Medical A sepsis, Dr. walaa elleithy, 2023.pdf

Medical A sepsis
Dr. Walaa El- Leithey
PhD Medical Surgical Nursing
Alexandria University
Technical Institute of Nursing
Mansoura University

learning objectives
• Describe microorganisms.
• Name the six components of the chain
of infection.
• Cite examples of biologic defense
mechanisms.
• Define nosocomial infection.
• Discuss the concept of asepsis.
• Differentiate between medical and
surgical asepsis.
• Identify at least three principles of
medical asepsis
• !List five examples of medical
aseptic practices.
• Name at least three techniques for
sterilizing equipment.
• List at least three nursing activities
that require application of the
principles of surgical asepsis.
Technical Institute of
Nursing.Mansoura University

Microorganisms
living animals or plants visible only with a microscope, are commonly called germs.
What they lack in size, they make up for in numbers. Microorganisms are
everywhere: in the air, soil, and water, and on and within virtually everything and
everyone.
• Once microorganisms invade, one of three events occurs:
the body’s immune defense mechanisms eliminate them,
they reside within the body without causing disease, or
they cause an infection or infectious disease.
Factors that influence whether an infection develops:
 the type and number of microorganisms,
 the characteristics of the microorganism (such as its virulence), and
 the person’s state of health (immunity). Technical Institute of

Types of Microorganisms
Microorganisms are divided into two main groups:
• nonpathogens or normal flora (harmless, beneficial
microorganisms) and
• pathogens (microorganisms that cause illness).
• Pathogens: also called contagious diseases and community acquired
infections. E.g. of communicable diseases are measles, streptococcal sore
throat, sexually transmitted infections, and tuberculosis (TB).

Bacteria
• Bacteria are single-celled microorganisms. They appear in various shapes:
round (cocci), rod shaped (bacilli), and spiral (spirochetes)
• Aerobic bacteria require oxygen to live, whereas
• anaerobic bacteria exist without oxygen.

Viruses
• visible only with an electron microscope. They
are filterable, Viruses are unique because they
do not possess all the genetic information
necessary to reproduce; they require metabolic
and reproductive materials from other living
species. An example is the herpes simplex
virus, which can cause cold sores (fever
blisters) to flare up years
• after an initial infection. Some viral infections, such as the common cold,
are minor and self-limited—that is, they terminate with or without
medical treatment. Others, such as rabies, poliomyelitis, hepatitis, and
AIDS, are more serious or fatal.

Fungi ‫فطريات‬
• Fungi include yeasts and molds. Only a few types of fungi produce
infectious diseases in humans. The three types of fungal (mycotic)
infections
• Superficial fungal infections affect the skin, mucous membranes, hair,
and nails. Examples include tinea corporis (ringworm), tinea pedis
(athlete’s foot), and candidiasis (a vaginal yeast infection).
• Intermediate fungal infections affect subcutaneous tissues such as fungal
granuloma (an inflammatory lesion under the skin).
• Systemic fungi infect deep tissues and organs such as histoplasmosis in
the lungs.

Rickettsiae ‫والفيروس‬ ‫البكتيريا‬ ‫تشبة‬
• Rickettsiae resemble bacteria; like viruses, however, they cannot survive outside
another living species. Consequently an intermediate life form, such as fleas, ticks,
lice, or mites, transmits rickettsial diseases to humans.
• Protozoans ‫طفيليات‬
• Protozoans are single-celled animals classified according to their ability to move.
Some use ameboid motion, by which they extend their cell walls and their
intracellular contents flow forward. Others move by cilia, hairlike projections, or
flagella, whiplike appendages. Some cannot move independently at all.
• Mycoplasmass ‫تشبة‬
‫البكتيريا‬
• Mycoplasmas lack a cell wall; they assume various shapes. Primarily they infect
the surface linings of the respiratory, genitourinary, and gastrointestinal tracts.

‫ديدان‬
Helminths
Helminths are infectious worms, They are classified into three major groups:
nematodes (roundworms), cestodes (tapeworms), and trematodes (flukes). Some
helminths enter the body in the egg stage, whereas others spend the larval
stage in an intermediate life form before finding their way into humans.

Chain of infection
• By interfering with the conditions of the
transmission of microorganisms,
• humans can avoid acquiring infectious
diseases.
• The six essential components of the chain of
infection.
• 1. An infectious agent
• 2. A reservoir for growth and reproduction
• 3. An exit route from the reservoir
• 4. A mode of transmission
• 5. A port of entry
• 6. A susceptible host
1

1- Infectious Agents
• Some microorganisms are less dangerous than others. Just as some animal species
coexist symbiotically (for mutual benefit), some normal flora help to maintain
healthy functioning.
• For example,
intestinal bacteria help produce vitamin K, which, in turn, helps control bleeding.
Vaginal bacteria create an acid environment hostile to the growth of pathogens.
Unless the supporting host becomes weakened, normal flora remain controlled. If the
host’s defenses are weakened,
benign microorganisms can cause opportunistic infections
infections result from pathogens that by their very nature produce illness after
invading body tissues and organs.

2- Reservoir
• uncooked and unrefrigerated food. They are present in intestinal excreta and
the earth’s organic material.
• “silent reservoir” is asymptomatic clients who harbor pathogens, especially
those resistant to antimicrobial agents—the most dangerous type of all.
3- Exit Route
• how microorganisms escape from their original reservoir and move about.
When present in or on humans, they are displaced by handling or touching
objects or whenever blood, body fluids, secretions, and excretions are
released.
• In the environment, factors such as flooding and soil erosion provide
mechanisms for escape

4-Mode of Transmission
• how infectious microorganisms move to another location.
• most microorganisms cannot travel independently. Microorganisms are
transmitted by one of five routes:
1. contact,
2. droplet,
3. airborne,
4. Vehicle
5. vector

ROUTE DESCRIPTION EXAMPLE
Direct
contact
from one infected person to another Sexual intercourse with an
infected person
Indirect
contact
Contact between a susceptible
person and a contaminated object
Use of a contaminated surgical
instrument
Droplet
transmission
Transfer of moist particles from an
infected person who is within a
radius of 3 feet
Inhalation of droplets released
during sneezing, coughing, or
talking
Airborne
transmission
microorganisms attached to
evaporated water droplets or dust
particles that have been suspended
and carried over distances greater
than 3 feet
Vehicle
transmission
Transfer of microorganisms present
on or in contaminated items such as
food, water, medications, devices,
and equipment
Consumption of water
contaminated with
microorganisms
Vector
transmission
Transfer of microorganisms from an
infected animal carrier
Diseases spread by
mosquitoes, fleas, ticks, or rats

5-Port of Entry
• One of the most common ports of entry is an opening in the skin or mucous
membranes, inhaled, swallowed, introduced into the blood, or transferred into body
tissues or cavities through unclean hands or contaminated medical equipment.
• biologic defense mechanisms often prevent them from producing infection
• The two types of biologic defense mechanisms (mechanical and chemical).
• Mechanical defense mechanisms: physical barriers that prevent microorganisms from
entering the body or expel them before they multiply. Examples include intact skin
and mucous membranes; reflexes such as sneezing and coughing; and infection-
fighting blood cells called phagocytes or macrophages.
• Chemical defense mechanisms: destroy microorganisms. For example, lysozyme,
an enzyme found in tears and other secretions, can dissolve the cell wall of some
microorganisms. Gastric acid creates an inhospitable microbial environment.
• Antibodies, complex proteins also called immunoglobulins, form when macrophages
consume microorganisms and display their distinct cellular markers.

6- Susceptible Host
• Humans become susceptible to infections when their defense mechanisms are
diminished or impaired. A susceptible host, the last link in the chain of infection,
is one whose biologic defense mechanisms are weakened in some way.
Particularly susceptible clients include those who
• • Are burn victims
• • Have suffered major trauma
• • Require invasive procedures such as endoscopy
• • Need indwelling equipment such as a urinary catheter
• • Receive implantable devices such as intravenous catheters
• • Are given antibiotics inappropriately, which promotes microbial resistance
• • Are receiving anticancer drugs and anti-inflammatory drugs such as
corticosteroids that suppress the immune system
• • Are infected with HIV

Factors Affecting Susceptibility to Infections
• " Inadequate nutrition
• " Poor hygiene practices
• " Suppressed immune system
• " Chronic illness
• " Insufficient white blood cells
• " Prematurity
• " Advanced age
• " Compromised skin integrity
• " Weakened cough reflex
• " Diminished blood circulation

Causes of Antibiotic Drug Resistance
• " Prescribing antibiotics for minor or self-limited bacterial infections
• " Administering antibiotics prophylactically (for prevention) in the
absence of an infection
• " Failing to take the full course of antibiotic therapy
• " Taking someone else’s prescribed antibiotic without knowing whether
it is effective for one’s illness or symptoms
• " Prescribing antibiotics for viral infections (antibiotics are ineffective
for treating infections caused by viruses).
• Dispersing antibiotic solutions into the environment

Causes of Antibiotic Drug Resistance Cont.’
Dispersing antibiotic solutions into the environment:
• " depositing partially empty IV bags containing antibiotic drugs in waste
containers
• " releasing droplets while purging IV tubing attached to secondary bags of
antibiotic solution
• " expelling air from syringes before injecting antibiotics
• " Administering antibiotics to livestock, leaving traces of drug residue that humans
consume after their slaughter
• " Spreading nosocomial pathogens via unwashed or poorly washed hands

Causes of Antibiotic Drug Resistance Cont’
Another example of adaptation is the development of antibiotic-resistant
bacterial strains of Staphylococcus aureus, Enterococcus faecalis and
faecium, and Streptococcus pneumoniae. Such strains no longer respond to
drugs that once were effective against them.

Stop • Think + Respond
Use the chain of infection to trace the transmission of a
common cold from one person to another.
How to break the chain?

Definitions
• Infection: An infection is an invasion of the body by pathogens, or
microorganism capable of producing disease.
• Asepsis: Is a freedom from disease- causing microorganisms. To decrease the
possibility of transferring microorganisms from one place to another, there are two
basic types of asepsis; medical asepsis and surgical asepsis.
• Medical asepsis: (clean technique)
includes procedures used to reduce the number of microorganisms and prevent their
spread. Include; Hand washing, Standard precautions, Transmission based precautions. E.g. of
medical asepsis are changing client’s bed linen daily, barrier techniques, & routine
environmental cleaning.
In medical asepsis, an area or object is considered contaminated only if it is suspected of
containing pathogen (e.g., used bedpan, the floor & a wet piece of gauze).

Surgical asepsis or (sterile technique): includes procedures used to
eliminated microorganisms from an area. Sterilization destroys all microorganisms
including spores & viruses.

Definitions
• Nosocomial infection: Are classified as infections that are associated with delivery
of health care services in a health care facility. Nosocomial infections either develop
during a client's stay in a facility or manifested after discharge.
• Cleaning: cleanliness inhibits the growth of microorganisms. It is the removal of
all foreign materials such as soil & organic material from objects. Generally,
cleansing involves use of water & mechanical action with or without detergents.
• Disposable object has to be discarded.
• Reusable objects must be cleansed thoroughly before disinfection & sterilization.
When cleaning equipment that is soiled by organic material such as blood, fecal matter,
mucus or pus, the nurse applies a mask, protective eyewear, & waterproof gloves. These
barriers provide protection from infectious organisms. A brush, detergent or soap are needed
for cleaning

Definitions
• Disinfecting: a chemical preparation. Such as phenol or iodine
compounds, used on inanimate object.
• Disinfection: process of eliminating pathogenic organisms on
inanimate object with the exception of spores.
• Sterilizing: Is the process that destroyed all microorganisms, including
spores and viruses.

Methods of sterilization
• 1. Moist heat (Autoclave supply steam under pressure121to 123C for 29 min).
• 2. Gas (ethylene oxide).
• 3. Boiling water, the water temp rises no higher than 100C for 15 min.
• 4. Radiation; both ionizing and no ionizing radiation such as
ultraviolet light type of non-ionizing radiation.

Purposes of medical asepsis
• 1- To prevent cross infection on hospital environment
• 2- To control infection
• 3- To ensure patient's comfort, safety and psychological well being
Types of infection
• 1. Local or systematic;
local is limited to the specific part of the body where the microorganism remains. If
systemic microorganisms spread and damage different parts of the body.
2. Acute or Chronic infections:
Acute: appear suddenly or last a short time.
A chronic infection may occur slowly, over long period, and May last month or years
•

Course of infection:
• An infection progresses through the different phases which include:
• 1- Incubation period: is interval between the invasion of the body by the
• pathogen or into the body and the appearance of the first symptoms of the
• infection, e.g.; chickenpox 2-3 weeks,
common cold 1-2 days,
tetanus 2 to 21 days.
• 2- Prodromal stage: is most infectious during this stage. It is an internal
from onset of nonspecific signs and symptoms (malaise, low grade fever, fatigue)
to more specific symptoms. During this time, microorganisms grow and multiply
and client is more capable of spreading disease to others.

Course of infection:
• 3- Full stage of illness: full stage of illness is an interval of the presence of
specific signs and symptoms indicates the full stage of illness. The type of
infection determines the length of illness and severity of manifestations.
• 4- Convalescent period: represents recovery from infection. It is an interval
when acute symptoms of infection disappear and the person returns to healthy
state-length of recovery depends on severity of infection and clients general state
of health; recovery may take several days to months.

Defenses against infection
• The body has normal defenses against infection. Normal body flora that reside
inside and outside of the body protect a person from several pathogens. Each
organ system has defense mechanism that minimize exposure to infectious
microorganism as follow:
• 1. Skin:
In skin intact multilayered surface is a body's first line of defense against infection,
that is, it provides barrier to microorganisms. The shading of outer layer of skin all
removes organism that adhere to skin outer layers. The sebum contains fatty acid that
kills some bacteria. These factor that may alter defense are cut abrasions, puncture
wounds, area of laceration; failure to bathe regularly and excessive bathing
reduces sebum.

2. Mouth:
• Intact multilayered mucosa of mouth provides mechanical barrier to
microorganisms. Saliva produces in the mouth, washes away particles containing
microorganism and it contain microbial inhibitor, e.g.: lysozyme, factors that alter
defense are lacerations, trauma, extracted teeth, poor oral hygiene, dehydration.
• 3. Respiratory tract:
• Cilia lining upper airway, coated by mucous will trap inhaled microbes and
sweep them outward in mucous to be expectorated or swallowed macrophages of
respiratory tract engulf and destroy microorganisms that reach lungs alveoli. The
factors that may alter defense here are smoking, high concentration of oxygen
and carbon dioxide, decreased humidity, cold air, etc.

• 4. Urinary tract:
• The flushing action of urine flow washes away microorganism on lining of
bladder and urethra. Multilayered epitheliums of the tract provide barrier
to microorganism. The factors which may alter defense here are obstruction
to normal flow by any means.
• 5. Gastrointestinal tract.
• Here the facility of the gastric secretions chemically destroys
microorganism's incapable of surviving low PH. The rapid peristalsis in
small intestine prevents retention of bacterial content.

6. Vagina:
• At puberty, normal flora causing vaginal secretion to achieve low PH, which inhibits
growth of many microorganisms. Antibiotics and oral contraceptives disrupting
normal flora, which alter defense.
• 7. The immune system:
• Composed of separate cells and molecules resistance to disease. the factors which
affecting immunological defense mechanism are as follow:
• a. Increasing age
• b. Stress
• c. Poor nutrition
• d. Inherited condition
• e. Type of disease process
• f. Environmental. Technical Institute of

Body’s Defenses Against Infection:
• The human body fights infection on three levels:
A.Primary defenses: involve body systems or parts of body systems that resist or
confine invading pathogens.
B. Secondary defenses: are physiological responses to toxins produced by
invading pathogens.
C.Tertiary defenses: are immune responses that react to the presence of an
antigen and precipitate protective mechanisms or act directly against
antigenic cells.
• Nurses must not only understand the way in which this three-level defense
system helps to protect the body from infection but also the types of immunity,
the role of immunizations (vaccines) that produce immunity to communicable
diseases, and nursing care specific to these issues.

A. Primary Defenses
1. Skin and mucous membranes: Mucous membranes produce mucus that traps
microorganisms.
2. Respiratory system: Cilia capture and move microorganisms out of
3. the respiratory tract
4. Gastrointestinal (GI) system: Saliva contains microbial inhibitors, such as lysozymes and
immunoglobulin A (IgA). Low pH (acetic) of stomach and high pH of small intestine
create inhospitable environments for microorganisms. Goblet cells lining the GI system
produce secretions that prevent penetration by microorganisms and destroy (lyse) the
cell walls of microorganisms. Peristalsis moves microorganisms out of the anus.
• Circulatory system: Blood carries components of the inflammatory response (e.g.,
fibrinogen; thromboplastin; platelets; and white blood cells [WBCs], including
neutrophils and monocytes).

A. Primary Defenses
• Circulatory system: Blood carries components of the inflammatory response (e.g.,
fibrinogen; thromboplastin; platelets; and white blood cells [WBCs], including
neutrophils and monocytes). Blood
5. carries components of the immune response (e.g., immunoglobulins, T cells,
and antibodies).
6. Eyes: Tears and blinking flush microorganisms out of the eyes. Tears
contain lysozymes that destroy microorganisms.
a. Genitourinary system: The vagina has a low pH that creates an inhospitable
environment for microorganisms. The low pH of urine and flushing action of
urination limits microbial growth.

B. Secondary Defenses
1. Fever: Products of pathogenic microorganisms (pyrogens) stimulate production of
prostaglandins that reset the body’s temperature thermostat in the hypothalamus to a
higher level. An elevated temperature facilitates some immune reactions and inhibits the
action of pathogens.
2. Complement cascade. Proteins in the blood trigger chemicals that destroy pathogens by
rupturing their cell membranes.
3. Inflammatory response: Local adaptation syndrome (LAS). A cellular response to
irritation, injury, or infection attempts to neutralize pathogens and repair body tissues.
• NB.
• Infection is always accompanied by the inflammatory response, but the inflammatory
response can occur without the presence of infection.

C. Tertiary Defenses
• 1. Immune response: Body’s reaction to and interaction with substances
identified by the body as being foreign. Humoral immunity reacts to the
presence of an antigen (e.g., toxins, foreign substances, or particulates, such
as bacteria, viruses, and proteins originating from within the body).
Cellular immunity T cells attack and destroy cells infected with
pathogens.

2. Types of immunity:
A.Active immunity: Antibodies are formed within the body.
1. Natural-active immunity: Antibodies are formed during the course of the
disease. Usually produces life-long immunity, such as to measles.
2. Acquired-active immunity: Antigen (e.g., vaccine or toxoid) is administered
to stimulate the formation of antibodies. Usually produces life-long immunity
or requires revaccination to maintain titers.

2. Types of immunity:
B.Passive immunity: Antibodies are acquired from a source other than the
individual’s body.
(1)Natural-passive immunity: Passage of antibodies occurs from a mother
to a fetus via the placenta or to a neonate via colostrum. Provides
immunity for 6 months to 1 year.
(2)Acquired-passive immunity: Antibodies produced from another source
(immune serum) are injected into a person. Provides immunity for 2 to 3
weeks.
(3) Immunizations (vaccines):Administration of a specific substance
that precipitates the immune system to produce antibodies (antigen) that protect
an individual from a specific disease.

Nursing Care to Interrupt the Chain of Infection:
• Microorganisms are transmitted when the chain of infection progresses without
interruption. However, the transmission of microorganisms can be prevented if
the chain is broken by practices performed by nurses, other healthcare
providers, and patients. Each link of the chain of infection necessitates specific
interventions to prevent transmission of an infectious agent.
• A. Infectious Agent (Microorganism)
1. Use soap and water or disinfectant to decrease microorganisms on the
skin.
2. Teach patients to:
a. Avoid taking antibiotics unless absolutely necessary to prevent antibiotic resistant
mutations and super infections.
b. Complete the full course of prescribed antibiotics to avoid resistance.
c. Not share antibiotics with others.

• B. Reservoir (Source):
1.Ensure potentially contaminated surfaces, such as sinks, toilets, and
over bed tables, are regularly cleaned.
2.Change bed linens regularly or whenever contaminated.
3.Use medical asepsis, such as fluid impervious garbage bags and
linen hampers, and avoid touching sinks and toilets in public
restrooms.
4.Clean and change water in covered water jugs every 8 hours.
5.Empty suction and drainage bottles at regular intervals (e.g., every
8 hours, end of each shift).
6.Teach patients to: a. Store food in a cool environment. b. Regularly
clean surfaces where food is prepared. c. Regularly perform hand
hygiene, particularly before and after handling food.

• C. Portal of Exit
1.Maintain the integrity of closed systems, such as urinary catheters,
portable wound drainage systems, and wound dressings.
2.Limit talking when performing sterile procedures, such as dressing
changes.
Teach patients to:
• a. Cough and sneeze into an elbow or upper arm.
• b. Formula feed infants if mother is HIV positive because breast milk may
contain the HIV

Nursing Care to Interrupt the Chain of Infection
• D. Mode of Transmission:
 Maintain isolation precautions, including standard- and
transmission-based precautions.
 Wash hands in sinks with foot pedals, keep hands above the level of
the sink; if faucet has handles, shut off faucets with a clean, dry
paper towel.
 Perform hand hygiene after touching contaminated articles.
 Keep fingernails short and avoid wearing artificial nails, fingernail
polish, and jewelry with stones.
 Wear clean gloves when potential exposure to blood or body fluids
exists.

 Use additional PPE, such as a mask, a face shield, a fluid
impervious gown, and gloves, when there is potential for splashing
of body fluids or if a patient is receiving transmission based
precautions.
 When removing soiled linen, fold the linen into itself.
 Put contaminated linen in a fluid impervious hamper.
 Provide fluid impervious bags at the bedside for disposal of used
tissues.
 Keep all items off the floor and off closet floors.
 Routinely disinfect items that act as fomites, such as stethoscopes,
clamps, eyeglasses, pens, and telephones.
 Place needles and needleless systems into puncture proof containers
(sharps containers).

 Dispose of urine and feces in appropriate receptacles, such as a
patient’s toilet.
 Ensure the patient’s immediate area is kept clean, including
overbed tables.
 Arrange for the area to be disinfected between patients.
 Clean spills immediately.
 Teach patients to:
o Use insect repellent and wear long-sleeve shirts and long pants when in areas
where insect-causing diseases are endemic.
o Dispose of used tissues into a fluid impervious bag.
o Use a sharps container for used puncture devices associated with self-blood
glucose monitoring or needles and syringes for injection of medication.

• E. Portal of Entry:
1. Use sterile technique when performing invasive procedures, such as injections, urinary
catheterizations, dressing changes, and catheter irrigations.
2. Ensure all drainage tubes and drainage containers are kept below the insertion site.
3. Change dressings as soon as they become moist.
4. Provide or encourage perineal care with soap and water daily and when necessary, such
as after toileting.
5. Teach patients to: a. Perform perineal care after toileting and to wash the genital area
with soap and water daily. b. Maintain medical or surgical asepsis concerning tubes that
enter the body (e.g., urinary catheter, portable wound drainage systems) and procedures
that must be performed (e.g., dressing changes, injections).

F. Susceptible Host:
• 1. Implement protective environmental precautions when the
patient is immune-compromised.
• 2. Ensure the patient has received all age-appropriate
immunizations.
• a. Provide a vaccine information statement, including the
safety, benefits, and risks concerning immunizations.
• b. Correct misconceptions regarding immunizations.
• c. Teach the parents potential adverse effects and appropriate
interventions (e.g., prescribed dose of acetaminophen to
minimize discomfort).

F. Susceptible Host:
d. Do not administer live virus vaccines (e.g., measles, mumps, and rubella [MMR] and
varicella [chickenpox]) to a person with a depressed immune system or a temperature within
the last 24 hours or a person who lives in a home with very young children, received another
vaccination within the last month, or had an allergic reaction to the vaccination in the past.
3. Teach patients to follow a healthy lifestyle as:
a. Avoid tobacco-related habits.
b. Eat a healthy diet.
c. Drink adequate fluids daily (e.g., 2 to 3 L/day).
d. Cough and deep breathe hourly when at an increased risk for stasis of respiratory
secretions (e.g., when sedentary or on bed rest, after receiving anesthesia).
• e. Maintain the integrity of the skin and mucous membranes, such as by bathing, using
moisturizing lotions, performing oral care, and alternating positions.

MCQ

Medical A sepsis, Dr. walaa elleithy, 2023.pdf

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