Infection Control in Nursing

Microorganisms exist everywhere: in water, in soil, and on body

surfaces such as the skin, intestinal tract, and other areas open to the
outside such as our mouth, upper respiratory tract, vagina, and lower
urinary tract. Many organisms are harmless, others are lethal, and some
are a normal part of our body. As such, the ones directly involved in
providing a biologically safe environment are none other than the
nurses.

What is Infection?
Infection is the growth of microorganisms in body tissue where they are not
usually found.

 Disease- A detectable alteration in normal tissue

function is called disease.
 Virulence- Microorganisms vary in their virulence or their
ability to produce disease, the severity of the
diseases they produce, and their degree of
communicability.
 Infectious agent- such a microorganism is called
an infectious agent, or the source, a germ, a virus or
other microbes.
 Medical asepsis- includes all practices intended to
confine a specific microorganism to a specific area,
limiting the number, growth, and transmission of
microorganisms.
 Pathogenicity- is the ability to produce disease; thus, a
pathogen is a microorganism that causes disease.
 Asepsis- is the freedom from disease causing
microorganism; aseptic technique is used to decrease
the possibility of transferring microorganisms from one
place to another.
 Sepsis-is the condition in which acute organ dysfunction
occurs secondary to infection.
  Surgical asepsis- or sterile technique refers to those
practices that keep an area or an object free of all
microorganisms; it includes practices that destroy
microorganisms and spores.

Types of Microorganisms
Four major categories of microorganisms cause infection in humans:
bacteria, viruses, fungi, and parasites.

 Parasites-Parasites live on other living organisms; they

include protozoa such as the one that causes malaria,
helminths (worms), and arthropods (mites, fleas,
ticks).
 Viruses- Viruses consist primarily of nucleic acid and
therefore must enter living cells in order to
reproduce; common virus families
include rhinoviruses (causes the common
cold), hepatitis, herpes, and human immunodeficiency
virus.
 Bacteria- are by far the most common infection-causing
microorganisms; several hundred species can cause
disease in humans and can live and be transported
through air, water, food, soil, body tissues and
fluids, and inanimate objects.
 Fungi-Fungi include yeast and molds; Candida albicans is
yeast considered to be normal flora in the human
vagina.
Types of Infection
Infection occurs when newly introduced or resident microorganisms succeed
in invading a part of the body where the host’s defense mechanisms are
ineffective and the pathogen causes tissue damage.

 Local infection-A local infection is limited to a specific

part of the body where the microorganisms remain.
 Systemic infection-If the microorganisms spread and damage
different parts of the body, the infection is a
systemic infection.
 Acute infection- generally appears suddenly or last a short
time.
 Chronic infection- may occur slowly, over a very long
period, and May last months or years.
 Bacteremia-When a culture of a person’s blood reveals
microorganisms, the condition is called bacteremia.
 Septicemia-When bacteremia results in systemic infection,
it is referred to as septicemia, which has become
common over time.

Nosocomial and Health-related

Infections
Nosocomial infections are classified as infections that originate in the
hospital, and are a subgroup of health care associated infections or HAIs.

 Bloodstream- The most common bloodstream microorganisms

include coagulase-negative staphylococci (inadequate
hand hygiene), Staphylococcus
aureus and Enterococcus species (improper intravenous
fluid, tubing, and site care technique).
  Pneumonia- The most common causative microorganisms
for pneumonia include Staphylococcus aureus (inadequate
hand hygiene), Pseudomonas
aeruginosa and Enterobacter species (improper
suctioning technique).
 Urinary tract- The most common microorganisms in the
urinary tract include Escherichia
coli (improper catheterization technique), Enterococcus
species (contamination of closed drainage system),
and Pseudomonas aeruginosa (inadequate hand hygiene).
 Surgical sites- The most common microorganisms in surgical
sites include Staphylococcus
aureus including MRSA (inadequate hand
hygiene), Enterococcus species including vancomycin-
resistant strains (improper dressing change technique),
and Pseudomonas aeruginosa.

Chain of Infection
 Reservoir-Reservoirs are sources of microorganisms;
common sources are other humans, the client’s own
microorganisms, plants, animals, or the general
environment; a carrier is a person or animal reservoir
of a specific infectious agent that usually does not
manifest any clinical signs of the disease.
 Etiologic agent- The extent to which any microorganism is
capable of producing an infectious process depends on
the number of microorganisms present, the virulence and
potency of the microorganisms, the ability of the
microorganisms to enter the body, the susceptibility of
the host, and the ability of the microorganisms to live
in the host’s body.
 Portal of exit from reservoir- Before an infection can establish
itself in a host, the microorganisms must leave the
reservoir; common human reservoirs include respiratory
tract, GI tract, urinary tract, reproductive tract,
blood, and tissues.
  Method of transmission-After a microorganism leaves its
source or reservoir, it requires a means of
transmission to reach another person or host through a
receptive portal of entry; there are three
mechanisms: direct transmission, which involves
immediate and direct transfer of microorganisms from
person to person through touching, biting, kissing, or
sexual intercourse; indirect transmission may be
either vehicle-borne (any substance that serves as an
immediate means to transport and introduce an
infectious agent into a susceptible host through a
suitable portal of entry) or vector-borne (an animal or
flying or crawling insect that serves as an
intermediate means of transporting an infectious
agent); airborne transmission may involve droplets or
dust such as a droplet nuclei (the residue of
evaporated droplets emitted by infectious host such as
someone with tuberculosis, can remain in the air for
long periods
 Portal of entry to susceptible hosts-Before a person can become
infected, microorganisms must enter the body; often,
microorganisms enter the body of the host by the same
route they used to leave the source.
 Susceptible host- A susceptible host is any person who is
at risk for infection; a compromised host is a person
at increased risk, an individual who for one or more
reasons is more likely than others to acquire an
infection.

Defenses against Infection

Individuals have defenses that protect the body from infection; they are
categorized as specific and nonspecific defenses.
Nonspecific Defenses
Nonspecific defenses protect the person against all microorganisms, regardless of prior
exposure; they include anatomic and physiologic barriers and the inflammatory response.
Anatomic and Physiologic Barriers
 The entrance to the urethra normally harbors many
microorganisms; urine flow has a flushing and
bacteriostatic action that keeps the bacteria from
ascending the urethra; an intact mucosal surface also
acts as a barrier.
 The flow of saliva and its partial buffering action
help prevent infections; saliva contains microbial
inhibitors, such as lactoferrin, lysozyme, and seethe
nasal passages have a defensive function: moist mucous
membranes and cilia trap microorganisms, dust, and
foreign materials. Secretory IgA.
 The eye is protected from infection by tears, which
continually wash microorganisms away and contain
inhibiting lysozyme.
 The high acidity of the stomach normally prevents
microbial growth.
 Intact skin and the mucous membranes are the body’s
first line of defense against microorganisms.
 The resident flora of the large intestine helps prevent
the establishment of disease-producing microorganisms.
 When a girl reaches puberty, lactobacillus ferment
sugars in the vaginal secretions, creating a vaginal pH
of 3.5 to 4.5; this low pH inhibits the growth of many
disease-producing microorganisms.
 The lungs have alveolar macrophages (large phagocytes);
phagocytes are cells that ingest microorganisms, dead
cells, and foreign particles.
 The oral cavity regularly sheds mucosal epithelium to
rid the mouth of colonizers.
 Peristalsis also tends to move microbes out of the
body.
Inflammatory Response
Inflammation is a local and nonspecific defensive response of the tissue to
an injurious or infectious agent; it is an adaptive mechanism that destroys or
dilutes the injurious agent, prevents further spread of the injury, and
promotes the repair of damaged tissue.

 First stage: Vascular and cellular responses-There is

constriction of blood vessels, dilatation of small
vessels, increased vessel permeability, increased
leukocytes, swelling, and pain; leukocytes begin to
engulf the infection.
 Second stage: Exudate production-This stage is characterized
by exudation with fluids and dead cells; serous (clear,
part of the blood), purulent (thick, pus with
leukocytes), and sanguineous (bloody).
 Third stage: Reparative phase-The repair of tissues;
examples are regeneration (same tissues), stroma
(connective tissues), parenchyma (functional part), and
fibrous (scar).

Specific Defenses
Specific defenses of the body involve the immune system; the immune’s
response has two components: antibody-mediated defenses and cellular-
mediated defenses.

Nursing Management
Nursing management for infection control includes the following:

 History-During the nursing history, the nurse assesses

(a) the degree to which the client is at risk of
developing an infection and (b) any client complaints
suggesting the presence of an infection.
 Physical exam- Signs and symptoms of an infection vary
according to the body area involved; for example,
sneezing, watery or mucoid discharge from the nose, and
 nasal stuffiness commonly occur with an infection of
the nose and sinuses; urinary frequency and cloudy or
discolored urine often occur with a urinary infection.
 Laboratory data- Laboratory data that indicate the
presence of an infection include the following:
elevated leukocyte count, increases in specific types
of leukocytes as revealed in the differential WBC
count, elevated erythrocyte sedimentation rate, urine,
blood, sputum, or other drainage cultures that indicate
the presence of pathogenic microorganisms.

Nursing Diagnosis
Based on the assessment data, the most appropriate nursing diagnosis are:

 Impaired social interaction or social isolation.

 Potential complication of infection: fever.
 Imbalanced nutrition: less than body requirements.
 Anxiety.
 Acute pain.

Nursing Care Planning and Goals

The major goals are:

 Maintain or restore defenses.

 Reduce or alleviate problems associated with the
infection.
 Avoid the spread of infectious organisms.
Implementation
The nurse prevents strategies to prevent infection.

 Preventing nosocomial infections- Meticulous use of medical

and surgical asepsis is necessary to prevent the
transport of potentially infectious microorganisms.

 Hand hygiene- It is important for both the nurses’ and

the clients’ hands to be cleansed at the following
times to prevent the spread of microorganisms: before
eating, after using the bedpan or toilet, and after the
hands have come in contact with anybody substances; for
routine client care, vigorous hand washing under a
stream of water for 15 to 20 seconds using granular
soap, soap-filled sheets, or liquid soap at the
beginning of the nurses’ shift, when hands are visibly
soiled, and after using the toilet, is recommended.

 Immunizations- The use of immunizations has dramatically

decreased the incidence of infectious diseases; it is
recommended that immunizations begin shortly after
birth and be completed in early childhood except for
boosters.

 Disinfecting- The first links in the chain of infection,

the etiologic agent and the reservoir, are interrupted
with the use of antiseptics (agents that inhibit the
growth of some microorganisms)
and disinfectants (agents that destroy pathogens other
than spores) and by sterilization; both antiseptics and
disinfectants are said to have bactericidal or
bacteriostatic properties; a bactericidal preparation
destroys bacteria, whereas a bacteriostatic preparation
prevents the growth and reproduction of some bacteria.
 Sterilization- Sterilization is a process that destroys all
microorganisms, including spores and viruses; four
commonly used methods of sterilization are: moist
heat (to sterilize with moist heat, steam under
pressure is used because it attains temperatures higher
than the boiling point); gas (ethylene oxide gas
destroys microorganisms by interfering with their
metabolic processes); boiling water (this is the most
practical and inexpensive method for sterilizing in the
home); and radiation (both ionizing and non-ionizing
are used for disinfection and sterilization.

 Nutrition- A balanced diet enhances the health of all body

tissues, helps keep the skin intact, and promotes the
skin’s ability to repel microorganisms; adequate
nutrition enables tissues to maintain and rebuild
themselves and helps keep the immune system functioning
well.

 Fluid- Fluid intake permits fluid output that flushes out

the bladder and urethra, removing microorganisms that
can cause an infection.

 Sleep- Adequate sleep is essential to health and to

renewing energy.

 Stress- Excessive stress predisposes people to

infections; nurses can assist clients to learn stress-
reducing techniques.
Infection Prevention and Control
Because it is not always possible to know which clients may have infectious
organisms, a set of guidelines has been established by the CDC and other
organizations outlining steps all healthcare workers must follow to reduce
the chances that organisms in blood and potentially infectious organisms
from other body tissues will be transmitted from the client to other
individuals.

Standard Precautions
Standard precautions are used in the care of all hospitalized individuals
regardless of their diagnosis and possible infection status.

 Wear clean gloves when touching blood, body fluids,

secretions, excretions, and contaminated items.
 Handle all soiled linen as little as possible.
 Place used needles and other “sharps” directly into
puncture-resistant containers as soon as their use is
completed.
 Wear a mask, eye protection, or face shield if splashes
or sprays of blood, body fluids, secretions, or
excretions can be expected.
 Wear a clean, non-sterile, water-resistant gown if
client care is likely to result in splashes or sprays
of blood, body fluids, secretions, or excretions; the
gown is intended to protect clothing.
 Designed for all clients in the hospital.
 These precautions apply to (a) blood; (b) all body
fluids, excretions, and secretions except sweat; (c)
nonimpact broken skin; and (d) mucous membranes.
 Designed to reduce risk of transmission of
microorganisms from recognized and unrecognized
sources.
 Handle client care equipment that is soiled with blood,
body fluids, secretions, or excretions carefully to
prevent transfer of microorganisms to others and to the
environment.
 Perform hand hygiene after contact with blood, body
fluids, excretions, secretions, and contaminated
objects whether or not gloves are worn.
Transmission-based Precautions
Transmission-based precautions are used in addition to standard precautions
for clients with known or suspected infections that are spread in one of
three ways: by airborne or droplet transmission, or by contact.
Antibody-Mediated Defenses
Another name for the antibody-mediated defenses is humoral (or
circulating) immunity because these defenses reside ultimately in the
B lymphocytes and are mediated by antibodies produced by B cells.

 Active immunity- In active immunity, the host produces

antibodies in response to natural antigens (e.g.
infectious agents) or artificial antigens (e.g.
vaccines); B cells are activated when they recognize
the antigen; they the differentiate into plasma cells;
the B cell may produce antibody molecules of five
classes of immunoglobulins: IgM, IgG, IgA, IgD, and
IgE.
 Passive immunity- With passive (or acquired) immunity, the
host receives natural (e.g. from a nursing mother) or
artificial (e.g. from an injection of immune serum)
antibodies produced by another source.
Cell-Mediated Defenses
The cell-mediated defenses, or cellular immunity, occur through the T-cell
system.

 There are three main groups of T-cells: helper T cells, cytotoxic T

cells, and suppressor T cells.
 On exposure to an antigen, the lymphoid tissues release large numbers
of activated T-cells into the lymph system.
 These T-cells pass into the general circulation.

 Helper T cells-help in the function of the immune system.

 Suppressor T cells-suppress the functions of the helper T

cells and cytotoxic T cells.
 Cytotoxic T cells-attack and kill microorganisms and
sometimes the body’s own cells.

Airborne Precautions
Use standard precautions as well as the following:

 Wear an N95 respirator mask when entering the room of a

client who is known to have or suspected of having
primary tuberculosis.
 Limit movement of clients outside the room to essential
purposes; place a surgical mask on the client during
transport.
 Susceptible people should not enter the room of a
client who has rubeola (measles) or varicella (chicken
pox).
 Place client in an airborne infection isolation room
that has negative air pressure, 6 to 12 air changes per
hour, and either discharge of air to the outside or
a filtration system for the room air.
 If a private room is not available, place the client
with another client who is infected with the same
microorganism.
Contact Precautions
Use standard precautions as well as the following:

 Place the client in a private room.

 If a private room is not available, place the client
with another client who is infected with the same
microorganism.
 Wear gloves as described in standard precautions.
 Wear a gown when entering a room if there is a
possibility of contact with infected surfaces or items,
or of the client is incontinent, or has diarrhea,a
colostomy, or wound drainage not contained by a
dressing.
 Limit movement of clients outside the room.
 Dedicate the use of noncritical client care equipment
to a single client or to clients with the same
infecting microorganisms.

Personal Protective Equipment

All healthcare providers must apply PPE according to the risk of exposure to
potentially infectious materials.
Gloves
 In all situations, gloves are changed between client
contacts.
 Gloves are worn for three reasons: first they protect
the hands when the nurse is likely to handle any body
substances; second, gloves reduce the likelihood of
nurses transmitting their own endogenous microorganisms
to individuals receiving care; and third, gloves reduce
the chance that the nurses’ hands will transmit
microorganism to from one client or object to another
client.
 The hands are cleansed each time the gloves are removed
for two primary reasons: (1) the gloves may have
imperfections or be damaged during wearing so that they
could allow microorganism entry; and (2) the hands may
become contaminated during glove removal.
Gowns
 Clean or disposable impervious (water-resistant) gowns
or plastic aprons are worn during procedures when the
nurse’s uniform is likely to become soiled.
 Single-use gown technique (using a gown only once
before it is discarded or laundered) is the usual
practice at hospitals.
 Sterile gowns may be indicated when the nurse changes
the dressings of a client with extensive wounds.

Face Masks
 Masks are worn to reduce the risk for transmission of
microorganisms by the droplet contact or airborne
routes and by splatters of body substances.
 All individuals entering the room if the infection is
transmitted by small particle aerosols (droplet
nuclei); small-particle aerosols remain suspended in
the air and thus travel great distances in the air.
 By those close to the client if the infection is
transmitted by large-particle aerosols (droplet); large
particle aerosols are transmitted by close contact and
generally travel short distances (about 1 m or 3 ft.).
 The CDC recommends that masks be worn.

Eye Wear
 Protective eyewear (goggles, glasses, face shields) and
masks are indicated in situations where body substances
may splatter the face.
 If the nurse wears prescription eyeglasses, goggles
must still be worn over the glasses because the
protection must extend around the sides of the glasses.
Sterile Technique
An object is sterile only when it is free of all microorganisms.

 Sterile technique is also employed for many procedures in

general care areas such as when administering injections,
changing wound dressings, performing urinary
catheterization, and administering intravenous therapies.
 In these situations, all principles of the surgical asepsis
are applied as in the operating or delivery room; however,
not all of the sterile techniques that follow are always
required.
 It is well known that sterile technique is practiced in
operating rooms and special diagnostic areas.

Principles of Surgical Asepsis

 Sterile objects become unsterile when touched by
unsterile objects.
 Sterile objects may become unsterile by prolonged
exposure to airborne microorganisms.
 Moisture that passes through a sterile object draws
microorganisms from unsterile surfaces above or below
to the sterile surface by capillary action.
 The edges of a sterile field are considered unsterile.
 Sterile objects that are out of sight or below the
waist or table level are considered unsterile.
 All objects used in a sterile field must be sterile.
 The skin cannot be sterilized and is unsterile.
 Conscientiousness, alertness, and honesty are essential
qualities in maintaining surgical asepsis.
 Fluids flow in the direction of gravity.