36 6 Infection Prevention 1. Define important words in this chapter 2. Define infection prevention and discuss types of infections 3. Discuss terms related to infection prevention 4. Describe the chain of infection 5. Explain why the elderly are at a higher risk for infection 6. Describe Centers for Disease Control and Prevention (CDC) and explain Standard Precautions 7. Define hand hygiene and identify when to wash hands 8. Discuss the use of personal protective equipment (PPE) in facilities 9. List guidelines for handling linen and equipment 10. Explain how to handle spills 11. Discuss Transmission-Based Precautions 12. Describe care of the resident in an isolation unit 13. Explain OSHA s Bloodborne Pathogen Standard 14. Discuss two important bloodborne diseases 15. Discuss MRSA, VRE, and C. Difficile Supplemental Tools transparency 6-1 the chain of infection transparency 6-2 portals of exit transparency 6-3 portals of entry transparency 6-4 airborne precautions transparency 6-5 droplet precautions transparency 6-6 contact precautions chapter 6: exam Assignments textbook reading, pp. 77-104 workbook exercises, pp. 39-44 Overview of Teaching Strategies This chapter introduces students to the concept of infection prevention. Students will learn about the infection prevention regulations established by OSHA, the CDC, and their facility (if applicable). Students will learn about the chain of infection and the techniques needed to break the chain and protect residents, staff, and visitors from infection. Students will also learn why the elderly are at greater risk for infection and the specific infection prevention practices needed to protect them. Infection prevention guidelines by the CDC and OSHA, including Standard Precautions, Transmission- Based Precautions, and the Bloodborne Pathogen Standard, should be discussed in depth. The instructor s emphasis on consistently and correctly practicing infection prevention will be the foundation for ensuring that students will follow these practices throughout their careers. The first procedures to be presented in the book are in this chapter. The instructor should demonstrate each procedure, emphasizing the importance of every step, and have students return the demonstration. Remind the students that they will be tested on these procedures before they are certified to work, and encourage them to practice them until they are comfortable and confident with them. This chapter also discusses the potential danger of bloodborne diseases to healthcare workers. Infection prevention will also be stressed as a method of preventing dangerous infections, including MRSA, VRE, and C. difficile, which are much easier to prevent than to cure.
37 1. Define important words in this chapter textbook pp. 77-79 workbook p. 39 Pronounce and define each of the key terms listed in the Learning Objective on pages 77-79. 2. Define infection prevention and discuss types of infections textbook pp. 79-81 workbook p. 39 Sanitation Infection prevention Microorganism Microbe Infection Pathogen Localized infection Systemic infection Healthcare-associated infection Drainage Infectious disease Resistance Communicable disease Contagious disease Non-communicable disease Cross-infection Reinfection Because students are being introduced to such an important topic and many key terms in this Learning Objective, it is a good time to emphasize how quality infection prevention can help prevent the spread of disease. 3. Discuss terms related to infection prevention textbook p. 81 workbook pp. 39-40 Transmission Medical asepsis Clean Contaminated Dirty Disinfection Sterilization Autoclave Surgical asepsis Discussion Emphasize the difference between disinfection and sterilization. Remind students of the importance of washing hands after touching items in the contaminated or dirty utility room. 4. Describe the chain of infection textbook pp. 82-84 workbook p. 40 Normal flora Incubation period Vaccine Immunity Direct spread Carrier Indirect spread Fomite Body fluids Direct contact Indirect contact Mucous membranes
38 Display Transparencies 6-1 the chain of infection 6-2 portals of exit 6-3 portals of entry Review the six links in the chain of infection: Causative agent Reservoir Portal of exit Mode of transmission Portal of entry Susceptible host Go over each of the portals of exit and entry as reinforcement of how pathogens can leave and enter the body. and Discussion Ask the students to think of ways (not listed in the textbook) to break each link in the chain of infection. Emphasize that only one link in the chain must be broken to stop the spread of infection. 5. Explain why the elderly are at a higher risk for infection textbook pp. 84-85 workbook p. 40 Catheter Malnourished Dehydration Explain that lack of thirst and appetite, illness or medication may cause residents to become malnourished or dehydrated. Discuss the changes of aging that cause older people to have a greater risk for infection: Hospitalized more often Recovery from illness takes longer Infections more dangerous Skin becomes less elastic, thinner and is easily torn Limited mobility Bones more brittle and more easily broken Decreased circulation and slow wound healing May require catheters or other types of tubing At risk for malnourishment and dehydration Emphasize the importance of promoting good health habits and using proper infection prevention methods to protect residents from infection. 6. Describe Centers for Disease Control and Prevention (CDC) and explain Standard Precautions textbook pp. 85-87 workbook p. 40 Centers for Disease Control and Prevention (CDC) Isolate Standard Precautions Explain Standard Precautions. Emphasize that Standard Precautions must be practiced with every resident. Review the elements of Standard Precautions: Treat blood, body fluids, non-intact skin, and mucous membranes as if they were infected. Wash hands before putting on gloves and after removing gloves. Wear gloves if there is possibility of coming into contact with blood, body fluids, secretions and excretions, broken or open skin, human tissue, or mucous membranes. Wash all skin surfaces that have been contaminated with blood and body fluids. Wear a disposable gown, mask, protective goggles, and/or a face mask when there is possibility of coming into contact with blood, body fluids, secretions and excretions, or when splashing or spraying blood or body fluids is likely. Wear gloves and use caution when handling sharps. Do not attempt to cap needles or sharps. Bag all disposable contaminated supplies.
39 Clean all surfaces that might be contaminated. Practice Standard Precautions on every resident in the NA s care. Review the additional guidelines for preventing infection in a facility: Clean cuts or breaks in skin immediately. Cover mouth and nose when coughing or sneezing. Stay as healthy as possible. Never use a resident s personal items for another resident. Never transfer personal items or equipment from one room to another. Hold equipment, personal care items, and soiled laundry and linens away from uniform. Do not use objects that have been dropped on the floor; obtain new items. Clean all equipment after use. Clean common areas. Remove food and utensils from residents rooms. Change and date water cups often. Clean toothbrushes and shaving equipment often. Never place contaminated items on overbed table. When cleaning, move from cleanest area to dirtiest area Discuss the information in the box on Respiratory/Cough Etiquette on page 87 in the textbook. Answer any questions students have. 7. Define hand hygiene and identify when to wash hands textbook pp. 87-89 workbook p. 41 Hand hygiene Hand rubs Antimicrobial Explain your facility s policy on the use of alcoholbased hand rubs. Emphasize that visibly soiled hands must be washed with soap and water. Review the times when nursing assistants must wash their hands: When arriving at work Whenever they are visibly soiled Before, between, and after all contact with residents Before putting on gloves and after removing gloves Before and after touching meal trays and/or handling food Before and after feeding residents Before entering a clean supply room Before getting clean linen Before leaving a dirty supply room Before and after you eat After contact with blood or any body fluids, mucous membranes, non-intact skin, or wound dressings After handling contaminated items After contact with any object, including medical equipment, in the resident s room After touching garbage After cleaning spills or picking up anything from the floor After using the toilet After coughing, sneezing, or blowing your nose After smoking After handling your hair or touching areas on your body, such as your nose, mouth, eyes, and face After touching jewelry After changing diapers After handling animals/pets and after contact with pet care items Before leaving work and after you get home from work before touching anything or anyone Emphasize that washing hands is the single most important thing a nursing assistant can do to prevent the spread of disease. Demonstrate procedure: Washing hands. Include all of the numbered steps in your demonstration.
40 8. Discuss the use of personal protective equipment (PPE) in facilities textbook pp. 89-94 workbook p. 41 Pronounce and define the following terms: Personal protective equipment (PPE) Don Doff Perineal care Non-intact skin List the types of PPE used in a facility: Gloves Gowns Masks Goggles Face shields Review the times when gloves must be worn: When there may be contact with blood, body fluids, open wounds, or mucous membranes When doing mouth care or care of any mucous membrane When doing perineal care When performing care on a resident who has non-intact skin When the nursing assistant has sores or cuts on her hands When shaving a resident When disposing of soiled bed linens, gowns, dressings, or pads When the NA will have direct contact with residents who require Contact Precautions When touching surfaces or equipment or handling equipment that is either visibly contaminated or may be contaminated Review the times when gloves must be changed: Before contact with mucous membranes or broken skin If gloves become wet, worn, soiled, or torn Remind students that they cannot exit the resident s room with their gloves on. Demonstrate procedure: Putting on (donning) gloves. Include all of the numbered steps in your demonstration. Discuss the times when gloves must be removed: When they have become contaminated Before touching surfaces Before caring for another resident Demonstrate procedure: Removing (doffing) gloves. Include all of the numbered steps in your demonstration. Review important information about gowns: Worn if there may be contact with blood, body fluids, secretions or excretions, tissue, or when splashing or spraying blood or body fluids is likely Gowns should fully cover torso Change gown if it becomes wet or soiled Demonstrate procedure: Putting on (donning) gown. Include all of the numbered steps in your demonstration. Review important information about masks: Worn when caring for residents who cough, sneeze, or have respiratory illness Prevent inhalation of microorganisms Should fully cover nose and mouth Must be changed if wet or soiled, and between resident care
41 Review important information about goggles: Used when blood or body fluids may be splashed or sprayed in eye area Should fit snugly over and around eyes or eyeglasses Demonstrate procedure: Putting on (donning) mask and goggles. Include all of the numbered steps in your demonstration. Review important information about face shields: Offers more protection than goggles Should cover the forehead and reach below the chin Use headband to secure on head Demonstrate procedure: Putting on (donning) and removing (doffing) the full set of PPE. Include all of the numbered steps in your demonstration. 9. List guidelines for handling linen and equipment textbook p. 94 workbook pp. 41-42 Mention that there will be specific disposal containers for linens, trash, equipment, and infectious waste. Discuss the guidelines for handling linen and equipment: Wear gloves when handling soiled linens. Check for items left inside linen. Fold or roll linen so that the dirty area is inside. Hold dirty linen away from uniform. Do not shake dirty linen or clothes. Place or dispose of linen and other equipment in the proper container. Do not touch the inside of disposal containers. Do not use re-usable equipment again until it has been properly cleaned and reprocessed. Dispose of single-use equipment properly. Wear gloves to clean and disinfect surfaces. 10. Explain how to handle spills textbook pp. 94-95 workbook p. 42 Discuss guidelines for cleaning spills: Don gloves immediately. First, absorb the spill with proper product. Scoop up the absorbed spill and dispose of it properly. Apply proper disinfectant to area. Allow it to stand wet for proper length of time. Do not pick up glass. For large spills, call the nurse. If a substance is spilled on the body, wash area immediately and follow exposure incident guidelines. Wash hands after cleaning spills. 11. Discuss Transmission-Based Precautions textbook pp. 95-97 workbook p. 42 Display Transparency 6-4 airborne precautions Explain that Airborne Precautions prevent the spread of pathogens that travel for a distance after being expelled. Tuberculosis is an airborne disease. Review Airborne Precautions: Follow all Standard Precautions. Resident will be in airborne infection isolation room (AIIR).
42 Keep doors and windows closed. Do not open or close door quickly. Wear special mask during resident care. Resident will wear mask when leaving room. Display Transparency 6-5 droplet precautions Explain that Droplet Precautions are used for diseases that are spread by droplets in the air that normally do not travel further than three feet, although they may travel further (CDC recommends droplet distance be increased to six feet for influenza). The mumps is a droplet disease. Review Droplet Precautions: Follow all Standard Precautions. Wear a mask during resident care. Residents will wear mask when leaving room and must observe Respiratory/Cough Etiquette. Cover nose and mouth when sneezing or coughing. Dispose of the tissue in a no-touch receptacle. Visits from uninfected people will be restricted. Pull the privacy curtain between beds of any residents in the same room. Display Transparency 6-6 contact precautions Explain that Contact Precautions are used when a resident may spread an infection by direct contact with another person or object. Conjunctivitis and Clostridium difficile (C. diff) are contact diseases. Review Contact Precautions: Follow all Standard Precautions. Wear proper PPE. While still in room, wash hands with antimicrobial soap after removing gloves. Put on a gown before entering a resident s room. Do not share resident s equipment with other residents. Do not share residents towels, bedding, or clothing with other residents. Resident will be placed in a private room. Emphasize that Transmission-Based Precautions are always used in addition to Standard Precautions. 12. Describe care of the resident in an isolation unit textbook pp. 97-98 workbook pp. 42-43 Review the guidelines for residents in isolation: Spend as much time with resident as possible. Apply proper PPE before entering the isolation room. Clean and disinfect equipment properly. Dispose of trash and disposable equipment in proper containers. Dispose of waste containing blood, body fluids, or sharps in biohazard containers. Bag used linen or equipment so that contaminated items do not touch outside of bag. Disinfect furniture and surfaces regularly. Assist visitors with putting on PPE as needed. Make sure TV, telephone, and radio are working. Encourage disposable reading material. Place call light within resident s reach. Explain steps for setting up an isolation unit: Wash hands and put on gloves. Adjust bed to proper height. Put away supplies. Leave clean pajamas in easy reach. Make sure equipment, doors, and windows in room are in working order. Check bathroom supplies and notify the nurse or proper department if supplies need to be refilled. If anything is damaged or is not working properly, tell the nurse. Remind students that Residents Rights must be protected when residents are in isolation.
43 13. Explain OSHA s Bloodborne Pathogen Standard textbook pp. 98-100 workbook p. 43 Pronounce and define the following terms: Bloodborne pathogens Occupational Safety and Health Administration (OSHA) Bloodborne Pathogen Standard Exposure control plan Exposure incident Review significant exposures: Needle stick Mucous membrane contact Cut from object containing potentially infectious body fluids Non-intact skin, including acne Discuss the steps taken after an exposure incident: Immediately follow facility policy regarding spill, splash, or cut. Report exposure incident to supervisor. Fill out exposure report form. Go to employer s health service department for any needed tests. Optional Activity Show students a copy of your facility s exposure control plan, if available. Make copies of exposure report forms and distribute to students. Have them practice filling out the form so they become familiar with it. 14. Discuss two important bloodborne diseases textbook pp. 100-101 workbook pp. 43-44 Discuss important information about HIV and AIDS: AIDS is caused by human immunodeficiency virus (HIV). HIV damages the immune system over time so that the body cannot fight infection. The stage of the disease when tumors and central nervous system symptoms appear is known as AIDS. People with AIDS can die from illnesses that a person with a healthy immune system could fight. HIV is transmitted by blood, infected needles, from mother to fetus, or sexual contact. Pronounce and define the following term: Hepatitis Review the different viruses that can cause hepatitis: Hepatitis A (HAV) Hepatitis B (HBV) Hepatitis C (HCV) Hepatitis D (HDV) Hepatitis E (HEV) Emphasize that HBV is a serious threat to healthcare workers. Review precautions to take to avoid being infected on the job: Use proper PPE. Handle needles and other sharps carefully. Dispose of sharps properly in biohazard container. A free HBV vaccine will be offered by the NA s employer. 15. Discuss MRSA, VRE, and C. Difficile textbook pp. 101-103 workbook p. 44 Multidrug-resistant organisms MRSA infection VRE Clostridium difficile (C. diff, C. difficile)
44 Review important information about MRSA: Often acquired in healthcare facilities Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is a type of MRSA infection that occurs in people who have not been in healthcare facilities and who have no past diagnosis of MRSA Spread by direct contact with infected person or indirect contact through contaminated objects Symptoms include drainage, fever, chills, and redness Handwashing is best way to control it Review important information about VRE: Very difficult to treat and may require several medications Spread through direct or indirect contact Symptoms include fever, fatigue, chills, and drainage Much easier to prevent than to get rid of Proper hand hygiene can help prevent the spread Discuss guidelines for caring for residents with MRSA or VRE: Help residents remain as active and social as possible. Assist residents to maintain good hygiene. Wash hands after contact with MRSA or VRE. After handwashing, discard paper towels immediately. Wear gloves when contact with body fluids may occur. Wash linen when soiled. Keep resident s room clean. Alert other caregivers to take proper precautions. Attend in-services about infection prevention. Review important information about C. difficile: May flourish in intestinal tract when normal flora is altered Enemas, nasogastric tube insertion, and GI tract surgery increase risk May cause colitis or sepsis Spread by spores in feces that are difficult to kill Alcohol-based hand sanitizers are not effective; soap and water must be used for hand hygiene Symptoms include foul-smelling watery stools, fever, diarrhea that contains blood and mucus, nausea, lack of appetite, and abdominal cramps Report symptoms immediately Chapter Review Exam distribute chapter 6: exam (appendix c, pp. 300-302) Allow students enough time to finish the test. See Appendix D for answers to the chapter exams. Answers to Chapter Review in Textbook 1. Infection prevention is the set of methods used to control and prevent the spread of disease. 2. Infections are caused by pathogens, which are harmful microorganisms. For infections to develop, pathogens must invade and grow within the human body. 3. A localized infection is limited to a specific part of the body; a systemic infection occurs when pathogens enter the bloodstream and move throughout the body. 4. A communicable disease is an infectious disease that is transmitted by direct contact with the infected person or his secretions, or indirectly, by touching objects contaminated by the infected person. A non-communicable disease is a disease not capable of being spread from one person to another. 5. An object can be called clean if it has not been contaminated with pathogens. An object that is dirty has been contaminated with pathogens. 6. Disinfection means that only pathogens are destroyed; sterilization means all microorganisms are destroyed, including those that form spores. 7. Surgical asepsis makes an object or area sterile, or completely free of all microorganisms. 8. Answers include: Link 1: Causative agent vaccines; Link 2: Reservoir keeping surfaces clean and dry; Link 3: Portal of exit covering
45 the mouth when sneezing; Link 4: Mode of transmission handwashing; Link 5: Portal of entry wearing gloves; Link 6: Susceptible host staying healthy and protecting the elderly and ill from pathogens 9. Mucous membranes are the membranes that line body cavities that open to the outside of the body. 10. Answers include: Multiple changes of aging tend to make the elderly more susceptible to infections. Elderly people are hospitalized more often, which increases their chances of getting healthcare-associated infections and other infections. When the elderly get sick, recovery may take longer and the infections themselves may be more dangerous. Skin becomes thinner, which makes it easier to tear. When fragile skin tears, pathogens can enter the body. Both thinner skin and limited mobility increase the risk of pressure ulcers and skin infections. Bones become more brittle and can break more easily. Decreased circulation and slow wound healing also contribute to infections in the elderly. Catheters and other types of tubing can greatly increase the risk of infections. Older adults are at risk for dehydration and malnutrition. When cells do not get proper nutrients and fluids, the chance of infection greatly increases. 11. Tears, saliva, sputum, urine, feces, semen, vaginal secretions, pus or other wound drainage, and vomit 12. With every resident in your care 13. Gloves must be worn if you may come into contact with with blood, body fluids, secretions and excretions, broken or open skin, human tissue, or mucous membranes. 14. Hand hygiene is washing hands with either plain or antiseptic soap and water or using alcohol-based hand rubs. 15. Artificial nails harbor bacteria, even if you wash your hands often. 16. Answers include: when you first arrive at work; whenever they are visibly soiled; before, between, and after all contact with residents; before putting on gloves and after removing gloves; before and after touching meal trays and/or handling food; before and after feeding residents; before entering a clean supply room; before getting clean linen; before leaving a dirty supply room; before and after you eat; after contact with blood or any body fluids, mucous membranes, non-intact skin, or wound dressings; after handling contaminated items; after contact with any object, including medical equipment, in the resident s room; after touching garbage; after cleaning spills or picking up anything from the floor; after using the toilet; after coughing, sneezing, or blowing your nose; after smoking; after handling your hair or touching areas on your body, such as your nose, mouth, eyes, and face; after touching jewelry; after changing diapers; after handling animals/pets and after contact with pet care items; before leaving work and after you get home from work before touching anything or anyone 17. Answers include: when you may come into contact with blood or any body fluids, open wounds, or mucous membranes; when performing or helping with mouth care or care of any mucous membrane; when performing or helping with perineal care; when performing care on a resident who has non-intact skin; when you have any open sores or cuts on your hands; when shaving a resident; when disposing of soiled bed linens, gowns, dressings, and pads; when you will have direct contact with residents who require Contact Precautions; when touching surfaces or equipment or handling equipment that is either visibly contaminated or may be contaminated 18. Wear a gown if you may come into contact with blood, body fluids, secretions or excretions, tissue, or when splashing or spraying blood or body fluids is likely. 19. Masks should be worn when caring for residents who cough, sneeze or have respiratory illnesses. Goggles are used whenever blood or body fluids may be splashed or sprayed into your eye area or your eyes. 20. PPE should be applied in this order: gown, mask or respirator, goggles or face shield, gloves; PPE should be removed in this order: gloves, goggles or face shield, gown, mask or respirator.
46 21. Hold and carry dirty linen away from your uniform. 22. Do not use re-usable equipment again until it has been properly cleaned and reprocessed. 23. No 24. Airborne Precautions prevent the spread of pathogens that travel through the air for a distance after being expelled. Droplet Precautions are used for diseases that are spread by droplets in the air. Contact Precautions are used when a resident may spread an infection by direct contact with another person or object. 25. Answers include: Spend as much time with the resident as possible. Listen to the resident. Encourage him or her to talk about feelings and concerns. Reassure the resident that it is the disease, not the person, that is being isolated. Explain why these special steps are being taken. Apply proper PPE before entering the isolation room. Clean and disinfect all equipment properly. Follow facility policy on equipment that belongs to staff and does not stay in the room. Dispose of trash in proper containers. Dispose of waste containing blood or body fluids and sharps in biohazard containers. Bag used linen and equipment so that the contaminated items do not touch the outside of the bag. Disinfect all furniture and surfaces regularly. Assist visitors with putting on gowns and masks as needed. Before you leave the room, make sure the TV, telephone, and radio are in working order. Encourage reading material that can be disposed of, such as magazines and newspapers. Make sure the resident has access to eyeglasses, if needed. Always place the call light within the resident s reach when leaving the isolation room. 26. These pathogens are transmitted by infected blood entering the bloodstream, or if infected semen or vaginal secretions contact mucous membranes. Sharing infected drug needles is another way to spread bloodborne diseases. Infected pregnant women may transmit bloodborne diseases to their babies. In health care professions, contact with infections blood or body fluids is the most common way to get a bloodborne disease. Infections may be spread by accidental contact with contaminated blood or body fluids, skin, needles or other sharp objects, or contaminated supplies or equipment. 27. Answers include: Give in-service training on the risks from bloodborne pathogens and updates on any new safety standards. Have an exposure control plan that outlines what to do if an employee accidentally becomes exposed to any infectious waste. All employees must be trained on the exposure control plan and know where to find it. Give all employees, visitors, and residents proper PPE to wear when needed. Place biohazard containers in each resident s room and, in other areas in the facility. Biohazard bags must be sealed tightly before leaving the resident s room and then be taken to the proper area. Provide a free hepatitis B vaccine. 28. Hepatitis is inflammation of the liver caused by certain viruses and other factors, such as alcohol abuse, some medications, and trauma. 29. HIV damages the immune system so that over time, the body cannot fight infections. 30. HBV is spread through sexual contact, by sharing infected needles, from a mother to her baby during delivery, through improperly sterilized needles used for tattoos and piercings, and through grooming supplies, such as razors, nail clippers, and toothbrushes. It is also spread by exposure at work from accidental contact with a used, infected needle or other sharp instrument, or from splashing blood. 31. By proper hand hygiene 32. Answers include: proper handwashing with soap and water and handling of contaminated wastes; additional Transmission-Based Precautions; cleaning surfaces with an appropriate disinfectant; and limiting the use of antibiotics