Question

Fatima is 86 years old female admitted to emergency room complains of skin tear of her right leg. She states she fell down and cut her leg. You use a septic technique to clean the skin tear and remove the clotted blood. You positioned the skin flap to approximate the edges of the wound. And then you covered the entire wound bed with a sterile non-stick dressing and bandage. You asked Fatima to come back in one week for reassessment of the wound. You instruct her on how to protect the area, the importance of keeping it clean and dry and signs of infection she needs to be aware of. She demonstrates a reasonable understanding of your instructions. Four days after Fatia has attended the hospital, she re admitted to ER complaining of throbbing pain in her leg at the location of skin tear but radiating up and down whole leg. She rates her pain as 8 out of 10. When you examine leg wound you found it is inflamed in the surrounding tissue and moderate amount of thick yellow exudate being discharged from the wound. Fatima vital signs taken were

BP – 189/92 mmHg

HR – 92 beats/minute

RR – 24 breaths/minute

T – 39.2°C

SpO2 – 95% on room air

She was admitted to the hospital for more active treatment of the wound, including antibiotics.

Questions

1. According to this case how could you break the chain of infection? Take in consideration all chain items
2. What are the isolation precautions would you use if needed for this case ?
3. What are the infection precautions you should use to protect her and yourself from infection? Write only precautions related to this case
4. Develop a nursing care plan for Fatima taking in consideration nursing process steps ( assessment, diagnosis, planning, implementation, and evaluation)

Answer 1

According to this case how could you break the chain of infection? Take in consideration all chain items

Answer 1,

Fatima is 86 years old female with infected sutured wound of the skin tear of her right leg draining pus. Inorder to break the chain of infection ,the various items/ elements of the chain like the infectious agent, the susceptible host , the reservior, the portal of entry,the portal of exit and mode of transmission have to be addressed in order to break the chain.

The following are the ways in which each of the individual items/ components of the chain of infection has to be handled in order to break the chain of infection.

1 infectious agent

Correct and prompt diagnosis of the microbe by sending the pus for culture and antibiotic sensitivity and institution of antibiotics therapy as per culture in order to prevent the infectious agent from spreading.

Use of topical antibiotic ointments and broad systemic antibiotics in order to contain the infection.

Use of wound debridement and saline/ bactericidal solution, irrigation of the wound in order to curb the infectious agent and minimize bacterial colonization.

2. susceptible host

The susceptible host here is Fatima who is a 86 years old female with infected sutured wound of the skin, tear of her right leg draining pus. Inorder to break the chain of infection, the patient must be placed in an isolation room and standard precautions and strict contact precautions along with patient isolation must be observed.

Patient isolation,patient education regarding the disease and risk of infection transmission with​​​​​​​ use of hygiene precautions ,regular handwashing and maintenance of patient's nutrition, patient's antibiotic and medical therapy with nutritional supplementation[ as patient is elderly ] if required are the measures to be followed to break the chain of infection in the susceptible host.

3. Reservoir

Reservoir includes the sources of contamination which may include dirt,soil, dirty surfaces and equipments which could be the reservoir for the microbes and bacteria causing infection of the wound in the patient.

The reservoir can be managed by proper cleaning,disinfection of the patients surroundings,equipments used with proper sterilization of all the equipments and implementation of strict infection prevention policies in order to break the chain of infection.

4. The portal of entry

This includes the the damaged skin at the area of the wound through which the infection causing microbe has entered into the leg.The patient's wound must be debrided, dressed and kept covered.The contamination of the wound with other surfaces must be avoided by keeping a proper barrier dressing and keeping the wound covered In order to prevent other microbial invasion and infection.

Use of hand hygiene, gloves, personal protective equipment and sterile dressings, antibacterial ointment for the wound must be followed in order to break the chain of infection.

5. The portal of exit

This means the wound with the discharging pus.The precautions to be taken  to break the chain of infection are hand hygiene, use of personal protective equipment, sterile dressing techniques and proper disposal of soiled linen and dressing materials especially pus containing dressings.Adequate disinfection and sterilization and cleaning of all the equipment and dressing material;patient's linen and other material in the patient's surrounding like bed ;bed rails,patient's towels, must be followed

5. The mode of transmission

The mode of transmission in bacterial wound infections is through contact transmission.The chain of transmission of infection can be controlled by isolating the patient ,limiting the visitors to the patient ,using appropriate hand hygiene, use of gown, mask,eyewear,gloves and wearing of proper personal protective equipment by all the healthcare workers attending the patient and ensuring correct disposal of the soiled linen and dressing materials of the patient.

Direct contact with the wound and the pus discharge must be avoided.

What are the isolation precautions would you use if needed for this case ?

Answer 2.

,Fatima is 86 years old female with infected sutured wound of the skin tear of her right leg with purulent discharge from the leg wound.As the patient is having purulent infection of the leg which could be multi bacterial or infection with staphylococcus aureus,MRSA strain or resistant bacteria.. Such infections are particularly dangerous as they can be transmitted through contact and hence strict isolation precautions would be needed especially if MRSA /resistant bacteria/immunosuppression states are suspected or diagnosed in this case.

The isolation precautions to be used if needed in this case would be to

1.keep the patient in a single patient room /private room as the patient requires isolation due to the extensive microbial infection and contamination

2. maintain more than three feet distance between the patients if there are multiple patients sharing the room and isolation in single room is not possible.

3.limit access to the patient’s room[if private room] and keep doors closed.

4.avoid the sharing of items between the patient and the other patients in case of room sharing

5 The health care personnel attending the patient must wear protective gowns,masks,eyewear and gloves and discard the soiled linen and gloves carefully in order to prevent contamination in the patient and limit the risk of infection to self and others.

6.Carefully collect the soiled linen,pus contaminated clothing,dressings,towels  and laundering them separately. using gloves while handling linen and trying to avoid direct contact with the linen while disposing.

What are the infection precautions you should use to protect her and yourself from infection? Write only precautions related to this case.

Answer 3.

,Fatima is 86 years old female with infected sutured wound of the skin tear of her right leg with purulent discharge from the leg wound.As the patient is having purulent infection of the leg which could be multi bacterial/resistant bacteria in origin,infection precautions should be used to protect her and the nursing professional from infection .

The infection precautions that should be used to protect the patient from infection are

1.Keep the patient in a private room separate from the other patients.

2..Treatment of the infection using suitable antibiotics as per culture sensitivity in order to prevent cross infection especially in MRSA cases or in cases of resistant bacteria.  

3. Minimal use of invasive procedures on the affected limb like intramuscular injections or intravenous lines in order to prevent the systemic spread of the infection.

4..Appropriate antibiotic therapy with appropriate hand hygiene to be used by the patient.Maintenance of optimum patient nutrition as patient is elderly with protein rich diet to help the patient to fight the infection and promote healing.

5.Topical antibiotics with regular wound debridement,wound irrigation to prevent ascending infection.

6 .Explain to the patient to avoid rubbing,itching near the wound and that direct contact with the wound and the pus discharge must be avoided.

7..Cleaning and disinfection of the patient's room carefully and the patient's bed, side tables, bed rails with regular change/washing of the patient's linen.

The infection precautions that should be used to protect the nursing professional are

1 Use of hand hygiene and washing hands before and after examining the patient, dressing the wound or cleaning the bed of the patient.

2..Wearing gown, mask,gloves and protective eyewear for any patient procedure,activity and for patient dressings in order to avoid contamination with the purulent discharge from the wound.

4.Cleaning and disinfect the patient's room carefully and the patient's bed side tables, bed rails and regular washing/changing of the patient linen.Proper washing and sterilization of all the reusable euipments.

5. Carefully collecting the soiled linen and laundering them separately. Using gloves while handling linen and pus soaked dressings and trying to avoid direct contact with the soiled dressings and pus soaked linen.

6.Strict aseptic contact precautions to be followed while dressing the patients wounds.

Thus by using the above listed precautions the nursing professional can protect himself/herself and the patient from the infection.