode of transmission," the report said.

Patient resuscitation

• Use a barrier or bag

Respiratory hygiene (cough etiquette)

• Cover • Turn• Toss• Wash

Airborne Precaution

• Private room • Negative pressure

room• Door closed• Mask• Mask client (out of

room)

Droplet precaution

• Private room • Mask• Mask client (out of

room)

Contact Precaution

• Private room • Enter with Gloves • Change gloves after contact • Gown & gloves when giving direct care • Leave equipment in the room• Wash hands after removing gloves

Nursing Process - Infection: Assessment

Subjective• Weak• Appetite• Pain• Medication history– Antipyretics– Antimicrobials– Immunization

Objective• Vital signs• Ht & Wt• S&S• Palpate (lymphs)• Labs– WBC– C&S

How does the infectious process affect weight?

• h– Edema

• i– Appetite i

Nrs Diagnosis: Risk for infection

• Precautions• Explain isolation• Collect C&S• Administer antimicrobials

Nrs. Diagnosis: Imbalanced nutrition

• Calories– h

• Protein– h

• Liquids– h

• Appealing• i offensive odors

Nrs. Diagnosis: Ineffective thermal regulation• h fluids• I&O• Administer antipyretic (per Rx)• Cool • Clean linens

How to study for this class

1. Tonight!2. Small group question3. Flash cards4. Study groups 5. Understand not just memorize!