Immunity/Infection

Normal Presentation
 Invasion of body tissue by microorganisms
 With potential to cause illness or disease
 Immune system body's major defense
 Infection control central to delivering high-quality nursing care
 Asymptomatic or subclinical infection
 Communicable disease
 Infectious disease
 Microorganisms vary in virulence
 Pathogenicity
 Pathogen
 Opportunistic pathogen
 Infectious diseases major cause of death
 Asepsis
 Medical asepsis
 Surgical asepsis
Types of Microorganisms Causing Infections
 Four categories of microorganisms
 Bacteria
 Most commonly cause infection
 Viruses
 Nucleic acid, must enter living cells
 Fungi
 Yeasts, molds
 Parasites
 Protozoa, helminths, arthropods
Types of Infections
 Colonization
 Infection occurs 🡪 microorganisms invade body part with ineffective defenses
 Types of infections
 Local infection
 Systemic infection (dental care is very important, kidneys, etc.)
 Acute infection
 Chronic infection
Chain of Infection
 Six links
1. Etiological agent
2. Reservoir
3. Portal of exit from reservoir
4. Method of transmission
 Direct
 Indirect
 Airborne
5. Portal of entry
 Skin is barrier to infectious agents
 Break in skin can readily serve as a portal of entry
  Enter the body as the same route as they left the source
 Mouth, throat, nose, eyes and genitalia are most frequent portals of entry
6. Susceptible host
 An individual who is at risk for infection
 Infants
 Young children
 Compromised host
 Individual at risk that is more likely than others to acquire infection
Physiological Review
 Specific defenses
 Anatomical and physiological barriers
 Intact skin
 Nasal passages
 Each body orifice has its own defenses
Genetic and Lifespan Considerations
 Age and heredity
 Newborns (born with passive immunity- also received through breastmilk)
 Immature immune systems
 Protected by immunoglobulins received from mother
 Infants begin to synthesize immune system at 1–3 months of age
 Older adults
 Have reduced defenses
 Physiological changes
 Cardiovascular changes
 Respiratory system changes
 Genitourinary changes
 Gastrointestinal changes
 Skin, subcutaneous tissue changes
 Immune changes
 Older adults
 Aging process
 Thymus gland atrophies
 Antibody responses decline
 Reduced resistance to antigens
 Classic signs of infection may be absent
Alterations
 Microorganisms invade human body and proliferate when they are undetected, uncontrolled, or
not eliminated by the inflammatory and immune responses
 Antibiotic-resistant strains of microorganisms
 Fecal–oral and respiratory routes are most common modes of transmission in children

Cell type and Increased Decreased

Normal Value
Total WBCs: 4500- Leukocytosis: Infection or Leukopenia: bone marrow depression,
10,000 per mm³ inflammation, leukemia, trauma or overwhelming infection, viral infections,
stress, tissue necrosis immunosuppression, autoimmune
disease, dietary deficiency
 Neutrophils (segs, Neutrophilia: acute infection or
PMNs, or polys): stress response, myelocytic
50%-70% leukemia, inflammatory or
metabolic disorders
Eosinophils (eos): Eosinophilia: parasitic infections,
1%-3% hypersensitive reactions,
autoimmune disorders
Basophils (basos): Basophilia: Hypersensitivity
0.4%-1% responses, chronic myelogenous
leukemia, chickenpox or smallpox,
splenectomy, hypothyroidism
Monocytes Monocytosis: chronic inflammatory
(monos): 4%-6% disorders, tuberculosis, viral
infections, leukemia, Hodkins
disease, multiple myeloma
Lymphocytes: Lymphocytosis: chronic bacterial
(lymphs): 25%-35% infection, viral infections,
lymphocytic leukemia, pertussis,
mononucleosis, tuberculosis
Neutropenia: bone marrow depression,
overwhelming bacterial infection, viral
infection, Addison’s disease
Eosinopenia: Cushing’s syndrome,
autoimmune disorders, stress, certain
drugs
Basopenia: Acute stress or
hypersensitivity reactions,
hyperthyroidism
Monocytopenia: bone marrow
depression, corticosteroid therapy
Lymphopenia: bone marrow depression,
immunodeficiency, leukemia, Cushing
syndrome, Hodgkin disease, renal failure

Pathogens
 Bacteria, viruses, fungi and parasites
 Evolution of pathogens to facilitate transmission
 Resistance to drying
 Producing toxins or enzymes that alter or destroy the normal function of host cells
 Adhesion factors
 Exotoxins
 Soluble proteins that the microorganisms secrete into surrounding tissue
 Highly poisonous
 Causes cell death or dysfunction
 Endotoxins
 Found in the cell wall of gram-negative bacteria
 Released only when the cell wall is disrupted
Stages of the Infectious Process
 Stages of the infectious process
1. Incubation period
2. Prodromal stage
3. Illness stage
4. Convalescent stage
 Carrier state
1. Host defenses eliminate infectious disease
2. Organism continues to multiply
Concepts related to Infection
 Elimination
 Inflammation
 Sexuality
 Tissue Integrity
 Teaching and Learning
Alterations and Manifestations
 Complications of infectious diseases
 Typically, specific to the infecting organism and the body system affected
 Sepsis is a severe reaction to infection
 Septic shock leads to diffuse cell and tissue injury and potentially to organ failure
 Healthcare-associated infections (HAIs)
 Can develop:
 During client's stay in the facility
 Manifest after discharge
 Sources
 Endogenous
 Exogenous
 Iatrogenic
 Urinary tract infection is the most common type of HAIs
 Prevention of HAIs
 Effective hand washing
 Invasive equipment, procedures minimally
 Meticulous medical, surgical asepsis
 Critical thinking, agency policy
 Hand hygiene for client, nurse
 Use of alcohol-based antiseptic hand scrubs before and after direct client
contact
 Antibiotic-resistant bacteria
 Prolonged, inappropriate antibiotic therapy
 Current resistant strains
 MRSA
 VRE
 Penicillin-resistant S. pneumoniae (PRSP)
 C. difficile common cause of nosocomial diarrhea
 Extended spectrum beta-lactamase–producing organisms
 Biological threat infections
 Most likely pathogens
 Anthrax
 Smallpox
 Botulism
 Pneumonic plague
 Viral hemorrhagic fevers
 Pediatric infectious and communicable diseases
 Elimination
 Rubella
 Serogroup A meningitis
 Neonatal tetanus
 Pediatric infectious and communicable diseases
 Reduction
 Pertussis
 Hepatitis B
 Varicella
 Measles
Prevalence
 Change of a healthcare worker becoming infected from exposure to pathogens varies widely
 30% hepatitis B
 1.8% for hepatitis C
 0.3% for HIV
Genetic Considerations and Nonmodifiable Risk Factors
 Some medical therapies may predispose an individual to infection
 Radiation treatments
 Medications such as antineoplastic medications
 Disease that lowers the body's defenses
 Good hand washing
 Getting immunizations
 Preventing airborne droplets from spreading
 Taking precautions when handling potentially contaminated materials
Healthcare Worker Precautions
 Disinfecting and sterilizing
 Etiologic agent and reservoir interrupted
 Disinfecting
 Disinfectant 🡪 used on inanimate objects
 Antiseptic 🡪 used on skin, tissue
 Bactericidal agent 🡪 destroys bacteria
 Bacteriostatic agent 🡪 prevents growth
 Disinfecting and sterilizing
 When disinfecting articles, consider:
 Type, number of infectious organisms
 Recommended concentration of disinfectant, duration of contact
 Presence of soap
 Presence of organic materials
 Surface areas to be treated
 Disinfecting and sterilizing
 Sterilizing
 Destroys all microorganisms
 Moist heat
 Gas
 Boiling water
 Radiation
 Isolation precautions
 Isolation
 Measures to prevent spread of infection
 Category-specific
 Disease-specific
 Universal precautions
 Body substance isolation
 Avoid injury from sharp instruments
 CDC (HICPAC) isolation precautions
 New guidelines
 Standard precautions
 Transmission-based precautions
  Airborne
 Droplet
 Contact
 Isolation practices
 Initiation of isolation nursing responsibility
 Based on comprehensive assessment
 Aseptic precautions
 Strict aseptic technique
 Change IV tubing, solution containers per policy
 Check all sterile supplies for expiration,
intact packaging
 Prevent UTIs
 Measures to prevent impaired skin integrity
 Personal protective equipment (PPE)
 Gloves
 Protect hands
 Reduce transmission of microorganisms
 Change between client contacts
 Clean hands with glove removal
 Latex allergy issues
 Gowns
 Clean or sterile
 Single-use gown technique
 Personal protective equipment (PPE)
 Face masks
 Reduce risk of droplet or airborne transmission
 Worn by:
 Those close to client if droplet route
 Personal protective equipment (PPE)
 Face masks
 Types of masks
 Single-use disposable
 Disposable particulate respirators
 N95
 Surgical asepsis
 Eyewear
 All individuals entering room if airborne
 Disposal of soiled equipment and supplies
 Specific policies, procedures
 Bagging
 Linens
 Laboratory specimens
 Dishes
 Blood pressure equipment
 Thermometers
 Sharps
 Transporting clients with infection
 Avoid transporting outside room
  Cover wound
 Surgical mask
 Psychosocial needs of isolation clients
 Sensory deprivation
 Decreased self-esteem
 Nursing interventions
Sterile Technique
 Sterile
 Free of all microorganisms
 Principles and practice of surgical asepsis
 Sterile field
 Microorganism-free area
 Use the innermost side of a sterile wrapper
 Use a sterile drape
 Sterile gloves
 May be donned by the open method or closed method
 Packaged with a cuff of approximately 5 cm and palms facing upward when package is
opened
 Sterile gowns
 Where surgical asepsis is necessary
Preventing healthcare-Associated Infections
 Effective handwashing is the single most important measure in infection control
 Invasive procedures and equipment should only be used when absolutely necessary
 Medical and surgical asepsis is necessary
Infection Control for Healthcare Workers
 NIOSH found majority of needlestick injuries preventable
 OSHA publishes and enforces regulations to protect healthcare workers from occupational
injuries
 Occupational exposure
 Modes of transmission in clinical setting
 Puncture wounds
 Skin contact
 Mucous membrane contact
Role of the Infection Control Nurse
 Specially trained
 Knowledgeable about:
 Prevention
 Detection
 Treatment
 All infections reported to IC nurse
 Employee education
Client Precautions
 Modifiable risk factors
 Hygiene
 Nutrition
 Fluid
 Sleep
 Stress (noises, fear of the unknown, communication is very important)
  Immunizations
 Dramatically decrease incidence of infectious disease
 Should begin shortly after birth
 Completed throughout childhood
 Injection
 Inhalation
 Oral solutions
 Nasal sprays
Nursing Assessment
 Nursing history
 Assess degree of client risk
 Chart review
 Interview
 Physical assessment
 Signs, symptoms vary with body area involved
 Skin, mucous membranes
 Signs of systemic infection
 Physical assessment
 Localized swelling
 Localized redness
 Pain or tenderness with palpation movement
 Palpable heat in infected area
 Loss of function in body part affected
 Depends on site and extent of involvement
 Physical assessment
 Signs of systemic infection
 Fever
 Increased pulse
 Malaise and loss of energy
 Loss of appetite and, in some situations, nausea and vomiting
 Enlargement or tenderness of lymph nodes that drain area of infection
Lifespan and Cultural considerations
 Infants and children
 Need special consideration during assessment
 Hands and instruments warm
 Explain procedures to children old enough to understand
 Infant and toddlers held by parents to feel secure
 Distractions might calm child
 Pregnant women
 Special considerations for infection that may cause birth defects
 Rubella
 Cytomegalovirus
 Parvovirus
 Chicken pox
 Infections that may be transmitted to the newborn
 HIV
 Group B Streptococcus
 Cytomegalovirus
  Listeriosis
Diagnostic Tests
 WBC count
 Procalcitonin
 Cultures of wound, blood, or other infected body fluids
 Serological testing
 Direct antigen detection methods
 Antibiotic peak, trough levels
 Radiological examination of the chest, abdomen, or urinary system
 Lumbar puncture
 Ultrasonic examination
 Urinalysis
Interventions and Therapies
 Identify organ system involved
 Identify causative agent
 Achieve a cure by the least toxic, least inexpensive and most effective means
 Once causative agent is identified, therapy can be specifically tailored
Independent
 Hand hygiene
 Basic medical asepsis
 Use of standard precautions
 Isolation techniques
 Sterile field
 Use of personal protective equipment and decontamination
Collaborative
 With physician or other healthcare professionals
 Nurse may be responsible for:
 Collecting specimens for laboratory testing
 Retrieving lab results
 Administering medications

Inflammation
 Adaptive response to injury, illness that brings plasma, dissolved substances, blood cells into
interstitial tissues where damage occurred.
 Nonspecific
Debridement
 Damaged cells, bacteria, exudate removed through phagocytosis
 Five signs
 Pain
 Swelling
 Redness (increased blood flow)
 Heat
 Impaired function
 “itis” describes inflammatory process
  The inflammatory process
 Complex response of vascular tissues triggered by harmful stimuli
 Acute or chronic
Stages of Inflammation
 Stage 1
 Vascular and cellular responses
 Blood vessels at site constrict
 Chemical mediators cause hyperemia
 Blood flow slows in dilated vessels
 Sprains, broken bones
Stage 2
 Exudate production
 Serous exudate
 Purulent
 Hemorrhagic
Stage 3
 Reparative phase
 Regeneration
 Fibrous tissue formation
 Mediators of inflammation
 Key chemical mediator of inflammation
 Stored in mast cells
 Directly stimulates pain receptors
 Dilates nearby blood vessels
 Anaphylaxis
 Histamine receptors
Genetic and Lifespan Considerations
 Several differences in anatomy, physiology influence effects of inflammation in adults versus
children
 Structural differences in airway
 Fewer and smaller lung alveoli
 Glomerular filtration not fully developed
 Absolute volumes of fluid loss represent a larger proportion of total body fluid
 Changes in the state of the heart reduce the sympathetic nervous system response to
changes in blood volume and stress
 Gastrointestinal inflammation
 Immune response to insult differs significantly
Alterations
 Can occur in any tissue
 Common disorders
 Appendicitis
 Crohn disease
 Arthritis
 Nephritis
 Peptic ulcers
 SLE
 RA
 Classic signs include redness and swelling
  Healthy inflammatory response includes activation and recruitment of WBCs to the affected site
 Localized
 Generalized
Prevalence
 RA typical onset is middle age with increased incidence among older adults
 RA also occurs in children and young adults
 1.3 million U.S. adults have RA
 8.2% of U.S. population has asthma
Genetic Considerations and Nonmodifiable risk Factors
 Native or Mexican Americans
 Increased risk for gallstones.
 Female gender
 African Americans
 More likely than Caucasians to develop nephritis as a result of lupus
 Family history
 Associated with peptic ulcer disease
Concepts related to Inflammation
 Infection
 Immunity
 Oxygenation
 Teaching and Learning
Prevention
 Avoid known triggers
 Avoid foods or beverages that are triggers
 Hand washing
Modifiable Risk Factors
 Crohn disease
 Diet low in refined sugars
 Increased fiber intake
 Smoking cessation
 Gallstone formation
 Maintain an appropriate weight
 Diet high in fiber and low in fat
 Avoid rapid weight loss
 Nephritis
 Diabetes mellitus
 Hypertension
 Overuse of NSAIDs
 Drug abuse
Screening
 Acute disorders with inflammation not possible
 Skin testing identifies allergen
 TSH test for Hashimoto thyroiditis
Nursing Assessment
 History
 Risk
 Client report that suggests inflammation
 Physical assessment
  Signs, symptoms vary according to area
 Widespread inflammation
 Diverse symptoms
 Assessment interview
Diagnostic Tests
 Erythrocyte sedimentation rate (ESR)
 Normal male = 0–15 mm/h
 Normal female = 0–20 mm/h
 C-reactive protein (CRP)
 Others
 WBC with differential
 Serum protein electrophoresis
 Routine chemistry panels
Interventions and Therapies
 Aimed at reducing mobility, edema
 Elevation
 Antipyretics, anti-inflammatory medications
 Specific treatment
 Antibiotics
 Surgery
 Steroids
 Independent
 Preventing further injury
 Medications as prescribed
 Maintaining intake of liquids, nutrients
 Collaborative
 Surgery
 Pharmacologic therapy
 NSAIDs
 Corticosteroids
 Analgesics