procedures basic to nursing

1. Procedures Basic to
Nursing Care
1. Asepsis and Infection
Control

2.  Asepsis is the freedom from
disease-causing microorganisms.
 Medical asepsis includes all
practices intended to confine a
specific microorganism to a
specific area, limiting the
number, growth, and transmission
of microorganisms.
 Surgical asepsis, or sterile
technique, refers to those
practices that keep an area or
object free of all
microorganisms; it includes
practices that destroy all
microorganisms and spores
(microscopic dormant structures
formed by some pathogens that are
very hardy and often survive
common cleaning techniques).
 Sepsis is the condition in which
are normal resident
flora (the
collective
vegetation in a
given area) in one
part of the body
yet produce
infection in
another.
growth of
microorganisms in
body tissue where
they are not
usually found. Such
a microorganism is
called an
infectious agent.
If the
microorganism
produces no
clinical evidence
of disease, the
infection is called
asymptomatic or
subclinical.
Disease is a
detectable
alteration in
normal tissue
function,
however, is
called disease.
Virulence is the
microorganism’s
ability to
produce disease.
Communicable disease
is the resulting
condition wherein the
infectious agent can
be transmitted to an
individual by direct
or indirect contact
or as an airborne
infection.
Pathogenicity is
the ability to
produce disease;
thus, a pathogen is
a microorganism
that causes
disease.
Opportunistic
pathogen causes
disease only in
a susceptible
individual.

3.  Septicemia – When bacteremia
results in systemic infection.
 Acute infections generally appear
suddenly or last a short time.
 Chronic infection may occur slowly,
over a very long period, and may
last months or years.
NOSOCOMIAL AND HEALTHCARE-ASSOCIATED
INFECTIONS
 Nosocomial infections are
classified as infections that
originate in the hospital.
 Nosocomial infections are a
subgroup of healthcare-associated
infections (HAIs)—those that
originate in any healthcare
setting.
 The microorganisms that cause
nosocomial infections can originate
from the clients themselves (an
endogenous source) or from the
TYPES OF MICROORGANISMS THAT CAUSE
INFECTIONS
FOUR MAJOR CATEGORIES:
•Bacteria are by far the most common infection-
causing microorganisms.
•Viruses consist primarily of nucleic acid and
therefore must enter living cells in order to
reproduce.
•Fungi include yeasts and molds.
•Parasites live on other living organisms.
Colonization is the process by which
strains of microorganisms become resident
flora.
TYPES OF INFECTIONS:
•Local infection is limited to the specific part of
the body where the microorganisms remain.
•Systemic infection - the microorganisms spread and
damage different parts of the body, the infection.
•Bacteremia – the condition when a culture of the

4. Emerging infectious diseases:
 Newly identified diseases caused by an
unrecognized microorganism (e.g., the virus
causing AIDS was unknown before 1980) or a known
organism (e.g., enterovirus D68, Streptococcus
infection causing toxic shock syndrome)
 Diseases occurring in new geographic areas
(e.g., 2014 ebola pandemic originating from
western Africa, West Nile virus in the Western
hemisphere) or settings, such as Clostridium
difficile, which was primarily a hospital-
acquired infection and now occurs in the
community
 Microorganisms in animals that extend their host
range to begin infecting humans (e.g., avian
influenza, or “bird flu”; and the H1N1 virus).
 Microbes that evolve to become more virulent
(e.g., a strain of Escherichia coli, which now
causes severe illness)
 Known diseases that dramatically increase in
incidence (e.g., mumps and pertussis, also known
as whooping cough)
Stages of Infection
• Incubation period
• Prodromal stage
• Full stage of illness
• Convalescent period
Why Should Nurses Be Aware of Emerging Pathogens and
Diseases?
• An epidemic is an
outbreak of a disease
that suddenly affects a
large group of people in
a geographic region
(e.g., a city or state)
or in a defined
population group (e.g.,
children, healthcare
workers).
• A pandemic is an
exceptionally widespread
epidemic—that is, one
that affects a large
number of people in an
entire country or
worldwide.

5.  Methicillin-resistant Staphylococcus
aureus (MRSA)
 Vancomycin-Resistant Enterococci
 Clostridium difficile
Example Problem: Drug-Resistant Pathogens
• Some microorganisms, mostly bacteria, have mutated
to develop resistance to one or more classes of
antimicrobial drugs.
• These organisms are said to be drug-resistant or
multidrug-resistant.
A variety of risk factors are associated
with MDRO infections Among them are the
following:
• Severe illness
• Previous exposure to antimicrobial agents (e.g.,
antibiotics)
• Underlying diseases or conditions that make it
difficult for the person to fight infection (in
particular, chronic renal disease, insulin-
dependent diabetes mellitus, peripheral vascular
disease, dermatitis, skin lesions)
• Invasive procedures and devices, such as dialysis,
urinary catheterization, and intravenous lines
• Repeated contact with the healthcare system,
especially acute care facilities, and especially
intensive care units (where infection rates tend to
be highest)
• Advanced age

8. Method of Transmission
1. Contact
 Direct transmission
 Indirect transmission
a. Vehicle-borne transmission
b. Vector-borne transmission
2. Airborne
3. Droplet
4. Vector
5. vehicle
Promoting Wellness to Support
Host Defenses
 Efforts to promote wellness help
break the chain of infection by
strengthening a person’s defenses
against invading pathogens.
o Nutrition
o Hygiene
o Rest and Sleep
o Exercise and Activity
o Stress Reduction
o Immunizations

9. • Some of the most common factors are:
• Developmental Stage
• Breaks in the First Line of Defense
• Illness or Injury
• Tobacco Use
• Substance Abuse
• Multiple Sexual Partners
• Environmental Factors
• Chronic Disease
• Medications
• Invasive Nursing and Medical Procedures
WHAT FACTORS INCREASE HOST
SUSCEPTIBILITY?

10. Secondary Defenses
 Phagocytosis—the process by which
phagocytes (specialized white blood
cells [WBCs]) engulf and destroy
pathogens directly is called
phagocytosis.
 The complement cascade—a process by
which a set of blood proteins,
called complement, triggers the
release of chemicals that attack
the cell membranes of pathogens,
causing them to rupture.
 Inflammation—a process that begins
when histamine and other chemicals
are released either from damaged
cells or from basophils being
activated by complement.
 Fever—a rise in core body
temperature that increases
metabolism, inhibits the
multiplication of pathogens and
triggers specific immune responses
The human body has three
“lines of defense” against
infectious disease:
• Primary defenses—Certain
anatomical features limit the
entry of pathogens.
• Secondary defenses—Protective
biochemical processes fight
pathogens that do enter.
• Tertiary defenses—The presence
of pathogens activates immune
responses against specific,
recognized invaders.
Other primary defenses
are as follows:
• Skin
• Respiratory tree
• Eyes
• Mouth
• Gastrointestinal Tract
• Genitourinary

11. Four types of T cells play a
role in fighting infection):
■ Cytotoxic (killer) T cells directly
attack and kill body cells infected
with pathogens.
■ Helper T cells play a supportive role
in cell-mediated responses by secreting
interleukin, which attracts infection-
fighting white blood cells.
■ Memory T cells. The first time an
antigen invades the body, T cells form
that respond to that specific antigen.
With subsequent infections, the memory
T cells are able to increase the speed
and amount of the T-cell response.
■ Suppressor T cells are thought to
stop the immune response when the
infection has been contained.
Humoral Immunity
• The humoral immune response (or
antibody-mediated response) protects
the body by circulating antibodies
to fight against pathogens.
The body’s defense system acts by
producing specialized white blood
cells (leukocytes) to seek out and
destroy invaders by any of the
following methods:
• Phagocytosis
• Neutralization
• Agglutination
• Activation of complement and
inflammation
Cellular Immunity
• Cellular (cell-mediated) immune
response acts directly to destroy
pathogens (i.e., viruses, fungi,
protozoans, cancers) without using
antibodies but rather activating
phagocytes and T and B cells.

12. A. Nonspecific Defenses
 anatomic and physiological barriers
 inflammatory response
FIVE SIGNS OF INFLAMMATION:
1. Pain (dolor)
2. Swelling (tumor)
3. Redness (rubor)
4. Heat (calor)
5. Impaired function of the injury
Three stages of the inflammatory
response:
 First stage: vascular and cellular
responses
 Second stage: exudate production
 Third stage: reparative phase
B. Specific Defenses
 Specific defenses of the body
involve the immune system.
 An antigen is a substance that
induces a state of sensitivity or
immune responsiveness (immunity).
The immune response has two
components:
 antibody-mediated defenses
 cell-mediated defenses
The types of immunity are:
 Natural active
 Natural Passive
 Artificial active
 Artificial passive
Five classes of immunoglobulins :
 IgM
 IgG
 IgA
 IgD
 IgE
There are three main groups of T
cells:
(1)helper T cells, which help in the
functions of the immune system
(2)cytotoxic T cells, which attack and
kill microorganisms and sometimes
the body’s own cells

17. ●◯● NURSING MANAGEMENT
 Assessing
o Nursing History
o Physical assessment
 Analysis/Nursing Diagnosis
 Planning outcomes/evaluation
 Planning intervention/implementation
Nursing History
 To elicit information related to infection, ask the
client about the following:
o Any exposure to pathogens in the environment,
including at work, recent or international travel,
contact with people who are ill, and unprotected
sexual behavior
o If the patient is febrile ask, “Have you recently
traveled outside the country?”
o Any unusual foods or products ingested
o Past and present disease or injury history
o Medications, over-the-counter preparations, herbal
products, alcohol intake, and any substances currently
in use

18. Laboratory Data
 Laboratory data that indicate
the presence of an infection
include the following:
o Elevated leukocyte (white
blood cell or WBC) count
(4,500 to 11,000/mL3 is
normal).
o Increases in specific types
of leukocytes as revealed in
the differential WBC count.
Specific types of white
blood cells are increased or
decreased in certain
infections.
o Elevated erythrocyte
sedimentation rate (ESR).
Red blood cells normally
settle slowly, but the rate
increases in the presence of
an inflammatory process.
o Urine, blood, sputum, or
• Signs and symptoms of an
infection vary according to the
body area involved.
• Commonly the skin and mucous
membranes are involved in a
local infectious process,
resulting in the following:
• Localized swelling
• Localized redness
• Pain or tenderness with
palpation or movement
• Palpable heat at the infected
area
• Loss of function of the body
part affected, depending on
the site and extent of
involvement
Physical
Assessment
• Fever
• Increased pulse and
respiratory rate if the
fever is high
• Malaise and loss of energy
• Anorexia and, in some
situations, nausea and
vomiting
• Enlargement and tenderness
of lymph nodes that drain
the area of infection.
Signs of
systemic
infection
include
the
following:

21. risk factors:
• Inadequate primary defenses such as broken
skin, traumatized tissue, decreased ciliary
action, stasis of body fluids, change in pH of
secretions, or altered peristalsis.
• Inadequate secondary defenses such as
leukopenia, immunosuppression, decreased
hemoglobin, or suppressed inflammatory
response.
•Examples of nursing diagnoses or collaborative
problems that may arise from the actual presence
of infection include the following:
• Potential Complication of Infection: Fever
• Imbalanced Nutrition: Less Than Body
Requirements if the client is too ill to eat
adequately
• Acute Pain if the client is experiencing tissue
damage and discomfort
• Impaired Social Interaction or Social Isolation
if the client is required to be separated from
others during a contagious episode
• Anxiety if the client is apprehensive regarding
changes in life activities resulting from the
infection or its treatment such as absence from
work or inability to perform usual functions.
Diagnosing
• The major goals for clients susceptible to
infection are to:
•Maintain or restore defenses.
•Avoid the spread of infectious organisms.
•Reduce or alleviate problems associated with the
Planning

22. PLANNING
INTERVENTIONS/
IMPLEMENTATION
Direct nursing care toward these concerns, and provide the
following broad interventions:
• Reduce exposure to pathogens through the use of aseptic
techniques (discussed shortly).
• Maintain skin integrity and support natural defenses against
infection.
• Reduce stress.
• Promote immune function through collaborative care.
• Provide supportive measures to decrease the length of time that
invasive devices, such as intravenous lines and urinary
catheters, are needed by a patient.
Specific nursing activities will be based on the unique situation
of the client, as described in the etiology of the diagnostic
statement. For example:
• For clients who have had surgery and general anesthesia or who
are at risk for pneumonia, promote coughing and deep breathing
on a regular basis.
• For clients being mechanically ventilated, provide special oral
care designed to prevent ventilator-associated pneumonia. (See
the accompanying QSEN box for an example.)
• For older adults, especially those who or frail or in a
debilitated state and those living in a group residence,
encourage immunizations that can help them acquire immunity from
some communicable diseases, such as influenza.
• Healthcare workers can also benefit from immunizations to
protect them from HAIs.
• Community health nurses can limit disease transmission through
surveillance of the community, tracking of disease patterns, and
initiation of prompt treatment.
• For clients who have breaks in the skin or incision sites,
provide regular assessment for infection status and follow

23. Other preventive nursing activities are:
 Provide client teaching
 supporting host defenses
 practicing medical and surgical asepsis

25. Other preventive nursing
activities are discussed in the
following sections:
 Provide client teaching
 supporting host defenses
 practicing medical and surgical
asepsis
• Cleaning
o Cleaning is the removal of visible
soil (organic and inorganic) from
objects and surfaces. It normally
is accomplished manually or
mechanically using water with
detergents or enzymatic products.
• Disinfecting
o Disinfection removes virtually all
pathogens on inanimate objects by
physical or chemical means,
including steam, gas, chemicals,
and ultraviolet light.
Three levels of disinfection:
o High-level disinfection
Disinfection is used for:
o semicritical items = are those
that contact mucous membranes or
nonintact skin
o noncritical items = are supplies
and equipment that come in
contact with intact skin but not
mucous membranes.
• Sterilizing
o Sterilization is a process that
destroys all microorganisms,
including spores and viruses.
o Four commonly used methods of
sterilization are:
 moist heat
 Gas
 boiling water
 Radiation
o Critical items are ones that
pose a high risk for infection
if they are contaminated with
any microorganism.

29. When disinfecting
articles, nurses need to
follow agency protocol
and consider the
following:
1. The type and number of
infectious organisms. Some
microorganisms are readily
destroyed, whereas others
require longer contact
with the disinfectant.
2. The recommended
concentration of the
disinfectant and the
duration of contact.
3. The presence of soap.
Some disinfectants are
ineffective in the
presence of soap or
detergent.
4. The presence of organic
Disinfecting
and
Sterilizing
The first links in the chain of
infection, the etiologic agent and the
reservoir are interrupted by the use of
antiseptics (agents that inhibit the
growth of some microorganisms) and
disinfectants (agents that destroy
pathogens other than spores) and by
sterilization.
Supporting
Defenses of a
Susceptible
Host
Susceptibility is the degree to
which an individual can be
affected, that is, the likelihood
of an organism causing an
infection in that person.
The following measures can reduce
a person’s susceptibility:
•Hygiene
•Nutrition
•Fluid
•Sleep
•Stress
•Immunizations

31.  Disease-specific isolation
precautions
o Airborne precautions
o Droplet precautions
o Contact precautions
Compromised Clients
 Have diseases, such as leukemia, or
treatments such as chemotherapy,
that depress the client’s
resistance to infectious organisms.
 Have extensive skin impairments,
such as severe dermatitis or major
burns, which cannot be effectively
covered with dressings.
Isolation Practices
 Initiation of practices to prevent
the transmission of microorganisms
is generally a nursing
Infection Prevention and Control
The isolation guidelines contain a two-tiered approach:
• standard precautions (SP)/universal
precautions (UP)
• Transmission-Based Precautions
Isolation refers to measures designed to prevent the spread
of infections or potentially infectious microorganisms to
health personnel, clients, and visitors.
Several sets of guidelines have been used in hospitals and
other healthcare settings:
Category-specific isolation precautions use seven categories:
• strict isolation
• contact isolation
• respiratory isolation
• tuberculosis isolation
• enteric precautions
• drainage/secretions precaution
• blood/ body fluid precautions

33. Addition To The Precautions:
 Use strict aseptic technique when
performing any invasive procedure
(e.g., inserting an intravenous
needle or catheter) and when
changing surgical dressings.
 Change intravenous tubing and
solution containers according to
hospital policy (e.g., every 48 to
72 hours).
 Check all sterile supplies for
expiration date and intact
packaging.
 Prevent urinary infections by
maintaining a closed urinary
drainage system with a downhill flow
of urine. Keep the drainage bag and
spout off the floor.
 Implement measures to prevent
impaired skin integrity and to
prevent accumulation of secretions
in the lungs (for example, encourage

34. Personal Protective Equipment
 All healthcare providers must apply
PPE
• clean or sterile gloves
• Gowns
• Mask
• protective eyewear

36. • Double-bagging if the above
conditions are not met.
• Follow agency protocol, or use the
following CDC guidelines to handle
and bag soiled items:
o Place garbage and soiled
disposable equipment, including
dressings and tissues, in the
plastic bag that lines the waste
container and ties the bag.
o Place nondisposable or reusable
equipment that is visibly soiled
in a labeled bag before removing
it from the client’s room or
cubicle and send it to a central
processing area for
decontamination.
o Disassemble special procedure
trays into component parts. Some
components are disposable; others
need to be sent to the laundry or
Disposal of Soiled Equipment and Supplies
• Appropriate handling of soiled equipment
and supplies is essential for these
reasons:
•To prevent inadvertent exposure of
health care workers to articles
contaminated with body substances
•To prevent contamination of the
environment.
Bagging
• Articles contaminated, or likely to have
been contaminated, with infective
material such as pus, blood, body
fluids, feces, or respiratory secretions
need to be enclosed in a sturdy bag
impervious to microorganisms before they
are removed from the room of any client.
CDC guidelines recommend the following
methods:
• A single bag, if it is sturdy and
impervious to microorganisms, and if the
contaminated articles can be placed in
the bag without soiling or contaminating
its outside.

37. Transporting Clients
with Infections
 Avoid transporting
clients with infections
outside their own rooms
unless absolutely
necessary.
Psychosocial Needs of
Isolation Clients
 Clients requiring
isolation precautions
can develop several
problems as a result of
the separation from
others and of the
special precautions
taken in their care.
 Two of the most common
are:
o sensory deprivation
o decreased self-esteem
Linens Handle soiled linen as little as possible and
with the least agitation possible before
placing it in the laundry hamper.
Laboratory
Specimens
Laboratory specimens, if placed in a
leakproof container with a secure lid with a
biohazard label, need no special precautions.
Dishes Dishes require no special precautions.
Blood
Pressure
Equipment
Blood pressure equipment needs no special
precautions unless it becomes contaminated
with infectious material.
Thermometers Nondisposable thermometers are generally
disinfected after each use. Check agency
policy.
Disposable
Needles,
Syringes,
and Sharps
Place needles, syringes, and “sharps” (e.g.,
lancets, scalpels, and broken glass) into a
puncture-resistant container.

38. Sterile Technique
 An object is sterile only
when it is free of all
microorganisms. It is well
known that sterile
technique is practiced in
operating rooms and special
diagnostic areas.
Sterile Gloves
 Sterile gloves may be
applied by:
• the open method
• the closed method.
Sterile Gowns
 Sterile gowning and closed
gloving are chiefly carried
out in operating or
delivery rooms, where
surgical asepsis is
Nurses need to provide care that
prevents these two problems or that
deals with them positively. Nursing
interventions include the following:
• Assess the individual’s need for
stimulation.
• Initiate measures to help meet the need,
including regular communication with the
client and diversionary activities, such
as toys for a child, and telephone,
books, television, computer, or radio for
an adult; provide a variety of foods to
stimulate the client’s sense of taste;
stimulate the client’s visual sense by
providing a view or an activity to watch.
• Explain the infection and the associated
procedures to help clients and their
support persons understand and accept the
situation.
• Demonstrate warm, accepting behavior.
Avoid conveying to the client any sense
of annoyance about the precautions or any
feelings of revulsion about the
infection.

41. Evaluating
 Using data collected during care—
vital signs, lung sounds, skin
status, characteristics of urine or
other drainage, laboratory blood
values, and so on—the nurse judges
whether client outcomes have been
achieved.
 If outcomes have not been
achieved, the nurse may need
to consider questions such as
the following:
• Were appropriate measures
implemented to prevent skin
breakdown and lung infection?
• Was a strict aseptic technique
implemented for invasive
procedures? • Are prescribed
medications affecting the immune
system?
Role of
the
Infection
Prevention
Nurse
All healthcare organizations
must have interdisciplinary
infection prevention
committees.
Infection
Prevention
for Health
Care
Workers
Occupational exposure is defined
as skin, eye, mucous membrane,
or parenteral contact with blood
or other potentially infectious
materials that may result from
the performance of an employee’s
duties.
There are three major modes of
transmission of infectious
materials in the clinical
setting
• Puncture wounds from
contaminated needles or other
sharps
• Skin contact, which allows
infectious fluids to enter
through wounds and broken or
damaged skin
• Mucous membrane contact, which
allows infectious fluids to
enter through mucous membranes
of the eyes, mouth, or nose.

44. 1.The client is a chronic carrier of infection. To prevent the spread of
the infection to other clients or health care providers, the nurse
emphasizes interventions that do which of the following?
A. Eliminate the reservoir.
B. Block the portal of exit from the reservoir.
C. Block the portal of entry into the host.
D. Decrease the susceptibility of the host.
2. Which is the most effective nursing action for preventing and controlling
the spread of infection?
A. Thorough hand hygiene
B. Wearing gloves and masks when providing direct client care
C. Implementing appropriate isolation precautions
D. Administering broad-spectrum prophylactic antibiotics
3. In caring for a client on contact precautions for a draining infected
foot ulcer, which action should the nurse perform?
A. Wear a mask during dressing changes.
B. Provide disposable meal trays and silverware.
C. Follow standard precautions in all interactions with the client.
D. Use surgical aseptic technique for all direct contact with the client.
4. When caring for a single client during one shift, it is appropriate for
the nurse to reuse only which of the following personal protective
equipment?

45. 5. While applying sterile gloves (open method), the cuff of the first
glove rolls under itself about 0.5 cm (1/4 in.). What is the best
action for the nurse to take?
A. Remove the glove and start over with a new pair.
B. Wait until the second glove is in place and then unroll the cuff
with the other sterile hand.
C. Ask a colleague to assist by unrolling the cuff.
D. Leave the cuff rolled under.
6. The nurse evaluates the chart of a 65-year-old client with no apparent
risk factors and concludes that which immunizations are current. Select
all that apply.
A. Last tetanus booster was at age 50
B. Receives a flu shot every year
C. Has not received the hepatitis B vaccine
D. Has not received the hepatitis A vaccine
E. Has not received the herpes zoster vaccine
7. A client with poor nutrition enters the hospital for treatment of a
puncture wound. An appropriate nursing diagnosis would be
_____________.
8. After teaching a client and family strategies to prevent infection
prevention, which statement by the client would indicate effective
learning has occurred?

46. 9.Which of the numbered areas is considered sterile on a person in the
operating room? You may assume that all articles were sterile when
applied.
10.The nurse determines that a field remains sterile if which of the
following conditions exist?
A. ps of wet forceps are held upward when held in ungloved hands.
B. The field was set up 1 hour before the procedure.
C. Sterile items are 2 inches from the edge of the field.
D. The nurse reaches over the field rather than around the edges.