Education

1. ASEPSIS

2. Nauman Peter

3. TERMINOLOGIES
Infection
The invasion and multiplication of microorganisms such as bacteria, viruses, and
parasites that are not normally present within the body.
Infectious Agent
Infectious agents is a term that is generally used to describe and encompass any
material that can cause an infection that can lead to a disease.
Microorganisms Living animals or plants visible only with a microscope, are commonly called germs.
Disease
Detectable alteration in normal tissue function and structure. Or
A incorrectly functioning organ, part, structure, or system of the body resulting from
the effect of genetic or developmental errors, infection, poisons, nutritional
deficiency or imbalance, toxicity, or unfavorable environmental factors; illness;
sickness; ailment.

4. Non -Pathogen Micro-organisms that do not cause disease
Pathogen Micro-organisms that cause disease
Normal Resident
Flora
Some microorganisms are normal resident flora (the collective vegetation in a
given area) in one part of the body, yet produce infection in another. For
example, Escherichia coli, commonly referred to as E. coli, is a normal inhabitant
of the large intestine but a common cause of infection of the urinary tract.
Virulence /
Pathogenicity
Ability of micro-organism to cause disease
Opportunistic
Pathogen
Organism that are normally harmless can cause disease under certain
circumstances.
It only cause disease in susceptible individuals
Communicable
disease
A communicable disease is a disease that spreads/ transmits from one person or
animal to individual by direct, indirect or airborne infection.

5. TYPES OF MICRO-ORGANISAM

6. Types of Microorganisms
Microorganisms are divided into two main groups:
a. Non-pathogens or normal flora ( Do not cause Disease)
b. Pathogens (Cause Disease)
Bacteria
Viruses
Fungi
Rickettsia
Protozoans
Mycoplasmas
Helminths

8. Chain of Infection
By interfering with the conditions that perpetuate the
transmission of microorganisms, humans can avoid
acquiring infectious diseases.

9. Chain of Infection
The six essential components of the chain of infection (sequence that enables the
spread of disease-producing microorganisms) must be in place if pathogens are to
be transmitted from one location or person to another:
An infectious agent.
A reservoir for growth and reproduction.
An exit route from the reservoir.
A mode of transmission.
A port of entry.
A susceptible host.

10. CHAIN OF INFECTION

11. Reservoir
A reservoir is a place where microbes grow and reproduce, providing a haven
for their survival. Examples:
Skin
Shafts of hair
Open wounds
Blood
Lower digestive tract
Nasal passages

12. Chain of Infection
• The exit route is how microorganisms escape from their original reservoir and
move about .
• A mode of transmission is how infectious microorganisms move to another
location.
• The port of entry is where microorganisms find their way onto or into a new host,
facilitating their relocation. One of the most common ports of entry is an opening
in the skin or mucous membranes.

13. Susceptible Host
Humans become susceptible to infections when their defense mechanisms are
diminished or impaired.
A susceptible host, the last link in the chain of infection, is one whose biologic
defense mechanisms are weakened in some way.

14. Susceptible Host
• Are burn victims
• Have suffered major trauma
• Require invasive procedures such as endoscopy
• Need indwelling equipment such as a urinary catheter
• Receive implantable devices such as intravenous catheters
• Are given antibiotics inappropriately, which promotes microbial resistance
• Are receiving anticancer drugs and anti-inflammatory drugs such as
corticosteroids that suppress the immune system
• Are infected with HIV

15. TYPEs OF

16. TYPES OF INFECTIONS
• Colonization is the process by which strains of microorganisms become resident flora. In
this state, the microorganisms may grow and multiply but do not cause disease. 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.
• A local infection is limited to the specific part of the body where the microorganisms
remain.
• If the microorganisms spread and damage different parts of the body, the infection is a
systemic infection.
• Bacteremia is presence of bacteria in blood.
• Septicemia When bacteremia results in systemic infection. If bacterial infection
spread/enter in blood.

17. TYPES OF INFECTIONS
• Nosocomial infections are classified as infections that originate in the hospital.
Nosocomial infections can either develop during a client’s stay in a facility or
manifest after discharge. Nosocomial microorganisms may also be acquired by
personnel working in the facility and can cause significant illness and time lost
from work. Nosocomial infections are a subgroup of health care–associated
infections (HAIs)—those that originate in any
• Iatrogenic infections are the direct result of diagnostic or therapeutic
procedures. One example of an iatrogenic infection is bacteremia that results from
an intravascular infusion line. health care setting.

18. TYPES OF INFECTIONS
• Infection also classify on the basis of onset.
• Acute infections generally appear suddenly or last a short time.
• Chronic infection may occur slowly, over a very long period, and may last months
or years

19. BODY DEFENSES AGAINST INFECTION

20. BODY DEFENSES AGAINST INFECTION
Individuals have defenses that protect the body from infection.
These defenses can be categorized as nonspecific and specific.
Nonspecific defenses protect the person against all microorganisms, regardless of
prior exposure.
Specific (immune) defenses, by contrast, are directed against identifiable bacteria,
viruses, fungi, or other infectious agents.

21. NON SPECIFIC DEFENSE
INFLAMMATORY RESPONSE
Inflammation is a local and nonspecific defensive response of the tissues 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.
It is characterized by five signs:
• Pain
• Swelling
• Redness
• Heat
• impaired function of the part, if the injury is severe.

22. NON SPECIFIC DEFENSE
INFLAMMATORY RESPONSE
• Injurious agents can be categorized as physical agents, chemical agents, and
microorganisms.
• Physical agents include mechanical objects causing trauma to tissues, excessive heat or
cold, and radiation.
• Chemical agents include external irritants (e.g., strong acids, alkalis, poisons, and
irritating gases) and internal irritants (substances manufactured within the body such as
excessive hydrochloric acid in the stomach).
• Microorganisms include the broad groups of bacteria,viruses, fungi, and parasites.A
series of dynamic events is commonly referred to as the three stages of the inflammatory
response:
• First stage: vascular and cellular responses Second stage: exudate productionThird stage:
reparative phas

23. VASCULAR AND CELLULAR
RESPONSES
At the start of the first stage of inflammation, blood vessels at the site of injury
constrict. This is rapidly followed by dilation of small blood vessels (occurring as a
result of histamine released by the injured tissues). Thus, more blood flows to the
injured area. This marked increase in blood supply is referred to as hyperemia and is
responsible for the characteristic signs of redness and heat.

24. EXUDATE PRODUCTION
In the second stage of inflammation, the inflammatory exudate is produced,
consisting of fluid that escaped from the blood vessels, dead phagocytic cells, and
dead tissue cells and products that they release. The plasma protein fibrinogen
(which is converted to fibrin when it is released into the tissues), thromboplastin
(released by injured tissue cells), and platelets together form an interlacing network
to wall off the area, and prevent spread of the injurious agent. During this stage, the
injurious agent is overcome, and the exudate is cleared away by lymphatic drainage.

25. REPARATIVE PHASE
The third stage of the inflammatory response involves the repair of injured tissues
by regeneration or replacement with fibrous tissue (scar) formation. Regeneration is
the replacement of destroyed tissue cells by cells that are identical or similar in
structure and function. Damaged cells are replaced one by one, but the cells are also
organized so that the architectural pattern and function of the tissue are restored.

26. SPECIFIC DEFENSES
Specific defenses of the body involve the immune system. An antigen is a substance
that induces a state of sensitivity or immune responsiveness (immunity). If the
proteins originate in a person’s own body, the antigen is called an autoantigen.The
immune response has two components:
Antibody-mediated defenses
Cell-mediated defenses.

27. ASEPSIS

28. ASEPSIS
Asepsis is the freedom from disease-causing microorganisms. To decrease the possibility
of transferring microorganisms from one place to another, aseptic technique is used.
The two basic types of asepsis are medical and surgical.
Medical asepsis includes all practices intended to confine a specific microorganism to a
specific area, limiting the number, growth, and transmission of microorganisms.
In medical asepsis, objects are referred to as clean, which means the absence of almost
all microorganisms, or dirty (soiled, contaminated), which means likely to have
microorganisms, some of which may be capable of causing infection.
Surgical asepsis, or sterile technique, refers to those practices that keep an area or
object free of all microorganisms; it includes practices that destroy all microorganisms
and spores (microscopic dormant structures formed by some pathogens that are very
hardy and often survive common cleaning techniques).
Surgical asepsis is used for all procedures involving the sterile areas of the body. Sepsis is
the condition in which acute organ dysfunction occurs secondary to infection

29. MEDICAL ASEPSIS

30. Medical Asepsis
Medical asepsis means those practices that confine or reduce the numbers of
microorganisms. Also called, clean technique, it involves measures that interfere with the
chain of infection in various ways.
Principles of Medical Asepsis:
• Microorganisms exist everywhere except on sterilized equipment.
• Frequent handwashing and maintaining intact skin are the best methods for reducing the
transmission of microorganisms.

31. Medical Asepsis
• Blood, body fluids, cells, and tissues are considered major reservoirs of microorganisms.
• Personal protective equipment such as gloves, gowns, masks, goggles, and hair and shoe
covers serves as a barrier to microbial transmission.
• A clean environment reduces microorganisms.
• Certain areas—the floor, toilets, and insides of sinks—are more contaminated than
others. Cleaning should be done from cleaner to dirtier areas.

32. Medical Asepsis
Examples of medical aseptic practices include:
Using antimicrobial agents.
Performing hand hygiene.
Wearing hospital garments.
Confining and containing soiled materials appropriately.
Keeping the environment as clean as possible.

33. Using Antimicrobial Agents
Antimicrobial agents are chemicals that destroy or suppress the growth of infectious
microorganisms.
Examples are :
Antiseptics,
Disinfectants,
Anti-infective drugs.

34. Antiseptics
Antiseptics, also known as, inhibit the growth of, but do
not kill, microorganisms. An example is alcohol.

35. Disinfectants
Disinfectants, also called and, destroy active microorganisms but not spores.
Phenol, household bleach, and formaldehyde are examples.
Disinfectants rarely are applied to the skin because they are so strong. Rather, they
are used to kill and remove microorganisms from equipment, walls, and floors.

36. HandWashing
Hand washing is an aseptic practice that involves scrubbing the hands with soap,
water, and friction. Hand washing is an aseptic practice that involves scrubbing the
hands with soap, water, and friction.
Considering how often health care personnel use their hands with clients, it is no
surprise that handwashing is the single most effective way to prevent infections.

38. SURGICAL ASEPSIS

39. Surgical Asepsis
Surgical asepsis means those measures that render supplies and equipment totally
free of microorganisms. Sterile technique is those practices that avoid
contaminating microbe- free items. Surgical asepsis means those measures that
render supplies and equipment totally free of microorganisms. Sterile technique is
those practices that avoid contaminating microbe- free items.

40. Sterilization
Sterilization consists of physical and chemical techniques that destroy all
microorganisms including spores. Sterilization consists of physical and chemical
techniques that destroy all microorganisms including spores.a

41. Sterilization
Sterilization is a process that destroys all microorganisms, including spores and
viruses.
Four commonly used methods of sterilization are moist heat, gas, boiling water, and
radiation.
Moist Heat To sterilize with moist heat (such as with an autoclave), 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. It is also effective against spores. Its advantages are good
penetration and effectiveness for heat-sensitive items. Its major disadvantage is
its toxicity to humans.

42. Sterilization
Boiling Water This is the most practical and inexpensive method for sterilizing in
the home. The main disadvantage is that spores and some viruses are not killed by
this method. Boiling a minimum of 15 minutes is advised for disinfection of articles
in the home at 212°F (100°C) .Boiling water is a convenient way to sterilize items
used in the home. To be effective, contaminated equipment needs to be boiled for
15 minutes at 212°F (100°C)
Radiation Both ionizing (such as alpha, beta, and x-rays) and nonionizing
(ultraviolet light) radiation are used for disinfection and sterilization. The main
drawback to ultraviolet light is that the rays do not penetrate deeply. Ionizing
radiation is used effectively in industry to sterilize foods, drugs, and other items
that are sensitive to heat. Its main advantage is that it is effective for items
difficult to sterilize; its chief disadvantage is that the equipment is very expensive

43. Other method of Sterilization
Free-flowing steam is a method in which items are exposed to the heated vapor
that escapes from boiling water. Free-flowing steam is a method in which items are
exposed to the heated vapor that escapes from boiling water.
Dry heat, or hot air sterilization, is similar to baking items in an oven.To destroy
microorganisms with dry heat, temperatures of 330°to 340°F (165° to 170°C) are
maintained for at least 3 hours.

44. Infection Prevention and Control
The isolation guidelines contain a two-tiered approach.
Standard precautions (SP).
Universal precautions (UP)

45. Standard Precautions
Standard precautions are used in the care of all hospitalized individuals regardless of
their diagnosis or possible infection status. They are used in any situations involving
blood, all body fluids, excretions, and secretions except sweat (whether or not blood
is present or visible), non-intact skin, and mucous membranes. SP include
Hand hygiene
Use of personal protective equipment (PPE), which includes gloves, gowns,
eyewear, and masks;
Safe injection practices;
Safe handling of potentially contaminated equipment or surfaces in the client
environment;
Respiratory hygiene/cough etiquette.

46. Respiratory Hygiene/ Cough Etiquette
The CDC-published recommendations reinforce the need for effective hand
hygiene, use of personal protective equipment, and environmental controls.
They also include respiratory hygiene/ cough etiquette that calls for covering the
mouth and nose when sneezing or coughing, proper disposal of tissues, and
separating potentially infected individuals from others by at least 1 m (3 ft) or having
them wear a surgical mask. Health care professionals use SP when providing care to
all clients. That is, the risk of caregiver exposure to client body tissues and fluids
rather than the suspected presence or absence of infectious organisms determines
the use of clean gloves, gowns, masks, and eye protection.

48. Isolation
Isolation refers to measures designed to prevent the spread of infections or
potentially infectious microorganisms to health personnel, clients, and visitors.
Several sets of guidelines have been used in hospitals and other health care settings.
Category-specific isolation precautions use seven categories: strict isolation, contact
isolation, respiratory isolation, tuberculosis isolation, enteric precautions,
drainage/secretions precautions, and blood/ body fluid precautions. Disease-specific
isolation precautions provide precautions for specific diseases. These precautions
delineate use of private rooms with special ventilation, having the client share a
room with other clients infected with the same organism, and gowning to prevent
gross soilage of clothes for specific infectious diseases.

49. 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:
• Airborne or
• Droplet transmission
• Contact.
The three types of transmission-based precautions may be used alone or in
combination but always in addition to standard precautions.

50. Transmission-Based Precautions
Airborne precautions are used for clients known to have or suspected of having
serious illnesses transmitted by airborne droplet nuclei smaller than 5 microns.
Examples of such illnesses include measles (rubeola), varicella (including
disseminated zoster), and tuberculosis.
Droplet precautions are used for clients known to have or suspected of having
serious illnesses transmitted by particle droplets larger than 5 microns.
Examples of such illnesses are diphtheria pharyngeal); mycoplasma pneumonia;
pertussis; mumps; rubella; streptococcal pharyngitis, pneumonia, or scarlet fever in
infants and young children; and pneumonic plague.

51. Transmission-Based Precautions
Contact precautions are used for clients known to have or suspected of having
serious illnesses easily transmitted by direct client contact or by contact with items
in the client’s environment.
According to the CDC, such illnesses include GI, respiratory, skin, or wound
infections or colonization with multidrug-resistant bacteria; specific enteric
infections such as C. difficile and entero-hemorrhagic E. coli O157:H7, Shigella, and
hepatitis A, for diapered or incontinent clients; respiratory syncytial virus,
parainfluenza virus, or enteroviral infections in infants and young children; and
highly contagious skin infections such as herpes simplex virus, impetigo, pediculosis,
and scabies.

52. Transmission-Based Precautions
• Another organism requiring contact precautions is methicillin- resistant S. aureus (MRSA).
Approximately half of all MRSA infections are acquired in the hospital, one fourth are
associated with having received health care but onset is in the community; the remainder
are considered community acquired (Jarvis, Jarvis, & Chinn, 2012).
• Special contact precautions are used for vancomycin-resistant enterococci (VRE)
infections. The CDC recommends use of an antimicrobial soap for hand washing and no
sharing of equipment among clients with and without VRE. The client should have a
private room (or a room with other clients who have VRE), and such isolation should
continue until at least three cultures taken 1 week apart are negative
• For clients infected with the coronavirus that causes severe acute respiratory syndrome
(SARS-CoV), standard (including eye protection), contact, and airborne precautions are
indicated (Siegel et al., 2007).

53. PERSONAL PROTACTIVE EQUIPMENTS

54. Personal Protective Equipment
All health care providers must apply PPE (clean or sterile gloves, gowns, masks, and
protective eyewear) according to the risk of exposure to potentially infective
materials.

56. GLOVES

57. Gloves
Gloves are worn for three reasons:
First, they protect the hands when the nurse is likely to handle any body substances, for
example, blood, urine, feces, sputum, and non-intact skin.
Second, gloves reduce the likelihood of nurses transmitting their own endogenous
microorganisms to individuals receiving care. Nurses who have open sores or cuts on the
hands must wear gloves for protection.
Third, gloves reduce the chance that the nurse’s hands will transmit microorganisms from
one client or an object to another client. In all situations, gloves are changed between
client contacts.
The hands are cleansed each time gloves are removed for two primary reasons:
The gloves may have imperfections or be damaged during wearing so that they could
allow microorganism entry
the hands may become contaminated during glove removal.

58. FACE MASK

59. Face Masks
Masks are worn to reduce the risk for transmission of organisms by the droplet contact and airborne
routes and by splatters of body substances.The CDC recommends that masks be worn:
By those close to the client if the infection (e.g., measles, mumps, or acute respiratory diseases in
children) is transmitted by
large-particle aerosols (droplets). Large-particle aerosols are transmitted by close contact and generally
travel short distances (about 1 m, or 3 ft).
By all individuals entering the room if the infection (e.g., pulmonary tuberculosis and SARS-CoV) is
transmitted by small particle aerosols (droplet nuclei). Small-particle aerosols remain suspended in the
air and thus travel greater distances by air. Special masks that provide a tighter face seal and better
filtration may be used for these infections.
Various types of masks differ in their filtration effectiveness and fit. Single-use disposable surgical
masks are effective for use while the nurse provides care to most clients but should be changed if they
become wet or soiled.These masks are discarded in the waste container after use.
Disposable particulate respirators of different types may be effective for droplet transmission, splatters,
and airborne microorganisms. Some respirators now available are effective in preventing inhalation of
tuberculin organisms.
The National Institute for Occupational Safety and Health tests and certifies such respirators. Currently,
the category “N” respirator at 95% efficiency (referred to as an N95 respirator) meets tuberculosis,
SARS, and influenza control criteria.

60. EYEWEARS

61. Eyewear
Eyewear Protective eyewear (goggles, glasses, or 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.

62. Disposal of Soiled Equipment and
Supplies
Many pieces of equipment are supplied for single use only and are disposed of after
use. Some items, however, are reusable. Agencies have specific policies and
procedures for handling soiled equipment (e.g., disposal, cleaning, disinfecting, and
sterilizing); the nurse needs to become familiar with these practices in the
employing agency. Appropriate handling of soiled equipment and supplies is
essential for these reasons:
To prevent inadvertent exposure of health care workers to articles contaminated
with body substances
To prevent contamination of the environment.

63. Bagging
Articles contaminated, or likely to have been contaminated, with infective material
such as pus, blood, body fluids, feces, or respiratory secretions need to be enclosed
in a sturdy bag impervious to microorganisms before they are removed from the
room of any client. Some agencies use labels or bags of a particular color that
designate them as infective wastes. CDC guidelines recommend the following
methods

64. Linens
Handle soiled linen as little as possible and with the least agitation possible before
placing it in the laundry hamper. This prevents gross microbial contamination of the
air and individuals handling the linen. Close the bag before sending it to the laundry
in accordance with agency practice.

65. Laboratory Specimens
Laboratory specimens, if placed in a leak-proof container with a secure lid with a biohazard label,
need no special precautions. Use care when collecting specimens to avoid contaminating the
outside of the container.
Dishes require no special precautions. Soiling of dishes can largely be prevented by encouraging
clients to cleanse their hands before eating. Some agencies use paper dishes for convenience,
which are disposed of in the refuse container.
Blood Pressure Equipment Blood pressure equipment needs no special precautions unless it
becomes contaminated with infective material. If it does become contaminated, follow agency
policy to decontaminate it. Cleaning procedures vary according to whether it is a wall or portable
unit. In some agencies, a disposable cuff is used for clients placed on contact precautions.
Thermometers Non-disposable thermometers are generally disinfected after each use. Check
agency policy.
Disposable Needles, Syringes, and Sharps Place needles, syringes, and “sharps” (e.g., lancets,
scalpels, and broken glass) into a puncture-resistant container. To avoid puncture wounds, use
approved safety or needleless systems and do not detach needles from the syringe or recap the
needle before disposal.a

66. STANDARD PRECAUTIONS

67. Standard Precautions
Transporting Clients with Infections
Avoid transporting clients with infections outside their own rooms unless absolutely necessary. If
a client must be moved, the nurse implements appropriate precautions and measures to prevent
contamination of the environment. For example, the nurse ensures that any draining wound is
securely covered or places a surgical mask on the client who has an airborne infection. In addition,
the nurse notifies personnel at the receiving area of any infection risk so that they can maintain
necessary precautions. Follow agency protocol.
Psychosocial Needs of Isolation Clients
Clients requiring isolation precautions can develop several problems as a result of the separation
from others and of the special precautions taken in their care. Two of the most common are
sensory deprivation and decreased self-esteem related to feelings of inferiority. Sensory
deprivation occurs when the environment lacks normal stimuli for the client, for example,
communication with others. Nurses should therefore be alert to common clinical signs of sensory
deprivation: boredom, inactivity, slowness of thought, daydreaming, increased sleeping, thought
disorganization, anxiety, hallucinations, and panic.

68. Standard Precautions
SterileTechnique
An object is sterile only when it is free of all microorganisms. It is well known that
sterile technique is practiced in operating rooms and special diagnostic areas. Less
known perhaps is that sterile technique is also employed for many procedures in
general care areas (such as when administering injections, changing wound
dressings, performing urinary catheterizations, and administering intravenous
therapy). In these situations, all of the principles of surgical asepsis are applied as in
the operating or delivery room; however, not all of the sterile techniques that follow
are always required.
For example, before an operating room procedure, the “scrub nurse” generally puts
on a mask and cap, performs a surgical hand scrub, and then applies a sterile gown
and gloves.

69. Standard Precautions
Sterile Field
A sterile field is a microorganism-free area. Nurses often establish a sterile field by
using the innermost side of a sterile wrapper or by using a sterile drape.When the
field is established, sterile supplies and sterile solutions can be placed on it. Sterile
forceps are used in many instances to handle and transfer sterile supplies. So that
sterility can be maintained, supplies may be wrapped in a variety of materials.
Commercially prepared items are frequently wrapped in plastic, paper, or glass.
Sterile liquids (e.g., sterile water for irrigations) are preferably packaged in amounts
adequate for one use only because once a container has been opened, there is no
assurance that it will remain sterile. Any leftover liquid is discarded.

70. NURSING MANAGEMENT
Assessing
During the assessing phase of the nursing process, the nurse obtains the client’s
history, conducts the physical assessment, and gathers laboratory data.
Nursing History
During the nursing history, the nurse assesses (a) the degree to which a client is at
risk of developing an infection and (b) any client complaints suggesting the presence
of an infection. To identify clients at risk, the nurse reviews the client’s chart and
structures the nursing interview to collect data regarding the factors influencing the
development of infection, especially existing disease process, history of recurrent
infections, current medications and therapeutic measures, current emotional
stressors, nutritional status, and history of immunizations (see the Assessment
Interview later in this section).

71. NURSING MANAGEMENT

72. Physical Assessment
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. Commonly the skin and mucous membranes are involved
in a local infectious process, resulting in the following:
Localized swelling
Localized redness
Pain or tenderness with palpation or movement
Palpable heat at the infected area
Loss of function of the body part affected, depending on the site and extent of
involvement.
In addition, open wounds may exude drainage of various colors.

73. Diagnosing
The NANDA nursing diagnostic label for problems associated with the transmission of microorganisms
Inadequate primary defenses such as broken skin, traumatized tissue, decreased ciliary action, stasis of
body fluids, change in pH of secretions, or altered peristalsis
Inadequate secondary defenses such as leukopenia, immunosuppression, decreased hemoglobin, or
suppressed inflammatory response.
Potential Complication of Infection:
Fever
Imbalanced Nutrition: LessThan Body Requirements if the client is too ill to eat adequately
Acute Pain if the client is experiencing tissue damage and discomfort
Impaired Social Interaction or Social Isolation if the client is required to be separated from others during
a contagious episode
Anxiety if the client is apprehensive regarding changes in life activities resulting from the infection or its
treatment such as absence from work or inability to perform usual functions.

74. Planning
The major goals for clients susceptible to infection are to:
Maintain or restore Avoid the spread of infectious organisms.
Reduce or alleviate problems associated with the infection. Desired outcomes
depend on the individual client’s condition.
Nursing strategies to meet the three broad goals generally include using
meticulous medical and surgical aseptic techniques to prevent the spread of
potentially infectious microorganisms, implementing measures to support the
defenses of a susceptible host, and teaching clients about protective measures to
prevent infections and the spread of infectious agents when an infection is
present. defenses.

75. Implementing
The nurse implements strategies to prevent infection. If infection cannot be
prevented, the nurse’s goal is to prevent the spread of the infection within and
between individuals, and to treat the existing infection. In the sections that follow,
nursing activities are described that interfere with the chain of infection to prevent
and control transmission of infectious organisms, and that promote care of the
infected client.

76. Evaluating
Using data collected during care—vital signs, lung sounds, skin status, characteristics of urine
or other drainage, laboratory blood values and so on—the nurse judges whether client
outcomes have been achieved. If outcomes have not been achieved, the nurse may need to
consider questions such as the following:
Were appropriate measures implemented to prevent skin breakdown and lung infection?
Was strict aseptic technique implemented for invasive procedures?
Are prescribed medications affecting the immune system?
Is client placement appropriate to reduce the risk of transmission of microorganisms?
Did the client and family misunderstand or fail to comply with necessary instructions?