Page 48 nursing.elitecme.com Complete Your CE Test Online - Click Here Ventilator-associated pneumonia (VAP) prevention ● ● Oral intubations are preferred to nasal unless contraindicated. ● ● Keep head elevated at 30˚ to 45° in the semirecumbent body position. ● ● Daily oral care with chlorhexidine solution of strength 0.12%. ● ● Monitor endotracheal tube cuff pressure (keep it > 20 cm H2O) to avoid air leaks around the cuff that can allow entry of bacterial pathogens into the lower respiratory tract. ● ● Closed endotracheal suction systems may be better than the open suction. ● ● Empty condensate that collects in the tubing of a mechanical ventilator. Urinary tract infection prevention ● ● Follow sterile technique for insertion of the urinary catheter. ● ● Maintain a closed drainage system. ● ● Maintain unobstructed urine flow. At all times, the urinary catheter should be placed and taped above the thigh, and the urinary bag should hang below the level of the bladder. ● ● The urine collection bag should never make contact with the floor. ● ● Changing indwelling catheters or drainage bags at fixed intervals is not recommended. Change only if there are clinical indications, such as infection or obstruction, or when the closed system is compromised. ● ● Reevaluate the need for the catheter at least daily, and remove the catheter when it is no longer needed. Catheter-related bloodstream infection (CRBSI) prevention ● ● A care bundle for central lines should be implemented, including staff education, catheter insertion cart, and a checklist for guidelines of insertion according to evidenced-based guidelines. ● ● Nurses should ensure proper procedure is followed and speak up if they notice a discrepancy. ● ● Use of maximal sterile barriers should be employed during the procedure: Mask, cap, sterile gown, and draping of the patient. ● ● Use of a chlorhexidine-based antiseptic for skin preparation before insertion and subsequent catheter care is suggested. ● ● Daily assessment should include site evaluation for redness and tenderness and appropriateness of possible removal of device. Nursing consideration: The prompt removal of any unnecessary invasive medical device will lessen the likelihood for infection development. The nurse should ensure that any unnecessary invasive devices are promptly removed as per physician order or institution protocol. Surgical site infection prevention ● ● Administer antimicrobial prophylaxis 1 hour before surgical procedure to maximize tissue concentration. Vancomycin and fluoroquinolones may be administered 2 hours before. ● ● Hair removal is recommended only if the hair will interfere with the surgical procedure. Hair should be removed with electrical clippers. ● ● Glucose levels should be monitored and controlled in the immediate postoperative period for patients having cardiac surgery. Glucose levels should be kept < 200 mg/dL for 2 days after the procedure. ● ● Address and treat any infection remote to the surgical site infection before elective surgery. EBP alert! Glucose levels of > 200 mg/dL in the postoperative period (< 48 hours) have been linked to increased risk of surgical site infection (Zerr et al., 1997). One study showed wound infection 3 times more likely in patients in the postoperative period with a glucose level > 300 mg/dL than in other patients ( Latham, Lancaster, Covington, & Pirolo, 2001). Hand washing Health care-associated, or nosocomial, infections are responsible for many cases of sepsis. Proper hand hygiene is important in the reduction of the spread of infection. Inadequate hand washing or improper technique is considered by the Centers for Disease Control to be an important risk factor for the development of infection, along with severity of patient’s illness, sanitization of equipment and environment, and adhering to proper infection control guidelines when performing invasive procedures, such as inserting central lines (CDC, 2002; Joint Commission, 2009). Pathogens can be present on normal skin flora and can be transferred during normal “clean” activities, such as taking a patient’s pulse or blood pressure, if proper hand washing does not occur between patients. Perineal and inguinal areas are the most colonized by pathogens. But Staphylococcus aureus, Proteus mirabilis, Klebsiella, and Acinetobacter are also found on the axillae, trunk, and upper extremity skin, including the hands (CDC, 2002). In addition, as a result of the normal shedding of skin, bed linens, gowns, and bedside furniture can be sources of Staphylococci or Enterococci (CDC, 2002). Phones, call lights, remote controls, and pulse oximetry devices are frequently not disinfected and can act as sources of pathogens. The CDC (2002) recommends the following hand hygiene guidelines: ● ● If hands are visibly dirty, wash with soap (nonantimicrobial or antimicrobial) and water. ● ● If hands are not visibly dirty, use an alcohol-based hand rub to decontaminate hands in the following situations: ○ ○ Before direct and after patient contact. ○ ○ Before donning sterile gloves for an invasive procedure, such as central line placement. ○ ○ Before donning gloves for peripheral catheter placement, urinary catheter placement, or placing other invasive devices that do not require surgery. ○ ○ After contact with a patient’s skin (taking a patient’s vital signs, lifting the patient). ○ ○ After contact with body fluids or excretions, nonintact skin, wound dressings, mucous membranes if hands are not visibly soiled. ○ ○ Before moving to a clean body site after touching a contaminated body site during care of the patient. ○ ○ After contact with inanimate objects in the same general area as the patient (tables, chairs, IV poles, computer keyboards). ○ ○ After removing gloves. For hands that are not visibly soiled, alcohol rubs are more effective than washing with antimicrobial soap (CDC, 2002). Use an alcohol- based hand sanitizer unless hands are visibly dirty, if C. difficile exposure or Bacillus anthracis is known or suspected, after contact with a patient with infectious diarrhea, before eating, and after using the restroom (Figure 1). For hands that are visibly soiled, it is recommended to wash with antimicrobial soap and water. When using an alcohol rub, thoroughly rub product into hands, and rub until product is dry. When using soap and water, wash hands thoroughly for a minimum of 15 seconds. Nursing consideration: Nurses should remember to wash their hands frequently during, before, and after patient care to reduce the spread of nosocomial infections. Wearing gloves does not replace the need to wash hands! Educating patients and families One very important role that nurses perform in and out of the health care setting is patient and family education. General awareness and spreading the word about sepsis and sepsis symptoms provides critical information for the public so that early symptoms are not ignored or minimalized and care can be started earlier, allowing for a better outcome. The Global Sepsis Alliance has started an initiative known as World Sepsis Day to increase general awareness of sepsis. Nurses can relay important educational information to patients and their families to prevent, recognize, and report symptoms of infection promptly. In the hospital setting, for example, a medical surgical nurse