The writer has chosen to base this assignment on the transmission of infection and implications in clinical practise. This will has been attempted by discussing infection, its causes and the ways it is transmitted. Followed by an investigation of the immune system, its' response to infection and who is most at risk. Implications in clinical practise were investigated, then related to an incident in clinical practise.
This assignment was a good opportunity to gain a better understanding of infections and the methods of control. The clinical experience the writer will focus upon was an elderly female who is fully mobile but slightly confused. In accordance with the 1992 UKCC Code of Professional Conduct, clause 10 the clients actual name and placement setting will not be disclosed in order to maintain confidentiality. The client has been named Julie. Julie was experiencing symptoms of the Varicella Zoster Virus when admitted to the ward.
Ayliffe, Fraise, Geddes and Mitchell (2000, p1) state that the term infection is generally used to refer to the deposition and multiplication of bacteria, and other micro-organisms in tissue or on surfaces of the body with an associated tissue reaction. The four types of micro-organisms are protozoa, bacteria, viruses and fungi. "The world around us contains an assortment of viruses, bacteria, fungi and parasites capable of not only surviving but thriving in our bodies - and potentially causing us great harm" Martini (2001, p129). Micro-organisms are living creatures that can only be seen under a microscope and are called pathogens. Hinchliff and Schober and Norman (1998, p365) also includes that many are essential for our survival but a small amount cause disease by invading and damaging tissue.
"To cause an infection a pathogen must have a way to enter the body - a portal of entry" Wilson (2001, p33). Also stated is that after gaining entry the micro-organisms may spread to other tissues and be expelled by the same or different route. To transmit to another person it must leave the body. According to Hinchliff et al. (1998, p369) the main ways of transmission of pathogens are hands, airborne particles, inanimate objects, blood borne, insects, food and water. Although all of these are important, one of the main routes is from hands.
"Infection control affects every aspect of healthcare and every nurse, irrespective of the setting in which they work, should ensure that their practice incorporates a sound knowledge and understanding of basic principles" May (2000, p5).
According to Wilson (2001, p35) hands should be washed between examination of all patients. Microbes on hands are acquired through contact with excretions, secretion or infected lesions and are easily transferred through touch. "Pathogens on hands will not survive long", Wilson (2001, p34) but as our hands are constantly touching the transmission rate will be high. This simple but essential skill is very important but is often overlooked or not performed with enough care. Mallet and Balley (1996, p41) supports that hand washing is the most important procedures for preventing infections. Either a lack of knowledge or time could be to blame for this. Also that wearing rings increases that number of micro-organisms on the hands.
All patients with known or suspected infections should be isolated until test results prove there is no infection according to Hinchliff et al. (1998, p386). The patient needs to be in a separate room with both washing and toilet facilities. If a single room
is not available then patients with the same infection may be situated together. Not only is it the staff which must be clearly informed but also the visitors according to Wilson (2001, p359). They are just as likely to spread the infection and staff must ensure they understand the importance of correct behaviour. Patients must remain in their room as much as possible and only leave for essential purposes.
All dirty laundry must be kept in the room and not mixed with the laundry of the other patients. "All clinical waste must be left in the room in the same way and disposed of into a yellow bag which will later be burnt" Hinchliff et al. (1998, p383). Adequate bins, bedding and other equipment may be stored in the room so staff do not need to keep leaving the room while attending to the infected patient. Staff must adhere to universal precautions and also take care when disposing of sharps.
When a patient is given the all clear from the infection they will either be discharged or admitted to a ward. The room must then be completely cleaned and disinfected. Every surface must be cleaned and linen washed, including changing the curtains.
Damani (1997, p4) investigates that Infection Control Teams are usually resident in most hospitals and their aim is to keep infections to a minimum but be on hand if there is the unfortunate incident of an outbreak. It is stated that a contingency plan should be held in case of an outbreak. "An outbreak is two or more epidemidogically linked cases of the same infection caused by the same micro-organism in the same place" Damani (1997, p21). The team are there to give advice and ensure all the correct regulations are abided by.
According to Damani (1997, p9) one third of all hospital infections could be prevented. These high numbers cost the health service greatly and put patients health and recovery at risk. More needs to be done to ensure patients have the best chance of not acquiring an infection during their stay in hospital.
Investigations into who is at risk of infection has found there to be a wide range of people included. Hinchliff et al. (1998, p373) states that hospital patients are particularly vulnerable to infection. "Their internal defences against micro-organisms may be breached by invasive devices or medical procedures and their illnesses may impair the ability of their immune system to cope with infection" Martini (2001, p278) includes many factors including age, general health, state of nutrition, chronic stress, severe depression, traumatic injuries, burns, previous exposure to infection and vaccination. Also affecting the immune system are some types of cancer and AIDS to name just a few examples.
"The immune system provides a complex means by which the human body is able to maintain health by protecting itself against disease." Hinchliff et al. (1998, p196). "It includes the thymus, bone marrow, lymph nodes, spleen and tonsils." McFerran (1994, p230).
"If the physical barriers of the body such as the skin and mucous membranes are penetrated, then the body is still able to defend itself against potentially harmful material." Watson (2000, p356). According to Wilson (2001, p59) the external defences against infection are the skin, the respiratory tract, lysozymes, gastrointestinal tract and genitourinary tract. Wilson (2001, p61) supports that the body has internal defences also. These include the inflammation response, phagocytic cells, eosinophils, complement proteins, interferon and natural killer cells. The most noticeable of these is the inflammation response.
Hinchliff et al. (1998, p372) has found evidence that this forms the initial attack against any micro-organisms which manage to invade the body intending to destroy invaders and limit their spread to other parts of the body. Martini (2001, p134) suggests that its three goals are to perform a temporary repair, to slow the spread of pathogens and to activate total repair.
Hinchliff et al. (1998, p373) states that the immune system contains T Lymphocytes and B Lymphocytes which both play an important but different role in maintaining immunity in our bodies. According to Martini (2001, p129) the cells only provide immunity when they work together. When a foreign body enters the body, a substance is produced to deal with it. The foreign body is called an antigen and the substance produced is called an antibody. Each time T cells or B cells are activated, some become memory cells.
There are three types of T Lymphocytes all with a different responsibility according to Watson (2000, p359). T-Killer cells help ingest the foreign bodies, T-Helper cells help activate the production of antibodies and T-Memory cells are responsible for consequent specific recognition of the invasion by the antigen.
The immune system is capable of defending against a large number of antigens and immunity can be reached in a variety of ways. "Immunity is the ability to resist infection and disease through the activation of specific defences." Martini (2001, p130). There are different types of immunity: Active Immunity and Passive Immunity.
Watson (2000, p359) discusses that Active Immunity is itself achieved in many ways. The Natural form of this is gained after actually having the specific disease and being exposed to that antigen. The antibody is produced to deal with the antigen and it stays in the blood stream after the antigen has been destroyed. Antibodies belong to a large family of proteins called immunoglobulins. The antibody is ready to prevent another attack but will only recognise and protect against the same disease. Here the memory cells take effect. This can occur even if we did not realise we had had the disease as it was very mild but enough for the antibodies to be formed.
Active Artificial Immunity is given in the form of an injection to travellers and children where the disease would prove serious or fatal according to Watson (2000, p360). It is discussed that the injection consists of killed or harmless micro-organisms. The body then produces antibodies and the immunity is built up. Harmful toxins are also used. These are chemical poisons produced from micro-organisms that when harmful produce antigens. Harmless micro-organisms are called vaccines and harmless toxins are called toxoids. Many diseases are prevented by Active Artificial Immunity including whooping cough, diphtheria, measles, smallpox, poliomyelitis and tuberculosis.
Watson (2000, p360) discusses that Passive Natural Immunity is given to the foetus from the mother before birth. Passive Artificial Immunity is extremely useful. It is produced in another person or animal and injected into the person who is at risk. Passive Immunity is short lived, the antibodies are destroyed after a short time.
"It is estimated that around 9 percent of hospitalised patients have a hospital acquired infection at any on time" Mallet et al. (1997, p40). This figure has risen from six percent in 1985. The fact this figure has risen proves just how important this topic is and how it needs constant updated research and knowledge if there is to be any chance of stopping epidemics from occurring.
Modern times tackle more complicated surgery performed on sicker patients. The implications of this are patients become more susceptible to infections. This means life expectancy has increased bringing with it greater infection risks and the cost of the implications of this.
The clinical incident chosen has been taken from an incident on a ward comprising of eight single rooms that are along side three side bays. The rooms are used for infectious patients when necessary. The chosen lady was elderly, mobile and experiencing dementia. The reason for choosing this incident is that it could have easily become serious and preventative methods had not been enforced.
Julie had been transferred from another ward with early stages of Herpes Zoster (Shingles). It is the Varicella Zoster Virus that causes both Shingles and Varicella (Chicken Pox). "Shingles is infectious from respiratory secretions and skin lesions." Mercier (1997, p42). "This condition produces a painful rash whose distribution corresponds to that is the affected sensory nerves." Martini (2001, p136). This disease is infectious for ten to twenty-one days from the start of the eruption and it is necessary to wait until all the lesions have crusted. According to Martini (2001. P136) it will develop in adults who have had Chicken Pox as a child and will usually only occur once. There are exceptions however if the immune system is weakened.
Julie had signs of the rash and lesions had not yet crusted so she was being treated as infectious. The precautionary methods needed according to Mallet et al. (1996, p48) are to keep the door closed and follow barrier nursing procedures. "This involves the use of practises aimed at controlling the spread of, and destroying pathogenic organisms". Also supported was that the patient must be isolated in a single room containing washing / toilet facilities and hand washing / protection of clothes must be adopted with care.
Julie was admitted to one of the single rooms around three in the afternoon. The nurses used barrier nursing at all times when in contact with the lady but the door was not shut to her room. She had signs of the rash and lesions had not yet crusted so she was being treated as infectious. A sign was placed outside her room to clearly inform visitors and members of staff instantly of her condition.
The main problem arose later in the evening whist nurses were attending to another patient. They were only gone around five minutes but this was enough time for the lady to disappear out of her room. Julie was found inside one of the wards that also had not had the doors closed. Julie luckily had not touched any of the other patients but this incident could have easily risked spreading the infection to them. It took a while for her to be encouraged back to her own room and into bed. If the nurses had followed the correct precautions and shut the door then Julie would not have been able to wander. Clearly outbreaks will occur easily when the care lapses.
This incident clearly shows that precautions could be enforced better. Infections change with time so it is vital that research and knowledge is up to date to ensure the most is known about the infection and the control of it. Additionally, education needs to be readily available to ensure heath workers are well informed and the infections are not spread unnecessarily.
"The acquisition of infection causes anxiety and discomfort, delays in recovery, and in some instances results in long-term morbidity or even death" Wilson (2001, p1). As well as being unpleasant complications, they prolong patients' length of stay and divert resources that could be utilised elsewhere. Costs are incurred by the extra length of stay in hospitals and by the cost of the extra medication needed to control the infection. The costs, estimated at £110 million, Mallet et al. (1996, p40) are not only to the heath care service but also for the patient with regards to lost income. Trauma may occur for not only the patient but also their family.
Staff need to be constantly aware of the importance of correct precautions when around infections. Often staff do not take enough care with tasks and following guidelines. Hand washing is vital in infection control for both the patient and the member of staff. White (2002, p8) introduces that new hand washing techniques are being successfully used in two London hospitals. The method involves using gel instead of water and is proving to be more effective and quicker. Hopefully this is a great breakthrough towards infection control.
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