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Файл:Clinical nursing practice. Study aid for foreign students of medical university
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61
Action
Rationale
6. Place a container for “sharps”
in the room
To contain contaminated “sharps”
within the infected area. When
the container is full, it should
be disposed of by incineration,
according to infection control
guidelines
7. Keep the patient's personal
property to a minimum. Advise him
or her to wear hospital clothing.
All belongings taken into the room
should be washable, cleanable or
disposable
The patient's belongings may
become contaminated and cannot
be taken home unless they
are washable or cleanable.
Anything else may have
to be destroyed
8. If at all possible, provide
the patient with his or her
own thermometer
and sphygmo-manometer, water
jug, glass and all items necessary
for attending to personal hygiene
Equipment used regularly
by the patient should be kept
within the infected area to prevent
the spread of infection
9. Keep wound dressing solutions,
creams and lotions to a minimum
and store them within the room
All partially used materials must
be discarded when barrier nursing
ends (sterilization is not possible),
therefore unnecessary waste
should be avoided
10. Set up a trolley outside the
door to hold plastic gowns, aprons,
gloves and bactericidal alcoholic
hand rub, if used
Staff are more likely to use
equipment if it is readily available
62
Attending to the patient
Action
Rationale
1. Meals and crockery.
Non-disposable crockery,
a personal water jug and glasses
should be kept at the bedside. They
should be washed separately from
the rest of the ward's utensils,
preferably in a dishwasher with
a hot disinfecting cycle. Uneaten
food should be discarded
in the appropriate refuse bag
Contaminated crockery
is a potential disease vector.
Cleaning can be difficult
and time-consuming. Separation
of contaminated crockery reduces
the risk of the spread of infection
in washing up water. Where
a dishwasher with a disinfecting
rinse (82 °C.) is not available, all
crockery must be washed in boiling
water with an appropriate
detergent
2. Excreta.
Ideally a toilet should be kept
solely for the patient's use. If this
is not available, a separate bedpan
or urinal and commode should
be left in the patient's room.
Gloves should be worn by staff
when dealing with excreta. Urine,
faeces and vomit should be
disposed of immediately according
to local infection control policy
guidelines. Bedpans and urinals
should be “bagged”
in the isolation room, emptied
down a sluice drain and washed
in a heat-disinfecting bedpan
washer, dried and returned
immediately to the patient's room
To minimize the risk of infection
being spread from excreta,
for example, via a toilet seat
or bedpan. If a heat disinfecting
bedpan washer is not available,
the excreta should be disposed
of down a sluice drain
and the receptacle cleaned,
wearing gloves and using
an appropriate detergent and very
hot water (82 °C)
63
Action
Rationale
3. Accidental spills.
Any suspected contaminated fluids
must be mopped up immediately
and the area cleaned
with disinfectant
Damp areas encourage microbial
growth and increase the risk
of spread of infection
4. Patient hygiene and bathing.
An infected patient must be bathed
last on the ward. Clean the bath
after the previous patient and after
the infected patient. If the patient
has infected lesions, disinfectant
may be added to the bath water.
Salt is not a disinfectant and has
little antibacterial effect
The numbers of some
microorganisms on the skin
will be reduced by using
an antiseptic detergent for skin
and hair washing (this has been
shown to be effective
in eradicating the carriage
of methicillin resistant
Staphylococcus aureus.
The antiseptic should be applied
directly to the flannel and rinsed
off thoroughly. Assessment
and evaluation of patients must
be made to establish which
patients will benefit most from
a standard bath and which
patients, for example, those with
indwelling intravenous lines, will
benefit from a shower bath. Studies
comparing standard baths with
shower baths showed no overall
significant difference between
the two bathing techniques
64
Action
Rationale
5. Wound Dressings.
Aseptic technique must be used
for changing all dressings. Waste
materials and dressings should
be discarded in the appropriate
refuse bag/container. Used
solutions, lotions and creams must
be kept in the room and not used
for other patients
Aseptic procedure minimizes
the risk of cross-infection. Lotions
and creams can become easily
contaminated
6. Linen.
Place linen in a separate laundry
bag, -which must be secured
tightly before it leaves the room.
Just outside the room, place this
bag into another bag which should
be secured tightly and not used
for other patients.
The contaminated laundry is thus
effectively “double bagged”. These
bags should await laundry
collection in a safe area
“Double bagging”, preferably
in polythene bags, confines
organisms. The use of color coding
or biohazard notices on these bags
allows staff handling the linen
to recognize the potential hazard
and handle the linen accordingly
3. Cleaning the room
Action
Rationale
1. Domestic staff must understand
why barrier nursing is required
and should be instructed
on the correct procedure
To reduce the risk of mistakes
and to ensure that barrier nursing
is maintained. Good liaison with
cleaning and domestic staff
is essential to maintaining
barrier-nursing precautions.
Scrupulous daily cleaning
of the barrier nursing room
is essential
65
Action
Rationale
2. The area where barrier nursing
is being carried out must
be cleaned last
To reduce the risk of transmission
of organisms
3. Separate cleaning equipment
must be kept for this area.
If the patient is in a single room,
a mop, bucket, cleaning fluid
and disposable cloths should
be kept solely for use in this room
Cleaning equipment can easily
become infected and crossinfection may result from shared
cleaning equipment. If the patient
is in a general ward, special care
must be taken with the cleaning
so that potentially infectious
material is not transferred from
the area around the infected
patient to other patient areas
4. Members of the domestic staff
must wear gloves and plastic
aprons
To reduce the risk of crossinfection
5. Floor (hard stir face). This must
be washed daily with a disinfectant
as appropriate. All excess water
must be removed
Daily cleaning will keep
the bacterial count reduced.
Organisms, especially Gramnegative bacteria, multiply quickly
in the presence of moisture
6. After use, the bucket must
be cleaned, dried and stored within
the barrier-nursing area
Bacteria will not survive on clean,
dry surfaces
7. Ideally mop heads should
be laundered in a hot wash each
day. When this is not possible,
the mop must be washed
and rinsed, with all excess water
removed and stored with the mop
head uppermost to allow for quick
drying, within the barrier —
nursing area
Mop heads become contaminated
easily
66
Action
Rationale
8. Floor (carpet). An infected
patient may have been admitted
to a room with a carpet. A vacuum
cleaner should be used which
is fitted with an efficient filter.
After use, the dust bag must
be changed and the brush head
washed and dried. On the patient’s
discharge, the carpet must
be steam cleaned
Vacuum cleaning reduces the dust
thus reducing organisms. Bacteria
can survive in dust trapped
in the carpet fibers. The heat
of the steam will kill these
bacteria
9. Furniture and fittings should
be damp-dusted using a disposable
cloth and a detergent solution
or a disinfectant if appropriate
To remove any organisms
10. The toilet, shower
and bathroom area must
be cleaned at least once a day
using a поп-abrasive hypochlorite
powder or cream. A disinfectant
is only required if soiling
of the area has occurred
Non-abrasive powders or creams
preserve the integrity
of the surfaces. These areas
decontaminate rapidly after
cleaning and routine chemical
disinfection is of little value
and should be saved for terminal
cleaning
4. Discharging the patient
1. Inform the microbiologist
or hospital hygienist when
the patient is due for discharge
The hygienist will advise on any
special precautions
2. The room should be stripped
and aired. All textiles must
be changed and curtains
and screens sent to the laundry
Curtains readily become colonized
with bacteria
67
3. Impervious surfaces such
as lockers, stools, blinds
and thermometer holders, should
be washed with soap and water
Wiping of surfaces is the most
effective way of removing
contaminants. Relatively
inaccessible places such
as ceilings, may be omitted. These
are not generally relevant to any
infection risk
4. The floor must be washed
and dried thoroughly
To remove any organisms present.
The floors of hospital wards
become easily contaminated
by large numbers of bacteria
Exercise. Nursing procedure guidelines for “Leaving the room”
Contact your local hospital hygienist or infection control nurse and
ask them to provide you with any guidelines relating to nursing action
when leaving the barrier nursing room or area.
Using the information that you have read so far, try to identify the
rationale for each action in your local guidelines in the same way as in
the preceding example on preparing the room.
Exercise. Transporting infected patients outside the barrier
nursing area
Think about the following scenario:
You are required to transport a patient who is being barrier nursed
from the barrier-nursing room or area to another department - in this
case, the X-ray department. What precautions would you need to take
and what would be the rationale for each?
It might be helpful to consider the following broad headings:
• Communications that would be necessary.
• The information the X-ray department would require.
• The timing of the person's visit to X-ray.
• Escort arrangements and precautions.
• Transport arrangements.
68
4.2. CARING FOR PEOPLE WHO ARE IMMUNO-SUPPRESSED
The general principles and precautions aimed at preventing the
spread of infection, which have been discussed in the previous section, apply also to protective isolation (reverse barrier nursing). These are:
• Hand washing.
• Protective clothing.
• Cleaning.
• Communication.
In this instance, however, the aim of isolation is to protect the immunosuppressed patient/client from potential pathogens, rather than isolating
him or her as a source of infection. The preparation of the room in which
the person is isolated, and the maintenance of general cleanliness, are the
same. As the priority is to protect the patient/client from being exposed to
sources of infection, however, all equipment, supplies and toilet and bathroom facilities are kept for the person’s sole use, in order to protect him or
her from sources of possible infection. If facilities have to be shared, the
person should use these before other patients and only after thorough
cleaning. The rationale for action in each case remains reducing the transfer of micro-organisms and the risk of cross infection.
In this section, in order to avoid duplication, specific aspects of care
are described. The nursing guidelines address the precautions necessary for
visitors to the immuno-suppressed person and those relating to food and
drinks.
Definition. Immuno-suppression is a generalized depression of the
immune system, which increases the patient/client’s risk of acquiring an
infection. This means that patients/clients who are immuno-suppressed
must be protected form micro-organisms carried in the environment —
from health care workers providing care, from visitors and from other patients. Protection can be achieved by protective isolation, previously termed
reverse barrier nursing. Protective isolation provides a safe environment
for patients/clients who are susceptible to infection and can be an appropriate form of care for many patients, for example, people who have suffered
69
bums, children with immuno-deficiency disease and patients receiving
bone marrow transplantation. The aim of protective isolation is to prevent
and treat infection until the period of immuno-suppression is past.
When to use protective isolation. Immuno-suppression can be caused
by many factors, including:
• Primary disease, such as leukemia, lymphoma, acquired immune
deficiency syndrome, severe combined immuno-deficiency disease.
• Secondary disease, such as diabetes, which may complicate prima-
ry disease.
• Drugs, in particular, cytotoxic drugs and corticosteroids.
• Anti-microbial therapy, causing changes in the patient/client's nat-
urally occurring microbial flora.
• Irradiation therapy: the degree of immuno-suppression is related to
the area being treated.
• Trauma and bums.
• Age.
The severity and expected length of immuno-suppression should be
assessed to decide the level of protection. The following principles generally apply:
• The greater the state of immuno-suppression, the greater the need
for protection.
• The greater the environmental hazard, the more limitation must be
put on the planned nursing care.
The risk of infection will be increased by breaches in the body's natural defense mechanisms, occurring as a result of many clinical procedures.
Such procedures require nursing care of the highest standard to reduce the
risk of infection as much as practically possible. Examples include:
• Skin: for example, indwelling catheters, repeated venipuncture,
pressure sores.
• Mucous membranes: from oral ulceration.
• Body cavities, by urinary catheters or endotracheal tubes.
Some patients/clients have an increased risk of infection due to
a combination of immuno-suppressive factors. For example, a patient with
70
leukemia who is undergoing bone marrow transplantation may develop
graft-versus-host disease, which requires treatment with increased doses of
immuno-suppressive drug.
Protective isolation may be achieved by:
• Purpose-built units, if available.
• Single rooms on a general ward.
• Shared rooms within a controlled environment on a general ward.
Purpose-built units. These are expensive to build, maintain and staff.
Although evidence shows that this form of protective isolation does reduce
infection, it does not affect long-term survival. Opinion is also divided as
to whether protective isolation causes psychological damage, particularly
among pediatric patients, requiring psychological support in the form of
social workers, play therapists, teachers and psychologists. It is also suggested that nursing on a protective isolation unit, particularly with patients
undergoing bone marrow transplantation, increases the stress suffered by
nurses themselves.
Single rooms and shared rooms in general wards. This method of
protective isolation is unlikely to reduce significantly the acquisition of potential pathogens, as it only prevents person-to- person transfer of infection
and does not guarantee clean air and pathogen-free food. The decision to
isolate a patient will be influenced by the availability of facilities and the
general condition of the ward area where the isolation is to take place. In
determining the most suitable area, a number of criteria need to be met.
These include:
• The relative cleanliness of the ward.
• The standard of domestic services support.
• The microbiological status of the other patients.
• The anticipated length of the isolation.
Preventing the transmission of infection.
Exogenous infection. The prevention of cross-infection is important
and can be achieved by careful monitoring of the environment to remove
items which could predispose to infection, for example flowers. Scrupulous cleaning, with special attention to furniture and equipment within the
room, will also prevent transmission.
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