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Файл:Clinical nursing practice. Study aid for foreign students of medical university
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this, and fear it in some cases, but they also understand, through their own
experiences, the complexity of the pain experience.
The development of effective interventions for pain relief depends
not only on our better understanding of the physiological processes involved, but also on nurses and other health care workers starting from the
point of believing that “pain is what the experiencing person says it is”.
Patients/clients need this to be the minimum standard of care that they can
expect. A problem-solving approach, based on a willingness to be open
minded about a whole range of strategies and interventions, is necessary to
finding solutions with patients/clients to their pain experiences.
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4. CARING FOR PEOPLE WHO HAVE AN INFECTIOUS
CONDITION OR ARE IMMUNO-SUPPRESSED
4.1. INTRODUCTION
In this section we explore developments in nursing related to:
• Barrier nursing (source isolation) of people who have an infectious
condition.
• Clinical guidelines for source isolation.
• Nursing patients/clients who are immuno-suppressed in the hospi-
tal setting.
• Guidelines relating to the care of people with human immunodefi-
ciency virus (HIV infection) and acquired immune deficiency syndrome
(AIDS).
The learning objectives for this section are:
1. To increase your understanding of the principles of barrier nurs-
ing in the care and management of patients/clients who have infectious
conditions.
2. To increase your understanding of the principles of reverse-barrier
nursing (protective isolation) in relation to the management of patients/
clients who are immuno-suppressed.
3. To develop your knowledge of HIV and AIDS.
Barrier nursing. Barrier nursing, or source isolation, means using
practices aimed at controlling the spread of and destroying pathogenic organisms. These practices may require the setting up of mechanical barriers
to contain the pathogenic organisms within a specified area.
Exercise
1. Try to recall the last time that you were involved in barrier nursing a patient/client. Write out what you remember in response to as many
of the questions below as you are able to answer.
What was the nature of the person's infection?
Where was the person nursed? In a single room or a corner of the
main ward?
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What explanation was given to the person to help them understand:
- why he or she needed to be barrier nursed?
- what was required of the person in order to maintain the safety
precautions?
What precautions were taken in relation to each of the following?
- the care of other patients;
- allocation of staff to care for the person;
- hand-washing technique;
- the use of protective clothing;
- dealing with waste materials from the person and the person's
excreta;
- cleaning of the environment in the barrier nursing area.
How effective do you think the precautions were?
Could they have been improved in any way?
Did everyone observe the precautions and follow the required
procedures?
How was this monitored?
Who was responsible for monitoring standards of practice in relation to maintaining the precautions? If no-one was responsible, what effect did this have?
How did the person react psychologically to the experience of being barrier nursed?
2. Refer back to the notes you have made as you work through the
rest of this section. Use the research findings and theory presented in the
section to reflect critically on your own nursing practice. Analyze the
strengths and weaknesses of your practice in relation to:
• Your own personal standards of practice.
• Other people's standards The level of knowledge and awareness
among staff about sources of infection and possible routes of infection —
is there a common knowledge base and understanding?
• How did practice in your work setting exceed the level described
in the guidelines? In which aspects did practice fall short of the
guidelines.
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• How did the environment in which you were working — for ex-
ample, staffing levels, space, equipment and other resources — affect the
quality of barrier nursing which you provided?
• Would this be any different in your current work setting?
• What changes would be necessary in order to achieve the prac-
tice described in the “nursing guidelines”?
• At what levels would change be required?
When barrier nursing is used. Most precautions against transferring
infection demand more effort, take more time and cost more than the comparable procedures in normal circumstances. Barrier nursing is required:
1. To prevent the spread of infection from patients with communica-
ble diseases (for example, contagious diseases such as glandular fever, or
infectious diseases such as chicken pox, COVID 19)
2. To prevent the spread of infection from patients infected with or-
ganisms which are resistant to the usual range of antibiotics; such as methicillin resistant Staphylococcus aureus (MRSA).
3. Protective isolation (or reverse barrier nursing) is used to protect
those patients whose susceptibility to infection is increased, for example,
people who are immuno-suppressed.
Sources of infection:
• Self-infection (endogenous infection) occurs when tissue becomes
infected from another site on the person's body.
• Cross infection (exogenous infection) may be caused by infection
from patients/clients, hospital staff or visitors who are suffering from the
relevant disease or who are symptom-free carriers of a pathogenic organism. Food and the environment may also be factors in cross-infection
Routes of transmission and reservoirs of infection.
A reservoir of infection is anywhere where organisms can survive
and multiply, for example a wound, or environmental reservoirs such as
ventilation systems, food and clinical waste). For infection to occur, there
has to be a route of transmission between the reservoir and a susceptible host.
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Routes of transmission of organisms include the following:
• Direct contact: where there is direct transmission to susceptib-
le people by contaminated equipment or by the hands of health care attendants.
• Air-borne: transmission in dust or skin scales carried by air. For
example, through water droplets or during procedures such as bedmaking,
when particles may land directly on open wounds or puncture sites.
• Food-borne: when contaminated foods are ingested, for example
foods contaminated with Salmonella species.
• Blood-borne: through inoculation accidents, existing breaks in the
skin, gross contamination of mucous membranes, infected blood products,
sexual activity or prenatally from mother to baby.
• Insect-borne: through insect bites and through contamination of
food and sterile supplies with pathogenic organisms carried in the bodies
and digestive tract of non-biting insects such as cockroaches.
Types of barrier nursing:
1. Protective isolation or reverse barrier nursing. This is discussed in
detail Caring for people who are immunosuppressed.
2. Source isolation: This is designed to prevent the spread of patho-
genic micro-organisms from an infected person to others. The decision to
isolate a patient/client will be influenced by the availability of facilities, as
well as by the physical condition of the area where the isolation is to take
place. In determining the most suitable area, a number of criteria need to
be met. Among these are the relative cleanliness of the ward, the standard
of domestic services support, the microbiological status of the other patients and the anticipated length of the isolation.
Source isolation may be achieved by:
• Purpose-built infectious disease wards.
• Plastic isolators found in some highly specialist settings and re-
served for very specific infection’s (such as the viral haemorrhagic infec-
tion — Lassa fever).
• Single rooms on general wards.
• With good technique, an area of a ward away from especially vul-
nerable patients can be used.
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• In some instances, where cross-infection has already occurred, it
may be appropriate to care for a group of patients together in a small ward
with designated staff, rather than using side-rooms on different wards —
so-called cohort isolation. Uninfected patients must not be admitted into
this area until all the infected patients have been discharged and the area
thoroughly cleaned.
General principles of barrier nursing. The most important issues in
successful barrier-nursing procedures are hand washing and protection of
clothes. Several general principles need to be maintained if effective barrier nursing is to occur. Every effort must be made to ensure that instructions are kept simple and realistic. Regular assessment and evaluation of
the situation must take place to see whether barrier nursing continues to be
the most appropriate form of care.
a) Recommendations for hand-washing. Hands must be washed after
direct patient contact or after contact with contaminated material, for example, toys, bed linen, etc. and before contact with susceptible patients.
They must be dried thoroughly, preferably using a good quality, disposable
paper towel.
b) Recommendations for protective clothing. See tab. 3.
Table 3
Recommendations for protective clothing
Protective
Clothing
Comments
Gowns or aprons
Wearing a protective gown or apron is an accepted part
of carrier-nursing technique, to prevent the spread
of microorganisms from one patient/client to another via clothing,
disposable plastic aprons are impermeable to bacteria and water,
if these are available, they should be used in preference to cotton
gowns for “dirty” procedures
Gloves
Clean gloves should be worn when handling blood or body
liquids, or when cleaning. These are not a substitute for hand
washing, however and hands must be washed with bactericidal
soap and water after removing gloves
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Protective
Clothing
Comments
Caps
Hair that is clean and tidy has not been implicated
in crossinfection. Therefore, unless heavy contamination
or splashing is present, wearing caps is not necessary
Masks
The rationale for wearing masks is that they protect the wearer
from inhaling airborne micro-organisms. Studies have indicated,
however, that masks are generally of little value. Masks
are sometimes worn when handling patients with viral
and bacterial meningitis or those patients with pulmonary
tuberculosis who are smear-positive, have a productive cough
and are unable to cover their mouth and nose when coughing
and sneezing, If they are worn, masks must be a filter type and fit
the face closely
Overshoes
Wearing overshoes has been found to have little value and may
even increase the risk of contaminating the hands when putting
on or taking off overshoes. If air-borne transmission
of microorganisms is a potential risk, a dry dust control mat
placed at the patient's door, which is vacuumed daily and washed
weekly, will be an effective means of limiting the spread
of infection by feet and trolley wheels
c) Further precautions include:
• Cleaning.
• Patient hygiene.
• Safe handling of contaminated items and waste.
• Linen.
• Cutlery and crockery.
• Urine, faeces and vomit.
d) Communications. Effective communication is important in insti-
gating barrier-nursing precautions promptly and in ensuring that all those
affected are aware of the precautions and what is required of them. This
includes:
Notification of infection. If a patient develops suspicious signs and
symptoms or if bacteriological analysis identifies an organism which necessitates barrier nursing, swift communication and prompt action are re-
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quired to put this into action. Any problems should be discussed with the
microbiologist, hospital hygienist or, if available, the infection control
nurse.
Liaison with domestic and cleaning staff:
• Communication within the nursing team and staff allocation. Ef-
fective communication to all members of the nursing team is essential, not
only for the maintenance of barrier-nursing precautions but also to protect
staff against the risk of infection. A minimum number of staff should be
involved in caring for an infected patient. The nurse concerned with the infected patient should not care for other susceptible patients. If the barrier
nursing is for an infectious disease, it is preferable that only personnel who
have already had the disease should attend the patient. Where staffing and
other requirements for effective barrier nursing cannot be met, patients
who require barrier nursing should be transferred to an environment where
it can be carried out.
• Informing the patient and their family/visitors. Perhaps most im-
portant of all is careful and effective communication with the person who
is to be barrier nursed and any family members or friends who visit. Their
co-operation with the restrictions is vital, but the psychological implica-
tions of being labelled “infectious” and of being confined in isolation, as
well as other possible consequences of the patient’s illness should not be
underestimated. For the person who is being barrier nursed the impact may
be considerable, including:
- delayed or prevented recovery;
- increased pain, discomfort and anxiety;
- extended hospitalization, with its emotional, practical and econom-
ic implications for the person, family and the hospital;
- psychological stress due to long periods spent in isolation.
Providing sensitive and careful explanations to the person is essential
so that they can co-operate with the restrictions. The patient's visitors must
also be informed why the barrier-nursing restrictions are necessary and
must be given an opportunity to ask questions and discuss any fears or
anxieties. Visitors will generally be allowed in the room at the discretion
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of the microbiologist. They need to be taught to observe the correct procedures for entering and leaving the room. As children are more susceptible
to infection than adults, any visit by a child should be discussed with the
patient and the appropriate personnel.
Clinical nursing procedures guidelines: source isolation.
Example
Equipment:
1. Isolation suite, if possible — with:
a) an anteroom for protective clothing;
b) hand-washing facilities;
c) toilet facilities.
2. All items required to meet the patient's needs during the period of
isolation, such as crockery, linen, instruments to assess vital signs.
Procedure:
Preparation of the isolation room (Note: This is a hospital standard
from the UK)
Action
Rationale
1. Place a “barrier nursing” sign
outside the door.
To inform anyone intending
to enter the room of the situation
2. List requirements for personnel
before entering and after leaving
the isolation area.
To decrease the number of entries
and exits to the room
3. Remove all non-essential
furniture. The remaining furniture
should be easy to clean and should
not conceal or retain dirt
or moisture either within
or around it
To minimize the risk of furniture
harboring microbial spores or
growth colonies
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Action
Rationale
Stock the hand basin — with
a suitable antibacterial detergent
or soap preparation and paper
towels (if possible) for staff use
Facilities for hand washing within
the infected area are essential for
effective barrier nursing. Washing
the skin removes harmful
organisms quickly. Studies of hand
washing by nurses and others have
shown that this procedure
is generally not carried out
efficiently. The use of disinfectants
improves the cleaning process,
but no method of chemical
disinfection will produce a sterile
hand. Soaps and detergent
emulsions containing
hexachlorophene build
a protective barrier in the skin
against gram-positive organisms.
A widely used solution is one
containing 4 % chlorhexidine.
Washing in running water
is essential. Basins should be deep
enough to contain any splashing
water and should be without plugs.
Taps should not be operated
by hand but by elbow, knee or foot
as appropriate
5. Place a clinical waste bag
in the room, preferably
on a foot-operated stand. The bag
must be sealed with tape before
it is removed from the room
For containing contaminated
rubbish within the room.
The appropriate nationally
recognized color for clinical waste
should be used, where such
a system has been adopted
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