An older person may not show the signs and symptoms of infection listed in Box 12-1. The person may have only a slight fever or no fever at all. Redness and swelling may be slight. The person may not complain of pain. Confusion and delirium may occur (Chapter 30).

An infection can become life-threatening before the older person has obvious signs and symptoms. Report minor changes in the person’s behavior or condition at once.

Healing takes longer in older persons. Therefore an infection can prolong the rehabilitation process. Independence and quality of life are affected.

Focus on Surveys

Infection

Infection control practices are a major focus of surveys. You may be asked:

• What do you do when you observe signs and symptoms of an infection?

• Who do you tell when you observe signs and symptoms of an infection?

The Chain of Infection

The chain of infection (Fig. 12-1) begins with a source—a pathogen. It must have a reservoir where it can grow and multiply. Humans, animals, and objects are reservoirs. A carrier is a human or animal that is a reservoir for microbes but does not develop the infection. Carriers can pass pathogens to others. To leave the reservoir, the pathogen needs a portal of exit. Exits are the respiratory, gastro-intestinal (GI), urinary, and reproductive tracts; breaks in the skin; and blood.

After leaving the reservoir, the pathogen must be transmitted to another host (Fig. 12-2). The pathogen enters the body through a portal of entry. Portals of entry and exit are the same. A susceptible host is needed for the microbe to grow and multiply.

FIGURE 12-2 Methods of transmitting microbes.

Susceptible Hosts.

Susceptible hosts are at risk for infection. They include persons who:

• Are very young or who are older.

• Are ill.

• Were exposed to the pathogen.

• Do not follow practices to prevent infection.

• Are burn patients. When burns destroy the skin, the wound is a portal of entry for microbes.

• Are transplant patients. A transplant involves transferring an organ or tissue from 1 person to another person or from 1 body part to another body part. The body’s normal immune response is to attack (reject) the new organ or tissue. Therefore, drugs are given to prevent rejection. Such drugs suppress (prevent) the immune system from producing the antibodies needed to fight infection.

• Are chemotherapy patients (Chapter 28). Some types of chemotherapy affect the bone marrow’s ability to produce white blood cells (WBCs). WBCs are needed to fight infection.

The human body can protect itself from infections. The ability to resist infection relates to age, nutrition, stress, fatigue, and health. Drugs, disease, and injury also are factors.

Healthcare-Associated Infection

A healthcare-associated infection (HAI) is an infection that develops in a person cared for in any setting where health care is given. The infection is related to receiving health care. HAIs also are called nosocomial infections. (Nosocomial comes from the Greek word for hospital.)

HAIs are caused by microbes normally found in the body. Or they are caused by microbes transmitted to the person from other sources. For example, Escherichia coli is normally in the colon and feces. E. coli can enter the urinary system from poor wiping after bowel movements. With poor hand washing, the hands can spread E. coli to any body part, thing, or person the hands touch.

Microbes can enter the body through care equipment and supplies. Such items must be free of microbes. Staff can transfer microbes from 1 person to another and from themselves to others. Common sites for HAIs are:

• The urinary system

• The respiratory system

• Wounds

• The bloodstream

The health team must prevent infection by following:

• Medical asepsis. This includes hand hygiene.

• Standard Precautions, p. 148.

• Transmission-Based Precautions, p. 148.

• The Bloodborne Pathogen Standard, p. 157.

Medical Asepsis

Asepsis is being free of disease-producing microbes. Microbes are everywhere. Measures are needed to achieve asepsis. Medical asepsis (clean technique) is the practices used to:

• Remove or destroy pathogens. The number of pathogens is reduced.

• Prevent pathogens from spreading from 1 person or place to another person or place.

Contamination is the process of becoming unclean. In medical asepsis, an item or area is clean when it is free of pathogens. The item or area is contaminated when pathogens are present. Sterile means the absence of all microbes—pathogens and non-pathogens. A sterile item or area is contaminated when pathogens or non-pathogens are present.

Common Aseptic Practices

Aseptic practices break the chain of infection. To prevent the spread of microbes, wash your hands:

• After elimination.

• After changing tampons or sanitary pads.

• After contact with your own or another person’s blood, body fluids, secretions, or excretions. This includes saliva, vomitus, urine, feces, vaginal discharge, mucus, semen, wound drainage, pus, and respiratory secretions.

• After coughing, sneezing, or blowing your nose.

• Before and after handling, preparing, or eating food.

• After smoking.

Also do the following.

• Provide all persons with their own linens and personal care items.

• Cover your nose and mouth when coughing, sneezing, or blowing your nose. If without tissues, cough or sneeze into your upper arm (Fig. 12-3). Do not cough or sneeze into your hands.

FIGURE 12-3 Sneezing into the upper arm.

• Bathe, wash hair, and brush your teeth regularly.

• Wash fruits and raw vegetables before eating or serving them.

• Wash cooking and eating utensils with soap and water after use.

See Focus on Older Persons: Common Aseptic Practices.

Focus on Older Persons

Common Aseptic Practices

Persons with dementia do not understand aseptic practices. The staff must protect them from infection. Assist them with hand washing:

• After elimination

• After coughing, sneezing, or blowing the nose

• Before or after they eat or handle food

• Any time their hands are soiled

Check and clean their hands and fingernails often. They may not or cannot tell you when soiling occurs.

Hand Hygiene

Hand hygiene is the easiest and most important way to prevent the spread of infection. You use your hands for almost everything. They are easily contaminated. They can spread microbes to other persons or items. Practice hand hygiene before and after giving care. See Box 12-2 for the rules of hand hygiene.

Box 12-2

Rules of Hand Hygiene

• Wash your hands (with soap and water) at these times.

• When they are visibly dirty or soiled with blood, body fluids, secretions, or excretions

• Before eating and after using a restroom

• If exposure to the anthrax spore is suspected or proven

• If an alcohol-based hand rub is not available

• Use an alcohol-based hand rub to practice hand hygiene if your hands are not visibly soiled. Follow this rule.

• Before direct contact with a person.

• After contact with the person’s intact skin. After taking a pulse or blood pressure are examples.

• After contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled.

• When moving from a contaminated body site to a clean body site.

• After contact with items in the person’s care setting.

• After removing gloves.

• Follow these rules for washing your hands with soap and water. See procedure: Hand Washing, p. 145.

• Wash your hands under warm running water. Do not use hot water.

• Stand away from the sink. Do not let your hands, body, or uniform touch the sink. The sink is contaminated. See Figure 12-4.

• Do not touch the inside of the sink at any time.

• Keep your hands and forearms lower than your elbows. Your hands are dirtier than your elbows and forearms. If you hold your hands and forearms up, dirty water runs from your hands to your elbows. Those areas become contaminated.

• Rub your palms together (Fig. 12-5, p. 144) and interlace your fingers (Fig. 12-6, p. 144) to work up a good lather. The rubbing action helps remove microbes and dirt.

• Pay attention to areas often missed during hand washing—thumbs, knuckles, sides of the hands, little fingers, and under the nails.

• Clean fingernails by rubbing the fingertips against your palms (Fig. 12-7, p. 144).

• Use a nail file or orangewood stick to clean under fingernails (Fig. 12-8, p. 144). Microbes grow easily under the fingernails.

• Wash your hands for at least 15 to 20 seconds. Wash longer if they are dirty or soiled with blood, body fluids, secretions, or excretions. Use your judgment and follow agency policy.

• Use clean, dry paper towels to dry your hands.

• Dry your hands starting at the fingertips. Work up to your forearms. You will dry the cleanest area first.

• Use a clean, dry paper towel for each faucet to turn the water off (Fig. 12-9, p. 144). Faucets are contaminated. The paper towels prevent you from contaminating your clean hands.

• Follow these rules when decontaminating your hands with an alcohol-based hand rub. See procedure: Using an Alcohol-Based Hand Rub, p. 145.

• Apply the product to the palm of 1 hand. Follow the manufacturer’s instructions for the amount to use.

• Rub your hands together.

• Cover all surfaces of your hands and fingers.

• Continue rubbing your hands together until your hands are dry.

• Apply hand lotion or cream after hand hygiene. This prevents the skin from chapping and drying. Skin breaks can occur in chapped and dry skin. Skin breaks are portals of entry for microbes.

Modified from Centers for Disease Control and Prevention: Guidelines for hand hygiene in health-care settings, Morbidity and Mortality Weekly Report 51 (RR-16), 2002.