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NURSING/ICU

NURSING PROTOCOLS (PART ONE)

PHYSICAL FACILITIES IN ICU
  1. Bed requirements
    • Number of ICU beds per hospital should depend on type of services available in the hospital as well as the needs of the community.
    • Ranges from 2-6% of total number of hospital beds
  1. working area about 200sq. ft/bed.
  2. Open concept is highly preferred.
  3. placing of bed in semi-circular position.
    • All patients can be viewed from the nursing station.
  1. Windows located near the bed.
  2. Day light in ICU.
  3. Nursing station with central monitor ( optional ).
  4. Sister’s office.
  5. Male and female changing room with toilet and shower facilities.
  6. Common rest rooms.
  7. Treatment / preparation room.
  8. Mini laboratory for essential test e.g. ABG, BUSE.
  9. Sluice room.
  10. Pantry.
  11. Reception / conference room and library.
  12. Waiting room for immediate family members.
  13. Store room
  14. Isolation room.
  15. Doctor’s room.
  16. Family waiting room.


Caring Nurses~The Critical Thinking

Make Sense and Feeling
Sense of Commitment - Devoted , dedicated and responsive in what ever action
Sense of Belonging - Ownership – security usage and maintenance
Sense of Guilt - Aware and realize the effect of failure for not fulfilling expectations or observing correct form guideline or procedures
Sense of Sin - Realized , acknowledge and regret of whatever wrong doings.
Sense of Shame - Having strong believe in protecting and preserving self – esteem and self – pride from moral decadence as a result of wrong doings ( written and unwritten rules and practices )

PROFESSIONAL DEVELOPMENT OF NURSES
Nursing involves the giving of care to the patients together with other members of the health care team including doctors. The person in the centre of these activities is a biopsychososial being called the PATIENT. Nurses exist because of these important individuals – THE PATIENTS.
A PROFESSIONAL NURSE is one who works with her patients at the highest level of knowledge, skills and a caring attitude while adhering to a set of code of ethics.
Of importance in the definition are:
  1. Highest level – best of the highest possible standards.
  2. Knowledge – Need to be aware of advances in knowledge and technologies in medical sciences.
  3. Skill – Competency in the various skills required in nursing.
  4. Caring attitude – Recognizing the need of the patient to be managed with compassion, courtesy, respect and dignity.
  5. Code of ethics – A set of rules to guide professional behaviour.
All the above are ingredients of the professional development of a nurse.
The early professional development of a nurse is initiated by training schools but it does not end here. Professional development is a continuous process in the nurses career. This is important if we nurses are to gain respect and recognition.
There is a need for the nurse to be assertive and to function as an equal member of the health care team. This would become possible if she develops appropriately in the following three arrears:
Ø KNOWLEDGE
Ø SKILLS
Ø ATTITUDES

Background
  1. The level of care provided in a general intensive care unit (ICU) is more complex than delivered in a general ward.
  2. It is about 3.8 times more expensive to maintain ICU than a general ward.
  3. currently, in United States the provision of ICU costs about 15% of the total hospital care.
  4. Level of ICU care defers from hospital to hospital in Malaysia, according to facilities available.

Philosophy
The philosophy of the unit is that each patient is a person with a unique human dignity for whom medical personnel assume the responsibility of giving comprehensive, safe, effective medical & nursing care and protection.
Objectives
Ø To provide directions in the nursing management of ICU.
Ø To develop protocols and guidelines in the running of ICU since it demands an extensive commitment of time, manpower, equipment and money.
Ø To manage critically ill patients with potential reversible pathology who require intensive monitoring and life support system.
Ø To provide training and skills for medical and paramedical staffs in the field of critical care.

Our vision
To provide nursing knowledge that can be applied in the clinical setting when caring for real people.
Ø Reflect current knowledge of the science and art of nursing in today’s world.
Ø Provide clear explanations of the pathophysiologic processes of various disorders.
Ø Emphasize the nurse’s role in collaborative care.
Ø Prioritize nursing interventions specific to altered human responses to illness.
Ø Foster critical-thinking skills
Ø Offer visual tools for learners


NURSE

JURURAWAT
Dalam bidang penjagaan kesihatan, jururawat adalah seseorang yang bertugas sebagai penjagaan profesional. Jururawat bertanggungjawab bagi keselamatan dan menyembuhkan mereka yang sakit teruk, penjagaan kesihatan bagi mereka yang sihat, dan menangani kecemasan dalam semua keadaan membahayakan nyawa dalam semua bidang penjagaan kesihatan.
Jabatan kejururawatan adalah [plan penjagaan jururawat, plan penjagaan], kadang-kadang memerlukannya bekerjasama dengan ahli fizik, ahli terapi,pesakit, keluarga pesakit dan rakan sejawat.Di united state dan united kingdom,[latihan kejururawatan], seperti [pakar klinik kerujurwatan] dan [jururawat terlatih],diagnosis masalah kesihatan dan menentukan [pengubatan]dan lain-lain terapi.jururawat akan membantu koordinat membantu menjaga pesakit yang dijalankan oleh ahli kesihatan yang lain seperti ahli terapi, pembantu perubatan terlatih, pakar pemakanan dan lain-lain. jururawat akan menyediakan segala tugasan antara satu-satu jabatan contohnya seperti dengan ahli terapi dan pakar jururawat.

Menurut International Council of Nursing (ICN)...
"Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings Nursing includes the promotion of health, prevention of illness, and the care of ill, disabled and dying . people environment, research, participation in shaping health policy and in patient and health systems management, and . Advocacy, promotion of a safe education are also key nursing roles— ICN - International Council of Nursing."


Apakah tugas-tugas yang dilakukan oleh jururawat?
Untuk mengetahui apa yang dilakukan oleh jururawat, elok jika anda fahami kata-kata Virginia Henderson ini
"Fungsi unik kejururawatan ialah untuk membantu klien, sama ada yang sakit atau sihat, dalam melakukan aktiviti-aktiviti yang membawa kepada kesihatan, penyembuhan, atau yang memudahkan kematian (aktiviti-aktiviti yang klien akan lakukan TANPA BANTUAN sekiranya mereka mempunyai kekuatan, semangat, dan pengetahuan yang diperlukan.). Juga, untuk melakukan perkara-perkara tersebut dalam cara-cara tertentu, supaya dapat membantu klien 'berdikari' secepat yang boleh." — Virginia Henderson, 'Definition of nursing' 1955,`66,`69,`78.
"The unique function of the nurse is to assist clients, sick or well, in performing those activities contributing to health, its recovery, or peaceful death -- activities that clients would perform unaided if they had the necessasary strengh, will, or knowledge. Also, to do so in such a way as to help clients gain independence as rapidly as possible." — Virginia Henderson, 'Definition of nursing' 1955,`66,`69,`78.

Jururawat membantu pesakit untuk berdikari dengan cepat. jadi sudah tentu tugas mereka banyak. Mereka bertanggung jawab daripada perkara asas manusia (makan, minum, kebersihan, etc.), memastikan klien mengambil ubat pada masa yang ditetapkan, memerhati keadaan pesakit (tanda-tanda vital, dan sebagainya), serta MENGURANGKAN risiko pesakit daripada mendapat masalah kesihatan lain di wad. Itu cuma di wad, bagaimana di tempat lain seperti dewan bedah.
Jururawat menjalankan kerja kejururawatan,biasanya menggunakan pendekatan menyelesaikan masalah yang melibatkan pentaksiran, pengenalan masalah, perancangan, perlaksanaan dan penilaian sebagai satu kitaran berterusan. Ini menghasilkan jagaan yang khas bagi seorang pesakit dan bukan jagaan rutin untuk suatu penyakit.
Oleh kerana bidang kejururawatan amat banyak, maka terdapat jururawat yang dilatih khas untuk disiplin-disiplin (bidang) tertentu. Seperti perawatan paliatif, diabetik, dewan bedah, dan ENT (Mata, hidung, dan telinga), dan banyak lagi.


GENERAL INTENSIVE CARE UNIT ,WARD [ GICU ]

The General Intensive Care Unit of the Hospital is a level 1 ICU* that manages critically ill patents with complicated needs requiring the continuous availability of sophisticated equipment, specialized nurses and doctors trained in the care of the critically ill. The management of the unit is the responsibility of the Department of Anaesthesia & Intensive Care.

This document is prepared in view of the need for guidelines’ that would serve those who require the services of the Intensive Care Unit.
It is hoped that these guidelines would avoid the misuse or inappropriate use of facilities and staff and improve the utilization of scarce and costly resources.

These policies and guidelines would be reviewed and revised, as necessary, on a regular basis. Compliance with these guidelines will be monitored by the Department of Anaesthesia & Intensive Care.

* A Level 1 ICU is one capable of providing all forms of intensive care monitoring and therapy, have 24-hour access to diagnostic facilities, have dedicated medical staff roistered for 24 –hour duty and have a preponderance of nursing staff with intensive care certification.



ADMISSION AND DISCHARGE POLICY

An ICU provides services that include both intensive monitoring and intensive treatment. During times of high utilization and scarce beds, patients requiring intensive treatment     ( Priority 1) have priority over patients requiring intensive monitoring ( Priority 2 ) and terminally or critically ill patients with a poor prognosis for recovery ( Priority 3 ). Eligibility for ICU admission and discharge is also based on reversibility of the clinical problems as well as the likely benefits of ICU treatment and expectation of recovery.

It is the responsibility of the patient’s attending doctor (or designee) to request ICU admission and to promptly transfer patients who meet discharge criteria.

It is to responsibility of the ICU specialist (or designee) to decide if the patient meets eligibility requirements for ICU.

In case of conflict regarding admission or discharge criteria, the ICU  specialist (or designee) of the admitting unit will decide which patient should be given priority.

Admission Criteria

Priority 1

Critically ill, unstable patients with single system disorder and/or good reversibility of conditions and who require ventilatory support and/or continuous vasoactive drug infusion:

·        Post-operative patients for stabilization and ventilation.
·        Acute respiratory failure from a reversible cause e.g. Guillain-Barre Syndrome, Myasthenia Gravis, Bronchial Asthma, Drug Overdose.
·        Patients with multiple trauma.
·        Patients with acute obstetric complications e.g. post- partum haemorrhage, eclampsia.

Priority 2

Patients, who at the time of admission are not critically ill but whose condition requires intensive monitoring. These patients who are at risk for needing immediate intensive treatment would benefit from monitoring available in the ICU e.g. peripheral or pulmonary arterial monitoring, pulse oximetry.

·        Patients with underlying hearts, lung or renal disease with acute exacerbation of the illness or the illness or who have undergone major surgery.
·        Patients with progressive paralysis of  neuromuscular origin


Some of these patients may be more suitable for High Dependency Ward admission. The underlying disease/s must be reversible or at least have a favourable outcome.


Priority 3

Critically ill, unstable patients whose previous state of health, underlying disease, or acute illness, either alone or in combination severely reduce the likelihood of recovery and benefits from ICU treatment,:

·        Patients with metastatic  malignancy complicated by infection.
·        Patients with end-stage heart or lung disease complicated by a severe acute illness.



Patients who do not meet routine admission criteria are:

·        Patients who have clinical evidence of brain death.
·        *organ donors but only for the purpose of life support before organ donation.
·        Patients with non-traumatic coma causing a permanent vegetative state.

Discharge Criteria

Priority 1 patients are discharged when their need for intensive treatment is no longer present.

Priority 2 patients are discharged when intensive monitoring has not resulted in aneed for intensive treatment and the need for intensive monitoring is no longer present.

Priority 3 patients are discharged when the need for intensive treatment is no longer present, but may be discharged earlier if continued is no longer present, but may be discharged earlier if continued treatment is futile or request for ICU bed for a Priority 1 or 2 patient is made.

Patients who are unlikely to benefit from continued ICU  treatment include:

·        Patients of advanced age with three or more organ system failures who have not responded to 72 hours or more of intensive therapy.
·        Patients who are brain dead (*exception).
·        Patients who have non-traumatic coma leading to a permanently vegetative state and a very low probability of meaningful recovery.
·        Patients with protracted respiratory failure who have not responded to initial aggressive efforts and who are also suffering from haematologic malignancy.
·        Patients with a variety of other diagnosis ( advanced chronic obstructive airway disease, end-stage cardiac disease or widespread carcinoma) who have failed to respond to ICU therapy, whose short term prognosis is also extremely poor and for whom no potential therapy exits to either the prognosis.
·        Physiologically stable patients who are at low risk of requiring ICU treatment.

The least justifiable ICU activity on cost-benefit analysis lies in the management of diseases causing multi-system failure and a low survival rate in patients with short remaining lifespans.

The decision to discharge the patient will be made by the ICU specialist and the primary unit will be informed of this. The primary unit should then make arrangements for appropriate ward or intermediate care and promptly transfer the patient out of ICU.

The ICU SHOULD NOT be used as a High Dependency Ward. Nursing care in acute surgical wards should be upgraded to manage patients who require close monitoring.

TRIAGE IN THE ICU

Role Of ICU Specialist As Triage Officer

In times when patient load exceeds optimal operational capacity ( in terms of bed or ICU nurse availability ), there should be a clear policy as to who is responsible for triage within the unit.

The regulation of admission and discharge of patients into and out of ICU  is a standard function assigned to the ICU specialist. However, another unenviable task of the latter is that of being a triage officer.

The triage officer should be a senior person who is knowledgeable about the prognosis of the various diseases related to the patients in the unit ( or able to obtain the information rapidly ), unbiased and a good negotiator. He / she must communicate directly with various primary attending doctors in order to identify  any additional factors not readily apparent that might charge priority listing. He must not be overruled by other doctors during periods of high census.

The person best suited to make complex and dynamic triage decisions is the ICU specialist who has been regularly involved in the care of the patients.

Patients factors considered during high census

*  Functional outcome.
*  Chronic underlying condition (s)
*  Age .
*  Marginal benefit present.
*  Hospital mortality probability estimate.

Conditions defining limited medical suitability

*    DNR orders issued.
*    Patient considered unsalvageable clinically ( no marginal benefit)
*    Rapidly fatal underlying condition.
*    Persistent vegetative state.
*    High probability estimate of hospital mortality.



Triage Approach

To reduce inflow of patients to ICU
·        Keep patient in Recovery bay, Casualty or other ICUs while queering to come to ICU.
·        Hold transfer of patients from ICUs of other hospitals.
·        Postpone high-risk elective surgery.

Increase performance of high census ICU
·        Identify triage patient on daily basis such that patient can be promptly transferred when the need when arises. ICU Specialists should perform this together at a fixed time e.g.1500 hrs.
·        Rapidly wean and extubate post-operative elective patient such that they are transferred out if stable for 4-6 hours after extubation.

Decrease workload per patient
Reducing nursing hours per patient by performing fewer  invasive procedures e.g. deferring insertion of PAC.

Transfer to alternative sites
·        Transfer the following patients to general wards.
·        Patients who have failed aggressive ICU therapy.
·        Patients who are considered unsalvageable.
·        “Stable” ventilator-dependent patients.
·        Transfer short-term recoverable patients to intermediate units e.g. other ICUs
·        It is preferable such transfers be done during the daytime or on a scheduled or planned basis rather than late at night or as an emergency triage. Scale back orders before transferring.

*if all ICU beds in hospital are full, then the primary unit should seek permission from Director of Hospital to transfer patient to another hospital. (This is applicable to only Priority 1 patients who are citizens of Malaysia ).

BED REQUESTS FOR ELECTIVE SURGICAL CASES
The details of the patient and date of surgery will be documented on the ICU board.
The patient’s attending Surgeon/ Anaesthetist must inform and discuss with the ICU specialist in advance of the need for ICU Care for his post-operative patient.

In the event that there are more requests for ICU  beds than beds available, than priority should be given to the following :
1.      patient whose surgical condition is likely to deteriorate within days if surgery is postponed.
2.      maternity patients.
3.      patient whose surgery has been repeatedly postponed due to lack of ICU bed.

If a bed is not available for elective admission, the surgeon has the option of
1.      Postponing surgery.
2.      Arranging alternative ICU care within the hospital.

It must be emphassised that priority of admission will always be given to unscheduled, emergency admissions over scheduled elective requests.

WITHDRAWAL OF INTENSIVE THERAPY

The decision to withdraw therapy should be joint decision between the
1.      Primary physician.
2.      ICU specialist in-charge of the patient.
3.      Designated senior specialist of the Department of Anaesthesia & Intensive Care.

The decision and rationale should be recorded in the medical record.


Intensive care therapies that are no longer indicated in such circumstances include:
*   CPR
*   Dialysis
*   Inotropes
*   Antibiotics
*   Parenteral nutrition

Therapy should be limited only to hygienic care and comfort.
The option to continue treatment for pain and suffering is available. Analgesics and anxiolytics may be used for this purpose.
The removal of life support from a patient should not be regarded as an abandonment of the patient by the healthcare team. Rather, the attention of the healthcare team must at this point be redirected to alleviating the suffering of the patient and his family and ensuring death comes with dignity.



DUTIES OF THE MEDICAL OFFICER

1. CARE OF THE PATIENTS IN ICU.
 To participate in patient care under the supervision of the ICU specialist.
 To surprise nursing procedures e.g. endotracheal suction, positioning of patient.
 To perform ususal critical care procedures e.g. arterial, central venous cannulation, chest tube insertion.
 Handle life threatening situations in ICU immediately e.g. tension pneumothorax, arrhythmias.
 Attend to new referrals immediately and manage the new case until reviewed by specialist.
2. RESUSCITATION OF PATIENTS IN CASUALITY AND WARDS.
 BASIC LIFE SUPPORT
• Recognition of cardiopulmonary arrest and maintenance of ventilation and circulation without equipment.

 ADVANCED CARDIAC LIFE SUPPORT
• Use of adjunctive equipment and special techniques for establishing and maintaining effective ventilation and circulation.
• ECG monitoring and arrhythmia recognition.
• Establishment and maintenance of IV access.
• Use of drug and electrical therapies.

3. REVIEW OF PATIENTS IN OTHER ICUS AND WARDS WHO ARE UNDER OUR CARE.
4. FOLLOW – UP OF PATIENTS DISCHARGED FROM ICU.
5. COLLECTION OF DATA FOR AUDIT AND RESEARCH PURPOSES.
6. PARTICIPATE IN TRAINING OF NURSES AND PARAMEDICS.
7. CASE PRESENTATION TO DEPARTMENT ON STURDAYS.






DAILY DUTIES OF ICU MEDICAL OFFICER
GUIDE FOR THE MEDICAL OFFICER – Basic knowledge and skill to acquire

AUDIT IN INTENSIVE CARE
Intensive care is very expensive and many patients treated in the ICU are very ill with a high mortality.
In the USA, intensive care has been estimated to consume about 1% of the gross national product, and in the UK estimates for the daily cost of ICU management are about £ 600, which is two to five times greater than for general ward treatment. As a means of cost containment and quality assurance, medical audit has been greatly emphasized in the last decade.

Audit in intensive care involves the examination of the following:
1. The process of medical care ( compliance with established standards )
2. Outcome ( survival rates, morbidity )
3. Adequacy of resources available
4. Staff workload

Problems of Audit in Intensive Care
Two major difficulties stand out:
1. The varied casemix.
2. The different severity of illness of the patients.

It was therefore not possible to compare the performance of two ICUs or even the same ICU over time.

To overcome the bias , several scoring systems have been devised among which the most well-known ones are:
1. SAPS ( Simplified Acute Physiology Score )
2. APACHE ( Acute Physiology and Chronic Health Evaluation )
3. TISS ( Therapeutic Intervention Scoring System )



 INFECTION CONTROL

Nosocomial infection is a major problem in the ICU leading to prolonged stay, increasing morbidity and mortality, and increased coasts.

The following guidelines aim to reduce the transmission of infection:
  • Everyone who comes into contact with the patient MUST WASH his or her hands before and after handing the patient. The ICU nurses have given the authority to ensure this practice is carried out.
  • All staff should be appropriately gowned, gloved and masked when carrying out invasive procedures.
  • To reduce the traffic flow in ICU, the ICU round by doctors of other units should be limited to 4 persons.

NOSOCOMIAL INFECTION CONTROL
GENERAL MEASURES

  1. PROPER HAND WASHING before and after each patient contact.
  2. Practice aseptic technique for all invasive procedures.
  3. Take standard precautions when handling all body secretions.
  4. Isolate all infectious patient.

SPECIFIC MEASURES
Venous Lines
  1. Insertion under aseptic technique.
  2. Apply sterile transparent dressings at insertion sites.
  3. Use minimum number of three-way-taps and stop-cocks.
  4. Use triple lumen for multiple drug infusion.
  5. Inspect the catheter site daily. Avoid blood residue to stagnate in the lines or three-way-tap.
  6. Replace lines
    • After 5 to 7 days routinely
    • Any signs of inflammation at sites
    • Any unexplained fever, increased TWDC or sepsis
    • If staphylococci is isolated in the blood
  7. TPN line must be dedicated line.


Arterial line
  1. To be done under aseptic technique.
  2. Do not push blood back into the line.
  3. Do not allow blood residue to stagnate in line or 3 way tap.
  4. Replace line after 5 to 7 days or at any time of signs of inflammation at puncture site.

Urethral Catheterisation
  1. To be done under aseptic technique.
  2. To use a closed drainage system to collect urine.
  3. To remove as soon as possible/weekly change of catheter.

Equipment
  1. Ventilator
    • Change of ventilator tubings/ humidifier/ resuscitation bag/oxygen apparatus every 48-72 hours.
  2. Suction catheters to be used once only.
Suction tubings
·        Tip must be covered when not in use.
·        To be discarded daily and every new admissions.

  1. Suction liner to be discarded when full/every admissions.
  2. Wipe surroundings daily and on discharge
·        Bed/ mattress / cables/ stethoscope/ monitors / perfusors / drip stand/etc.

Staffing
1.      minimize number of visiting doctors/nurses in ICU  to 4 doctors per discipline.
2.      all ICU staffs to be well-versed with nosocomial infection control protocol.

Visitors
  1. Discourage casual visitors
  2. Educate close relatives to wash hands before and after touching the patients.


BARRIER NURSING

To be carried out for patients who present a risk to others or vice versa.

  1. Nursing patient in isolated area.
    • To wear gown and gloves when attending to patient.
    • To remove gown and gloves and wash hands before leaving the room.
    • The staff in-charge to remain in the isolated room.

  1. Minimize visitors.
  2. Do not overstock equipment.
·        Necessary equipments only to be kept  in the room.
  1. Linen to be sent separately to laundry unit. Dressings and waste to be disposed according to protocol e.g. to pour hydrogen peroxide before disposal of gas gangrene dressings.
  2. Once the room is vacated
·        Disinfect and clean the equipments in the room thoroughly.
·        To clean and disinfect the room.
·        Linen used to pack and label separately before sending to laundry unit.



PROTECTION YOURSELF AND OTHERS
HEALTH HAZARDS ON THE JOB

Tuberculosis , Hepatitis. AIDS. As a healthcare worker in today’s world, it may seem that all you hear about are communicable diseases and the increasing risks they pose to your health.
Although you shouldn’t be overly alarmed, you need to be aware of the risks and the simple ways in which you can avoid them-----to protect yourself as well as your coworkers and patients.

Hidden Dangers

Some health risks in your workplace are obvious. Others are not. Infectious organisms may be anywhere around you. From needle sticks to coughing patients, a variety of accidents and situations can expose you to infection----and lead to life-threatening consequences. How should you deal with these possible dangers? Start by understanding which infectious diseases can be spread in your workplace.

The Risk of Infection
Healthcare workers are at risk of exposure to infectious diseases such as:
Ø      Tuberculosis ( TB ), a bacterial infection that effects the lungs, but can also be present in other parts of the body;
Ø      Hepatitis B virus ( HBV ), a virus that can cause severe liver damage and even death; and
Ø      Human immunodeficiency virus ( HIV ), a virus that causes acquired immunodeficiency syndrome ( AIDS )

Other common health risks in your workplace include hepatitis C, malaria, syphilis, lice, scabies, measles, cytomegalovirus, chickenpox, herpes, ‘staph’ infections, colds, ‘ flu and diarrheal infections. If you suspect that you or a patient has been infected, be sure to report it according to your employer’s policies.

Simple Steps to Protection

Once you are aware of the risks around you, you need to know the steps for preventing exposure to those risks. This booklet will show you how to protect yourself and others against several specific infections by using precautions.
No matter what you come into contact with, two of your best defenses are handwashing and the use of personal protective equipment ( PPE )-----specialized clothing or equipment worn for protection against hazards.

Wash Your Hands Often

Removing germs by handwashing provides vital protection against many types of infection. Always wash your hands before and after you have contact with a patient or anything a patient has touched.
Remember the following:
Ø      Wash your hands immediately after removing gloves---and before eating, drinking , smoking, applying makeup or handling contact lenses.
Ø      Work up a good lather with nonabrasive soap and running water. Clean between your fingers and around your nails. Then rimes well.
Ø      If your hands or any other part of your body fluids, immediately wash exposed skin thoroughly.


Use PPE ( Personal protective equipment )
Designed to protect you from a variety of hazards, PPE helps guard your skin, eyes, mouth and personal clothing from exposure to infectious germs. Your employer will provide the type of PPE that is most effective for your particular job. Never wear PPE that’s damaged or soiled. After use, remove PPE and palace it in the proper container for cleaning, decontamination or disposal.

TUBERCULOSIS

An infectious disease that usually begins in the lungs, TB may spread to the brain, kidney or spine. Most people who are infected with TB will never develop the active disease, but the disease can develop at any time if it is not treated with medication.

How TB Infection Occurs

TB can be spread when a person with active TB  disease coughs, shouts, or laughs, spraying bacteria-contaminated droplets into the air. The infection is most likely to be spread in small, poorly ventilated rooms, and usually results from prolonged exposure.
Inactive  TB

In  most people, infectious TB bacteria remain inactive for a lifetime---their immune systems prevent the infection from progressing. A person who is infected with inactive TB  isn’t sick, doesn’t have symptoms, and can’t infect others. In fact, the only way to know if you’ve been infected is to get tested. That’s why it’s vital for healthcare workers to have a TB skin test once or twice a year. If you are infected, medication can help ensure that you will not develop active disease.

Active TB

Inactive infection becomes active disease if the TB bacteria grow and begin to attack a body organ, often the lungs. Symptoms may include persistent coughing, fatigue, weight loss, fever, loss of appetite and night sweats. If left untreated, TB can be fatal. Fortunately, when taken properly, medication can completely cure the disease. People who stop their medications or who take them irregularly may develop drug-resistant TB, which is sometimes impossible to cure.

Using the Right PPE

When working in or visiting areas with suspected or confirmed cases of TB, use appropriate masks, such as HEPA ( high-efficiency particulate air ) filter respiratory masks or dust-fume-mist masks. Your employer’s respiratory protection policy may recommend other types of PPE, as well.

Controlling TB
You  and your facility can use a variety of methods to limit the spread of TB:

  • Place TB patients in negative-pressure isolation rooms with a minimum of six air changes per hour ( preferably 10 – 12 air changes per hour ).
  • Ask TB patients to cover their noses and mouths with tissue when they cough or sneeze. When transporting TB patients outside of their rooms, be sure they wear surgical masks.
  • Use a HEPA filter hood to prevent the spread of TB germs when inducing and collecting sputum.


BLOODBORNE PATHOGENS

Whether or not you work directly with patients, you need to protect yourself from expose to bloodborne pathogens ie, disease-causing germs carried by blood or certain body fluids. Knowing how these infections are spread will help you prevent them.

How Bloodborne Diseases Are Spread
Many infectious germs are carried in blood and in other body fluids in which blood may be present such as saliva, semen, fecal matter, and amniotic fluid. If infected blood comes into contact with any opening or break in your skin, you may be exposed to disease. Two of the most common and dangerous types of bloodborne disease that may infect healthcare workers are caused by the hepatitis B virus ( HBV ) and the human immunodeficiency virus ( HIV ).

HBV
HBV infection can lead to liver damage, cancer ,and even death. Symptoms may be mild and flulike. Some people have no symptoms are all.
A vaccination series is available to prevent hepatitis B infection. Your employer provides the hepatitis B vaccination free of charge to employees who are at risk for bloodborne exposure.
HIV
Although HIV is much less likely than hepatitis B to be spread in the workplace, it could potentially be spread anywhere that blood is present. HIV weakens the body’s immune system and causes AIDS. Symptoms may include weight loss, night sweats, fever, fatigue, gland pain and swelling, and muscle or joint pain. There is currently no vaccine for HIV and no cure for AIDS.
Other Bloodborne Diseases
Blood may carry other serious infections, such as hepatitis C, malaria , and syphilis. If discovered early enough, these conditions can usually be treated with medication.






Exposure Control Plan
Your employer’s exposure control plan is a document that describes when or where an exposure could occur, standard precautions, exposure reporting procedures, and training requirements. You have the right to see that plan at any time. Ask your supervisor for more information.

Standard Precautions
The idea behind standard precautions is simple but effective: Since you don’t always know whose blood is carrying infectious germs, treat all blood and certain body fluids as potentially infectious. Protective controls to help you avoid bloodborne hazards include the following:

Engineering controls, such as safely mounted sharps containers, are your company’s technological means of isolating or removing hazards from the workplace to reduce your exposure to blood.
Work practice controls, such as avoiding contact with blood, are ways that you can perform your job more safely to prevent exposure to bloodborne pathogens

Engineering Controls
By making the work environment safer, your employer can greatly reduce your risk of exposure to bloodborne infections. Sharps containers and medical safety devices are examples of protective engineering controls.

Sharps Containers
Immediately after using sharps, dispose of them in containers are:
  • Puncture-resistant
  • Leak proof on  sides and bottom
  • Labeled or color-coded as biohazardous
  • Closable
  • Located in areas that can be safely and conveniently reached






Safer Medical Devices

Many needles and other medical instruments now have safety features to help prevent accidents and exposure to disease. These devices include:
  • Self – sheathing needles
  • Needless IV connectors or connectors with recessed needles
  • Phlebotomy devices and lancets with safety features such as retractable blades
  • Face masks used for mouth – to – mouth resuscitation or cardiopulmonary resuscitation ( CPR )

Work Practice Controls
Engineering controls alone won’t do much good unless you follow safe work practices. Proper waste disposal, safe needle handling and thorough cleaning are a few important ways to help ensure on – the – job safety.

Marking Infectious Materials
Any potentially infectious materials must be labeled or color – coded as biohazardous. Labels must also be placed on cabinets, refrigerators, freezers or any other containers holding blood or other potentially infectious materials.

Disposing of Waste
Whether you’re disposing of used needles, blood-stained towels, tissue specimens, or other contaminated materials, always follow your facility’s waste disposal guidelines. All medical waste should be stored in labeled, closed containers that can hold the contents without leakage during handling, storage, and transportation.









More Work Practice Controls
Handling Needles
One of the most important ways to prevent exposure to infection is to handle needles carefully. Keep the following guidelines in mind.
  • Never bend or break needles;
  • Never remove needles from disposable syringes;
  • Do not recap needles. If you do, use an approved recapping method.
  • Always dispose of needles in proper sharps containers.
  • If  a needlestick occurs, wash the affected area thoroughly with soap and running water. Then report it according to your employer’s policies.

Removing Gloves
To prevent contact with any blood that may be on your gloves, remove them carefully, using the following steps:
Peel one glove off from wrist to fingertips and hold it in the other, gloved hand.
Peel the other glove off from the inside with your exposed hand, holding the first glove inside the second.
Properly dispose of the gloves. Then wash your hands thoroughly.

Staying Aware
Throughout the working day, pay attention to your activities and your environment. Do not eat, drink, apply cosmetics, or handle contact lenses in patient care areas of possible contamination.

Housekeeping
When cleaning any contaminated  materials or surfaces, remember the following:
  • Wear gloves and protective covering over your clothing.
  • When cleaning up  blood  spills, use disposable towels and an approved disinfectant. Dispose of waste properly. If splashing may occur, wear protection for your eyes and face.
  • Separate contaminated laundry into leak proof, biohazard-labeled bags or containers.



INFECTION ( Part 11)


SEPSIS

Definitions

  1. Bacteraemia : Positive blood culture.
  2. Sepsis : Clinical evidence of infection and evidence of systemic response to infection:
  • Temperature >38ºC or <36ºC .
  • Heart rate > 90 bpm
  • Respiratory rate > 20 breaths per min or PaCO² < 32 mmHg.
  • WBC > 12,000/mm³.

3. Sepsis Syndrome : Sepsis and altered organ perfusion (at least 1 of the following ):

* Hypoxemia
* Elevated lactate
* Oliguria
* Altered mentation

4.Septic shock : Sepsis syndrome and hypotension.
  sBP < 90 mmHg or decrease in MAP of > 40 mmHg from baseline.

5. Refractory Septic Shock : Septic shock and duration more > 1 hr with lack of response to IV fluids or pharmacologic intervention.

Causes in ICU

  • Nosocomial Pneumonia
Usually aerobic Gm –ve bacteria e.g. Pseudomonas, Klebsiella, Acinetobacter.
Sometimes Staph. Aureus, rarely fungus.

  • Operation site
  • Wound : S.aureus, Gm-ve rods
  • Central Venous Catheter : S.epidermidis.
  • Peripheral IV : S.aureus, Strep
  • Sinuses: (Gm-ve, oral anaerobes, S.aureus)
  • Urinary Tract Infection (Gm-ve)
  • Bowel/splanchnic ischemia.

Prevention

  1. Reduce available routes of infection.
  • Remove invasive lines, catheter as soon as no longer necessary.
  • “Clean” sites preferred e.g.internal jugular, subclavian over femoral.
  • Keep lines clean: remove blood residue or change lines, stopcocks if heavily blood-stained.

  1. Prevent transfer of organisms.
  • Strict handwashing between patients : VERY IMPORTANT!
  • Strict asepsis during procedures.

  1. Improve host defence.
  2. Nutrition.
  3. Surgery : Remove focus.


Early Detection
Be suspicious!

Management

Resuscitation

Aims:
Cardiac index (Cl ) > 4.5 L/min/m²
O² Delivery ( DO²) > 600 ml/min/m² [ { 0.031 x PaCO²} + {Hb x SaO² x 1.34}] x CO
O² Consumption ( VO²) > 170 ml/min/m²
[ CaO² - CvO²] x CO

Clear CXR             }
Low CVP              }        Volume expansion – colloid / crystalloid
Low PCWP           }

Wet CXR             }
High CVP            }          Inotropes
High PCWP         }




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