Infection Prevention and Control Chapter 28 Infection Prevention and Control The incidence of patients developing infection as the direct result of contact during health care is increasing. Current trends, public awareness, and rising costs of health care have increased the importance of infection prevention and control. In all health care settings, health care providers, as well as patients and their families, need to recognize sources of infection and be able to apply protective measures. Increases in drug-resistant microorganisms and heightened awareness of occupational exposure to tuberculosis, human immunodeficiency virus (HIV), and hepatitis have increased concern about transmission of infection. Infection prevention and control are some of the most important functions nurses will perform.

Scientific Knowledge Base Nature of infection Infection is the invasion of a susceptible host by pathogens or microorganisms, resulting in disease. Entry and multiplication of organisms result in disease Colonization occurs when a microorganism invades the host but does not cause infection. Patients in all health care settings are at risk for acquiring infection because of lower resistance to pathogens; increased exposure to pathogens, some of which may be resistant to most antibiotics; and invasive procedures. These basic concepts were introduced in microbiology. [Ask students to review these concepts.] If clinical symptoms are present, the infection is symptomatic. If clinical signs and symptoms are not present, the infection is asymptomatic.

Nature of Infection Communicable disease is the infectious process transmitted from one person to another. If pathogens multiply and cause clinical signs and symptoms, the infection is symptomatic. If clinical signs and symptoms are not present, the illness is termed asymptomatic. Hand hygiene is the most important technique to use in preventing and controlling transmission of infection. Disease or infection results only if pathogens multiply and alter normal tissue function. Some infectious diseases such as viral meningitis and pneumonia have low or no risk for transmission. Microorganisms are transmitted by direct and indirect contact, airborne spread, and vectors and contaminated articles. The Centers for Disease Control and Prevention (CDC) now recommends use of alcohol-based waterless antiseptics as an alternative to handwashing, unless hands are visibly soiled.

Chain of Infection Infectious agent or pathogen Reservoir or source for pathogen growth Portal of exit Mode of transmission Portal of entry Susceptible host •Remember that the presence of a pathogen does not mean that an infection will occur. •Infection develops if the chain stays intact. [Ask students to define these six links.] Microorganisms include bacteria, viruses, fungi, and protozoa. A reservoir is a place where microorganisms survive, multiply, and await transfer to a susceptible host. After microorganisms find a site to grow and multiply, they must find a port of exit if they are to enter another host and cause disease. The major route of transmission for pathogens identified in the health care setting is the unwashed hands of the health care worker. Organisms enter the body through the same routes that they use for exiting. Susceptibility to an infectious agent depends on the individual’s degree of resistance to pathogens. [See Table 28-1 on text p. 400 Common Pathogens and Some Infections or Diseases They Produce, and Box 28-1 on text p. 401 Modes of Transmission for further discussion.] [Image is Figure 28-1 on text p. 399 Chain of infection.]

Additional Terminology Immunocompromised means having an impaired immune system. Virulence is the ability to produce disease. Aerobic bacteria require oxygen for survival and for multiplication sufficient to cause disease. Anaerobic bacteria thrive where little or no free oxygen is available. bacteriostasis—prevention of growth and reproduction of bacteria. bactericidal—destructive to bacteria [Ask students how they can protect themselves from infection.] •Health care workers protect themselves from contact with infectious material, sharps injury, and/or exposure to a communicable disease by applying knowledge of the infectious process and by using appropriate personal protective equipment (PPE). The potential for microorganisms to cause disease depends on the number of organisms, virulence, ability to enter and survive in a host, and susceptibility of the host.

Quick Quiz! 1. A patient is admitted to a medical unit for a home-acquired pressure ulcer. The patient has Alzheimer’s disease and has been incontinent of urine. The nurse inserts a Foley catheter. You will identify a link in the infection chain as A. Restraints. B. Poor hygiene. C. Foley catheter bag. D. Improper positioning. Answer: C

Infectious Process Incubation period Prodromal stage Four stages: Localized versus systemic infection Incubation period Prodromal stage Illness stage Convalescence •The incubation period is the time interval between entrance of the pathogen and appearance of first symptoms. •Prodromal stage is the interval from onset of nonspecific signs and symptoms to more specific symptoms. •Illness stage is the interval when the patient manifests signs and symptoms specific to the type of infection. •Convalescence is the interval when acute symptoms of infection disappear. [Box 28-2 on text p. 401 Course of Infection by Stage gives specific examples of these four stages.] •If an infection becomes localized, as in a wound infection, use standard precautions, personal protective equipment, and hand hygiene to block the spread of infection to other parts of the body. [What does PPE consist of?] •PPE includes mask, face shield/protective eye equipment, gloves, and gown. •An infection that affects the entire body instead of just a single organ or part is systemic and can become fatal if undetected and untreated.

Defenses Against Infection Normal flora Microorganisms Normal body flora helps to resist infection by releasing antibacterial substances and inhibiting multiplication of pathogenic microorganisms. Body system defenses Organs •Normal flora: microorganisms that reside in the body. [Where are these floras located? Floras are located in the skin, saliva, oral mucosa, and intestinal walls.] •Refer to the pharmacology course students have taken. Recall that use of broad-spectrum antibiotics for the treatment of infection may eliminate or change normal flora, leading to a superinfection. •A number of body organ systems have unique defenses against infection. For example, the airways are lined with moist mucous membranes and cilia, which rhythmically beat to move mucus or cellular debris up to the pharynx to be expelled through swallowing. [See Table 28-2 on text p. 402 Normal Defense Mechanisms Against Infection for more examples.]

Defenses Against Infection (cont’d) Inflammation Vascular and cellular responses Exudates (serous, sanguineous, or purulent) Tissue repair Signs of local inflammation and infection are identical. •The inflammatory response is a protective cellular and vascular reaction that neutralizes pathogens and repairs body cells. It delivers fluid, blood products, and nutrients to an injured area. The accumulation of fluid appears as localized swelling (edema). •The process neutralizes and eliminates pathogens or dead (necrotic) tissues and establishes a means of repairing body cells and tissues. Signs and symptoms usually include fever, leukocytosis, malaise, anorexia, nausea, vomiting, and lymph node enlargement. •Leukocytosis, or an increase in circulating white blood cells (WBCs), is the body’s response to WBCs leaving blood vessels. Phagocytosis is the process of destroying and absorbing bacteria. •Inflammatory exudate is the accumulation of fluid, dead tissues, and WBCs that forms at the site of infection. The lymph system usually carries this fluid away. Exudate may be serous (clear, like plasma), sanguineous (containing red blood cells), or purulent (containing WBCs and bacteria). •Tissue repair occurs when tissue cells undergo an injury. Damaged cells are replaced with healthy new cells. If an inflammation is chronic, tissues will be replaced with granulation tissues, which is not as strong as normal tissue and will leave a scar.

Case Study Mrs. Eldredge is a 63-year-old woman who underwent a total hip replacement. Kathy Jackson is a nursing student caring for Mrs. Eldredge on her home health clinical rotation. Two weeks after surgery, Mrs. Eldredge complains to Kathy that she has increased pain in her hip and low-grade fever. Kathy observes the incision and notes that it is red, swollen, and warm. [What do the fever and the warm, swollen incision likely indicate? The inflammatory response has been engaged. The incision may have become infected.] [Is an infection at a wound site likely to be systemic or localized? Wound site infections are usually localized.]

Health Care–Associated Infections Results from delivery of health services in a health care facility Patients at greater risk for health-care associated infections (HAIs) Multiple illnesses Older adults Poorly nourished Lowered resistance to infection Health care–associated infection (HAI) can occur as the result of invasive procedures, antibiotic administration, the presence of multidrug-resistant organisms, and breaks in infection prevention and control activities. Invasive procedures, medical therapies, long hospitalization, and contact with health care personnel increase a hospitalized patient’s risk for acquiring a health care–associated infection. •Patients who develop HAIs, such as the elderly, are usually more susceptible to infection. •Meticulous hand hygiene practices, use of chlorhexidine washes, and other advances in intensive care unit (ICU) infection prevention help to prevent these infections. [See Box 28-4 on text p 404 Focus on Older Adults for additional discussion.] •Health care–associated infection significantly increases the costs of health care.

Health Care–Associated Infection (cont’d) Types of HAI infection: Iatrogenic—from a procedure Exogenous—from microorganisms outside the individual Endogenous—when the patient’s flora becomes altered and an overgrowth results •Iatrogenic infection is a type of HAI that results from a diagnostic or therapeutic procedure. For example, procedures such as bronchoscopy and treatment with broad-spectrum antibiotics have been shown to increase the risk for certain infections. •Health care–associated infections may be exogenous or endogenous. An exogenous infection comes from microorganisms found outside the individual such as Salmonella. They do not exist as normal floras. Endogenous infection occurs when part of the patient’s flora becomes altered and an overgrowth results, as with streptococci. This often happens when a patient receives broad-spectrum antibiotics.

Health Care–Associated Infection (cont’d) Risk factors Number of health care employees with direct contact with the patient Types and numbers of invasive procedures Therapy received Length of hospitalization Major sites for HAI infection Surgical or traumatic wounds Urinary and respiratory tracts Bloodstream Major sites for health care–associated infection include the urinary and respiratory tracts, the bloodstream, and surgical or traumatic wounds. [See Box 28-3 on text p. 404 Sites for and Causes of Health Care-Associated Infections for further discussion.]

Nursing Knowledge Base Factors influencing infection prevention and control: Age Nutritional status Stress Disease process Treatments or conditions that compromise the immune response •Multiple factors influence a patient’s susceptibility to infection. It is important to understand how each of these factors alone or in combination increases this risk. •Throughout life, susceptibility to infection changes. An infant has immature defenses against infection. The young or middle-aged adult has refined defenses against infection. In older adults, immune response declines, particular cell-mediated immunity. •A patient’s nutritional health directly influences susceptibility to infection. A reduction in the intake of protein and other nutrients such as carbohydrates and fats reduces body defenses against infection and impairs wound healing. (This is discussed in greater detail in Chapter 48.) •The body responds to emotional or physical stress by the general adaptation syndrome (discussed in detail in Chapter 37). If stress continues or becomes intense, elevated cortisone levels result in decreased resistance to infection. •If a patient has a condition or a disease that compromises the patient’s ability to fight off infection, he or she becomes more susceptible. [What conditions can you think of that would make a patient more susceptible to infection?] •For example, AIDS compromises the immune system, and bronchitis impairs the lungs’ defense system by impairing ciliary action and thickening mucus. Patients with burns are susceptible owing to damage to the skin surface.

Case Study (cont’d) Mrs. Eldredge’s wound was infected. She was admitted and received IV antibiotics and wound irrigation. She was discharged on day 4. At present, the wound remains open, but it is healing with new granulation tissue that is healthy. [What is granulation tissue?] •Granulation tissue is not as strong as tissue collagen and assumes the form of scar tissue.

Nursing Process: Assessment Assessment includes a thorough investigation: Review of systems, travel history Immunizations and vaccinations Early recognition of risk factors •As you may recall, assessment is the first step of the nursing process (see Chapter 16). •You may elicit information from the patient, family members, or past medical records. •Early recognition of infection or risk factors helps you make the correct nursing diagnosis and establish a treatment plan. [See Box 28-5 Nursing Assessment Questions on text p. 406.]

Nursing Process: Assessment (cont’d) See through the patient’s eyes. Status of defense mechanisms Patient susceptibility Medical therapy Clinical appearance Signs and symptoms of infection Laboratory data •Some patients with infection have a variety of problems. It is important to ask specific questions to determine the patient’s and family’s needs related to the risk for infection or disease status. [See Table 28-3 on text p. 405 Assessing the Risk of Infection in Adults for further discussion.] •Encourage patients to verbalize their expectations so you are able to establish interventions to meet patients’ priorities. •Review physical assessment findings and the patient’s medical condition to determine the status of normal defense mechanisms against infection. [What are the factors that influence patient susceptibility? Age, nutritional status, stress, and disease process are factors that influence susceptibility to infection.] •Assess your patient’s medication history to determine whether he or she takes any medications that increase infection susceptibility. •Signs and symptoms of infection may be local or systemic. Systemic infection can develop after treatment for localized infection has failed, so treatment of localized infections is indeed vital. •Laboratory values such as increased WBCs and/or a positive blood culture often indicate infection. [See Table 28-4 on text p. 407 Laboratory Tests to Screen for Infection for further discussion.]

Quick Quiz! 2. You are caring for a patient who underwent surgery 48 hours ago. On physical assessment, you notice that the wound looks red and swollen. The patient’s WBCs are elevated. You should A. Start antibiotics. B. Notify the physician. C. Document the findings and reassess in 2 hours. D. Place the patient on isolation precautions. Answer: B

Nursing Process: Nursing Diagnosis Nursing diagnoses for infection: Risk for infection Imbalanced nutrition: less than body requirements Impaired oral mucous membrane Risk for impaired skin integrity Social isolation Impaired tissue integrity Readiness for enhanced immunization status Success in planning appropriate nursing interventions depends on the accuracy of the diagnosis and the ability to meet the patient’s needs. [See Box 28-6 Nursing Diagnostic Process: Risk for Infection Related to Impaired Immunity.]

Nursing Process: Planning Goals and outcomes Common goals of care applicable to patients with infection often include the following: Preventing exposure to infectious organisms Controlling or reducing the extent of infection Maintaining resistance to infection Verbalizing understanding of infection prevention and control techniques (e.g., hand hygiene) Develop a plan that sets realistic outcomes so interventions are purposeful, direct, and measurable. Patients often have multiple nursing diagnoses that are interrelated, and one diagnosis impacts on another diagnosis. [See also the concept map, Figure 28-2 on text p. 409.]

Nursing Process: Planning (cont’d) Setting priorities Establish priorities for each diagnosis and for related goals of care. Teamwork and collaboration Remember to plan care and include other disciplines as necessary. •For example, you are caring for a patient with cancer who develops an open wound and is unable to tolerate solid foods. The priority of administering therapies to promote wound healing such as improved nutritional intake overrides the goal of educating the patient to assume self-care therapies at home. [See text p. 408 for an example of a Nursing Care Plan on risk for infection.]

Case Study (cont’d) Mrs. Eldredge continues recovering at home. When she visits Mrs. Eldredge, Kathy teaches her about infection prevention and control practices. [What outcome would you set for this activity? Patient will assume self-care using proper infection prevention and control techniques.] [What are some examples of teaching strategies to achieve this outcome? Instruct patient about proper hand hygiene practices before and after wound care. Demonstrate proper hand hygiene, explaining that the patient should perform before and after all wound care and when infected body fluids are contacted. Instruct patient about signs and symptoms of wound infection and when to notify the physician. Instruct patient to place contaminated dressings and other disposable items containing infectious body fluids in impervious plastic or brown paper bags. Place needles in metal containers such as soda cans or coffee cans, and tape the openings shut. Some states have specific requirements for sharps disposal. Check local regulations. Instruct patient to clean noticeably soiled linen separate from other laundry. Wash in warm water with detergent. No special recommendations for setting dryer temperature.]

Implementation Health promotion Acute care Preventing an infection from developing or spreading Acute care Treating an infectious process includes eliminating the infectious organisms and supporting the patient’s defenses. Use your critical thinking skills to prevent an infection from developing or spreading. In health care settings, implement procedures to minimize the numbers and kinds of organisms that could be transmitted. Be aware that various cultural and religious beliefs or practices influence patients’ decisions to seek treatment for an infection or to use methods to prevent infection. [See also Box 28-7 on text p. 410 Cultural Aspects of Care Implications for Infection Control—AIDs in New York City.]

Implementation (cont’d) When implementing care, consider: Medical and surgical asepsis Control or elimination of infectious agents Control or elimination of reservoirs Control of portals of entry Control of transmission Hand hygiene Isolation precautions •In the nursing skills laboratory, you will practice hand hygiene, how to prepare a sterile field, surgical hand asepsis, how to apply a sterile gown, and how to perform closed and open gloving.

Implementation: Asepsis Asepsis = Absence of pathogenic (disease-producing) microorganisms. Aseptic technique = Practices/ procedures that assist in reducing the risk for infection. Medical asepsis, or clean technique, includes procedures for reducing the number of organisms present and preventing the transfer of organisms. Surgical asepsis or sterile technique prevents contamination of an open wound, serves to isolate the operative area from the unsterile environment, and maintains a sterile field for surgery. •Surgical asepsis requires more stringent techniques than medical asepsis and is directed at eliminating microorganisms. •If the skin is broken or if an invasive procedure into a body cavity normally free of microorganisms is performed, follow surgical aseptic practices.

Standard Precautions Standard precautions prevent and control infection and its spread. Apply to contact with blood, body fluid, nonintact skin, and mucous membranes from all patients. Hand hygiene includes using an instant alcohol hand antiseptic before and after providing patient care, washing hands with soap and water when they are visibly soiled, and performing a surgical scrub. Handwashing is the act of washing hands with soap and water, followed by rinsing under a stream of water for 15 seconds. Standard precautions protect the patient and provide protection for the health care worker. Standard precautions use generic barrier techniques when caring for all patients. A major component of patient and worker protection is hand hygiene. [See also Box 28-8 on text p. 411 Evidence-Based Practice: Pathogens and Artificial Fingernails.]

Disinfection versus Sterilization Disinfection: a process that eliminates many or all microorganisms, with the exception of bacterial spores, from inanimate objects Disinfection of surfaces High-level disinfection, which is required for some items such as endoscopes Sterilization: the complete elimination or destruction of all microorganisms, including spores You accomplish disinfection using a chemical disinfectant or wet pasteurization (used for respiratory therapy equipment). [See also Table 28-5 on text p. 413 Examples of Disinfection and Sterilization Processes, and Box 28-9 on text p. 412 Categories for Sterilization, Disinfection, and Cleaning.] •Proper cleaning requires mechanical removal of all soil from an object or area.

Infection Prevention and Control Patient safety Separate personal care items Handling solid and fluid waste Wound cleaning Patient education Cough etiquette Isolation and isolation precautions Surgical asepsis Effective prevention and control of infection require you to remain aware of the modes of transmission and ways to control them. Many measures that control the exit of microorganisms likewise control the entrance of pathogens. In the hospital, home, or extended care facility, a patient needs a personal set of care items. Often patients must learn to use infection prevention and control practices at home. [Cough etiquette, isolation, and surgical asepsis are discussed on subsequent slides.] [See also: Box 28-10 on text p. 413 Infection Prevention and Control to Reduce Reservoirs of Infection Table 28-6 on text p. 414 Centers for Disease Control and Prevention Isolation Guidelines Box 28-11 Infection Prevention and Control: Protecting the Susceptible Host Box 28-15 on text p. 421 Patient Teaching: Infection Prevention and Control]

Cough Etiquette Cover your nose/mouth with a tissue when you cough, and promptly dispose of the contaminated tissue. Place a surgical mask on a patient if it does not compromise respiratory function or is applicable; this may not be feasible in pediatric populations. Perform hand hygiene after contact with contaminated respiratory secretions Maintain spatial separation greater than 3 feet from persons with respiratory infection To control organisms exiting via the respiratory tract, cover your mouth or nose when coughing or sneezing. Teach patients, health care staff, patient’s families, and visitors respiratory hygiene or cough etiquette. The elements of a respiratory hygiene or cough etiquette are listed here.

Isolation and Isolation Precautions Isolation is the separation and restriction of movement of ill persons with contagious diseases. Standard precautions Isolation precautions: airborne, droplet, contact, and protective environment Health care facilities are required to have the capability of isolating patients. Isolation practices may prevent personnel and patients from acquiring infections and from transmission of microorganisms to other persons. Barrier precautions include the appropriate use of personal protective equipment (PPE) such as gowns, gloves, masks, eyewear, and other protective devices or clothing. A patient in isolation is subject to sensory deprivation because of the restricted environment. .Regardless of the type of isolation system, follow these basic principles: • Use thorough hand hygiene before entering and leaving the room of a patient in isolation. • Dispose of contaminated supplies and equipment in a manner that prevents spread of microorganisms to other persons as indicated by the mode of transmission of the organism. • Apply knowledge of a disease process and the mode of infection transmission when using protective barriers. • Protect all persons who might be exposed during transport of a patient outside the isolation room. An infection prevention and control professional—a valuable resource for assisting nurses in controlling HAIs—monitors the incidence of infection within an institution and provides educational and consulting services.

Isolation Psychological implications Isolation environment Personal protective equipment Specimen collection Bagging of trash or linen Patient transport When a patient requires isolation in a private room, a sense of loneliness may develop because normal social relationships become disrupted. This situation can be psychologically harmful, especially for children. Private rooms used for isolation sometimes provide negative-pressure airflow to prevent infectious particles from flowing out of a room to other rooms and to the air handling system. Obtain all culture specimens using clean gloves and sterile equipment. A single, intact, standard-sized linen bag that is not overfilled and is tied securely is adequate to prevent infection transmission. Patients infected with organisms transmitted by the airborne route normally leave their rooms only for essential purposes such as diagnostic procedures or surgery. When a patient has an airborne infection, he or she must wear a mask when leaving the room. [See also Box 28-12 on text pp. 417-418 Procedural Guidelines: Caring for a Patient on Isolation Precautions Box 28-13 on text p. 419 Procedural Guidelines Applying a Surgical Type of Mask Box 28-14 on text p. 420 Specimen Collection Techniques]

Surgical Asepsis Patient preparation Sterile field: an area free of microorganisms and prepared to receive sterile items Principles Performing sterile procedures Surgical asepsis includes procedures used to eliminate all microorganisms, including pathogens and spores, from an object or area. Surgical asepsis is used during procedures that require intentional perforation of the patient’s skin such as insertion of IV catheters or central lines; when the integrity of the skin is broken as a result of trauma, surgical incision, or burns; and during procedures that involve insertion of catheters or surgical instruments into sterile body cavities, such as insertion of a urinary catheter. Frequently you place sterile objects on a sterile towel, drape, or tray. Because the edge of the drape touches an unsterile surface such as a table or bed linen, a 1-inch border around the drape is considered contaminated. Because surgical asepsis requires exact techniques, you need to have the patient’s cooperation. Explain how you will perform a procedure and what the patient can do to avoid contaminating sterile items. [Principles of surgical asepsis are discussed on a subsequent slide, as are sterile procedures to be performed.] [Images shown are Figure 28-4 from text p. 422 Placing sterile item on sterile field, and Figure 28-5 from text p. 423 Nurse opens sterile package on work area above waist level.]

Principles of Surgical Asepsis 1. A sterile object remains sterile only when touched by another sterile object. 2. Only sterile objects may be placed on a sterile field. 3. A sterile object or field out of the range of vision or an object held below a person’s waist is contaminated. 4. A sterile object or field becomes contaminated by prolonged exposure to air. Performing sterile aseptic procedures requires a work area in which objects can be handled with minimal risk of contamination. A sterile field provides a sterile surface for placement of sterile equipment. It is an area considered free of microorganisms and may consist of a sterile kit or tray, a work surface draped with a sterile towel or wrapper, or a table covered with a large sterile drape.

Principles of Surgical Asepsis (cont’d) 5. When a sterile surface comes in contact with a wet, contaminated surface, the sterile object or field becomes contaminated by capillary action. 6. Fluid flows in the direction of gravity. 7. The edges of a sterile field or container are considered to be contaminated. When beginning a surgically aseptic procedure, nurses follow certain principles to ensure maintenance of asepsis. Failure to follow these principles places patients at risk for infection.

Performing Sterile Procedures Donning and removing caps, masks, and eyewear Opening sterile packages Opening a sterile item on a flat surface Opening a sterile item while holding it Preparing a sterile field Pouring sterile solutions Surgical scrub Applying sterile gloves Donning a sterile gown Assemble all of the equipment that will be needed before a procedure. Have a few extra supplies available in case objects accidentally become contaminated. Do not leave a sterile area. Before a sterile procedure, explain each step so the patient can cooperate fully. If an object becomes contaminated during the procedure, do not hesitate to discard it immediately. Wear a surgical mask and eyewear without a cap for any sterile procedures on a general nursing unit. Sterile items such as syringes, gauze dressings, or catheters are packaged in paper or plastic containers and are impervious to microorganisms as long as they are dry and intact. Commercially packaged items are usually designed so you only have to tear away or separate the paper or plastic cover. To open a small sterile item, hold the package in your nondominant hand while opening the top flap and pulling it away from you. When performing sterile procedures, you need a sterile work area that provides room for handling and placing sterile items. You prepare the sterile field by using the inner surface of a sterile wrapper as the work surface, or by using a sterile drape or dressing tray. A bottle containing a sterile solution is sterile on the inside and contaminated on the outside; the neck of the bottle is also contaminated, but the inside of the bottle cap is considered sterile. Nurses working in operating rooms perform surgical hand antisepsis to decrease and suppress the growth of skin microorganisms in case of glove tears. Sterile gloves are an additional barrier to bacterial transfer. Nurses wear sterile gowns when assisting at the sterile field in the operating room, delivery room, and special treatment areas.

Evaluation See through the patient’s eyes: Patient outcomes Have the patient’s expectations been met? Patient outcomes Measure the success of the infection control techniques. Compare the patient’s actual response with expected outcomes. If goals are not achieved, determine what steps must be taken. The patient at risk for infection needs to understand the measures needed to reduce or prevent microorganism growth and spread. Documentation of the patient's response to therapy is critically important.

Evaluation (cont’d) Exposure issues Patients and health care personnel are at risk for acquiring infection from accidental needlesticks. Report any contaminated needlestick immediately. Follow-up for risk of acquiring infection begins with source patient testing. Access to testing the source patient is stated in the testing law for each state. Testing the exposed employee at the time of the exposure is not needed immediately unless required by the state testing law. If the patient tests positive for a bloodborne pathogen, or if the source patient is unknown, prophylactic treatment is recommended for the employee. Exposures involving non-bloodborne pathogens, such as airborne pathogens, also may occur. The Centers for Disease Control and Prevention (CDC) (2010a) has published a list of recommended immunizations and vaccinations for health care workers. Employee Health should review your health history and offer appropriate prevention. Declination forms are needed if these are declined. [See also Box 28-16 Hepatitis B Vaccination and Follow-up After Hepatitis C and Human Immunodeficiency Virus Exposure.]