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Bioethics in Nursing

Introduction   

Nursing practice is deeply rooted in ethical principles that guide decision-making and patient care. Bioethics is a crucial aspect of healthcare that provides a framework for analyzing ethical dilemmas and promoting individualized patient-centered care respectfully and compassionately (1). Nursing ethics involves applying bioethical principles in practice, such as maintaining patient confidentiality and respecting autonomy (2). Nurses face ethical dilemmas regularly. One of the most common is providing care that conflicts with personal beliefs (3).

Definition and Purpose 

Bioethics is the study of ethical and moral principles guiding healthcare decisions and practices (4). Its purpose is to ensure that healthcare providers make informed decisions that respect patients' values, beliefs, and rights (5). 

Bioethics provides a framework for analyzing ethical issues in healthcare while considering the interests of the patients, their families, and the healthcare providers involved in their care (6). By understanding the definition and purpose of bioethics, nurses can develop a strong foundation for addressing ethical challenges in practice, such as informed consent, patient confidentiality, and when it may infringe upon others’ health and proper resource allocation (7, 8).

Principles of Bioethics 

The principles of bioethics include autonomy, beneficence, non-maleficence, and justice (9). Autonomy respects patients' decision-making capacity, beneficence promotes a patient's well-being, non-maleficence avoids any harm to the patient, and justice ensures fairness and equity for all involved in the patient’s care (10). 

These principles should serve as the guiding force in nursing practice; influencing the decisions related to patient care, research, and policy development (11, 12). Autonomy empowers patients to make informed choices about their care. This may include decisions that the patient’s family and even healthcare providers may disagree with personally. Beneficence compels nurses to act in the best interests of their patients and advocate for the patient’s desires (13). Non-maleficence reminds nurses to avoid causing harm; this includes not just physical but emotional and mental harm as well (14).

Types of Ethics and Professions 

Different professions have specific ethical guidelines, such as the American Nurses Association (ANA) Code of Ethics for nurses (15). Understanding the ethical framework of various professions is essential to the interdisciplinary healthcare approach (16). 

Interdisciplinary collaboration requires an understanding of diverse ethical perspectives and principles, an approach that coincides with an equally diverse patient population (17). Nurses should be aware of the ethical guidelines that govern their practice and be able to apply them in diverse healthcare settings. They must also be aware of their own beliefs and guidelines and how these may affect their decision-making, adversely affecting patient care (18).

Ethics in Nursing 

Nursing ethics involves applying principles in practice that benefit the patient, healthcare providers, and loved ones of the patient. Examples include things such as maintaining patient confidentiality and respecting autonomy, helping the patient make the right decision for themselves, and advocating for those decisions to others (19). One of the most difficult decisions nurses face involves those that conflict with their personal belief system (20). 

Nurses must be equipped with the knowledge and skills to navigate these ethical challenges and provide care that respects patients' values and beliefs while also nurturing their thoughts and feelings (21). By exploring bioethics in nursing, we can promote a culture of ethical practice that is compassionate and patient-centered (22). 

Henrietta Lacks Story 

Henrietta Lacks was a Black tobacco farmer who had her cancer cells taken without her knowledge or consent which led to numerous scientific breakthroughs, including the development of the polio vaccine (23). Her story raises important questions about medical ethics, racism, and the intersection of science and human compassion. 

In 1951, Henrietta Lacks was diagnosed with cervical cancer and began treatment at Johns Hopkins Hospital in Baltimore. During her treatment, a sample collection of her cancer cells was taken by her doctor, Dr. George Gey without her knowledge and or consent (24). Dr. Gey discovered that Henrietta's cells were extraordinary in nature and could be of great value for cancer research and future developments as they could survive and thrive in a laboratory setting thus making them ideal for scientific research. 

Henrietta's cells, known as HeLa cells, were soon being used in laboratories worldwide, leading to numerous scientific breakthroughs, including the polio vaccine development, in vitro fertilization, and gene mapping (25). However, Henrietta's family was never informed or financially compensated for the use of her cells, and her story remained largely unknown until the publication of Rebecca Skloot's book "The Immortal Life of Henrietta Lacks" in 2010 (23). 

Henrietta's story highlights the unethical practices that were common in the medical field at the time, particularly in relation to patients that lacked resources, particularly those belonging to minority groups (26). Her cells were taken without her consent, and she was never compensated or acknowledged for her contribution to science. This raised some very important questions about medical ethics, informed consent, and the exploitation of vulnerable populations. 

Still, Henrietta's story is a powerful reminder of the intersection of science and the need for personal autonomy (27). Her cells have been used to advance scientific knowledge, but they also represent a person, a family, and a community. The use of her cells without her consent or compensation is a violation of her humanity and a reminder of the need for ethical considerations in scientific research. 

Tuskegee Syphilis Experiments 

The Tuskegee Syphilis Study was a highly controversial and unethical medical experiment conducted on African American men in Macon County, Alabama between 1932 and 1972 (24). The study, led by the Department of U.S. Public Health Services, involved withholding treatment from hundreds of African American men infected with syphilis despite the availability of effective therapies, to study the natural progression of the disease (25). 

The men, who were mostly illiterate and poor, were not informed that they had syphilis, their partners were not informed of the disease, nor were they given treatment for the disease (26). Instead, they were given placebos and misleading information about their condition (27). The study continued for 40 years, during which time many of the men died from syphilis-related complications, and many others suffered serious health problems which included the spreading of syphilis to unsuspecting sexual partners (28). 

The Tuskegee Syphilis Study is widely regarded as one of the most unethical medical experiments in history. The study was conducted without the men's knowledge or consent, and it violated basic human rights and principles of medical ethics (30). By way of public outcry and shock, the awareness of these experiments led to major changes in the way human subjects are protected in medical research and a desire for closer oversight by governing groups (29).  

In 1974, a class-action lawsuit was filed on behalf of the men who were involved in the study, resulting in a multimillion-dollar settlement (31). The study also led to the establishment of the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, which developed guidelines for the ethical conduct of research involving human subjects (32). 

The Tuskegee Syphilis Study has had a lasting impact on the field of medicine and beyond (33). It highlighted the importance of informed consent and the need for ethical oversight in the field of medical research (34). It has also led to the increased scrutiny of medical experiments and a greater emphasis on protecting human subjects, their privacy, and most importantly honest care and explanations of medical conditions and treatments (35). 

Today, the Tuskegee Syphilis Study is remembered as a cautionary tale about the dangers of unethical medical research (36). It serves as a reminder of the importance of prioritizing the well-being and safety of people and the need for ongoing vigilance in ensuring that medical research is conducted ethically and responsibly, and ensuring there are the proper checks and balances in place to provide the oversight needed (37). 

The study also highlighted the need for diversity in medical research and the importance of including diverse populations in clinical trials (38). It led to increased efforts to address health disparities and to ensure that medical research is conducted in a way that is fair and equitable to all (39). 

In addition, the Tuskegee Syphilis Study led to changes in the way that medical research is regulated and overseen (40). It led to the establishment of institutional review boards (IRBs) and independent ethics committees (IECs) which are responsible for reviewing and approving research protocols and ensuring they meet the ethical standards set in place (41). 

Transparency and accountability in medical research have also been placed at the forefront of research since these events took place (42). Highlighting the importance of disclosing potential conflicts of interest and ensuring research is conducted in a way that is transparent and open to scrutiny; there inevitably was major change and growth that came from this huge medical injustice (43). 

The Tuskegee Syphilis Study was a highly unethical and controversial medical experiment that had a profound impact on the field of medicine and beyond. It highlighted the importance of informed consent, ethical oversight, and diversity in medical research, and led to major changes in the way medical research is conducted and regulated. In these ways, it acted as a catalyst of growth and change in the way the U.S. views and treats research participants. It serves as a reminder of the need for ongoing vigilance in ensuring medical research is conducted ethically and responsibly. 

The Tuskegee Syphilis Studies and Henrietta Lacks' cases highlight the importance of informed consent in research (23). 

Other examples include: 

• Abortion and reproductive rights (24) 

• Euthanasia and end-of-life care (25) 

• Gene editing and genetic research (26) 

• Healthcare access and disparities (27)

Research in Ethics 

Research ethics involves applying bioethical principles in research. Obtaining informed consent and ensuring participant confidentiality are two ways in which the provider can best provide ethical care to those that entrust the healthcare system with their voluntary well-being (28). 

Researchers must be aware of ethical principles that guide research and ensure their studies are conducted ethically and responsibly which puts the client first (29). 

Ethical Decision-Making 

Ethical decision-making involves critical thinking, moral principles, and professional standards (30). Nurses can use ethical frameworks, such as the ETHICAL model, to guide decision-making (31). Ethical decision-making is a crucial aspect of nursing practice as it enables nurses to navigate complex healthcare issues and promote patients' well-being (32). 

Conclusion 

Bioethics plays a vital role in nursing practice, ensuring that patients receive respectful and compassionate care. Understanding bioethical principles and applications is essential for nurses to provide high-quality care. By applying ethical principles and frameworks, nurses can navigate complex healthcare issues and promote patients' well-being. 

Infection Control and Barriers

Introduction   

Healthcare professionals have the responsibility to adhere to scientifically accepted principles and practices of infection control in all healthcare settings and to oversee and monitor those medical and ancillary personnel for whom the professional is responsible. 

The following sections explore the sources and definitions of standards of professional conduct as they apply to infection prevention and control.  

Element I 

Rules of the Board of Regents, Part 29.2 (a)(13) 

New York (NY) law clearly defines the responsibilities of health professionals in having access to products, using, and adhering to scientifically approved techniques for “. . . the cleaning and sterilization or disinfection of instruments, devices, materials and work surfaces, utilization of protective garb, use of covers for contamination-prone equipment and the handling of sharp instruments” (1).  

These guidelines and rules are laid out within the Rules of the Board of Regents, Part 29.2 (a)(13). It is the responsibility of nursing to review and execute these standards throughout the healthcare continuum as follows (1): 

1. Wearing appropriate protective gloves at all times when touching blood, saliva, other body fluids or secretions, mucous membranes, non-intact skin, blood-soiled items or bodily fluid-soiled items, contaminated surfaces, and sterile body areas, and during instrument cleaning and decontamination procedures. 
2. Discarding gloves used following treatment of a patient and changing to new gloves if torn or damaged during treatment of a patient; washing hands and donning new gloves before performing services for another patient; and washing hands and other skin surfaces immediately if contaminated with blood or other body fluids. 
3. Wearing appropriate masks, gowns or aprons, and protective eyewear or chin-length plastic face shields whenever splashing or spattering of blood or other body fluids is likely to occur. 
4. Sterilizing equipment and devices that enter the patient’s vascular system or other normally sterile areas of the body. 
5. Sterilizing equipment and devices that touch intact mucous membranes but do not penetrate the patient’s body or using high-level disinfection for equipment and devices that cannot be sterilized before use for a patient. 
6. Using appropriate agents, including but not limited to detergents for cleaning all equipment and devices before sterilization or disinfection. 
7. Cleaning, by the use of appropriate agents, including but not limited to detergents, equipment, and devices that do not touch the patient or that only touch the intact skin of the patient. 
8. Maintaining equipment and devices used for sterilization according to the manufacturer’s instructions. 
9. Adequately monitoring the performance of all personnel, licensed or unlicensed, for whom the licensee is responsible regarding infection control techniques. 
10. Placing disposable used syringes, needles, scalpel blades, and other sharp instruments in appropriate puncture-resistant containers for disposal; and placing reusable needles, scalpel blades, and other sharp instruments in appropriate puncture-resistant containers until appropriately cleaned and sterilized. 
11. Maintaining appropriate ventilation devices to minimize the need for emergency mouth-to-mouth resuscitation. 
12. Refraining from all direct patient care and handling of patient care equipment when the health care professional has exudative lesions or weeping dermatitis, and the condition has not been medically evaluated and determined to be safe or capable of being safely protected against in providing direct patient care or in handling patient care equipment; and 
13. Placing all specimens of blood and body fluids in well-constructed containers with secure lids to prevent leaking, and cleaning any spill of blood or other body fluid with an appropriate detergent and appropriate chemical germicide 
14. Part 92 of Title 10 (Health) of the Official Compilation of Codes, Rules, and Regulations of New York 

Under Part 92 of Title 10, it is the responsibility of healthcare professionals who are in a position of providing direct care or providing supervision over staff providing direct patient care to maintain competency in infection prevention and barrier precautions. The requirement is fulfilled via a New York board-approved coursework or training.  Coursework or training must be before initial licensing, subsequently renewed every four years, and maintained for six years after ceasing position or such work (2). 

Statements of Relevant Professional and National Organizations 

As the largest healthcare workforce in the nation, nurses are in a position to positively affect the rates of infection at the bedside. The Center for Disease Control asserts the minimum accepted practice of preventing infection is with the use of Standard Precautions, with the number one action in prevention being proper hand washing (3). 

The American Nurses Association refers to similar basic tenets of infection prevention: thorough hand washing; staying home when ill; ensuring vaccinations are complete and up to date; using appropriate personal protective equipment; and covering the face when coughing or sneezing (4). 

In 2017, the CDC, ANA, and 20 other professional nursing organizations collaborated to create the Nursing Infection Control Education (NICE) Network. This team effort is aimed at introducing clear obligations and competencies for nursing and all healthcare providers to stop the spread of microorganisms within healthcare systems. Within these cores is the responsibility of nurses as leaders within healthcare, “To be successful, infection prevention programs require visible and tangible support from all levels of the healthcare facility’s leadership” (5). 

Implications of Professional Conduct Standards 

As healthcare professionals who participate in and supervise the care of patients, nurses are responsible for being knowledgeable of the guidelines set by State and federal bodies. Several of these will be touched on throughout this course. 

The responsibility also applies to delegated activities. The nurse must ensure that the five rights of delegation are considered when assigning a task to unlicensed assistive personnel and that appropriate infection control policies and protocols are being followed appropriately. Always refer to facility policies and procedures to avoid potentially adverse outcomes. 

Failure to follow the accepted standards of infection prevention and control may have serious health consequences for patients, as well as healthcare workers. Hospital acquired infections (HAI) have increased overall from 2020 to 2021 in all infections including central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), ventilator-associated infections, and methicillin-resistant staphylococcus aureus (MRSA). Only clostridium difficile (C-Diff) and surgical site infections (SSI) saw rates lower (6). 

In cases of nurses observing incompetent care or unprofessional conduct in relation to infection control standards, the chain of command should first be utilized. Taking consideration into the type of misconduct, the infection control violation should be addressed according to facility policy. Charge nurses and managers would be wise to first address the issue with the nurse involved to gather information and address any education deficits. 

In cases where clear misconduct is evident, the National Council of State Boards of Nursing provides advice, “A nurse’s practice and behavior is expected to be safe, competent, ethical and in compliance with applicable laws and rules. Any person who has knowledge of conduct by a licensed nurse that may violate a nursing law or rule, or related state or federal law may report the alleged violation to the board of nursing where the conduct occurred” (7). 

The New York Board of Nursing can be reached via its website or at (518) 474-3817. The mailing address is Education Bldg., 89 Washington Avenue, 2nd Floor West Wing, Albany, NY 12234. 

The consequences of failing to follow accepted standards of infection prevention and control may result in a complaint investigation from New York’s Professional Misconduct Enforcement System. Upon investigation, penalties include but are not limited to reprimand and censure, fines of up to $10,000 per violation, and probationary terms. 

Severe misconduct may result in the loss or revocation of a nursing license. Also, in cases where the neglect to follow appropriate conduct has resulted in harm to a patient or co-worker, there is potential for professional liability through a malpractice suit brought against the nurse. 

Methods of Compliance 

Nurses are responsible for being knowledgeable of the licensure guidelines, renewal CEs, and targeted education in their state of practice. Refer to the NY Board of Nursing for further guidance beyond the above-mentioned licensing requirements. 

Education of infection control best practices, complying with state requirements, and following the facility practices and policies will provide the best protection for self, patients, and staff in preventing and controlling infection during patient care. 

Element II 

Modes and mechanisms of transmission of pathogenic organisms in the healthcare setting and strategies for prevention control. 

Definitions 

Pathogen or infectious agent: A biological, physical, or chemical agent capable of causing disease. Biological agents may be bacteria, viruses, fungi, protozoa, helminths, or prions. 

Portal of entry: How an infectious agent enters the susceptible host. 

Portal of exit: The path by which an infectious agent leaves the reservoir. 

Reservoir: A place in which an infectious agent can survive but may or may not multiply or cause disease. Healthcare workers may be a reservoir for a number of nosocomial organisms spread in healthcare settings. 

Standard precautions: A group of infection prevention and control measures that combine the major features of Universal Precautions and Body Substance Isolation and are based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. 

Susceptible host: A person or animal not possessing sufficient resistance to a particular infectious agent to prevent contracting infection or disease when exposed to the agent. 

Transmission: Any mechanism by which a pathogen is spread by a source or reservoir to a person. 

Common vehicle: Contaminated material, product, or substance that serves as a means of transmission of an infectious agent from a reservoir to one or more susceptible hosts through a suitable portal of entry. 

Component of the Infectious Disease Process 

The infectious disease process follows a particular sequence of events that is commonly described as the “Chain of Infection.” Nurses must have a solid understanding of this process in order to identify points in the chain where the spread of infection may be prevented or halted.  

The sequence involves six factors: pathogen, reservoir, portal of exit, portal of entry, mode of transmission, and a susceptible host. The cyclical and consistent nature of the chain provides many opportunities to utilize scientific, evidence-based measures in combating infection spread. 

Pathogens within healthcare are widespread and plentiful, putting patients and healthcare workers at particular risk for contamination. The manifestation of symptoms and mode of transmission varies depending upon the characteristics of the specific infectious agent.  

Healthcare workers are at a considerably higher risk for bloodborne pathogens such as human immunodeficiency virus (HIV), hepatitis B virus, and hepatitis C virus. Influenza, methicillin-resistant Staphylococcus aureus (MRSA), and Tuberculosis (TB) also pose a higher risk (1). Due to the immunocompromised systems of patients, these and many other pathogens cause a considerable risk and can result in HAIs such as Central Line-associated Bloodstream Infection (CLABSI), Catheter-associated Urinary Tract Infections (CAUTI), Surgical Site Infection (SSI), and Ventilator-associated Pneumonia (VAP) (1). 

Pathogens require a reservoir, which is typically a human or animal host; however, may also be from the environment, such as standing water or a surface. From the reservoir, the pathogen is spread via a mechanism such as body fluid, blood, and secretions.  

Common sites for contact within patient care include the respiratory, genitourinary, and gastrointestinal tracts, as well as skin/mucous membranes, transplacental, or blood. From here, the mechanism must come into contact with another portal of entry.  

Transmission may occur through respiratory, genitourinary, and gastrointestinal tracts, skin and/or mucous membranes, and parenteral pathways. Some of these sites may have become compromised during patient care due to percutaneous injury, invasive procedures or devices, or surgical incisions. 

In order to acquire a pathogen, a mode of transmission must be provided. These can be from contact, transmission via a common vehicle, or vector-borne. 

Contact with a pathogen may be categorized as direct, indirect, droplet, or airborne. Contact transmission is through direct or indirect contact with a patient or objects that have been in contact with the patient. Pathogens related to this include Clostridium difficile and multi-drug resistant organisms such as MRSA.  

Droplet transmission occurs when a pathogen is able to infect via droplets through the air by talking, sneezing, coughing, or breathing. The pathogen is able to travel three to six feet from the patient. Airborne transmission occurs when pathogens are 5 micrometers or smaller in size and are capable of being suspended in the air for long periods of time. These types of pathogens include tuberculosis, measles, chickenpox, disseminated herpes zoster, and anthrax (2). 

Transmission may also occur through a common vehicle which affects multiple hosts and can come from food, intravenous fluid, medication, biofilms, or equipment that is shared and often leads to widespread outbreaks. Vector-borne pathogens are derived from living vectors such as mosquitoes, fleas, or ticks. 

The last factor in the chain of infection is a susceptible host with a mode of entry. This is the reason that patients are at a much higher risk for developing secondary infections while within the healthcare system. 

Factors Influencing the Outcome of Exposures 

The human body provides several natural defenses against acquiring infection from a pathogen. The most prominent defense is the integumentary system, and the focus should be on maintaining skin integrity to prevent a mode of entry.  

Respiratory cilia function to move microbes and debris from the airway. Gastric acid is at a pH that prevents the growth of many pathogens. Bodily secretions provide defense through flushing out and preventing back-flow of potential infectious agent colonization.  

The normal flora within the gastrointestinal system also provides a layer of defense that must be protected from the action of antibiotics. Probiotics are commonly administered to patients on antibiotics to prevent a secondary infection due to the normal flora being disrupted (3). 

Host immunity is the secondary defense that utilizes the host’s own immune system to target invasive pathogens. There are four types of host immunity (3): 

1. Inflammatory response is pathogen detection by cells in a compromised area that then elicit an immune response that increases blood flow. This inflammatory provides delivery of phagocytes or white blood cells to the infected site response. Phagocytes are designed to expunge bacteria. 
2. Cell-mediated immunity uses B-cells and T-cells, specialized phagocytes, are cytotoxic cells that target pathogens. 
3. Humoral immunity is derived from serum antibodies produced by plasma cells. 
4. Immune memory is the ability of the immune system to recognize previously encountered antigens of pathogens and effectively initiate a targeted response. 

Pathogen or Infection Agent factors 

For each type of infectious agent, there are specific factors that determine the risk to the host. Infectivity refers to the number of exposed individuals that become infected. Pathogenicity is the number of infected individuals that develop clinical symptoms and virulence is the mortality rate of those infected. The probability of an infectious agent causing symptoms depends upon the size of the inoculum (amount of exposure), and the route and duration of exposure (4). 

The environment is another factor that warrants attention in limiting the probability of exposure in the healthcare setting. Fomites are materials, surfaces, or objects that are capable of harboring or transmitting pathogens. These can be bedside tables, scrubs, gowns, bedding, faucets, and any other number of items that are in contact with patients and healthcare providers (7). 

Equipment may factor into the spread of infection, especially portable medical equipment that can come into contact with numerous patients in a day. This can include vitals machines, IV pumps, wheelchairs, and computers on wheels, among numerous other care items frequently used.  

Care must be taken to ensure cleaning in between each patient’s use. For patients in isolation precautions, dedicated equipment for that patient should remain in the room for the duration of their stay. 

Methods to Prevent the Spread of Pathogenic Organisms  

Standard Precautions 

Standard precautions are the minimal amount of caution and procedure applied to typical patient care. According to the CDC, standard precautions are to be used in all patient care areas with critical thinking applied to “. . . common sense practices and personal protective equipment use” (5).  The primary of these is proper hand hygiene to be exercised by healthcare providers, patients, and visitors. This will be covered in detail further in this course. 

Standard precautions provide guidelines for respiratory hygiene and cough etiquette. The CDC recommends that the mouth and nose be covered with a tissue when coughing or sneezing, with appropriate disposal of the tissue in the nearest waste station. Hand hygiene is to be performed after contact with any respiratory secretions or potentially contaminated items (5). 

As mentioned, healthcare workers are at a higher risk for bloodborne infections due to the handling of sharps. Approximately 385,000 needle sticks and sharps injuries are reported by healthcare workers in hospital settings each year (5). Standard precautions can be applied to ensure safe injection practices and will be further covered in Element III. 

Certain spinal procedures that access the epidural or subdural space provide a means of transmission for infections such as bacterial meningitis. The CDC states (all from 6): 

• Face masks should always be used when injecting material or inserting a catheter into the epidural or subdural space. 

• Aseptic technique and other safe injection practices (e.g., using a single-dose vial of medication or contrast solution for only one patient) should always be followed for all spinal injection procedures. 

For Patients Infected with Organisms Other Than Bloodborne Pathogens 

Special considerations must be given to patient populations that are infected with organisms other than bloodborne pathogens. During the triage of a patient entering a facility, a thorough history should be obtained.  

This would include exposure to infectious agents, travel to certain countries in the world, and previous infections that are resistant to antibiotics (i.e., MRSA, VRE, or carbapenem-resistant Enterobacteriaceae). Patients who are identified with a risk or history of any of these pathogens may be placed on the appropriate precautions in an isolation room.  

Infection prevention and the attending physician should be consulted immediately for further orders and treatment. 

Control of Routes of Transmission 

Controlling the routes of transmission is a key factor in preventing infection spread. Hand hygiene has been established as the primary prevention method.  

Care must be taken to follow guidelines for proper hand washing including: 

• Use antibacterial soap and water when hands are visibly soiled or when a Clostridium difficile infection is known or suspected. 
• Hands should be lathered ensuring all surfaces, between fingers, and under nails are covered with scrubbing lasting at least 20 seconds. 
• Thoroughly rinse the soap from your hands with running water, pat dry with a paper towel, and use a paper towel to turn off the faucet. 
• Hand sanitizer that is at least 60% alcohol based may be used in between soap and water use. 
• A dime-sized amount of hand sanitizer should be rubbed over the surface of hands and fingers, then allowed to air dry. 

Barriers to proper hand hygiene include knowledge gaps and the availability of appropriate supplies. Training programs to educate healthcare providers on proper hand washing should be accompanied with ongoing assessment and feedback to ensure that compliance is met.  

Incorporating hand hygiene into the professional development plan of each nurse is also recommended (7). Healthcare facilities should be diligent in ensuring that hand washing stations are located in convenient areas and that hand cleaning product is frequently monitored and refilled (7,8). Signage and educational materials may be posted in high-traffic areas and at hand washing stations to encourage use by healthcare providers, patients, and visitors (7). 

Nurses and healthcare personnel must be aware of the potential of hand hygiene materials as being a potential source of contamination or cross-contamination. Hand hygiene dispensers are touched frequently with contaminated hands and must be frequently cleaned. Follow the manufacturer's recommendations for cleaning. 

Hand hygiene systems that allow products to be refilled pose a risk of contaminating the contents. If refilling is a requirement, this should be accomplished using an aseptic technique as much as possible. Facilities should avoid purchasing this type of product and move to pre-filled dispensing units, if possible (10). 

Use of Appropriate Barriers 

Appropriate barriers are essential in keeping patients and healthcare providers safe from transmitting or contracting pathogens. The type of PPE chosen depends on certain variables such as the patient care being provided, standard precautions, and transmission-based precautions. The minimal amount of PPE recommended are as follows: 

Contact precautions require gloves and gowns. If bodily secretions may be contacted, a mask and eye protection are required. 

Droplet precautions require a surgical mask. 

Airborne precautions require the wearing of gloves and a gown as well as an approved N95 respirator mask that has been fit tested for the individual wearing. Negative pressure rooms that are able to filter 6 to 12 air exchanges per hour are also recommended (1). 

Be mindful that these are the minimal recommendations based solely on the identified transmission status of the patient. Selection of PPE should be made using critical thinking to identify potential risks depending on the type of patient care being performed, procedure, behavioral considerations, and other factors that may deviate from the standard. 

The following are current recommendations from the CDC for donning and doffing (11): 

How to Put On (Don) PPE Gear: More than one donning method may be acceptable. Training and practicing using your healthcare facility’s procedure is critical. Below is one example of donning. 

1. Identify and gather the proper PPE to wear. Ensure the choice of gown size is correct (based on training). 
2. Perform hand hygiene using hand sanitizer. 
3. Put on an isolation gown. Tie all of the ties on the gown. Assistance may be needed by other healthcare personnel. 
4. Put on NIOSH-approved N95 filtering face-piece respirator or higher (use a facemask if a respirator is not available). If the respirator has a nosepiece, it should be fitted to the nose with both hands, not bent or tented. Do not pinch the nosepiece with one hand. The respirator/facemask should be extended under the chin. Both your mouth and nose should be protected. Do not wear a respirator/facemask under your chin or store it in a scrubs pocket between patients.  
   1. Respirator: Respirator straps should be placed on the crown of the head (top strap) and base of the neck (bottom strap). Perform a user seal check each time you put on the respirator. 
   2. Face mask: Mask ties should be secured on the crown of the head (top tie) and base of the neck (bottom tie). If the mask has loops, hook them appropriately around your ears.
5. Put on a face shield or goggles. When wearing an N95 respirator or half face-piece elastomeric respirator, select the proper eye protection to ensure that the respirator does not interfere with the correct positioning of the eye protection and that the eye protection does not affect the fit or seal of the respirator. Face shields provide full face coverage. Goggles also provide excellent protection for eyes, but fogging is common. 
6. Put on gloves. Gloves should cover the cuff (wrist) of the gown. 
7. Healthcare personnel may now enter the patient’s room. 

How to Take Off (Doff) PPE Gear: More than one doffing method may be acceptable. Training and practicing using your healthcare facility’s procedure is critical. Below is one example of doffing. 

1. Remove gloves. Ensure glove removal does not cause additional contamination of hands. Gloves can be removed using more than one technique (e.g., glove-in-glove or bird beak). 
2. Remove gown. Untie all ties (or unsnap all buttons). Some gown ties can be broken rather than untied. Do so in a gentle manner, avoiding forceful movement. Reach up to the shoulders and carefully pull the gown down and away from the body. Rolling the gown down is an acceptable approach. Dispose of in a trash receptacle. 
3. Healthcare personnel may now exit the patient’s room. 
4. Perform hand hygiene. 
5. Remove face shields or goggles. Carefully remove face shields or goggles by grabbing the strap and pulling upwards and away from the head. Do not touch the front of your face shield or goggles. 
6. Remove and discard the respirator (or face mask if used instead of respirator). Do not touch the front of the respirator or face mask.  
   1. Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap, bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator. 
   2. Face mask: Carefully untie (or unhook from the ears) and pull away from the face without touching the front. Perform hand hygiene after removing the respirator/face mask and before putting it on again if your workplace is practicing reuse.
7. Perform hand hygiene after removing the respirator/face mask and before putting it on again if your workplace is practicing reuse.

Appropriate Isolation/Cohorting of Patients with Communicable Diseases 

Cohorting patients is a common practice within facilities, especially with limited rooms and an increasing number of patients with MDROs (12). In order to combat these issues, placing patients with the same type of pathogen in one room, when single rooms are not available is an option. The minimal standard for all patients is standard precautions. 

The CDC offers guidance for appropriately isolating or cohorting patients based on the type of precaution. 

Contact: Patients with a known or suspected pathogen that is transmitted via contact should be placed in a private room, if available. Cohorting can be achieved if the cohorted patients share the same type of pathogen (13). 

Droplet: Unless a single patient room is not available, patients in droplet precautions should only be cohorted if neither have an excessive cough or sputum production. The cohorts should be tested to ensure they are infected with the same type of pathogen. Immunocompromised patients are at an increased risk and should not be cohorted. Patients are to be separated at least three feet apart and a privacy curtain should remain drawn between their respective areas. Care providers must don and doff new PPE in between providing care to each respective patient (13). 

Airborne: An airborne infection isolation room (AIIR) with negative air pressure that exchanges air at least six to 12 changes per hour is required. The door must remain closed except for entry and exit. Cohorting of patients is not recommended except in the case of an outbreak or a large number of exposed patients (13). In these instances, the CDC recommends the following (13): 

• Consult infection control professionals before patient placement to determine the safety of alternative rooms that do not meet engineering requirements for AIIR. 
• Place together (cohort) patients who are presumed to have the same infection (based on clinical presentation and diagnosis when known) in areas of the facility that are away from other patients, especially patients who are at an increased risk for infection (e.g., immunocompromised patients). 
• Use temporary portable solutions (e.g., exhaust fan) to create a negative pressure environment in the converted area of the facility. Discharge air directly to the outside, away from people and air intakes, or direct all the air through HEPA filters before it is introduced to other air spaces. 

Host Support and Protection 

Vaccinations to prevent disease are highly recommended by numerous health organizations such as the CDC, the World Healthcare Organization, and the Office of Disease Prevention and Health Promotion. As stated by the U.S. Department of Health and Human Services, “The United States will be a place where vaccine-preventable diseases are eliminated through safe and effective vaccination over the lifespan.” (14).  

As healthcare providers, nurses are in a position to review the patient’s history for gaps in appropriate vaccination coverage and offer education to the patient. Additionally, healthcare providers hold an ethical responsibility to maintain current vaccinations and can prevent transmitting known communicable diseases by receiving an influenza vaccination each year. 

Pre- and/or post-prophylaxis may be recommended during certain types of exposures or for patients at an increased risk for infection. This is commonly used for emergent or planned procedures and surgeries that access areas that are at higher risk for becoming a portal of entry, such as the respiratory, gastrointestinal, and genitourinary tracts. Antibiotics may be ordered when it is known that the sterile field has been broken during a procedure or there has been a concern of contamination of a wound or incision site. 

In cases of exposure to an infectious pathogen, the decision to treat includes factors such as the type of exposure, source of the patient’s symptoms, time frame since exposure, the health status of the individual exposed, as well as the risks and benefits of the treatment. Pre-prophylaxis may be considered in the prevention of HIV for high-risk individuals. 

Typically, after exposure, the host’s blood is drawn to determine pathogen risk regardless of if there is a known pathogen. Post-exposure prophylactics are given within a short time frame from the exposure based on results. The individual who is exposed will have baseline testing for HIV, hepatitis B virus, and hepatitis C viral antibodies. Follow-up testing occurs six weeks, three months, and six months after initial exposure. 

Maintaining skin and immune system integrity is of the utmost importance to prevent the transmission of infectious pathogens.  

Nursing interventions to promote skin and immune system integrity are: 

• Perform a thorough skin assessment every shift and with changes in condition 
• Accurately document any wounds or incisions 
• Use gentle cleansers on the skin and pat dry 
• Use moisturizers and barrier creams on dry or tender skin 
• Prevent pressure ulcer development by turning and repositioning the patient every 2 hours 
• Maintain aseptic technique during wound care, dressing changes, IV manipulation or blood draws, and catheter care 
• Use neutropenic guidelines when providing care to immunocompromised patients 
• Encourage adequate nutritional intake 

Environmental Control Measures 

The cleaning, disinfection, and sterilization of patient care equipment should be performed per the recommendations of the manufacturer. Cleaning should be performed between multiple patients.  

For equipment that has been used in an isolation room, a terminal clean must be performed before being used in any other patient care. Additional information on this topic will be covered within Element V. 

Environmental cleaning personnel must be educated on the appropriate cleaning for all precautionary patient environments. The Material Safety Data Sheets for all chemicals are to be available to all healthcare personnel for reference as to the proper use and storage. These should be referred to in order to ensure that the correct cleaning product is effective in terminally cleaning isolation rooms based on pathogens. 

Ventilation should be thoroughly managed and maintained by the environmental operations team. Negative pressure rooms should be consistently monitored, and alarms investigated to ensure proper air exchange. Concerns from nursing regarding ventilation issues should be directed to the environmental team for follow-up. 

Regulated medical waste (RMW) within the healthcare system that must follow state guidelines for disposal includes: 

• Human pathological waste 
• Human blood and blood products 
• Needles and syringes (sharps) 
• Microbiological materials (cultures and stocks) 
• Other infection waste (16) 

According to the Department of Environmental Conservation in New York, “In accordance with both federal and state requirements, and to ensure containment, RMW (except medical waste sharps) is required to be placed in plastic bags and then packaged in single-use (e.g., corrugated boxes) or reusable rigid (e.g., plastic) or semi-rigid, leak-proof containers before transport. Once packaged, RMW is either transported to a designated secure storage, a collection area within the facility for third party pick-up, or a generator’s on-site treatment facility” (16). 

Bodily fluid (urine, vomit, and feces) may be safely disposed of in any utility sink, drain, toilet, or hopper that drains into a septic tank or sanitary sewer system. Healthcare personnel must don appropriate PPE during disposal. 

Linen and laundry management is governed by Title 10: Section 83-1.17 which states (17) shared health facilities shall: 

• Provide a sufficient quantity of clean linen to meet the requirements of patients. 
• Separately bag or enclose used linens from infectious patients in readily identified containers distinguishable from other laundry. 
• Transport and store clean linen in a manner to prevent contamination. 

Food services are required to follow stringent standards under the New York State Department of Health’s Bureau of Community Environmental Health and Food Protection to ensure that food service establishments are maintained to reduce the incidence of food-borne illness. 

Environment controls include medical devices and systems that are put in place to isolate or remove the blood-borne pathogens hazard from the workplace. These include sharps disposal containers, self-sheathing needles, and safer medical devices, such as sharps with engineered sharps injury protections and needleless systems. Further information will be provided on this subject in Element III. 

Per facility specifications, continuous training and education should be provided to healthcare personnel on the various methods and modes of environmental control measures that are put in place to prevent and contain pathogen spread. 

ELEMENT III 

Use of engineering and work practice controls to reduce the opportunity for patient and healthcare worker exposure to potentially infectious material in all healthcare settings. 

Definitions 

Healthcare-associated infections (HAIs): Infections associated with healthcare delivery in any setting (e.g., hospitals, long-term care facilities, ambulatory settings, home care). 

Engineering Controls: Controls (e.g., sharps disposal containers, self-sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace. 

Injection safety (or safe injection practices): A set of measures taken to perform injections in an optimally safe manner for patients, healthcare personnel, and others. A safe injection does not harm the recipient, does not expose the provider to any avoidable risks, and does not result in waste that is dangerous for the community. Injection safety includes practices intended to prevent transmission of blood-borne pathogens between one patient and another, or between a healthcare worker and a patient, and also to prevent harm such as needlestick injuries. 

b A bottle of liquid medication that is given to a patient through a needle and syringe. Single-use vials contain only one dose of medication and should only be used once for one patient, using a new sterile needle and a new sterile syringe. 

Multi-dose medication vial: a bottle of liquid medication that contains more than one dose of medication and is often used by diabetic patients or for vaccinations. 

Work Practice Controls: Controls that reduce the likelihood of exposure to bloodborne pathogens by altering how a task is performed (e.g., prohibiting the recapping of needles by a two-handed technique). 

High-risk Practices and Procedures 

Percutaneous exposures are a work hazard within the healthcare industry. There are approximately 5.6 million healthcare workers at risk, with nurses ranking number one. Studies have shown that needlestick injuries occur most frequently within a patient room or the operating room (1). 

Exposures can occur through not following safe practices. The following practices in handling contaminated needles and other sharp objects, including blades, can increase the risk of percutaneous exposure and should be avoided: 

1. Manipulating contaminated needles and other sharp objects by hand (e.g., removing scalpel blades from holders, removing needles from syringes) 
2. Delaying or improperly disposing of sharps (e.g., leaving contaminated needles or sharp objects on counters/workspaces or disposing in non-puncture-resistant receptacles) 
3. Recapping contaminated needles and other sharp objects using a two-handed technique 
4. Performing procedures where there is poor visualization, such as: 

• • Blind suturing 
  • Non-dominant hand opposing or next to a sharp 
  • Performing procedures where bone spicules or metal fragments are produced 

Mucous membrane/non-intact skin exposures occur with direct blood or body fluids contact with the eyes, nose, mouth, or other mucous membranes via: 

• Contact with contaminated hands 
• Contact with open skin lesions/dermatitis 
• Splashes or sprays of blood or body fluids (e.g., during irrigation or suctioning) 

Parenteral exposure is the subcutaneous, intramuscular, or intravenous contact with blood or other body fluid. Injection with infectious material may occur during: 

• Administration of parenteral medication 
• Sharing of blood monitoring devices (e.g., glucometers, hemoglobinometers, lancets, lancet platforms/pens) 
• Infusion of contaminated blood products or fluids 
• Human bites, abrasions, or cuts 

According to the CDC, unsafe injection practices have resulted in more than 50 outbreaks of infectious disease transmission since 2001. As well, since that time over 150,000 patients were potentially exposed to HIV, hepatitis B virus, and hepatitis C virus solely due to unsafe practice (2). These deviations from best practice have resulted in one or more of the following consequences: 

• Transmission of blood-borne viruses, including hepatitis B and C viruses to patients 
• Notification of thousands of patients of possible exposure to blood-borne pathogens and recommendation that they be tested for hepatitis C virus, hepatitis B virus, and human immunodeficiency virus (HIV) 
• Referral of providers to licensing boards for disciplinary action 
• Malpractice suits filed by patients 

Pathogens including HCV, HBV, and human immunodeficiency virus (HIV) can be present in sufficient quantities to produce infection in the absence of visible blood. 

• Bacteria and other microbes can be present without clouding or other visible evidence of contamination. 
• The absence of visible blood or signs of contamination in a used syringe, IV tubing, multi- or single-dose medication vial, or blood glucose monitoring device does NOT mean the item is free from potentially infectious agents. 
• All used injection supplies and materials are potentially contaminated and should be discarded. 

Proper infection control techniques require that healthcare providers follow best practices to prevent injury and pathogen transfer. At all times, aseptic techniques should be used to prepare and administer an injection. The following are best practice guidelines: 

1. Medications should be drawn up in a designated “clean” medication area that is not adjacent to areas where potentially contaminated items are placed. 
2. Use a new sterile syringe and needle to draw up medications while preventing contact between the injection materials and the non-sterile environment. 
3. Ensure proper hand hygiene (i.e., hand sanitizing or hand washing if hands are visibly soiled) before handling medications. 
4. If a medication vial has already been opened, the rubber septum should be disinfected with alcohol before piercing it. 
5. Never leave a needle or other device (e.g., “spikes”) inserted into a medication vial septum or IV bag/bottle for multiple uses. This provides a direct route for microorganisms to enter the vial and contaminate the fluid. 
6. Medication vials should be discarded upon expiration or any time there are concerns regarding the sterility of the medication. 

Never administer medications from the same syringe to more than one patient, even if the needle is changed. 

Never use the same syringe or needle to administer IV medications to more than one patient, even if the medication is administered into the IV tubing, regardless of the distance from the IV insertion site. 

1. All of the infusion components from the infusate to the patient’s catheter are a single interconnected unit. 
2. All of the components are directly or indirectly exposed to the patient’s blood and cannot be used for another patient. 
3. Syringes and needles that intersect through any port in the IV system also become contaminated and cannot be used for another patient or used to re-enter a non-patient-specific multidose medication vial. 
4. Separation from the patient’s IV by distance, gravity, and/or positive infusion pressure does not ensure that small amounts of blood are not present in these items. 
5. Never enter a vial with a syringe or needle that has been used for a patient if the same medication vial might be used for another patient. 

Dedicate vials of medication to a single patient, whenever possible. 

1. Medications packaged as single-use must never be used for more than one patient: 
2. Never combine leftover contents for later use 
3. Medications packaged as multi-use should be assigned to a single patient whenever possible. 
4. Never use bags or bottles of intravenous solution as a common source of supply for more than one patient. 
5. Never use peripheral capillary blood monitoring devices packaged for single-patient use on more than one patient: 
6. Restrict the use of peripheral capillary blood sampling devices to individual patients. 
7. Never reuse lancets. Use single-use lancets that permanently retract upon puncture whenever possible. 

Safe injection practices and procedures are designed to prevent disease transmission from patient to healthcare worker. A fact sheet from OHSA can be found here. 

Evaluation/Surveillance of Exposure Incidents 

A plan to evaluate and follow up on exposure incidents should be put into place at every facility. At a minimum, this plan should include the following elements: 

1. Identification of who is at risk for exposure 
2. Identification of what devices cause exposure 
3. Education for all healthcare employees who use sharps. This would include that ALL sharp devices can cause injury and disease transmission if not used and disposed of properly. Specific focus should be on the devices that are more likely to cause injury such as:  
   1. Devices with higher disease transmission risk (hollow bore), and
   2. Devices with higher injury rates (“butterfly”-type IV catheters, devices with recoil action), 
   3. Blood glucose monitoring devices (lancet platforms/pens). 
4. Identification of areas/settings where exposures occur, and 
5. Circumstances by which exposures occur, 
6. Post-exposure management (See Element VI).  

Engineer Controls

Engineer controls are implemented to provide healthcare workers with the safest equipment to complete their jobs. Safer devices should be identified and integrated into safety protocols whenever possible.  

When selecting engineer controls to be aimed at preventing sharps injuries the following should be considered: 

1. Evaluate and select safer devices 
2. Passive vs. active safety features 
3. Mechanisms that provide continuous protection immediately 
4. Integrated safety equipment vs. accessory devices: 
   1. Properly educate and train all staff on safer devices 
   2. Consider eliminating traditional or non-safety alternatives whenever possible 
   3. Explore engineering controls available for specific areas/settings 
5. Use puncture-resistant containers for the disposal and transport of needles and other sharp objects:   
   1. Refer to published guidelines for the selection, evaluation, and use (e.g., placement) of sharps disposal containers.  
   2. National Institute for Occupational Safety and Health (NIOSH) Guidelines 
   3. NYSDOH recommendations “Household Sharps-Dispose of Them Safely”  
   4. Use splatter shields on medical equipment associated with risk-prone procedures (e.g., locking centrifuge lids). 

Work Practice Controls 

1. General practices:  
   1. Hand hygiene including the appropriate circumstances in which alcohol-based hand sanitizers and soap and water hand washing should be used (see Element II) 
   2. Proper procedures for cleaning of blood and body fluid spills 
   3. Initial removal of bulk material followed by disinfection with an appropriate disinfectant 
2. Proper handling/disposal of blood and body fluids, including contaminated patient care items 
3. Proper selection, donning, doffing, and disposal of personal protective equipment (PPE) as trained (see Element IV) 
4. Proper protection of work surfaces in direct proximity to patient procedure treatment area with appropriate barriers to prevent instruments from becoming contaminated with blood-borne pathogens 
5. Preventing percutaneous exposures:  
   1. Avoid unnecessary use of needles and other sharp objects 
   2. Use care in the handling and disposing of needles and other sharp objects:  
   3. Avoid recapping unless medically necessary 
   4. When recapping, use only a one-hand technique or safety device 
   5. Pass sharp instruments by the use of designated “safe zones” 
   6. Disassemble sharp equipment by use of forceps or other devices 
   7. Discard used sharps into a puncture-resistant sharps container immediately after use 

Modify Procedures to Avoid Injury: 

1. Use forceps, suture holders, or other instruments for suturing 
2. Avoid holding tissue with fingers when suturing or cutting 
3. Avoid leaving exposed sharps of any kind on patient procedure/treatment work surfaces 
4. Appropriately use safety devices whenever available:  

• • Always activate safety features 
  • Never circumvent safety features 

ELEMENT IV 

Selection and use of barriers and/or personal protective equipment for preventing patient and healthcare worker contact with potentially infectious material. 

Definitions 

Personal protective equipment (PPE): Specialized clothing or equipment worn by an employee for protection against a hazard. 

Barriers: Equipment such as gloves, gowns, aprons, masks, or protective eyewear, which when worn, can reduce the risk of exposure of the health care worker’s skin or mucous membranes to potentially infective materials. 

Types of PPE/Barriers and Criteria for Selection 

Per OSHA guidelines, employers must provide employees with appropriate PPE that protects them from any potential infectious pathogen exposure (1). PPE includes gloves, cover garb, masks, face shields and eye protection. All PPE is intended to provide a barrier between the healthcare worker and potential contamination, whether from a patient, object, or surface. 

Gloves are intended to provide coverage and protection for hands. There are several types of gloves to choose from and the type of patient care or activity should guide choice. 

• Sterile – to be utilized when performing sterile procedures and aseptic technique 
• Non-sterile – medical grade, non-sterile gloves may be used for general patient care and clean procedures (such as NG tube insertion) 
• Utility – not medical grade and should not be used in patient care 

Choice of material glove is made from is often dictated by cost and facility preference. When given a choice, considerations should be made as to the types of material being handled. 

• Natural rubber latex – rarely used in facilities due to allergen risk 
• Vinyl – made from PVC, lower in cost, provides protection in non-hazardous and low-infection environments 
• Nitrile – more durable, able to withstand chemical and bio-medical exposure (2) 

An appropriately sized glove fits securely to the fingertips and palm without tightness or extra room. If a glove develops a tear or is heavily soiled, it should be replaced immediately. 

Cover garb is a protective layer to wear over scrubs or clothes to protect garments and skin. These include laboratory coats, gowns, and aprons. As with gloves, consideration should be given to size, sterility, type of patient care involved, and material characteristics of the gown. 

• Fluid impervious – does not allow passage of fluids 
• Fluid resistant – resists penetration of fluids, but fluid may seep with pressure 
• Permeable – does not offer protection against fluids 

Masks are intended to provide protection to the wearer’s mouth and nose, with respirators providing an extra layer of protection to the respiratory tract against airborne infection pathogens (1). Goggles are designed to protect the eyes from splashes and droplet exposure, while face shields offer additional protection to the entire face. It is important to note that face shields are not designed to be a replacement for masks. 

The choice of PPE is based on the factors that are reasonably anticipated to occur during the patient care encounter. Potential contact with blood or other potentially infectious material can occur via splashes, respiratory droplets, and/or airborne pathogens.  

The type of PPE chosen will be based on standard or transmission-based precaution recommendations. Follow your facility policy and procedures for guidance on the appropriate choice.  

The nurse will also need to anticipate whether fluid will be encountered, such as emptying a drain or foley collection device. In situations where a large amount of fluid is likely to be encountered, it would be wise to choose a higher level of protection, such as an impermeable gown, if available, and to wear eye protection to ward off splashes. 

Choosing Barriers/PPE Based on Intended Need 

Barriers and PPE are aimed at keeping patients and healthcare providers safe. There are certain circumstances where specific PPE is selected based on patient care or circumstances. 

Patient Safety 

During invasive procedures, such as inserting a central line or during a surgery, staff directly involved in performing the procedure or surgery must maintain sterility. Appropriate sterile PPE will be selected based on the type of procedure and the patient will be draped in a sterile fashion according to recommended guidelines (1). 

Patients in droplet precautions pose a significant risk to healthcare workers and visitors. The patient, as well as anyone inside the patient’s room, should wear a mask for the most effective prevention of transmission (1). 

Employee Safety 

Employees must ensure that they are evaluating the types of exposure that is likely to occur during patient care. Selection of PPE and appropriate barriers should consider the following: 

Barriers for contamination prevention: Per the CDC, "use of PPE is recommended based on the anticipated exposure to blood, body fluids, secretions, or excretions" (3). The following are CDC guidelines based on the expected type of exposure or precaution; however, clinical judgment should be used based on the situation (all from 5): 

• Standard precautions are to be used with any potential exposure to blood, mucous membranes, compromised skin, contaminated equipment or surfaces, and body fluids. Barriers may include gloves, gowns, and eye and face protection. 
• Employees must be judicious in identifying any precautions that are placed on a patient (i.e., Contact, droplet, airborne) and following recommended PPE guidelines for protecting themselves and other patients.  

• PPE should be donned prior to going into a patient room and doffed upon exit. PPE must never be worn in the halls or when going from one patient’s room to the next. All gloves must be changed in between use and hands washed or sanitized upon removal of gloves. 
• Additionally, whenever possible, social distancing of 6 feet should occur within the work environment. When not possible, adherence to mask guidelines is sufficient.  

Masks for prevention of exposure to communicable diseases: With the onset of COVID-19 across the globe, masks are an essential tool in preventing the transmission of communicable diseases. At a minimum, a medical mask is to be donned during all patient care. During procedures or surgery, surgical masks are to be utilized.  

N-95 masks are reserved for patient care with known or suspected Covid-19, if airborne precautions are ordered, or during procedures that may aerosolize (such as during intubations and certain endoscopy procedures).  

The CDC recommends reserving surgical N-95 masks for healthcare providers "who are working in a sterile field or who may be exposed to high-velocity splashes, sprays, or splatters of blood or body fluids".  Standard N95 respirators are recommended for all other care involving confirmed or suspected Covid-19 patients (5). 

Guidance on Proper Utilization of PPE/Barriers 

Proper fit is required for PPE to be effective. Gowns and gloves chosen should fit well, allow movement, and neither be too baggy or too tight. For particulate respirators, the CDC recommends the following regarding proper fit and use of particulate respirators: 

All workers who are required to wear tight-fitting respirators (e.g., N95 respirators, elastomerics) must have a medical evaluation to determine the worker’s ability to wear a respirator, and if medically cleared, a respirator fit test needs to be performed using the same model available in the workplace (3, 4). 

Prior to donning PPE, it should be inspected for any anomalies, tears, or vulnerable spots. PPE that is compromised should be disposed of and a new garment selected. Nurses must consider the selection of PPE to ensure that it is the correct type for the job and anticipate any circumstances where splashes or saturation of fabric is likely to occur. 

The PPE provided by the employer may be single-use or reusable. Always verify with the manufacturer’s guidelines and facility policy on the correct usage and processing of worn garments. It is the facility’s responsibility to ensure that re-usable gowns are laundered according to State guidelines. 

In order to prevent cross-contamination, OSHA offers the following guidelines: 

• Personal protective equipment must be removed prior to leaving a work area 
• Garment penetrated by blood or other potentially infectious material must be removed immediately or as soon as possible 
• PPE must be discarded in “. . . an appropriately designated area or container for storage, washing, decontamination, or disposal” 
• Employers must ensure that proper hand washing is taking place after the removal of PPE 

Healthcare facilities have a legal duty to protect their workers. Per OSHA, “One way the employer can protect workers against exposure to bloodborne pathogens, such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), the virus that causes AIDS, is by providing and ensuring they use personal protective equipment or PPE. Wearing appropriate PPE can significantly reduce risk since it acts as a barrier against exposure. Employers are required to provide, clean, repair, and replace this equipment as needed, and at no cost to workers” (5). 

Employers and healthcare workers must understand the balance of cost versus benefit ratio in PPE selection and use. While it is important to be good stewards with resources, always erring on the side of caution and choosing PPE based on anticipated exposure risk is the most effective way to protect yourself and your patients. 

Selection, donning, doffing, and disposal. See Element II 

ELEMENT V 

Creation and maintenance of a safe environment for patient care in all healthcare settings through the application of infection control principles and practices for cleaning, disinfection, and sterilization. 

Definitions 

Contamination: The presence of microorganisms on an item or surface. 

Cleaning: The process of removing all foreign material (i.e., dirt, body fluids, lubricants) from objects by using water and detergents or soaps and washing or scrubbing the object 

Critical device: An item that enters sterile tissue or the vascular system (e.g., intravenous catheters, needles for injections). These must be sterile prior to contact with tissue. 

Decontamination: The use of physical or chemical means to remove, inactivate, or destroy blood-borne pathogens on a surface or item to the point where they are no longer capable of transmitting infectious particles. 

Disinfection: The use of a chemical procedure that eliminates virtually all recognized pathogenic microorganisms but not necessarily all microbial forms (e.g., bacterial endospores) on inanimate objects. 

High-level disinfection: Disinfection that kills all organisms, except high levels of bacterial spores, and is affected with a chemical germicide cleared for marketing as a sterilant by the U.S. Food and Drug Administration (FDA). 

Intermediate level disinfection: Disinfection that kills mycobacteria, most viruses, and bacteria with a chemical germicide registered as a “tuberculocide” by the U.S. Environmental Protection Agency (EPA). 

Low-level disinfection: Disinfection that kills some viruses and bacteria with a chemical germicide registered as a hospital disinfectant by the EPA. 

Non-critical device: An item that contacts intact skin but not mucous membranes (e.g., blood pressure cuffs, oximeters). It requires low-level disinfection. 

Semi-critical device: An item that comes in contact with mucous membranes or non-intact skin and minimally requires high-level disinfection (e.g., oral thermometers, vaginal specula). 

Sterilization: The use of a physical or chemical procedure to destroy all microbial life, including highly resistant bacterial endospores. 

Universal Principles 

Instruments, medical devices, and equipment should be managed and reprocessed according to the recommended and appropriate methods regardless of a patient’s diagnosis, except for cases of suspected prion disease. 

Due to the infective nature and steam-resistant properties of prion diseases, special procedures are required for handling brain, spinal, or nerve tissue from patients with known or suspected prion disease (e.g., Creutzfeldt-Jakob disease [CJD] or Bovine spongiform encephalopathy [BSE]). Consultation with infection control experts before performing procedures on such patients is warranted. 

Industry guidelines as well as equipment and chemical manufacturer recommendations should be used to develop and update reprocessing policies and procedures. Written instructions must be made available for each instrument, medical device, and equipment reprocessed.  

The CDC recommends that critical medical and surgical devices and instruments that would be expected to enter a system through which sterile body fluids, blood, or sterile tissue be sterilized prior to use on each patient. (1). 

Potential for Contamination  

The type of instrument, medical device, equipment, or environmental surface cause variables that are more likely to be a source of contamination. External contamination may be caused by the presence of hinges, crevices, or multiple interconnecting pieces.  

If able, these devices should be disassembled. Endoscopes provide a particular challenge for both internal and external contamination, due to their lumens as well as the crevices and joints present.  

The disinfectant must reach all surfaces and assurance that there are no air pockets or bubbles to impede penetration (2). As well, these devices may be made of material that is not heat resistant, which prevents the ability to sterilize. In these instances, chemicals must be utilized to provide disinfection. 

Once rendered sterile, there are multiple opportunities for potential contamination due to the frequency of hand contact with the device or surface. Packaging may be overhandled and breached, or the item may come into contact with potential contaminants via poor storage, improper opening, or environmental factors. 

The efficacy of sterilization and disinfection is dependent upon the number and type of microorganisms present. Several types of pathogens carry an innate resistance, making successful decontamination more challenging (2).  

Most infections are caused by bacteria, followed by viruses, fungi, protozoa, and prions (3).  Due to the nature of their outer membranes, spores, and gram-negative bacteria have a natural barrier that prevents the absorption of disinfectants.  

Bacterial spores are especially resistant to chemical germicides, as are the following pathogenic organism types (all from 2): 

• Coccidia – i.e. Cryptosporidium 
• Mycobacteria – i.e. M. tuberculosis 
• Nonlipid or small viruses – i.e. poliovirus, coxsackievirus 
• Fungi – i.e. Aspergillus, Candida 
• Vegetative bacteria – i.e. Staphylococcus, Pseudomonas 
• Lipid or medium-size viruses – i.e. herpes, HIV 

The number of microorganisms that are present on a medical instrument, device or surface affects the time that must be factored into disinfection and sterilization efficacy. As stated by the CDC, “Reducing the number of microorganisms that must be inactivated through meticulous cleaning, increases the margin of safety when the germicide is used according to the labeling and shortens the exposure time required to kill the entire microbial load” (2) 

In general, used medical devices are contaminated with a relatively low bioburden of organisms. Inconsistencies or incorrect methods of reprocessing can easily lead to the potential for cross-contamination (1). 

Steps of Reprocessing 

Reprocessing medical instruments and equipment is completed sequentially depending upon the instrument and the process chosen. 

Pre-cleaning is the process of removing soil, debris, and lubricants from internal and external surfaces through mopping, wiping, or soaking. It must be done as soon as possible after use to lower the number of microorganisms present on the object. 

Cleaning may be accomplished manually or mechanically. Manual cleaning relies upon friction and fluidics (fluids under pressure) to remove debris and soil from the inner and outer surfaces of the instrument. There are several different machines used in mechanical cleaning including ultrasonic cleaners, washer-disinfectors, washer-sterilizers, and washer-decontaminators. Studies have shown that automated cleaning is more effective than manual; however, the frequency of fluid changes must follow the manufacturer's guidelines to eliminate the risk of contaminating debris (1). 

Disinfection involves the use of disinfectants, either alone or in combination, to reduce the microbial count to near insignificant. Common disinfectants used in the healthcare setting include chlorine and chlorine compounds, hydrogen peroxide, alcohols, iodophors, and quaternary ammonium compounds, among others. These products are formulated and then approved by the Environmental Protection Agency and Food and Drug Administration for specific uses. 

Sterilization is used on most medical and surgical devices that are utilized in healthcare facilities. This requires sufficient exposure time to heat, chemicals, or gases to ensure that all microorganisms are destroyed. 

Choice/Level of reprocessing sequence 

The choice or level of reprocessing is based on the intended use: 

• Critical instruments and medical devices require sterilization 
• Semi-critical instruments and medical devices minimally require high-level disinfection 
• Noncritical instruments and medical devices minimally require cleaning and low-level disinfection 

Manufacturer’s recommendations must always be consulted to ensure that appropriate methods, actions, and solutions are used. There is a wide variability of compatibility among equipment components, materials, and chemicals used. Rigorous training is required to appropriately understand the various equipment heat and pressure tolerance as well as the time and temperature requirements for reprocessing.  

Failure to follow the manufacturer’s recommendations may lead to equipment damage, elevated microbial counts on instruments after reprocessing, increased risk for infections, and possibly patient death. 

Effectiveness of reprocessing instruments, medical devices, and equipment 

Pre-cleaning and cleaning before disinfection is one of the most effective ways to reduce the microbial count. This is only effective when completed prior to disinfection.  

Disinfection relies upon the action of products to eliminate microbial count. Depending on the medical instrument or device design, the product may only be required to cover the surface. However, due to the lumens of scopes, crevices, or hinges on certain instruments, immersion products and dwell times are required (4). 

The presence of organic matter, such as blood, serum, exudate, lubricant, or fecal material can drastically reduce the efficacy of a disinfectant. This may occur due to the presence of organic material acting as a barrier.  It may also occur from a chemical reaction between the organic material and the disinfectant being utilized. 

Biofilms pose a particular challenge and offer protection from the action of disinfectants. Biofilms are composed of microbes that build adhesive layers onto the inner and outer surfaces of objects, including instruments and medical devices, rendering certain disinfectants ineffective. Chlorine and Monochloramines remain effective against inactivating biofilm bacteria (1). 

Per the CDC, “. . . a given product is designed for a specific purpose and is to be used in a certain manner. Therefore, users should read labels carefully to ensure the correct product is selected for the intended use and applied efficiently” (1). The label will indicate sufficient contact time with the chemical solution to achieve adequate disinfection. 

After disinfection, staff and management must adopt a system of record keeping and tracking of instrument usage and reprocessing. Reprocessing equipment must be on a schedule to be maintained and regularly cleaned, according to the manufacturer’s guidelines. 

There are several methods of sterilization used such as steam sterilization (autoclaves), flash sterilization, and more recently, low-temperature sterilization techniques created for medical devices that are heat sensitive. Selection depends upon the type of instrument, material, ability to withstand heat or humidity, and targeted microbes. 

There are several methods of ensuring that sterilized instruments are processed and tracked appropriately. Indicators or monitors are test systems that provide a way of verifying that the sterilization methods were sufficient to eradicate the regulated number of microbes during the process. These safeguards include: 

• Biologic monitors 
• Process monitors (tape, indicator strips, etc.) 
• Physical monitors (pressure, temperature gauges) 
• Record keeping and recall/ tracking system for each sterilization processing batch/item 

Studies have shown that the best practice of handling and storage of reprocessed medical equipment and instruments uses a system of event-related shelf life, rather than time-related. The rationale for this lies in the theory that the sterile items remain sterile as long as the packaging is not compromised (2).  

Factors that are considered event-related include internal or external contamination such as damage to the packaging, humidity, insects, vermin, open shelving, temperature fluctuations, flooding, location, and the composition of packaging material. 

Standards for handling must also focus on the protection of workers from health issues. 

Recognizing Potential Sources of Cross-Contamination in The Healthcare Environment  

1. Surfaces or equipment which require cleaning between patient procedures/treatments 
2. Practices that contribute to hand contamination and the potential for cross-contamination 
3. Consequences of reuse of single-use/disposable instruments, medical devices, or equipment 

Factors That Have Contributed to Contamination in Reported Disease Transmission Cases 

At any point in reprocessing or handling, breaks in infection control practices can compromise the integrity of instruments, medical devices, or equipment. Specific factors include: 

• Failure to reprocess or dispose of items between patients 
• Inadequate cleaning 
• Inadequate disinfection or sterilization 
• Contamination of disinfectant or rinse solutions 
• Improper packaging, storage, and handling 
• Inadequate/inaccurate record keeping of reprocessing requirements. 

Expectations Regarding Differing Levels of Disinfection and Sterilization Methods 

Professionals who practice in settings where handling, cleaning, and reprocessing equipment, instruments, or medical devices is performed elsewhere (e.g., in a dedicated Sterile Processing Department) are responsible for ensuring understanding of the core concepts and principles: 

• Standard and Universal Precautions (e.g., wearing of personal protective equipment) 
• Cleaning, disinfection, and sterilization (Sections III and IV above) 
• Appropriate application of safe practices for handling instruments, medical devices, and equipment in the area of professional practice 
• Designation and physical separation of patient care areas from cleaning and reprocessing areas is strongly recommended by NYSDOH. 
• Verify with those responsible for reprocessing what steps are necessary prior to submission of pre-cleaning and soaking 

Professionals who have primary or supervisory responsibilities for equipment, instruments, or medical device reprocessing (e.g., Sterile Processing Department staff or clinics and physician practices where medical equipment is reprocessed on-site) are responsible for understanding core concepts and principles: 

• Standard and Universal Precaution 
• Cleaning, disinfection, and sterilization described in Sections III and IV above 
• Appropriate application of safe practices for handling instruments, medical devices, and equipment in the area of professional practice 
• Designation and physical separation of patient care areas from cleaning and reprocessing areas is strongly recommended by NYSDOH 

Facilities must be fastidious in developing appropriate reprocessing practices that follow regulatory guidelines. When selecting appropriate methods, consideration must be given to the antimicrobial efficacy, time constraints, and requirements of these methods, as well as compatibility. Compatibility among equipment/materials includes corrosiveness, penetrability, leaching, disintegration, heat tolerance, and moisture sensitivity. 

The toxicity of the products used can pose occupational and environmental hazards to staff and patients. Facilities must adopt procedures and policies to reduce exposure to harmful substances, monitor for harmful exposures, and train staff using reprocessing cleaning and chemicals.  

To reduce potential exposure to harmful substances, OSHA mandates that training for workers before use include (all from 5): 

• Health and physical hazards of the cleaning chemicals 
• Proper handling, use, and storage of all cleaning chemicals being used, including dilution procedures when a cleaning product must be diluted before use 
• Proper procedures to follow when a spill occurs 
• Personal protective equipment required for using the cleaning product, such as gloves, safety goggles and respirators 
• How to obtain and use hazard information, including an explanation of labels and SDSs 

Other considerations in developing a safety plan for appropriate reprocessing practices include: 

• Potential for patient toxicity/allergy 
• Residual effects including antibacterial residual and patient toxicity/allergy 
• Ease of use 
• Stability of products, including concentration, potency, efficacy of use, and effects of organic material 
• Odor 
• Cost 
• Monitoring requirements and regulations 
• Specific labeling requirements for reprocessing single-use devices 

ELEMENT VI 

Prevention and control of infectious and communicable diseases in healthcare workers. 

Definitions 

Infectious Disease: A clinically manifest disease of humans or animals resulting from an infection. 

Communicable Disease: An illness due to a specific infectious agent or its toxic products that arises through transmission of that agent from an infected person, animal, or inanimate source to a susceptible host. 

Occupational Health Strategies: As applied to infection control, a set of activities intended to assess, prevent, and control infections and communicable diseases in healthcare workers. 

Pre-Placement and Periodic Health Assessments  

Occupational health strategies are aimed at ensuring employees are healthy and keeping them healthy. Upon hiring, employees should undergo an initial health screening that reviews immunization records.  

The CDC suggests that healthcare workers are screened when newly hired and periodically ongoing to (all from 1): 

• Ensure sufficient immunity to vaccine-preventable diseases such as measles, mumps, rubella, varicella, hepatitis B, annual influenza and any other recommended or mandated requirements 
• Assess for and manage underlying conditions and illnesses that may affect workplace safety 
• Prevent, assess, and treat any potential infectious exposures or illnesses that may be acquired or transmitted within the healthcare setting 
• Initiate and continue personalized health counseling 
• Thorough history and physical 

A tuberculosis screening should be completed before a new employee provides patient care and upon possible exposure for an existing employee. A thorough assessment should include an evaluation of the following symptoms: 

• Fever 
• Cough 
• Chest pain, or pain with breathing or coughing 
• Night sweats 
• Chills 

A Mantoux tuberculin skin test (TST) must also be completed. The test is performed by injecting a small amount of tuberculin into the epidermis of the forearm. The test is then evaluated for a reaction in 48 to 72 hours.  

If there is no reaction, the test result is negative. If reactive, a scale is used to interpret the measurement of induration and to direct further testing or treatment (2). 

When working in healthcare, nursing staff must be healthy to provide optimal care. This is especially true in the care of vulnerable patients who have weakened immune symptoms.  

The following symptoms require immediate evaluation by a licensed medical professional: 

• Fever 
• Cough 
• Rash 
• Vesicular lesions 
• Draining wounds 
• Vomiting 
• Diarrhea 

Upon evaluation, there may be possible restrictions from patient care activities and work clearance must be completed prior to return. 

Management Strategies for Potentially Communicable Conditions  

Management and the Infection Prevention department should collaborate and strategize to ensure that employees who have had an exposure or possible exposure are protected and have support in seeking treatment without fear of retaliation or job loss (3). Managerial support should prioritize: 

• Appropriate evaluation and treatment 
• Limiting contact with susceptible patients and staff  
• Placement in a non-clinical setting 
• Depending on the severity of symptoms or potential transmission, a furlough until no symptoms are present may be necessary 

Prevention and Control Strategies for Bloodborne Pathogen Transmission 

Robust training and educational programs are essential for the prevention of healthcare worker exposure and transmission. Prevention strategies should include education, training, and availability of the following: 

• Information on potential agents such as HBV, HCV, and HIV 
• HBV vaccination (including safety, efficacy, components, and recommendations for use) 
• Hand hygiene 
• Appropriate PPE and barrier precautions (see Element II) 
• Sharps safety (see Element III) 
• Standard and Universal Precautions 
• Education on the availability of confidential and anonymous testing for bloodborne pathogens (4) 

Post-Exposure Evaluation and Management.  

Each facility must plan for post-exposure evaluation and management in the case that any employee or patient experiences a potential or actual bloodborne exposure. The plan should incorporate the following: 

• Prompt evaluation by a licensed medical professional 
• Risk assessment in occupational exposures 
• Recommendations for approaching source patient and healthcare worker evaluations 
• Recommendations for post-exposure prophylaxis emphasizing the most current NYSDOH and CDC guidelines 
• Post-exposure management of patients or other healthcare workers when the exposure source is a healthcare worker obligates the patient to be informed of the type of exposure, whether it is the healthcare worker’s blood or other potentially infectious material. 

Airborne or droplet pathogens require several special considerations. The above guidelines should be applied appropriately. As well, New York requires mandatory reporting of certain communicable diseases is required, including tuberculosis. The New York State Department of Health (NYSDOH) states: 

Reporting of suspected or confirmed communicable diseases is mandated under the New York State Sanitary Code (10NYCRR 2.10,2.14). The primary responsibility for reporting rests with the physician; moreover, laboratories (PHL 2102), school nurses (10NYCRR 2.12), daycare center directors, nursing homes/hospitals (10NYCRR 405.3d), and state institutions (10NYCRR 2.10a) or other locations providing health services (10NYCRR 2.12) are also required to report (5). 

NYSDOH follows the CDC's recommended guidelines when exposure to TB occurs. The HCW should be retested for TB using TST and be monitored for symptoms of disease progression. If found to have a TST reaction of 10 or more millimeters, the patient would be given high priority to receive drug treatment under the criteria of working within a high-risk setting (6). Drug treatment typically consists of 3 months of isoniazid once weekly in addition to rifapentine in adults and children over 2 years old. 

Post-exposure of other Airborne pathogens such as varicella, measles, mumps, rubella, and pertussis should be directed toward the most current federal, state, or local requirement for post-exposure evaluation and management. As with tuberculosis, mandatory reporting may be required. The Communicable Disease Reporting Requirements form may be found here. 

For additional, up-to-date information and guidance, the New York State Department of Health Bureau of Communicable Disease Control can be reached at (518) 473-4439 or (866) 881-2809 after hours. 

All patients and health care workers who have been potentially exposed to any pathogens should be educated and counseled about (all from 7): 

• Risk of exposure or illness 
• Testing 
• Options for and risks and benefits of post-exposure prophylaxis or treatment 
• Need for specialty care 
• Follow-up testing and treatment 
• Work restrictions, if indicated 
• Risk of transmitting infections to others and methods to prevent transmission, and 
• Signs and symptoms of illness to report after exposure, including side effects such as prophylaxis. 

Evaluation of Healthcare Workers Infected with Bloodborne Pathogens 

The NYSDOH provides the following rules and recommendations based on scientific evidence-based practice in relation to policies to prevent infected healthcare personnel-related blood-borne pathogen transmission (HIV, HBV, HCV) (all from 4): 

• Strict adherence to Standard Precautions 
• Voluntary testing without fear of disclosure or discrimination 
• Mandatory screening of New York HCW for blood-borne pathogens is not recommended. Such a program would cost millions of dollars and would not produce any appreciable gain in public safety. Negative antibody tests for HIV, HBV, and HCV do not rule out the presence of infection since it can take some time for measurable antibodies to appear. 
• Employer notification of a blood-borne pathogen is not a requirement for employment 

Criteria must be followed when evaluating infected healthcare workers for the risk of transmission in order to adhere to laws protecting workers from discrimination and disability laws. The following outlines a general assessment to determine the risks posed: 

1. Nature and scope of professional practice 
2. Techniques used in the performance of procedures that may pose a transmission risk to patients 
3. Assessed compliance with infection control standards 
4. Presence of weeping dermatitis, draining, or open skin wounds 
5. Ability to carry out duties with Cognitive status examination 

Expert Panels for Evaluating Healthcare Workers Infected with Bloodborne Pathogens 

Upon request, a blood-borne pathogen-infected HCW may seek advice from the NYSDOH regarding potential risk during patient care of blood-borne disease transmission. A state advisory panel would convene with, at minimum, representation by a state or local public officer, an epidemiologist, and an infectious disease expert (4).  

The purpose of the panel is to provide consultation to the MCW regarding the risk of blood-borne disease transmission related to occupation and to give recommendations on best practices, needs for limitations, modifications, or restrictions if there is an identified risk to patient care. Confidentiality is maintained with the restriction that recommendations are followed, and any restrictions are disclosed to the facilities where the HCW is currently employed or seeks future employment (4)

ELEMENT VII 

Sepsis awareness and education 

Definitions 

Sepsis: Sepsis is a life-threatening condition caused by a host’s extreme response to infection. The Surviving Sepsis Campaign 2016 International Guidelines define sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. Earlier definitions defined sepsis as an inflammatory response to infection, while sepsis associated with organ dysfunction was identified as severe sepsis. Septic shock is a subset of sepsis that manifests with circulatory and cellular/metabolic dysfunction; it is associated with a higher mortality risk. 

Scope of the Problem 

Over 1.7 million Americans are diagnosed with sepsis each year, with the incidence rising by approximately 8% annually. In New York, there are approximately 50,000 patients treated for severe sepsis and septic shock, resulting in just under 30% of patients dying each year (1).  

Sepsis is a life-threatening medical emergency that requires early recognition and intervention. Sepsis occurs when the body overcompensates in response to an infection, resulting in multiple organ dysfunction and damage.  

Most sepsis cases are community-acquired. Seven in 10 patients with sepsis had recently used healthcare services or had chronic conditions requiring frequent medical care (1).  Early recognition and treatment are the most effective ways to combat sepsis. 

In 2013, New York State became the first in the U.S. to develop a state mandate that requires all hospitals to develop and adopt sepsis protocols. The mandate is dubbed “Rory’s Regulations,” after Rory Staunton, a 12-year-old boy whose death was attributed to lack of sepsis recognition. These protocols were required to adopt the following practices (2): 

• A process for the screening and early recognition of patients with sepsis, severe sepsis, and septic shock. 
• A process to identify and document individuals appropriate for treatment through severe sepsis protocols, including explicit criteria defining those patients who should be excluded from the protocols, such as patients with certain clinical conditions or who have elected palliative care. 
• Guidelines for hemodynamic support with explicit physiologic and biomarker treatment goals, methodology for invasive or non-invasive hemodynamic monitoring, and time frame goals. 
• For infants and children, guidelines for fluid resuscitation with explicit time frames for vascular access and fluid delivery are consistent with current evidence-based guidelines for severe sepsis and septic shock with defined therapeutic goals for children. 
• A procedure for identification of infection source and delivery of early antibiotics with time frame goals; and 
• Criteria for use, where appropriate, of an invasive protocol and for use of vasoactive agents. 
• Medical staff also gained responsibility for the collection, use, and report quality measures and for the mortality data of peers, including national, hospital, and expert stakeholders (2). 

This led to The New York State Sepsis Care Improvement Initiative, started in 2014, to increase early recognition of suspected sepsis and competence in implementing the new sepsis protocols by all healthcare professionals.  

This was to be achieved through mandatory training or coursework on sepsis (3). The goal was to stress the importance of timely initiation of evidence-based protocols to improve sepsis outcomes. 

Causes of Sepsis  

As stated by the Sepsis Alliance, “Sepsis is the body’s overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death” (4).  

Bacterial infections commonly trigger sepsis, although other microbial infections (e.g., fungal or viral) can also trigger sepsis. The triggering infection most commonly originates from the lungs, urinary tract, skin, and/or gastrointestinal tract. 

Certain populations are at an increased risk of developing sepsis including: 

• Babies (under 1 year), and individuals 65 years of age and older. 
• People with chronic conditions such as diabetes, lung disease, kidney disease, or cancer; and 
• People with impaired immune systems. 

Early Recognition of Sepsis  

• Manifestations of sepsis vary based on the type of infection and host factors. 
• Some people may have subtle sepsis presentations. 
• Signs and symptoms that may be associated with sepsis in persons with confirmed or suspected infection can include: 
• Altered mental state 
• shortness of breath 
• fever 
• clammy or sweaty skin 
• extreme pain or discomfort 
• high heart rate 

Signs and symptoms in children and the elderly may not present the same. In children and the elderly sepsis symptoms may present as above or any of the following: decreased temperature; pallor or bluish tone to skin; non-blanching rash; high respiratory rate; lethargy; and seizure. 

Sepsis can progress to more severe forms of sepsis, including septic shock. When septic shock occurs, the body’s inflammatory response causes extensive vasodilation throughout the body. This results in a sudden drop in blood pressure that can quickly lead to organ failure and damage (5). 

If a person presents with suspected or confirmed infection, healthcare professionals should assess for signs of, and risk factors for sepsis following facility sepsis protocols. 

Principles of Sepsis Treatment  

Sepsis treatment starts with prompt recognition and diagnosis. The diagnosis of sepsis starts with the assessment of a patient with a known or suspected infection. For adults, sepsis is defined as having two or more symptoms of systemic inflammatory response syndrome, which includes (6): 

• Temperature (>38 o C or <36 o C) 
• Elevated heart rate > 90 bpm 
• WBC (<4×109/L or >12×109/L) 
• Respiratory rate (>20 breaths/min, PACO2<32 mm Hg 

Severe sepsis has traditionally been defined as having sepsis plus organ failure, while septic shock involves sepsis along with refractory hypotension after fluid resuscitation or requiring vasopressors to maintain hemodynamics (6). The standard changed in 2016 with the elimination of severe sepsis; however, most facilities still adhere to the above criteria. Follow sepsis protocol and bundles per facility. 

With the recognition of sepsis and/or septic shock, previously state law mandated that one- and three-hour care bundles be created. While these may vary slightly per facility, Surviving Sepsis promotes a one-hour bundle that incorporates all the recommendations of the other bundles yet decreases the time to treat (7): 

One Hour Bundle 

1. Obtain lactate level. Reorder if initial lactate is > 2 mmol/L 
2. Obtain blood cultures before administering antibiotics 
3. Administer broad-spectrum antibiotics 
4. Rapidly infuse crystalloids at a rate of 30 mL/kg for hypotension or lactate ≥ 4 mmol/L 
5. If hypotensive post fluid resuscitation, administer vasopressors to maintain a mean arterial pressure ≥ 65 mm Hg. 

In addition to blood cultures, type and screens may be ordered for urine, wound exudate, or respiratory secretions depending upon where the suspected infection originates from. Blood tests may also include a complete blood count and a basic metabolic panel to assess for any damage to the kidneys or liver. Other diagnostic imaging may include chest X-rays, CTs, ultrasounds, and MRIs (8). 

Fluid resuscitation and vasopressors, if needed, will continue until the patient is hemodynamically stable. Physicians should be notified when blood cultures result in order to ensure that the ordered antibiotic is effective against the identified organism (8). 

Patient Education and Prevention  

Patient education should strive to provide memorable and simple ways to stay free of infection. The number one method of preventing infection is adequate hand hygiene. The CDC also suggests that patients keep wounds and cuts clean and covered until healed. 

Patients at higher risk should be notified of their risk factors, including (9): 

• Adults 65 or older 
• People with chronic medical conditions, such as diabetes, lung disease, cancer, and kidney disease 
• People with weakened immune systems 
• Sepsis survivors 
• Children younger than one 

Patients should be educated on warning signs and symptoms of sepsis that are easy to remember. The Sepsis Alliance suggests the following acronym and verbiage for seeking immediate care (4): 

Patients should be encouraged to give relevant history and information to clinicians, including if they have had a recent infection, sepsis in the past, or are immunocompromised. 

Hypertension Updates

Introduction

This course aims to provide nurses and healthcare professionals with an up-to-date understanding of hypertension (HTN). The course covers epidemiological evidence, etiology, diagnostic tools, medication management, other interventions, and future research on HTN. 

Hypertension, or high blood pressure, is a chronic condition and a significant risk factor for heart disease, stroke, kidney failure, and other serious health problems. The American College of Cardiology defines hypertension as systolic blood pressure greater than 130 mmHg or diastolic blood pressure greater than 80 mmHg [1].

Statistical Evidence/Epidemiology 

According to the Centers for Disease Control and Prevention (CDC), hypertension afflicts 108 million Americans and contributes to almost 500,000 deaths per year in the United States [2]. The prevalence of hypertension varies by race and ethnicity, with non-Hispanic Black adults having the highest majority (57.1%), followed by Hispanic adults (43.7%) and non-Hispanic White adults (43.6%).  

Hypertension is also more common among older adults, with (74.5%) of adults aged 60 and over having high blood pressure [3]. Despite the high prevalence of hypertension, less than a quarter of all adults with hypertension in the United States have their blood pressure under control [2].  

This leaves millions at risk for serious health problems from uncontrolled hypertension, such as heart disease, stroke, kidney failure, and eye problems. In 2021, high blood pressure was a primary or contributing cause of death for more than 691,095 Americans [4]. 

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Etiology/Pathophysiology of Hypertension 

Hypertension (high blood pressure) is a multifactorial disease characterized by persistent elevated blood pressure in the systemic arteries. Understanding hypertension's etiology, pathophysiology, and sequela is crucial for effective management and treatment.  

There are two main types of hypertension: primary hypertension and secondary hypertension. Primary or essential hypertension (idiopathic hypertension), which accounts for about 80-95% of all cases, has no identifiable cause and results from complex interactions between genetic, environmental, and other unknown factors [5].  

The cause of secondary hypertension (15-30% of cases) is often an underlying medical condition, such as kidney disease, adrenal gland tumors, diabetes, or thyroid disease [6]. Family history plays a role, although science has identified no genetic factor as the "hypertension gene" [7].  

A key mechanism in hypertension is the imbalance between the forces that constrict and dilate blood vessels. This imbalance can be caused by several factors, including increased activity of the sympathetic nervous system, which leads to vasoconstriction, increased production of vasoconstrictor hormones, such as angiotensin II and aldosterone, a decreased output of vasodilator hormones, such as nitric oxide, and structural changes in the blood vessels, such as thickening of the vessel walls [8]. 

The most understood mechanism of hypertension involves increased peripheral vascular resistance due to constriction of small arterioles. The Renin-Angiotensin-Aldosterone System (RAAS) is a hormonal system that regulates blood pressure. Dysfunction of the RAAS can lead to fluid retention and vasoconstriction [9]. Endothelial dysfunction involves the inner lining of the blood vessels (endothelium) and the release of nitric oxide, which promotes blood vessel relaxation. The dysfunction of nitric oxide is a primary contributor to hypertension [10]. 

Secondary hypertension often involves: 

• The kidneys and volume overload. 
• Leading to elevated blood pressure. 
• Often affecting younger patients and those with resistant or refractory hypertension. 

The typical secondary causes of hypertension include: 

• Primary aldosteronism (PA). 
• Renovascular disease. 
• Chronic kidney disease (CKD). 
• Obstructive sleep apnea (OSA). 
• Drug-induced or alcohol-induced hypertension [11]. 

Overactivation within the sympathetic nervous system can result in increased heart rate (tachycardia) and vasoconstriction, both of which can cause a temporary elevation in blood pressure. Within the metabolic process, insulin resistance has been associated with endothelial dysfunction and hypertension [12]. 

Diagnostic and Screening Tools 

The primary current diagnostic and screening tools around hypertension include blood pressure measurement. Blood pressure consists of systolic blood pressure (SBP) and diastolic blood pressure (DBP).  

SBP is the pressure when the heart is beating, and DBP is the pressure when the heart is resting. A diagnosis of hypertension can be established when the Systolic Blood Pressure (SBP) is 130 mmHg or above or when the Diastolic Blood Pressure (DBP) is at least 80 mmHg [1].  

The American Heart Association (AHA) recommends that all adults have their blood pressure checked at least once a year. People with risk factors for hypertension, such as obesity, diabetes, and kidney disease, should have their blood pressure checked more often [13]. 

Secondary tools for evaluating hypertension include ambulatory blood pressure monitoring (ABPM). ABPM is a more accurate way to measure blood pressure, measuring blood pressure over 24 hours. ABPM is an integral part of hypertensive care [14].  

Urine tests can check for protein in the urine, a sign of kidney damage. Kidney damage is a risk factor for hypertension. Blood tests can be used to check for other medical conditions that can cause hypertension, such as diabetes and kidney disease, cholesterol levels, and other risk factors for heart disease.  

Hormonal Tests can measure hormones produced by the adrenal and thyroid glands, which can help diagnose secondary hypertension. Regardless of the diagnostic or screening tools, early diagnosis and management of hypertension save lives [15]. 

Imaging and Other Diagnostic Tests 

Ultrasound of the Kidneys: To rule out kidney abnormalities. 

Echocardiogram: To assess heart function and structure. Useful if hypertension has been longstanding. 

Eye Exam: A fundoscopic examination can reveal changes in the retinal blood vessels, indicative of chronic hypertension. 

Telemedicine: Remote monitoring can be helpful for ongoing assessment and titration of treatment. 

Healthcare Apps: Smartphone apps can log and track blood pressure readings over time. 

Medication Management 

The management of hypertension has evolved over the years, with numerous classes of medications available for treatment. The type of medication best suited for your patients will depend on their needs and health history.  

Treatment strategies often begin with monotherapy, a single drug, usually a diuretic, beta-blocker, ACE inhibitor, or Angiotensin II receptor blocker (ARBs) [16]. Combination therapy for patients with stage 2 hypertension or those not reaching the target BP with monotherapy, which may include two or more drug classes, is also used.[16].  

Step therapy involves starting with one drug and adding others to achieve the desired effect. A tailored approach is considered if comorbid conditions are present, such as diabetes or heart failure, which may influence drug choice. 

Several standard classes of antihypertensive medications are used to treat hypertension, including first-line thiazides such as hydrochlorothiazide, which help rid excess salt and water and lower blood pressure [17]. Angiotensin-converting enzyme (ACE) inhibitors such as lisinopril and ramipril block the production of angiotensin II, a hormone that narrows blood vessels.  

Angiotensin II Receptor Blockers (ARBs) such as losartan and valsartan which inhibit the action of angiotensin II, leading to vasodilation [17]. Beta-blockers such as atenolol or metoprolol slow the heart rate and reduce the force of the heart's contractions, which can lower blood pressure [17].  

Calcium channel blockers such as amlodipine and diltiazem relax the muscles of the blood vessels by inhibiting the movement of calcium into vascular smooth muscle cells, thus lowering blood pressure [17]. Alpha-blockers such as doxazosin work by blocking alpha-adrenergic receptors, leading to vasodilation. Vasodilators such as hydralazine and minoxidil relax the muscles in blood vessel walls [17]. 

Central action agents such as clonidine, methyldopa, and moxonidine work on the central nervous system to lower blood pressure [17]. Moxonidine is a new-generation antihypertensive drug that works by activating imidazoline-I1 receptors in the brain, and it may be used when other antihypertensive drugs, such as thiazides, beta-blockers, ACE inhibitors, and calcium channel blockers, are not appropriate or have failed [18].  

Thiazide-like diuretics such as chlorthalidone and indapamide have found increased use for their more prolonged duration of action and better cardiovascular outcomes when compared to traditional thiazides [19]. New evidence-based medications are coming into play, such as angiotensin receptor-neprilysin inhibitors (ARNIs), and a clinical trial is underway to test the effectiveness of a new drug called finerenone in preventing heart failure and kidney disease in people with hypertension and diabetes [20] [21]. 

Due to their safety profiles, there are special considerations with hypertensive management, including methyldopa and labetalol for pregnancy [22].  

For older people, care is taken to avoid overtreatment, considering the risks of low blood pressure. For patients with chronic kidney disease (CKD), ACE inhibitors and ARBs are often favored due to their renal protective effects.  

Generics are preferred when appropriate to reduce patient costs [23]. Digital adherence tools, including smartphone apps and telemedicine platforms, monitor patient compliance and adjust treatment as necessary. 

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Other Interventions  

Beyond medication, lifestyle changes, including dietary interventions like the DASH diet and exercise, have proven effective in managing hypertension [24]. The DASH diet focuses on a high intake of fruits, vegetables, and low-fat dairy foods and is low in saturated and total fat.  

A reduction in dietary sodium has been shown to lower blood pressure, with a general recommendation to consume less than 2,300 mg per day, with an ideal limit of 1,500 mg for most adults [24]. Regular aerobic exercise such as walking, jogging, or swimming can lower blood pressure.  

Weight loss of even 5-10% can significantly impact reducing blood pressure [25]. Alcohol moderation and smoking cessation can also lead to blood pressure reduction. 

Behavioral therapies, including stress management techniques such as deep breathing, meditation, and relaxation exercises, can help reduce short-term spikes in blood pressure. There is some evidence that suggests that Cognitive CBT can be effective in managing hypertension [26].  

Biofeedback can help manage stress triggers and measure physiological functions like heart rate and blood pressure [26]. Although evidence is mixed, some studies suggest acupuncture can help lower blood pressure.  

Renal denervation is an invasive procedure using radiofrequency energy to destroy kidney nerves contributing to hypertension. Central sleep apnea therapy can treat central sleep apnea and lower blood pressure.  

Weight loss surgery can be an effective way to lower blood pressure in people who are obese or overweight. Several stress management techniques, such as yoga, meditation, and deep breathing, can be helpful. 

Self-monitoring and regular medical check-ups can ensure that the treatment plan is effective and can be adjusted as needed. Remote consultations can offer more frequent touchpoints for adjustments in treatment plans.  

Various mobile applications can help patients track blood pressure readings, medication schedules, and lifestyle changes. Community-based interventions to educate the public about hypertension risks, prevention, and management can be effective.  

On a policy level, changes and initiatives that reduce sodium in processed foods can have a broader societal impact [27]. 

Upcoming Research 

Using "Omics" genomic, proteomic, and metabolomic data to tailor antihypertensive therapies to individuals' researchers are working to identify the genes that contribute to hypertension and specific genetic markers that can help predict an individual's risk for developing hypertension and their potential response to treatments [28].  

This information could be used to create new genetic tests to identify people who are at risk of developing the condition. Personalized medicine seeks to create customized approaches to managing hypertension, which would involve tailoring treatment to the individual's needs and risk factors.  

Non-invasive treatments, such as devices worn on the body to deliver medication or stimulate the nerves, may also be effective. Researchers are developing a new type of blood pressure monitor that can be worn on the wrist and measure blood pressure throughout the day. 

A study is underway to investigate the use of artificial intelligence to develop personalized treatment plans for people with hypertension. With predictive analytics, AI models are trained to predict hypertension risk and disease progression using large-scale electronic health records [29]. 

In the area of new therapeutic targets, researchers are looking into novel ways to improve endothelial function and vascular health. Studies into how the gut microbiome may influence blood pressure regulation offer potential for new treatment modalities [30]. Research on how diet interacts with genes within the gut microbiome may affect blood pressure. 

Awareness and Patient Education 

What your patients should know: 

• Early diagnosis and treatment of hypertension are essential for preventing complications. 
• There are several different types of medications available to treat hypertension. 
• Lifestyle changes, such as eating a healthy diet, exercising regularly, and maintaining a healthy weight, can also help to lower blood pressure. 

Nurses and healthcare professionals should be aware of the following: 

• Nurses and healthcare professionals play a vital role in educating patients about hypertension and helping them manage their condition. 
• The latest epidemiological statistics on hypertension, including its prevalence, risk factors, and impact on public health. 
• The etiology and pathophysiology of hypertension, including the different types of hypertension and their underlying causes. 
• The diagnostic tools used to diagnose hypertension include blood pressure measurement, ambulatory blood pressure monitoring, urine tests, blood tests, and imaging tests. 
• The different types of medications available to treat hypertension, as well as their side effects and interactions. 

Nurses and healthcare professionals can help patients to manage their hypertension by: 

• Educating patients about hypertension and its risks. 
• Helping patients develop a treatment plan that includes lifestyle changes and medications. 
• Monitoring their blood pressure and adjusting their treatment plan as needed. 
• Providing support and encouragement. 

By working together, nurses and healthcare professionals can help patients manage their hypertension and reduce their risk of complications. 

Conclusion

Hypertension is a significant public health problem in the United States and worldwide [1]. It is a chronic condition that can lead to serious health problems like heart disease, stroke, kidney failure, and eye problems. However, despite its complexity, hypertension is manageable with lifestyle changes, medications, and the potential information from future genomic discoveries [25] [17]. 

GI Bleed: An Introduction

Introduction   

Gastrointestinal bleeding (GI Bleed) is an acute and potentially life-threatening condition. It is meaningful to recognize that GI bleed manifests an underlying disorder. Bleeding is a symptom of a problem comparable to pain and fever in that it raises a red flag. The healthcare team must wear their detective hat and determine the culprit to impede the bleeding.  

Nurses, in particular, have a critical duty to recognize signs and symptoms, question the severity, consider possible underlying disease processes, anticipate labs and diagnostic studies, apply nursing interventions, and provide support and education to the patient. 

Epidemiology  

The incidence of Gastrointestinal Bleeding (GIB) is broad and comprises cases of Upper gastrointestinal bleeding (UGIB) and lower gastrointestinal bleeding (LGIB). GI Bleed is a common diagnosis in the US responsible for approximately 1 million hospitalizations yearly (2). The positive news is that the prevalence of GIB is declining within the US (1). This could reflect effective management of the underlying conditions.  

Upper gastrointestinal bleeding (UGIB) is more common than lower gastrointestinal bleeding (LGIB) (2). Hypovolemic shock related to GIB significantly impacts mortality rates. UGIB has a mortality rate of 11% (2), and LGIB can be up to 5%; these cases are typically a consequence of hypovolemic shock (2).  

Certain risk factors and predispositions impact the prevalence. Lower GI bleed is more common in men due to vascular diseases and diverticulosis being more common in men (1). Extensive data supports the following risk factors for GIB: older age, male, smoking, alcohol use, and medication use (7).  

We will discuss these risk factors as we dive into the common underlying conditions responsible for GI Bleed.  

Etiology/ Pathophysiology

Gastrointestinal (GI) bleeding includes any bleeding within the gastrointestinal tract, from the mouth to the rectum. The term also encompasses a wide range of quantity of bleeding, from minor, limited bleeding to severe, life-threatening hemorrhage.

We will review the basic anatomy of the gastrointestinal system and closely examine the underlying conditions responsible for upper and lower gastrointestinal bleeding.

Let's briefly review the basic anatomy of the gastrointestinal (GI) system, which comprises the GI tract and accessory organs. You may have watched The Magic School Bus as a child and recall the journey in the bus from the mouth to the rectum! Take this journey once more to understand the gastrointestinal (GI) tract better.

The GI tract consists of the following: oral cavity, pharynx, esophagus, stomach, small intestine, large intestine, and anal canal (5). The accessory organs include our teeth, tongue, and organs such as salivary glands, liver, gallbladder, and pancreas (5). The primary duties of the gastrointestinal system are digestion, nutrient absorption, secretion of water and enzymes, and excretion (5, 3). Consider these essential functions and their impact on each other.

This design was created on Canva.com on August 31, 2023. It is copyrighted by Abbie Schmitt, RN, MSN and may not be reproduced without permission from Nursing CE Central. 

As mentioned, gastrointestinal bleeding has two broad subcategories: upper and lower sources of bleeding. You may be wondering where the upper GI tract ends and the lower GI tract begins. The answer is the ligament of Treitz. The ligament of Treitz is a thin band of tissue that connects the end of the duodenum  and the beginning of the jejunum (small intestine); it is also referred to as the suspensory muscle of the duodenum (4). This membrane separates the upper and lower GI tract. Upper GIB is defined as bleeding proximal to the ligament of Treitz, while Lower GIB is defined as bleeding beyond the ligament of Treitz (4). 

Upper GI Bleeding (UGIB) Etiology 

Underlying conditions that may be responsible for the UGIB include: 

• Peptic ulcer disease 

• Esophagitis 
• Foreign body ingestion 
• Post-surgical bleeding 
• Upper GI tumors 
• Gastritis and Duodenitis 

• Varices 
• Portal hypertensive gastropathy (PHG) 
• Angiodysplasia 
• Dieulafoy lesion 
• Gastric antral valvular ectasia 

• Mallory-Weiss tears 
• Cameron lesions (bleeding ulcers occurring at the site of a hiatal hernia 
• Aortoenteric fistulas 
• Hemobilia (bleeding from the biliary tract) 
• Hemosuccus pancreaticus (bleeding from the pancreatic duct) 

(1, 4, 5, 8. 9) 

Pathophysiology of Variceal Bleeding. Variceal bleeding should be suspected in any patient with known liver disease or cirrhosis (2). Typically, blood from the intestines and spleen is transported to the liver via the portal vein (9). The blood flow may be impaired in severe liver scarring (cirrhosis). Blood from the intestines may be re-routed around the liver via small vessels, primarily in the stomach and esophagus (9). Sometimes, these blood vessels become large and swollen, called varices. Varices occur most commonly in the esophagus and stomach, so high pressure (portal hypertension) and thinning of the walls of varices can cause bleeding within the Upper GI tract (9). 

Liver Disease + Varices + Portal Hypertension = Recipe for UGIB Disaster 

Lower GI Bleeding (LGIB) Etiology

• Diverticulosis
• Post-surgical bleeding
• Angiodysplasia
• Infectious colitis
• Ischemic colitis
• Inflammatory bowel disease
• Colon cancer
• Hemorrhoids
• Anal fissures
• Rectal varices
• Dieulafoy lesion
• Radiation-induced damage

(1, 4, 5, 9)

Unfortunately, a source is identified in only approximately 60% of cases of GIB (8). Among this percentage of patients, upper gastrointestinal sources are responsible for 30–55%, while 20–30% have a colorectal source (8).

Laboratory and Diagnostic Testing

Esophagogastroduodenoscopy (EGD) and colonoscopy identify the source of bleeding in 80–90% of patients (4). The initial clinical presentation of GI bleeding is typically iron deficiency/microscopic anemia and microscopic detection of blood in stool tests (6).

The following laboratory tests are advised to assist in finding the cause of GI bleeding (2):

• Complete blood count
• Hemoglobin/hematocrit
• International normalized ratio (INR), prothrombin time (PT), and activated partial thromboplastin time (PTT)
• Liver function tests

Low hemoglobin and hematocrit levels result from blood loss, and blood urea nitrogen (BUN) may be elevated due to the GI system's breakdown of proteins within the blood (9).

The following laboratory tests are advised to assist in finding the cause of GI bleeding:

• EGD (esophagogastroduodenoscopy)- Upper GI endoscopy
  • Clinicians can visualize the upper GI tract using a camera probe that enters the oral cavity and travels to the duodenum (9)
• Colonoscopy- Lower GI endoscopy/ (9)
  • Clinicians can visualize the lower GI tract.
• CT angiography
  • Used to identify an actively bleeding vessel

Signs and Symptoms 

Clinical signs and symptoms depend on the volume/ rate of blood loss and the location/ source of the bleeding. A few key terms to be familiar with when evaluating GI blood loss are overt GI bleeding, occult GI bleeding, hematemesis, hematochezia, and melena. Overt GI bleeding means blood is visible, while occult GI bleeding is not visible to the naked eye but is diagnosed with a fecal occult blood test (FOBT) yielding positive results of the presence of blood (5). Hematemesis is emesis/ vomit with blood present; melena is a stool with a black/maroon-colored tar-like appearance that signifies blood from the upper GI tract (5). Melena has this appearance because when blood mixes with hydrochloric acid and stomach enzymes, it produces this dark, granular substance that looks like coffee grounds (9). 

Mild vs. Severe Bleeding  

A patient with mild blood loss may present with weakness and diaphoresis (9). Chronic iron deficiency anemia symptoms include hair loss, hand and feet paresthesia, restless leg syndrome, and impotence in men (8). The following symptoms may appear over time once anemia becomes more severe and hemoglobin is consistently less than 7 mg/dl: pallor, headache, dizziness from hypoxia, tinnitus from the increased circulatory response, and the increased cardiac output and dysfunction may lead to dyspnea (8). Findings of a positive occult GI bleed may be the initial red flag. 

A patient with severe blood loss, which is defined as a loss greater than 1 L within 24 hours, hypotensive, diaphoretic, pale, and have a weak, thready pulse (9). Signs and symptoms will reflect the critical loss of circulating blood volume with systemic hypoperfusion and oxygen deprivation, so that cyanosis will also be evident (9). This is considered a medical emergency, and rapid intervention is needed. 

Stool Appearance: Black, coffee ground = Upper GI; Bright red blood = Lower GI. 

History and Physical Assessment

History

A thorough and accurate history and physical assessment is a key part of identifying and managing GI bleed. Remember to avoid medical terminology/jargon while asking specific questions, as this can be extremely helpful in narrowing down potential cases. It is a good idea to start with broad categories (general bleeding) then narrow to specific conditions.

Assess for the following:

• Previous episodes of GI Bleed
• Medical history with contributing factors for potential bleeding sources (e.g., ulcers, inflammatory bowel disease, liver disease, varices, PUD, alcohol abuse, tobacco abuse, H.pylori, diverticulitis) (3)
• Contributory medications (non-steroidal anti-inflammatory drugs (NSAIDs, anticoagulants, antiplatelet agents, bismuth, iron) (3)
• Comorbid diseases that could affect management of GI Bleed (8)

Physical Assessment

1. Head to toe and focused Gastrointestinal, Hepatobiliary, Cardiac and Pancreatic
2. Assessments
   Assess stool for presence of blood (visible) and anticipate orders/ collect specimen for occult blood testing.
3. Vital Signs

Signs of hemodynamic instability associated with loss of blood volume (3):

• Resting tachycardia
• Orthostatic hypotension
• Supine hypotension
• Abdominal pain (may indicate perforation or ischemia)
• A rectal exam is important for the evaluation of hemorrhoids, anal fissures, or anorectal mass (3)

Certain conditions place patients at higher risk for GI bleed. For example, patients with end-stage renal disease (ESRD) have a five times higher risk of GIB and mortality than those without kidney disease (2).

Treatment and Interventions

Treatment and interventions for GIB bleed will depend on the severity of the bleeding. Apply the ABCs (airway, breathing, circulation) prioritization tool appropriately with each unique case. Treatment is guided by the underlying condition causing the GIB, so this data is too broad to cover. It would be best to familiarize yourself with tools and algorithms available within your organization that guide treatment for certain underlying conditions. Image 2 is an example of an algorithm used to treat UGIB (8). The Glasgow-Blatchford bleeding score (GBS) tool is another example of a valuable tool to guide interventions. Once UGIB is identified, the Glasgow-Blatchford bleeding score (GBS) can be applied to assess if the patient will need medical intervention such as blood transfusion, endoscopic intervention, or hospitalization (4).

Unfortunately, there is currently a lack of tools available for risk stratification of emergency department patients with lower gastrointestinal bleeding (LGIB) (6). This gap represents an opportunity for nurses to develop and implement tools based on their experience with LGIB.

(8) 

The first step of nursing care is the assessment. The assessment should be ongoing and recurrent, as the patient's condition may change rapidly with GI bleed. During the evaluation, the nurse will gather subjective and objective data related to physical, psychosocial, and diagnostic data. Effective communication is essential to prevent and mitigate potential risk factors.

Subjective Data (Client verbalizes)

• Abdominal pain
• Nausea
• Loss of appetite
• Dizziness
• Weakness

Objective Data (Clinician notes during assessment)

• Hematemesis (vomiting blood)
• Melena (black, tarry stools)
• Hypotension
• Tachycardia
• Pallor
• Cool, clammy skin

Nursing Interventions

Ineffective Tissue Perfusion:

1. Monitor vital signs frequently to assess blood pressure, heart rate, and oxygen saturation changes.
2. Obtain IV access.
3. Administer oxygen as ordered.
4. Elevate the head of the bed (support venous return and enhance tissue perfusion).
5. Administer blood products (packed red blood cells, fresh frozen plasma) as ordered to replace lost blood volume.

Acute Pain:

1. Assess the patient's pain (quantifiable pain scale)
2. Administer pain medications as ordered.
3. Obtain and implement NPO Orders: Allow the GI tract to rest and prevent further irritation while preparing for possible endoscopic procedures.
4. Apply heat/cold therapy for comfort.

Risk for Decreased Cardiac Output

1. Assess the patient's heart rate and rhythm. (Bleeding and low cardiac output may trigger compensatory tachycardia.) (9)
2. Assess and monitor the patient's complete blood count.
3. Assess the patient's BUN level.
4. Monitor the patient's urine output.
5. Perform hemodynamic monitoring.
6. Administer supplemental oxygenation as needed.
7. Administer intravenous fluids as ordered.
8. Prepare and initiate blood transfusions as ordered.
9. Educate and prepare the patient for endoscopic procedures and surgical intervention as needed.

Risk for Deficient Fluid Volume:

1. Monitor intake and output.
2. Maintain hydration.
3. Administer intravenous fluids as ordered.
4. Monitor labs, including hemoglobin and hematocrit, to assess the effectiveness of fluid replacement therapy.
5. Educate the patient on increasing oral fluid intake once the bleeding is controlled.
6. Vital signs
7. Assess the patient's level of consciousness and capillary refill time to evaluate tissue perfusion and response to fluid replacement.
8. Collaborate with the healthcare team to adjust fluid replacement therapy based on the patient's response and laboratory findings.

Nursing Goals / Outcomes for GI Bleed:

• The patient's vital signs and lab values will stabilize within normal limits.
• The patient will be able to demonstrate efficient fluid volume as evidenced by stable hemoglobin and hematocrit, regular vital signs, balanced intake and output, and capillary refill < 3 seconds.
• The patient will exhibit increased oral intake and adequate nutrition.
• The patient will verbalize relief or control of pain.
• The patient will appear relaxed and able to sleep or rest appropriately.
• The patient verbalizes understanding of patient education on gastrointestinal bleeding, actively engages in self-care strategies, and seeks appropriate support when needed.

Case Study

Mr. Blackstool presents to the emergency department with the following:

CHIEF COMPLAINT: "My stool looked like a ball of black tar this morning."

He also reports feeling "extra tired" and "lightheaded" for 3-5 days.

HISTORY OF PRESENT ILLNESS: The patient is a 65-year-old tractor salesman who presents to the emergency room complaining of the passage of black stools, fatigue, and lightheadedness. He reports worsening chronic epigastric pain and reflux, intermittent for 10+ years.

He takes NSAIDS as needed for back, and joint pain and was recently started on a daily baby aspirin by his PCP for cardiac prophylaxis. He reports "occasional" alcohol intake and smokes two packs of cigarettes daily.

PHYSICAL EXAMINATION: Examination reveals an alert and oriented 65-YO male. He appears anxious and irritated. Vital sips are as follows. Blood Pressure 130/80 mmHg, Heart Rate 120/min - HR Thready - Respiratory Rate - 20 /minute; Temperature 98.0 ENT/SKIN: Facial pallor and cool, moist skin are noted. No telangiectasia of the lips or oral cavity is noted. The parotid glands appear full.

CHEST: Lungs are clear to auscultation and percussion. The cardiac exam reveals a regular rhythm with an S4. No murmur is appreciated. Peripheral pulses are present but are rapid and weak.

ABDOMEN/RECTUM: The waist shows a rounded belly. Bowel sounds are hyperactive. Percussion of the liver is 13 cm (mal); the edge feels firm. Rectal examination revealed a black, tarry stool. No Dupuytren's contractions were noted.

LABORATORY TESTS: Hemoglobin 9gm/dL, Hematocrit 27%, WBC 13,000/mm. PT/PTT - normal. BUN 46mg/dL.

Discuss abnormal findings noted during History and Physical Examination; Evaluate additional data to obtain possible diagnostic testing, treatment, nursing interventions, and care plans.

Conclusion

After this course, I hope you feel more knowledgeable and empowered in caring for patients with Gastrointestinal bleeding (GIB). As discussed, GIB is a potentially life-threatening condition that manifests as an underlying disorder. Think of gastrointestinal bleeding as a loud alarm signaling a possible medical emergency. Nurses can significantly impact the recognition of signs and symptoms that determine the severity of bleeding and underlying disease process while also implementing life-saving interventions as a part of the healthcare team. As evidence-based practice rapidly evolves, continue to learn, and grow your knowledge of GIB. 

Constipation Management and Treatment

Introduction   

In the realm of healthcare, where every aspect of patient well-being is meticulously tended to, constipation is a condition that often remains in the shadows. Often dismissed as a minor inconvenience, constipation is a prevalent concern that can have significant repercussions on the health and comfort of hospitalized and long-term care patients (8).  

Imagine a scenario where a middle-aged patient, recently admitted to a hospital for a non-related condition, is experiencing discomfort due to constipation. Despite the patient's hesitation to bring up this seemingly "embarrassing" topic, a skilled nurse takes the initiative to initiate an open conversation.  

By actively listening and empathetically addressing the patient's concerns, the nurse alleviates the discomfort and also plays a crucial role in preventing potential complications. This scenario exemplifies the pivotal role that nurses play in the comprehensive management of constipation. 

Envision a long-term care facility where an elderly resident's mobility is limited, leading to a sedentary lifestyle. As a result, this individual becomes more susceptible to constipation, which could potentially lead to more severe issues if left unattended. Here, the nurse's expertise in identifying risk factors and tailoring interventions comes into play.  

By suggesting gentle exercises, dietary adjustments, and adequate hydration, the nurse transforms the resident's daily routine, ensuring a healthier digestive tract and enhanced overall well-being. 

Through the above scenarios, it becomes evident that constipation is not merely a minor inconvenience but a legitimate concern that warrants attention. As the first line of defense in patient care, nurses are uniquely positioned to identify, address, and holistically prevent constipation.  

Nurses possess the knowledge and skills to create a profound impact on patient lives by acknowledging and addressing this issue. This course aims to equip nurses with an in-depth understanding of constipation, enabling them to be proactive vigilant advocates for patient comfort, bowel health, and overall well-being. 

Epidemiology  

To truly comprehend the significance of constipation in healthcare settings, it's essential to grasp its prevalence and impact. Statistics reveal that constipation holds a prominent spot in healthcare challenges, with up to 30% of patients in hospitals and long-term care facilities experiencing this discomfort (4). This means that in a unit with 100 patients, nearly a third of them might be grappling with constipation-related issues.  

Even though constipation transcends demographics, elderly patients, who are a substantial part of long-term care settings, are more susceptible to constipation due to factors like decreased mobility, altered dietary habits, and medication use. Understanding this demographic predisposition is crucial for nurses as it guides their vigilance in recognizing and managing constipation among this vulnerable group. By unraveling its prevalence and its penchant for affecting diverse patient groups, nurses can step into their roles armed with knowledge, ready to make a tangible difference in patient lives. 

Etiology/Pathophysiology  

Embarking on the journey to comprehend constipation's root causes and underlying mechanisms offers a fascinating glimpse into the intricate workings of the digestive system. The digestive system is a well-orchestrated symphony where even a slight disruption can lead to a discordant note, constipation being one such note.  

Constipation arises from an intricate interplay of factors. Lifestyle choices, such as physical inactivity, dietary habits, and even medication use, can disturb the symphony of digestion. These disruptions impact the stool's consistency, its journey through the intestines, and the efficiency of water absorption.  

Some examples of how lifestyle choices can cause constipation include the following: 

• The digestive tract, like a finely tuned instrument, requires regular movement to maintain its rhythm and balance. Without physical activity to nudge food along, its journey through the digestive process slows down, potentially leading to constipation. 
• Mismanagement of water absorption in the colon can also contribute to constipation. Excess absorption of water in the colon can turn the stool hard and dry, making it a formidable challenge to pass.  
• When fiber is lacking in the diet, stool encounters resistance and sluggishness, akin to a symphony losing its guiding rhythm. This lack of fiber can lead to constipation, underscoring the importance of dietary choices in maintaining a harmonious digestive process (10). 

Understanding the above dynamics empowers nurses to decode the origins of constipation and tailor interventions that restore the harmonious rhythm of the digestive orchestra. Just as a conductor guides a symphony to its crescendo, nurses can orchestrate the path to relief and comfort for patients grappling with constipation. 

Signs and Symptoms  

Constipation's signs and symptoms are the stars that guide nurses toward effective management. Infrequent bowel movements, excessive straining, abdominal discomfort, and bloating are like constellations, revealing the narrative of digestive imbalance. 

Recognizing the constellation of signs and symptoms becomes the compass guiding nurses toward effective care. Just as a seasoned sailor navigates by the stars, nurses navigate constipation's landscape by deciphering the cues that patients present. 

Research by Anderson and Brown (1) reveals that patients grappling with constipation often experience infrequent bowel movements as a telltale sign. Nurses, armed with this insight, recognize that infrequent bowel movements warrant vigilant assessment and timely interventions. 

Excessive straining, much like tugging at sails in adverse winds, emerges as another hallmark of constipation (6). Patients' tales of discomfort during bowel movements point to an underlying imbalance. Nurses adeptly interpret this discomfort as a call for action, initiating strategies that ease the passage of stool and restore harmony to the digestive symphony. 

Discomfort serves as an indicator of the digestive system's struggle to find its equilibrium. Nurses, like skilled navigators, probe further, discerning the nuances of the discomfort to tailor interventions that address its root cause (11). 

Bloating is another symptom. Research by Smith and Williams (9) illuminates the link between constipation and bloating. This connection heightens nurses' vigilance, prompting them to delve into patients' experiences and offer relief from the discomfort. 

Pharmacological/Non-Pharmacological Treatment 

Constipation management encompasses a harmonious blend of pharmacological and non-pharmacological strategies. Just as a symphony thrives on a balanced ensemble, nurses can orchestrate a symphony of relief and comfort by selecting the right interventions for each patient's unique needs. Through this holistic approach, nurses play a pivotal role in restoring the digestive symphony to its harmonious rhythm. 

Pharmacological 

As nurses step into the realm of constipation management, they encounter a diverse array of strategies that can harmonize the digestive symphony. Picture a pharmacist's shelf adorned with an assortment of medications, each with a specific role in alleviating constipation. 

Fiber supplements work by increasing stool bulk and promoting regular bowel movements. They're gentle and mimic the natural process, ensuring a harmonious flow. 

Osmotic laxatives introduce more water into the stool, creating a balanced blend of moisture, preventing dry and challenging stools, and facilitating movement.  

Stimulant laxatives stimulate bowel contractions, hastening the stool's journey through the digestive tract. They're like the energetic beats that invigorate a symphony, leading to a rhythmic and effective passage. 

Lastly, stool softeners ensure that the stool is neither too hard nor too soft, striking the perfect balance. They act by moistening the stool, making it easier to pass without straining. By introducing this harmony, stool softeners contribute to patient comfort. 

Non-pharmacological 

Beyond the realm of medications lies an equally vital avenue: non-pharmacological interventions. Nurses can craft a holistic care plan, carefully considering dietary adjustments and lifestyle modifications as the foundation. Examples of non-pharmacological interventions include the following: 

A diet rich in fiber guides the stool's journey with ease. Nurses can educate patients on incorporating fruits, vegetables, and whole grains, ensuring a harmonious flow through the intestines. 

Engaging in regular physical activity not only stimulates bowel movements but also enhances overall well-being. Nurses can encourage patients to integrate movement into their routines, contributing to a dynamic and efficient digestive process. 

Relaxation techniques play a vital role in constipation management. Nurses can provide guidance on techniques like deep breathing or gentle abdominal massages that soothe the digestive tract, facilitate a smoother passage, and transform discomfort into relaxation. 

Complications 

Constipation complications can disrupt the symphony of health. Nurses, armed with knowledge and interventions, become conductors of comfort, guiding patients toward a harmonious journey free from discomfort and dissonance. Through their skilled care, nurses harmonize the symphony of patient well-being, preventing complications and promoting relief. Examples of complications include the following. 

Hemorrhoids 

These are swollen blood vessels around the rectal area that cause pain, itching, and even bleeding during bowel movements. Nurses can educate patients about preventive measures, such as adequate fiber intake, staying hydrated, and avoiding straining during bowel movements. 

Anal Fissure 

This is a small tear in the anal lining that can cause pain and bleeding, disrupting daily life. Nurses can gently guide patients toward hygiene practices and proper self-care, restoring comfort and preventing further disruption. 

Fecal Impaction 

Here, the stool accumulates, creating an obstruction that can be likened to an unexpected pause in flow. This impaction causes severe discomfort and can even lead to bowel obstruction. Nurses should be attentive to patients at risk of fecal impaction, promptly intervening with measures such as stool softeners, gentle digital disimpaction, and regular bowel assessments.  

Rectal Prolapse 

This protrusion of the rectal lining is a disruptive problem that not only causes physical discomfort but also emotional distress. Nurses can empower patients by educating them about the importance of managing constipation and preventing rectal prolapse.  

Nausea and Vomiting 

The buildup of waste and toxins can trigger these unsettling symptoms. Nurses should be vigilant, recognizing these cues as a sign of digestive imbalance. Collaborating with healthcare teams, nurses can address the underlying constipation, restoring harmony and alleviating discomfort. 

Bowel Obstruction 

This is a medical emergency. Patients experience severe abdominal pain, bloating, and the inability to pass stool or gas. Nurses should be well-equipped to recognize these symptoms and act swiftly, seeking immediate medical intervention.  

Prevention  

Prevention is composed of dietary choices, hydration, exercise, and lifestyle awareness. Nurses, as conductors of preventive care, guide patients toward a harmonious journey of well-being. By embracing preventive measures, patients become active participants in the symphony of their health, ensuring that the digestive rhythm remains soothing and uninterrupted. Sample preventive measures include the following: 

Dietary Adjustments 

Nurses can educate patients about the importance of incorporating fiber into their diets. Picture a patient's plate adorned with vibrant fruits, vegetables, and whole grains — these fiber-rich choices act as the brushstrokes that create a smooth flow through the digestive system.  

Hydration 

Like the gentle spray that keeps a garden vibrant, staying adequately hydrated ensures the digestive landscape remains fluid and inviting. Nurses can encourage patients to drink sufficient water, allowing the stool's journey to be as effortless as the water's flow.  

Exercise 

Nurses can guide patients in incorporating regular physical activities like brisk walks, or gentle stretching into their daily routines, creating a rhythm that enhances bowel motility and overall well-being. Movements, much like instrument tuning before a performance, prepare the digestive system for optimal function.  

Lifestyle Awareness 

Nurses can educate patients about the importance of timely bowel movements and creating a comfortable environment for digestion. Patients can cultivate their well-being by avoiding prolonged periods of sitting and adopting healthy toileting habits.  

Patient Education 

Nurses can provide insights into the importance of fiber-rich foods, hydration, and movement. By empowering patients with knowledge, nurses equip them with the tools needed to prevent constipation and maintain digestive well-being.   

Nursing Implications 

Nurses are instrumental in managing constipation and improving patient outcomes. Nurses should be skilled in assessing patients for constipation risk factors, communicating effectively about symptoms, and tailoring interventions to individual patient needs. Collaborating with other healthcare professionals to develop comprehensive care plans is essential. Examples of useful nursing skills include: 

Holistic Assessment 

Nurses are vigilant observers, attuned to the nuances of patient well-being. Like skilled detectives, nurses delve into patients' histories, medications, and lifestyles, identifying constipation risk factors. Holistic assessments allow nurses to understand the unique backdrop against which constipation may unfold. Armed with this knowledge, nurses can tailor interventions that resonate with each patient's needs (12). 

Effective Communication 

Envision a nurse as a skilled communicator, bridging the gap between patient concerns and medical insights. Like a translator, nurses help patients express their symptoms and experiences, ensuring nothing gets lost in translation. Effective communication not only nurtures trust but also facilitates accurate assessment, enabling nurses to identify constipation-related cues and initiate timely interventions (14). 

Collaboration with Multidisciplinary Teams 

Consider a care setting where the patient's well-being is a collective effort, much like an orchestra composed of diverse instruments. Nurses collaborate with physicians, dietitians, physical therapists, and other healthcare professionals to ensure a harmonious approach to constipation management. This interdisciplinary collaboration ensures that each note of patient care resonates in unison, creating a symphony of comprehensive well-being (7). 

Patient-Centered Care Plans 

Imagine nurses as architects of care plans, designing blueprints that reflect patients' unique needs and preferences. Just as architects tailor a building to its occupants, nurses craft patient-centered care plans that incorporate dietary preferences, lifestyle routines, and individualized interventions. This tailored approach ensures that patients feel heard and empowered in their constipation management journey (13). 

Education and Empowerment 

Envision nurses as educators, empowering patients with knowledge that transforms them into active participants in their care. Much like a guide, nurses navigate patients through the maze of constipation management strategies, ensuring clarity and understanding. By imparting information about dietary choices, hydration, exercise, and self-care, nurses equip patients with the tools needed to harmonize their digestive well-being (2). 

Continuous Monitoring and Evaluation 

Imagine nurses as diligent conductors, continuously assessing the rhythm of constipation management. Just as a conductor listens to every note, nurses monitor patients' responses to interventions, ensuring their effectiveness. Regular evaluation allows nurses to fine-tune strategies, ensuring that the symphony of constipation management remains harmonious and effective (5). 

Compassionate Support 

Envision nurses as compassionate companions on the patient's constipation management journey. Like trusted friends, nurses offer emotional support, addressing patients' concerns and fears with empathy. This compassionate approach fosters a sense of security and trust, enabling patients to navigate the challenges of constipation with resilience and a sense of camaraderie (3). 

Conclusion

Constipation is a significant concern that impacts the comfort and well-being of hospitalized and long-term care patients. Nurses' proactive role in identifying, managing, and preventing constipation is essential for promoting patient health. By employing a combination of pharmacological and non-pharmacological interventions, nurses can significantly enhance patient comfort and quality of life.  

Envision nurses as educators who share the symphony of knowledge with patients, empowering them to become proactive partners in their well-being. With insights about dietary choices, hydration, exercise, and relaxation techniques, patients become active participants in the harmony of their digestive health. 

Think of nurses as vigilant observers, continuously assessing the rhythm of constipation management, listening to every note, monitoring patient responses, and adjusting interventions to ensure a harmonious and effective approach.  

Finally, visualize nurses as compassionate companions on the constipation management journey. They offer unwavering support, much like friends sharing the weight of challenges. This compassionate presence fosters trust, comfort, and a sense of unity, creating a symphony of emotional well-being alongside physical relief. 

As this course concludes, let us remember that constipation management is not just about alleviating discomfort but about orchestrating a symphony of care that encompasses every aspect of the patient’s experience.  

By blending knowledge, empathy, and skill, nurses elevate constipation management from a routine task to a transformative experience. With this newfound understanding, nurses are prepared to guide patients toward a harmonious symphony of relief, comfort, and overall well-being. 

Spinal Cord Injury: Bowel and Bladder Management

Introduction   

Imagine one day you are able to walk and take care of your own needs. Now, imagine one week later you wake up no longer able to walk, feel anything below your waist, or hold your bowels.  

This is a reality for many people who sustain spinal cord injuries. Managing changes in bowel and bladder function is one of many challenges that people with spinal cord injuries and their families or caregivers face.  

This course will provide learners with the knowledge needed to assist patients who have spinal cord injuries with bowel and bladder management to improve the quality of life in this group.

Spinal Cord Injuries: The Basics

Spinal Cord Function 

Before defining a spinal cord injury, it is important to understand the function of the spinal cord itself. The spinal cord is a structure of the nervous system that is nestled within the vertebrae of the back and helps to distribute information from the brain (messages) to the rest of the body [1].  

These messages result in sensation and other neurological functions. While it may be common to primarily associate the nervous system with numbness, tingling, or pain, nerves serve an important purpose in the body’s function as a whole.

Spinal Cord Injury Definition 

When the spinal cord is injured, messages from the brain may be limited or entirely blocked from reaching the rest of the body. Spinal cord injuries refer to any damage to the spinal cord caused by trauma or disease [2]. Spinal cord injuries can result in problems with sensation and body movements.  

For example, the brain sends messages through the spinal cord to muscles and tissues to help with voluntary and involuntary movements. This includes physical activity like running and exercising, or something as simple as bowel and bladder elimination.  

Spinal Cord Injury Causes 

Spinal cord injuries occur when the spinal cord or its vertebrae, ligaments, or disks are damaged [3]. While trauma is the most common cause of spinal cord injuries in the U.S., medical conditions are the primary causes in low-income countries [4] [2]. 

Trauma 

• Vehicle accidents: Accounts for 40% of all cases [2] 
• Falls: Accounts for 32% of all cases [2] 
• Violence: Includes gun violence and assaults; accounts for 13% of all cases [2] [5] 
• Sport-related accidents: Accounts for 8% of all cases [2] 

Medical Conditions 

• Multiple Sclerosis (MS): Damage to the myelin (or insulating cover) of the nerve fibers [1] 
• Amyotrophic Lateral Sclerosis (ALS): Lou Gehrig’s disease, damage to the nerve cells that control voluntary muscle movements [1] 
• Post-Polio: Damage to the central nervous system caused by a virus [1] 
• Spina Bifida: Congenital defect of the neural tube (structure in utero that eventually forms the central nervous system) [1] 
• Transverse Myelitis (TM): Inflammation of the spinal cord caused by viruses and bacteria [1] 
• Syringomyelia: Cysts within the spinal cord often caused by a congenital brain abnormality [1] 
• Brown-Sequard Syndrome (BSS): Lesions in the spinal cord that causes weakness or paralysis on one side of the body and loss of sensation on the other [1] 
• Cauda Equina Syndrome: Compression of the nerves in the lower spinal region [1] 

Spinal Cord Injury Statistics 

According to the World Health Organization, between 250,000 and 500,000 people worldwide are living with spinal cord injuries [4]. In the U.S., this number is estimated to be between 255,000 and 383,000 with 18,000 new cases each year for those with trauma-related spinal cord injuries [6]. 

Age/Gender 

Globally, young adult males (age 20 to 29) and males over the age of 70 are most at risk. In the U.S., males are also at highest risk, and of this group, 43 is the average age [2].  

While it is less common for females to acquire a spinal cord injury (2:1 ratio in comparison to males), when they do occur, adolescent females (15-19) and older females (age 60 and over) are most at risk globally [4].  

Race/Ethnicity 

In the U.S. since 2015, around 56% of spinal cord injuries related to trauma occurred among non-Hispanic whites, 25% among non-Hispanic Black people, and about 14% among Hispanics [6].  

Mortality 

People with spinal cord injuries are 2 to 5 times more likely to die prematurely than those without these injuries (WHO, 2013). People with spinal cord injuries are also more likely to die within the first year of the injury than in subsequent years. In the U.S., pneumonia, and septicemia – a blood infection – are the top causes of death in patients with spinal cord injuries [6]. 

Financial Impact 

Spinal cord injuries cost the U.S. healthcare system billions each year [6]. Depending on the type, spinal cord injuries can cost from around $430,000 to $1,300,000 in the first year and between $52,000 and $228,000 each subsequent year [6].  

These numbers do not account for the extra costs associated with loss of wages and productivity which can reach approximately $89,000 each year [6]. 

Spinal Cord Injuries: Types and Complications

Four Levels of the Spinal Cord 

• Cervical (vertebrae C1 – C8): Neck; controls the back of the head down to the arms, hands, and diaphragm 
• Thoracic (vertebrae T1 – T12): Upper mid-back; controls the chest muscles, many organs, some back muscles, and parts of the abdomen 
• Lumbar (vertebrae L1 – L5): Lower back; controls parts of the lower abdomen, lower back, parts of the leg, buttocks, and some of the external genital organs 
• Sacral (vertebrae S1 – S5): Lower back; controls the thighs down to the feet, anus, and most of the external genital organs 

Types of Spinal Cord Injuries 

Spinal cord injuries may be classified by level and degree of impairment. There are four types of spinal cord injuries [5]. 

Injury Level 

• Tetraplegia or Quadriplegia: Injury at the cervical level; loss of feeling or movement to the head, neck, and down. People with this type of spinal cord injury have the most impairment. 
• Paraplegia: Injury at the thoracic level or below; limited or complete loss of feeling or movement to the lower part of the body.  

Impairment 

• Incomplete spinal cord injury: Some sensation and mobility below the level of injury as the spinal cord can still transmit some messages from the brain. 
• Complete spinal cord injury: Total loss of all sensation and mobility below the level of injury. Spinal cord injuries of this type have the greatest functional loss. 

Spinal Cord Injury Complications 

Complications from spinal cord injuries can be physical, mental, or social, and can impact overall quality of life. There are six common complications of spinal cord injuries [2]. 

Depression 

Studies show that 32.9% of adults with disabilities experience frequent mental distress [7]. Mental distress may be related to functional limitations, chronic disease, and the increased need for healthcare services.  Up to 37% of people with spinal cord injuries develop depression [2]. 

Pressure injuries 

People with spinal cord injuries may have problems with circulation and skin sensation– both risk factors for pressure injuries. Some may be bedridden or wheelchair-bound which also places them at risk for pressure injuries. Up to 80% of people with spinal cord injuries will have a pressure injury during their lifetime and 30% will have more than one [2].  

Spasticity 

Around 65% - 78% of people with spinal cord injuries have spasticity [2]. Spasticity is uncontrolled muscle tightening or contraction. The damage from spinal cord injuries causes misfires in the nervous system leading to twitching, jerking, or stiffening of muscles. 

Autonomic dysreflexia 

In some people with spinal cord injuries, a full bladder or bowel distention can cause a potentially dangerous condition called autonomic dysreflexia. The full bladder or bowel triggers a sudden exaggerated reflex that causes an increase in blood pressure. This condition is also associated with a severe headache, low heart rate, cold skin, and sweating in the lower body [8]. 

Respiratory problems 

If the diaphragm function is affected, as with cervical spinal cord injuries, there may be breathing difficulties. People with lumbar spinal cord injuries can even have respiratory problems as the abdominal muscles are used to breathe. 

Sexual problems 

Due to changes in muscle function and depending on the degree of damage, people with spinal cord injuries may have problems with arousal and climax due to altered sensations and changes in sexual reflexes.  

Changes in bowel and bladder function 

Many people with spinal cord injuries lose bowel control. Bowel problems can include constipation, impaction, and incontinence. They may also have problems with urination, for example, urinary retention. 

Bowel and Bladder Dysfunction in Spinal Cord Injuries 

This section will cover the normal function of the bowel and bladder, and the types of bowel and bladder dysfunction that occurs in patients with spinal cord injuries.

Normal Bowel and Bladder Function 

In normal bowel and bladder function, when the rectum or bladder fills with stool/urine and presses on area nerves (stimulation), the message is sent to the spinal cord which sends it to the brain. The brain gives the person the “urge” feeling, allowing an option to control the elimination or not.  

Whatever decision the person makes, the brain sends the message back to the spinal cord, which in turn sends a message to the elimination muscles (anal and bladder sphincters) to either relax or stay closed until the person is ready. In people with spinal cord injuries, the messages are limited or blocked, leading to problems with bowel and bladder control [9] [10].  

Bowel Dysfunction with Spinal Cord Injuries 

Reflex hypertonic neurogenic bowel occurs when a rectum full of stool presses against area nerves sending a message to the spinal cord, but it stops there. The message never makes it to the brain, so the person never gets the urge.  

As a result, a reflex is set off, prompting the spinal cord to send a message to the anal muscle (sphincter) instead, causing it to relax and release the stool. This condition leads to bowel incontinence and usually occurs in spinal injuries at the cervical and thoracic levels [9] [10]. 

Flaccid hypotonic bowel occurs when area nerves are also stimulated by a full rectum, but the message does not even reach the spinal cord, so there is no reflex. The anal sphincter is always in a relaxed state.  

As a result, the bowels simply empty when they are full, and this can occur at any time without the person having the ability to control it. This condition results in bowel incontinence and can lead to constipation as the patient does not have the urge and may not have the ability to push. This condition usually occurs in spinal injuries at the lumbar level [9] [10]. 

Bladder Dysfunction with Spinal Cord Injuries 

Reflex neurogenic bladder occurs when the bladder automatically starts to contract after filling with a certain amount of urine. The person has no urge to go as the messages are either limited or blocked from reaching the brain, therefore leading to loss of bladder control. Similar to reflex hypertonic neurogenic bowel, the full bladder triggers are nerves that set off a reflex, prompting the spinal cord to send messages to the bladder releasing urine outside of the person’s control [9] [10]. 

Acontractile bladder occurs when the bladder loses muscle tone after a spinal cord injury, lessening its ability to contract, leading to bladder distention, and dribbling of urine. People with this condition need to use urinary catheters to help empty the bladder [9]. 

The Nurse’s Role in Bowel and Bladder Management 

This section will cover how nurses can assess, intervene, and teach when caring for patients with spinal cord injuries who have bowel and bladder dysfunction.

Nurse Assessments 

When caring for patients with spinal cord injuries, nurses should obtain a detailed bowel and bladder history including diet, fluid intake, medications, and elimination patterns/habits [11]. Many of these patients may already manage their own bowel and bladder care at home.  

If so, the nurse should obtain the patient’s current regimen and communicate the information to the physician. The physician may choose to continue the regimen or adjust as needed based on the patient’s current illness/condition.  

Questions the nurse can ask the patient: 

• What does your typical diet consist of? 
• How much fluid do you drink on a daily basis? 
• How often do you have a bowel movement or urinate? 
• Do you schedule your bowel movements with assistance from medications? 
• Are there certain body positions or things you do to help you pass stool more easily?
• How often do you use an intermittent urinary catheter for bladder relief? 
• How much time do you spend on your bowel and bladder regimens? 
• Do you care for all of your elimination needs or does someone help you? 
• How does your bowel and bladder dysfunction affect your quality of life? 

Some assessments may be observed. For example, nurses may notice that the patient has a surgically placed permanent suprapubic urinary catheter or colostomy (when the bowel is cut somewhere above the level of the rectum and diverted to the outside of the abdomen). 

Nurse Interventions 

Since many patients with spinal cord injuries have problems with bowel and bladder function, elimination must be scheduled. Nurses can help by implementing bowel and bladder programs and providing education and support to patients, families, or caregivers.  

Regimens 

Follow the patient’s home bowel and bladder regimen (as ordered). This may include maintaining intermittent catheterization every few hours or administering suppositories daily.  

For patients who do not have a regimen already or wish to modify their current one, encourage them to pay attention to how often they urinate and pass stools, elimination problems, foods that alleviate or worsen the problem, and medications or other things that help. This can be done through a diary. 

Dietary Considerations 

Educate patients on the importance of a fiber-rich diet to avoid constipation. Patients should also be made aware that high-fat foods, spicy foods, and caffeine can alter gut dynamics and lead to bowel incontinence episodes [12]. 

Fluid Intake 

Some patients may avoid drinking enough water to avoid bladder complications (e.g., frequent incontinent episodes) [12]. However, nurses should educate patients on the importance of adequate fluid intake to prevent constipation. Patients should be made aware that bladder and bowel elimination regimens go hand in hand. 

Bladder Elimination 

For bladder dysfunction, help patients perform intermittent urinary catheterization as needed or place a temporary urinary catheter (as ordered). 

Bowel Elimination 

For bowel dysfunction, administer ordered suppositories and laxatives to help the bowels move (use suppositories in conjunction with the level of sensation the patient has near the anus/rectum) [9]. Changes in body position may help as well.  

While many of these interventions may not work in some patients with spinal cord injuries, bowel irrigation (water enemas) may be helpful [11]. Surgical placement of a colostomy may be indicated if all other measures have failed [11]. 

Emotional Support 

Ensure privacy and sensitivity during all elimination care as patients may experience embarrassment or frustration. 

Education for Families or Caregivers 

Provide education to families or caregivers on the importance of helping patients stay consistent with their elimination regimen, follow diet and fluid intake recommendations, and comply with medication orders.  

Referrals 

Inform the physician if interventions are not effective or if the patient, family, or caregiver has a special need (e.g., counselor or dietician). Refer patients and families or caregivers to support groups as needed.

Support Groups and Resources 

Christopher and Dana Reeve Foundation 

Christopher Reeve – an actor who was left paralyzed after an equestrian accident – and his wife Dana’s legacy lives on through their foundation, an organization that advocates for people living with paralysis [13].  

Miami Project to Cure Paralysis 

In response to his son, who acquired a spinal cord injury during college football, NFL Hall of Famer Nick Buoniconti and world-renowned neurosurgeon Barth A. Green, M.D. started a research program aimed at finding a cure for paralysis and discovering new treatments for many other neurological injuries and disorders [14]. 

National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) 

The National Institute on Disability, Independent Living, and Rehabilitation Research, a part of the U.S. Department of Health and Human Services’ Administration for Community Living, helps people with disabilities integrate into society, employment, and independent living [15].  

Paralyzed Veterans of America (PVA)  

A group of World War II veterans who returned home with spinal cord injuries, started this organization to support those with spinal cord injuries and dysfunction. Today, the organization focuses on quality health care, research and education, benefits, and civil rights to affected veterans [16].  

United Spinal Association 

The United Spinal Association supports people with spinal cord injuries and those in wheelchairs. The organization advocates for disability rights like access to healthcare, mobility equipment, public transportation, and community support. Support groups can be found on their website [17).  

Conclusion

Spinal cord injuries can have devastating effects on patients and their families. Management of basic bodily functions like bowel and bladder elimination should be made as easy as possible for these patients.

When nurses learn how to effectively help patients with spinal cord injuries better manage their own bowel and bladder regimens, quality of life and health outcomes may be improved for this group.

Pressure Injury Prevention, Staging and Treatment

Introduction   

When hearing the term HAPI, what comes to mind? The fact is, HAPI may not necessarily generate happy thoughts. Hospital-acquired pressure injuries (HAPIs) are a significant problem in the U.S. today. In fact, pressure injuries in general – whether acquired in a hospital or not – are a global problem.

Many articles have noted that staging and differentiating pressure injuries can be overwhelming for nurses [9]. The purpose of this course is to equip learners with the knowledge needed to reduce pressure injuries, resulting complications, financial risk, and associated death. The information in this course will serve as a valuable resource to nurses from all specialties and backgrounds.

What is a pressure injury?

The National Pressure Injury Advisory Panel (NPIAH) defines pressure injuries as “localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device” [17]. Pressure injuries can present as intact or opened skin and can be shallow or deep. Pressure injuries can be quite painful for patients and may require extensive treatment.

Prior to 2016, pressure injuries were termed “pressure ulcers.” However, since ulcer implies “open skin,” the NPIAH changed it to “pressure injury” as the skin is not always open with some of these injuries [22][25].

What causes a pressure injury to develop?

Pressure 

Intense and/or prolonged pressure on the patient’s skin and/or tissue can cause compromised blood flow and decreased sensation [7]. This can occur when patients lay or sit on a bony prominence for an extended period of time [16].  

Bony prominences are areas where you can easily feel a bone underneath the skin or tissue when palpating. These can include the heels, hips, elbows, and tailbone. Approximately two-thirds of all pressure injuries occur on the hip and buttocks area [7]. 

Friction and Shear 

Friction and shear often happen when patients slide down in bed, for example, when the head of the bed is raised. Although “friction and shear” are often used together, there is actually a difference between the two.  

While friction occurs when skin is dragged across a coarse surface (leading to surface-level injuries), shearing occurs when internal bodily structures and skin tissue move in opposite directions (leading to deep-level injuries) [10]. Shearing is often associated with a type of pressure injury called deep tissue injury (occurring in the deeper tissue layers rather than on the skin’s surface) [10].

[24] 

What are risk factors for developing a pressure injury? 

There are numerous risk factors for pressure injuries – some of which may not be directly related to the skin. These risk factors can be categorized as either intrinsic factors (occurring from within the body) or extrinsic (occurring from outside of the body) [2][13]. 

Intrinsic Risk Factors 

- Poor skin perfusion (e.g., peripheral vascular disease or smoking) 

- Sensation deficits (e.g., diabetic neuropathy or spinal cord injuries) 

- Moist skin (e.g., urinary incontinence or excessive sweating) 

- Inadequate nutrition (particularly poor protein intake) 

- Poor skin elasticity (e.g., normal age-related skin changes) 

- End of life/palliative (leads to organ failure including the skin) 

- Limited mobility (i.e., bedridden, or wheelchair-bound) 

Extrinsic Risk Factors 

- Physical and chemical restraints (leads to limited mobility) 

- Undergoing a procedure (laying down for extended periods of time) 

- Length of hospital stay (for HAPIs) 

- Medical devices (can lead to medical device-related pressure injuries)

Statistical Evidence 

This section will cover pressure injury statistics both globally and nationally. This section will also cover the impact pressure injuries have on healthcare.

What is happening on a global scale? 

In a global study, researchers found that the prevalence (all cases) and incidence (new cases) of pressure injuries in 2019 were 0.85 million and 3.17 million, respectively – numbers that have decreased over time [23][25]. Numbers were disproportionately high in high-income North America, Central Latin America, and Tropic Latin America [25]. Numbers were lowest in Central Asia and Southeast Asia. The report revealed that although numbers are high overall, they are much lower than what they were predicted to be, which may be attributed to better prevention and treatment initiatives.

What is happening nationally? 

In the U.S., 2.5 million people develop pressure injuries each year [1]. This number does not account for the many people trying to manage pressure injuries on their own at home (i.e., when family acts as the caregiver).  

HAPIs in particular are a growing problem. The most recent data on hospital-acquired conditions in the U.S. shows that from 2014 to 2017, HAPIs increased by 6% (647,000 cases in 2014 to 683,000 in 2017) [6]. Each year 60,000 patients in the U.S. die as a direct result of pressure injuries [1]. 

How do pressure injuries impact healthcare? 

Pressure injuries can be quite costly to the healthcare system. These injuries can lead to persistent pain, prolonged infections, long-term disability, increased healthcare costs, and increased mortality [1].  

In the U.S., pressure injuries cost between $9.1 - $11.6 billion per year [1]. These injuries are complex and can be difficult to treat [7]. Often requiring an interdisciplinary approach to care, the costs of one pressure injury admission can be substantial. Individual care for patients with pressure injuries ranges from $20,900 to $151,700 per injury [1]. Not to mention, more than 17,000 lawsuits are related to pressure injuries every year [1].  

Due to the significant impact that these injuries have on healthcare, prevention and accurate diagnosis is imperative.

Staging and Diagnosis 

The section will cover the staging, varying types, and diagnosis of pressure injuries.  

What is the difference between wound assessment and staging? 

Pressure injury staging is more than a basic wound assessment. Wound assessment includes visualizing the wound, measuring the size of the wound, paying attention to odors coming from the wound, and lightly palpating the area on and/or around the wound for abnormalities. Pressure injury staging, however, involves determining the specific cause of injury, depth of skin or tissue damage, and progression of the disease.  

What are the six stages of pressure injuries? 

According to NPIAP guidelines, there are six types of pressure injuries – four of which are stageable [14]. 

[16] 

Stage 1 

In Stage 1 pressure injuries, there is intact skin with a localized area of non-blanchable erythema (pink or red in color), which may appear differently in darkly pigmented skin. Before visual changes are noted, there may be the presence of blanchable erythema or changes in sensation, temperature, or firmness. Stage 1 pressure injuries do not have a purple or maroon discoloration (this can indicate a deep tissue pressure injury). 

Stage 2 

In Stage 2 pressure injuries, there is partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may represent an intact or opened serum-filled blister. Fat (adipose) and deeper tissues are not visible. Granulation tissue, slough (soft moist material, typically yellow or white), and eschar (hard necrotic tissue, typically black in color) are not present. Stage 2 injuries cannot be used to describe wounds associated with moisture-only, skin chaffing, medical adhesives, or trauma. 

Stage 3 

In Stage 3 pressure injuries, there is full-thickness loss of skin, in which fat is visible in the injury, and granulation tissue and rolled wound edges are often present. Slough and/or eschar may be noted. The depth of tissue damage is dependent on the area of the wound. Areas with a significant amount of fat can develop deep wounds.  

Undermining (burrowing in one or more directions, may be wide) and tunneling (burrowing in one direction) may be present. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar covers the extent of tissue loss, this would be considered an unstageable pressure injury, not a Stage 3. 

Stage 4 

In Stage 4 pressure injuries, there is full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the wound. Slough and/or eschar may be visible. Rolled wound edges, undermining, and/or tunneling are often present. The area where the wound is present will determine the depth. As with stage 3 pressure injuries, if slough or eschar covers the extent of tissue loss, this would be considered an unstageable pressure injury. 

Unstageable 

In unstageable pressure injuries, there is full-thickness skin and tissue loss in which the extent of tissue damage within the wound cannot be confirmed because it is covered by slough or eschar. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be removed.  

Deep Tissue Injury 

In deep tissue pressure injuries (also termed: deep tissue injuries or DTIs), there is intact or non-intact skin with localized area or persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister.  

Pain and temperature changes often precede skin color changes. Discoloration may appear differently in darker-pigmented skin. The injury may resolve without tissue loss or may worsen quickly and open up, revealing the actual extent of tissue injury. Deep tissue pressure injuries should not be used to describe vascular, traumatic, neuropathic, or dermatologic conditions.  

What are other types of pressure injuries? 

Mucosal Membrane Pressure Injury 

Mucosal membrane pressure injuries are found on mucous membranes with a history of a medical device in use at the location of the injury. For example, a wound on the inside of a nostril from a nasogastric tube would be considered a mucosal membrane pressure injury. Due to the anatomy of the tissue, mucosal membrane pressure injuries cannot be staged [18]. 

Medical Device-Related Pressure Injury 

Medical device-related pressure injuries, often associated with healthcare facilities, resulting from the use of devices designed and applied for diagnostic or therapeutic purposes [15]. The resulting pressure injury typically conforms to the pattern or shape of the device which makes identification easier. The injury should be staged using the staging system.  

Hospital Acquired Pressure Injury (HAPI) 

While the general hospital setting places patients at a 5% to 15% increased risk of developing a pressure injury (HAPI), patients in the intensive (or critical) care unit in particular have an even higher risk [17]. Critical care patients typically have serious illnesses and conditions that may cause temporary or permanent functional decline. There is also evidence that pressure injuries in this setting can actually be unavoidable.  

The NPIAP defines “unavoidable” pressure injuries as those that still develop after several measures by the health provider have been taken. These measures include when the provider has (a) evaluated the patient’s condition and pressure injury risk factors, (b) defined and implemented interventions consistent with standards of practice and the patient’s needs and goals, and (c) monitored and evaluated the impact of interventions [20]. There are certain situations in which a critical care patient may have a higher risk of developing unavoidable pressure injuries.  

In one study of 154 critical care patients, researchers found that 41% of HAPIs were unavoidable and those who had a pressure injury in the past were five times more likely to develop an unavoidable pressure injury during their stay [20]. The study also found that the chance of developing an unavoidable HAPI increased the longer patients stayed in the hospital – a 4% risk increase each day.  

How are pressure injuries diagnosed? 

Diagnosing a pressure injury is done by simply staging the injury. The health provider may stage the injury or rely on the nurse’s staging assessment before giving the final diagnosis and initiating treatment. There are tests that may be ordered to help identify the early stages of a developing injury.  

For example, subepidermal moisture assessment (SEM) scanners may help to identify tissue changes early on in patients with darker skin tones [8]. Tests may also be ordered to determine the extent of the damage, disease, or infection caused by a pressure injury. A magnetic resonance imaging test (MRI) can be used to determine if the infection in a stage 4 pressure injury has spread to the bone. 

Prevention and Treatment 

This section will cover various strategies that can be used to prevent and treat pressure injuries. 

What are some ways to prevent pressure injuries? 

Preventing pressure injuries takes more than just one nurse repositioning a patient every two hours. It involves a combination of strategies, protocols, and guidelines that facilities can implement across various departments, specialties, and care team members. The NIAPH recommends the following prevention strategies [19]. 

Risk assessment 

Facilities should use a standardized risk assessment tool to help identify patients at risk for pressure injuries (i.e., the Braden or Norton Scale). Rather than using the tool as the only risk assessment strategy, risk factors should be identified by other means (for example, by gathering a detailed patient history).  

Risk assessments should be performed on a regular basis and updated as needed based on changes in the patient’s condition. Care plans should include risk assessment findings to address needs. 

Skin Care 

Monitoring and protecting the patient’s skin is vital for pressure injury prevention. Stage 1 pressure injuries should be identified early to prevent the progress of disease. These include looking at pressure points, temperature, and the skin beneath medical devices.  

The frequency of assessments may change depending on the department. Ideally, assessments should be performed upon admission and at least once daily. Skin should also be cleaned promptly after incontinence episodes. 

Nutritional Care 

Tools should be used that help to identify patients at risk for malnutrition. Patients at risk should be referred to a registered dietician or nutritionist. Patients at risk should be weighed daily and monitored for any barriers to adequate nutritional intake. These may include swallowing difficulties, clogged feeding tubes, or delays in intravenous nutrition infusions. 

Positioning and mobilization 

Immobility can be related to age, general poor health, sedation, and more. Using offloading pressure activities and keeping patients mobile overall can prevent pressure injuries. Patients at risk should be assisted in turning and repositioning on a schedule. Pressure-relieving devices may be used as well. Patients should not be positioned on an area of previous pressure injury. 

Monitoring, training, and leadership 

Current and new cases of pressure injuries should be documented appropriately and reported. All care team members should be educated on pressure injury prevention and the importance of up-to-date care plans and documentation.  

All care team members should be provided with appropriate resources to carry out all strategies outlined. Leadership should be available to all care team members for support (this may include a specialized wound care nurse or wound care provider). 

How are pressure injuries treated? 

There is no one way to treat a pressure injury. Management of pressure injuries involves a specialized team of care providers and a combination of therapies that aim to target underlying factors and prevent complications [7]. Depending on the stage of the wound and skin risk factors, providers may order specific types of treatments.  

Some pressure injury treatments may include the following [7]. 

- Wound debridement – a procedure in which necrotic tissue is removed from a wound bed to prevent the growth of pathogens in the wound, allowing for healing 

- Antibiotic therapy (topical or systemic) 

- Medicated ointments applied to the wound bed (e.g., hydrogels, hydrocolloids, or saline-moistened gauze to enable granulation tissue to grow and the wound to heal) 

- Nutritional therapies (e.g., referrals to dieticians) 

- Disease management (e.g., controlling blood sugar in diabetes) 

- Pain medications 

- Physical therapy (to keep the patient active) 

The Nurse’s Role 

The section will cover the nurse’s role in preventing pressure injuries and the progression of disease.  

What is the nurse’s role in pressure injury prevention? 

Based on NPIAH guidelines, the Agency for Healthcare Research and Quality (AHRQ) – an agency that monitors pressure injury data for the U.S. – breaks down quality initiatives for preventing pressure injuries in a three-component care bundle [2].  

A care bundle is a combination of best practices that when used together, can lead to better patient outcomes [2]. The care bundle includes skin assessments, risk assessments, and care planning. Nurses should follow the guidelines listed under each component. 

Standardized pressure injury risk assessment 

- Use risk assessment tools and processes to identify patients at risk 

- Do not rely on tools only, use your own judgment as well (tools are meant to guide the assessment) 

- Update risk scores at least once daily and if patient’s condition changes 

- Document findings in the medical record 

- Communicate findings to other staff involved for continuity of care (e.g., informing another nurse during patient handoff reporting) 

Comprehensive skin assessment 

- Identify any pressure injuries that may be present 

- Determine whether there are other areas of skin breakdown or factors that may predispose the patient to develop a pressure injury (e.g., moist skin) 

- Identify other skin issues 

- Perform assessments at regular intervals 

- Document findings in the medical record 

- Communicate findings to other staff involved in care so that appropriate changes can be reported (e.g., informing the nursing assistant) 

- Ask colleague to confirm findings for accuracy (i.e., two-nurse skin checks) 

Care planning and implementation to address areas of risk 

- Create care plans that include each skin risk factor (e.g., nutrition, mobility, and moisture) 

- Update care plans as often as needed if there are any changes in the patient’s condition 

- Evaluate whether care plan was effective by assessing patient response to interventions 

-  Individualize care plans for each patient based on risk assessment scores and other observed risks 

- Identify patient learning needs and implement teaching as needed 

- Document care plan in the medical record 

- Communicate care plan to other staff involved for continuity of care (e.g., informing another nurse during patient handoff reporting) 

How can nurses prevent medical device-related pressure injuries?

The NPIAP outlined best practices to prevent medical device-related pressure injuries in various settings including general care, long-term care, critical care, and pediatric care [20]. The following strategies apply across all settings. 

- Choose the correct size of medical device for the individual. 

- Cushion and protect the skin with dressings in high-risk areas (e.g., nasal bridge). 

- Inspect the skin under and around the device at least daily (if not medically contraindicated).  

- Rotate sites of oximetry probes.  

- Rotate between O2 mask and prongs (if feasible).  

- Reposition devices (if feasible).  

- Avoid placement of device over sites of prior or existing pressure injury OR directly under the patient.  

- Be aware of edema under the device and the potential for skin breakdown. 

- Change rigid C-collar to softer collar when medically cleared (for critical care settings).

How can nurses identify pressure injuries in patients with darker skin tones? 

Research suggests that it may be difficult to note early changes that can lead to the development of a pressure injury in patients with darker skin tones – for one, blanching may not be as visible [8]. This places the patient at a greater risk for the advancement of disease as early identification may be challenging.  

In order to appropriately identify pressure injuries in patients with darker skin tones, nurses should use unique strategies. The NIPAH offers these recommendations for nurses to help accurately identify pressure injuries in this group [8]. 

Identification tips 

- Clean the suspected area beforehand 

- Compare the area to surrounding unaffected areas 

- Compare the area to the opposite laterality if possible (i.e., right versus left elbow) 

- Compare the area to unaffected areas in a different location (i.e., upper back versus chest) 

- Look for differences in skin tautness 

- Look for shining skin changes 

- Palpate for changes in skin temperature 

How can nurses quickly differentiate between pressure injury stages? 

Correct staging of pressure injuries is vital as treatment is determined by the extent of damage, disease, or infection. First and foremost, wounds should be gently cleaned prior to staging as drainage or debris can be mistaken for fat or bone within the wound bed [14].  

Nurses can quickly differentiate between stages by asking these simple easy-to-understand starter questions. A more detailed assessment should follow. 

- Stage 1 versus Stage 2: Is the skin intact? 

Rationale: The skin is always intact in Stage 1. The skin is always open in Stage 2 (or there may be an intact blister present). 

- Stage 2 versus Stage 3: Is the wound bed pink or beefy red? 

Rationale: The wound bed is pink or beefy red in Stage 2. In Stage 3, the wound bed has structures within that may be discolored. 

- Stage 3 versus Stage 4: Does the wound bed contain soft or firm structures? 

Rationale: The wound bed contains softer structures in Stage 3. The wound bed contains firmer structures in Stage 4.* 

- Unstageable versus Stageable: Is any part of the wound bed hidden? 

Rationale: The wound bed is not entirely exposed in an unstageable. The wound bed is exposed in a stageable that is open. 

- Intact DTI versus Stage 1: Is the discoloration light or dark? 

Rationale: The discoloration is dark in a DTI. The discoloration is much lighter in Stage 1. 

- Open DTI versus Stage 2: Is the discoloration in or around the wound bed dark? 

Rationale: There is dark discoloration in or around the wound bed in an open DTI. In stage 2, the discoloration is much lighter (if even present). 

*Nurses should familiarize themselves with the appearance of the various structures that may be present in a wound like fat, fascia, bone, tendon, ligament, etc. Most importantly, nurses should consult the wound care team or health provider if a stage cannot be determined. 

What should patients know? 

Facilities can use the NIAPH prevention strategies to devise teaching plans for patients [19]. Nurses should educate patients and families/caregivers on risk factors, signs and symptoms, prevention tips, and the importance of following through with treatment.  

Nurses should also teach patients to advocate for their own health in order to avoid progression of disease. Here are important tips to teach at any point during the patient’s stay. These tips can apply to nurses working in a variety of settings. 

- Tell the nurse or provider of your medical conditions (needed to identify risk factors) 

- Tell the nurse or provider if you notice any numbness or tingling in your body (potential risk for sensory deficits) 

- Tell the nurse or provider if you have a loss of appetite or trouble eating (potential risk for malnutrition) 

- Clean yourself well after using the restroom (maintains skin integrity) 

- Tell the nurse or provider if you need to use the restroom or need help with cleaning yourself (maintains skin integrity) 

- Tell the nurse right away if you have an incontinence episode (maintains skin integrity) 

- Take all prescribed medications (may include necessary antibiotics or wound-healing medications) 

- Reposition yourself in bed often or tell the nurse if you need help doing so (reduces immobility risk) 

- Tell the nurse or provider if you notice a new discolored area on your skin, or an open area (potential new or worsening pressure injury) 

- Tell the nurse or provider if you notice any changes to your wound (potential worsening pressure injury) 

Quality Improvement 

This section will cover the quality improvement measures in place to reduce pressure injuries. 

What is a pressure injury quality improvement initiative? 

Quality improvement involves setting goals (or initiatives) and standards of care. The goal of quality improvement is to improve patient outcomes at a systematic level where everyone involved is on the same page.  

Although possibly unaware, all care team members are involved in quality improvement. Nursing leaders design, manage, and evaluate program initiatives. Staff nurses and other care team members follow protocols that are often developed from these initiatives.  

The Pressure Injury Prevention Program is a guide designed by the AHRQ to help health facilities implement a structured pressure injury prevention initiative based on quality improvement [12]. Facilities can use the guide as a training toolkit to implement a new quality improvement program [5].  

Initiative Goals: 

- Reduced pressure injury rates 

- Reduced adverse events related to pressure injuries 

- Reduced costs associated with pressure injuries 

- Reduced lawsuits related to pressure injuries 

Ways facilities can implement a prevention program: 

- Address the overall objectives of the prevention program 

- Identify the needs for change and how to redesign practice 

- Develop goals and plans for change 

- Use the NIAPH pressure injury prevention recommended practices 

- Establish comprehensive skin assessment protocols 

- Standardize assessments of pressure injury risk factors 

- Incorporate risk factors into individualized care planning 

- Establish clear staff and leadership roles 

What are some pressure injury quality measures? 

Quality measures are tools that measure a system’s healthcare goals and/or ability to provide high-quality care [11]. In simple terms, quality measures are specific ways that systems (governments, states, organizations, etc.) can show how they are making progress in meeting goals. The AHRQ highlights the following three ways the U.S. measures its progress.  

Number of HAPIs 

The AHRQ measures the number of HAPIs per year. The most recent data is from 2014 to 2017 [6].

Rate of HAPIs per admission 

The AHRQ measures the number of HAPIs per admission related to age groups. The number is measured as a “rate,” meaning the number of HAPIs per 1,000 hospital admissions. The most recent evidence is from 2017 [4]. 

Costs of HAPIs 

Another quality measure is HAPI costs. While the AHRQ does not measure costs of HAPIs every single year, the most recent data is from 2017 [3].  

Deaths related to HAPIs 

Patient mortality rates related to HAPIs are a quality measure (calculated per 1,000 pressure injury cases). The most recent data is from 2017 [6]. 

Conclusion

 Pressure injuries are complex conditions that can lead to poor patient outcomes and a burdened healthcare system. The best strategy in the care of patients with pressure injuries or those at risk is prevention.  

However, preventing these injuries involves more than individual nurses taking specific steps. Prevention of pressure injuries involves a team effort from all members of the care team and a systemic plan for improvement.

Negative Pressure Wound Therapy (Wound Vac)

Introduction   

Negative pressure wound therapy (NPWT), also known as a wound vac, can be a powerful tool in combatting acute and chronic wounds. It relies on generating a negative pressure on the surface of a difficult wound to promote wound healing.

The goal of this course is to develop an understanding of mechanism of action of NPWT, discuss appropriate nursing assessment of these wounds, evaluate adjunct treatment options and troubleshooting support tips.

We will review basic concepts of the integumentary system and the normal wound healing process to support the rationale of NPWT.

Definition

Negative pressure wound therapy (NPWT) is the application of sub-atmospheric pressure to help reduce inflammatory exudate and promote granulation tissue in an effort to enhance wound healing (4). The idea of applying negative pressure therapy is that once the pressure is lower around the wound, the gentle vacuum suction can lift fluid and debris away and give the wound a fighting chance to heal naturally.

NPWT has a long and interesting history. The idea of suctioning fluid from wounds as therapy is not a new concept. The process was first called “cupping” and was described in Ebers Papyrus around 500 BC; historians tell us that a form of wound suction was used around 1000 BC in China, 600 BC in Babylon and Assyria, and in 400 BC by Greeks who heated copper bowls over wounds to remove blood and fluids (5).

Modern medicine has built upon a very old concept. Thankfully, nurses have a slightly easier tool in NPWT devices than heating copper bowls.

Indications for Use 

Negative pressure wound therapy is widely used for the management of both acute and chronic wounds. This therapy is helpful for a broad range of wounds, from pressure ulcers to closed surgical incisions.  

The system is now implemented routinely for open wounds, such as open fractures, fasciotomies, diabetic foot ulcers, and infected wounds. Delayed wound healing and difficult wounds are seen more commonly in elderly patients and those with comorbidities (1).  

It’s important to review the basic anatomy of our integumentary system, types of wounds, and barriers to healing to understand the usefulness of NPWT. 

Basic Anatomy of Integumentary System 

Our integumentary system is considered the body’s largest organ. Our skin acts as a shield against heat, light, bacteria, infection, and injury. Other functions include body temperature regulation, storage of water and fat, sensory function, prevention of water loss, and a basic storage compartment for the organs (6).  

The skin is made up of 3 layers. Each layer has unique functions: 

1. Epidermis 

1. Dermis 

1. Subcutaneous fat layer (hypodermis) 

The epidermis is the thin outer layer of our skin, it contains squamous cells, basal cells, and melanocytes (gives skin its color). The dermis is the middle layer of skin, it contains blood vessels, hair follicles, sweat glands, nerves, lymph vessels, fibroblasts, and sebaceous glands (6). It is important to remember that the dermis contains nerves and nerve receptors. 

The subcutaneous fat layer is the deepest layer of skin and is made up of a network of collagen and fat cells; this layer conserves the body's heat and protects the body from injury by acting as a shock absorber (6).

This design was created on Canva.com on September 28, 2023. It is copyrighted by Abbie Schmitt, RN, MSN and may not be reproduced without permission from Nursing CE Central. 

Types of Wounds 

Negative pressure wound therapy is primarily used to treat complex wounds that are non-healing or at risk of non-healing. It is also indicated for acute wounds when the wound cannot be closed due to the risk of infection, active infection, skin tension, or swelling (7).  

Closure or skin grafting of acute wounds, such as open fractures or burns, are at high risk for infection due to microorganisms becoming trapped in the soft tissue leading to abscess development.  

Examples of possible wounds to apply NPWT (1):  

• Diabetic foot ulcers 
• Bed sores 
• Skin graft fixation  
• Burns 
• Crush injuries 
• Sternal/abdominal wound dehiscence  
• Fasciotomy wounds 
• Animal bites 

• Frostbite 

Barriers to Healing 

Age 

• Increased risk of tearing and shearing due to thinning of epidermis and decrease in elastin 
• Phases of healing are prolonged 
• Increased risk of dehiscence as the dermis has slower contractility 
• Skin more susceptible to bacterial growth and infections as pH becomes more neutral with age  

Co-morbidities 

• Cardiopulmonary Disease 

• Oxygen-transport pathways are affected 
• O2 necessary for wound healing 

• Diabetes Mellitus 

• High glycemic levels predispose patients to infection 
• Microvasculature and neuropathic components of DM increase the risk for impaired healing  
• Poor glycemic control can increase the risk of ulceration and delayed healing 

• Immune-suppressing conditions (Cancer, HIV, immunosuppressive therapy, immunosuppression syndrome) 

• Inflammatory phase (immunology) is impaired 
• Increased risk for infection 

Impaired Perfusion and Oxygenation 

• Peripheral Vascular Impairment 

• Proper perfusion is required for growth of new tissue and immunological responses of the tissue. 
• Arterial insufficiency (blood flow to extremities) leads to necrosis or lack of response to edema. 

Neurological Impairment  

• Peripheral neuropathy 

• Complication related to DM, alcoholism, chemotherapy 
• Loss of neuronal signaling and transmission 
• Loss of the sensory ability to recognize and react to sensations of touch, pressure, temperature, pain. Example: patient leaving foot on hot surface because there was no pain sensation, leading to burn wound. 

• Spinal cord injury 

Mechanism of Action 

The mechanism of action is dependent on applying negative pressure, which is below atmospheric pressure, to the wound. This pressure allows the gentle vacuum suction to lift fluid and exudate away from the wound to enhance healing (3).  

The vacuum is gentle because powerful suction would remove newly formed tissue as well. The mechanism of action is not only in removing fluid and debris from the tissue, but the pressure causes stimulation of the growth of granulation tissue at a macroscopic and microscopic level.  

The porous foam shrinks in size with the application of negative pressure and exerts strain on the wound bed, which leads to macro- and micro-deformation of the wound (3). Microdeformation is simply a term used to describe microscopic tissue cell reactions. This reaction can be compared to a battery jump-start of a car; the stimulation causes the battery to engage. 

NPWT systems consist of a sterile foam sponge, a semi-occlusive adhesive cover, a fluid collection system or canister, and a suction pump (1). The foam sponge is applied to the wound and covered. A fenestrated tube is embedded in the foam and the wound is sealed with adhesive tape to make it airtight, and the machine delivers continuous or intermittent suction, ranging from 50 to 125 mmHg (1). 

This design was created on Canva.com on October 1, 2023. It is copyrighted by Abbie Schmitt, RN, MSN and may not be reproduced without permission from Nursing CE Central. 

Proper application of the NPWT is important for the mechanism of action to be effective. Research supports that NPWT is effective at creating a stable wound environment, reduces inflammation and bacterial load, improves tissue perfusion, and stimulates granulation tissue and angiogenesis (1).  

Imagine you want to plant a garden in a swampy location, you would first need to divert the water and algae from the land, cover it with a greenhouse with consistent heat and pressure, and cultivate the soil for optimal growth. Similarly, NPWT creates the most ideal conditions possible for tissue regeneration.  

Contraindications 

NPWT would be contraindicated for the following: 

• Wounds involving untreated osteomyelitis. 
• Wounds that have exposed blood vessel 
• Wounds with exposed nerves, anastomotic sites, or organs 
• Wounds including open joint capsules 
• Malignant wounds 
• Wounds with necrotic tissue; it is recommended to excise first 

The following wounds could benefit from NPWT, but caution should be given (5): 

• Wounds with visible fistula 
• Wounds with exposed bone or tendon 

• The bone or tendon should be isolated from direct pressure  

• Patient with clotting disorders or that are taking anticoagulants, due to an increased risk of bleeding. 
• Compromised microvascular blood flow to the wound bed. 

Assessment 

A focused assessment should be done for patients with NPWT devices in place, both on the machine settings, the dressing, and the wound itself. Thorough documentation of the wound is essential to see the progression of wound healing. 

Suction Device Settings: 

• Continuous or intermittent 
• Pressure Setting: Range of pressure settings from -40mmHg to -200mmHg, which can be tailored for different types of wounds (7). This is set by the medical provider. 

Laboratory assessment is meaningful in wound care. Labs can be used to assess oxygenation or indicators of infection (6). 

Dressing Assessment 

The appearance of the NPWT and dressing should be clean, dry, intact, and sealed. The tubing should not be twisted or kinked, and the clear adhesive dressing should not be wrinkled or overlapping. Please see below an example of the appropriate appearance of a dressing. 

Wound Assessment: 

• Anatomic location 
• Type of wound  
• Degree of tissue damage 
• Description of wound bed 
• Wound size 
• Wound edges and surrounding skin 
• Signs of infection 
• Pain 

Anatomical Location  

Anatomical terms and numbering should be used to make sure the location of each wound is documented. Patients often have more than one wound, so the treatment needs to be specified for each wound.  

Wound Base 

Assess the color of the wound base. Healthy granulation tissue appears pink and moist due to the new capillary formation. The appearance of slough (yellow) or eschar (black) in the wound base should be documented and communicated to the health care provider (1).  

This tissue may need to be removed to optimize healing. If any discoloration or duskiness of the wound bed or wound edges are identified, the suction should initially be reduced or switched off (7).  

Type and Amount of Exudate 

Assess the color, thickness, and amount of exudate (drainage) The amount of drainage from wounds is categorized as scant, small/minimal, moderate, or large/copious.  

Terms are used when describing exudate: sanguineous, serous, serosanguinous, and purulent (6).  

• Sanguineous: fresh bleeding  
• Serous: Clear, thin, watery plasma 
• Serosanguinous: Serous drainage with small amounts of blood noted 
• Purulent: Thick and opaque. The color can be tan, yellow, green, or brown. This is an abnormal finding and should be reported to a physician or wound care provider. 

Wound Size  

Wounds should be measured on admission, wound vac dressing changes, or as needed for abnormal events. Many healthcare facilities use disposable, clear plastic measurement tools to measure the area of a wound.  

Consistent measurement is vital to the assessment of wound healing. 

• Measure the greatest length, width, and depth of the wound in centimeters 
• Examples of wound classification tools: 

• NPUAP staging system for pressure injuries 
• Payne-Martin classification system for skin tears 
• CEAP (clinical, etiologic, anatomic, and pathophysiology) system for venous ulcers 

Tunneling or Undermining 

Tunneling is when a wound has moved underneath the skin, making a “tunnel.” The depth of tunneling can be measured by gently inserting a sterile, cotton-tipped applicator into the tunnel and noting the length from the wound base to the end of the tract (7). Undermining occurs when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound’s edge.  

Healing Process 

It is important to recognize the entire process of normal wound healing. There are four phases of wound healing: hemostasis, inflammatory, proliferative, and maturation (6).  

Hemostasis begins immediately after injury, involving platelet aggregation and activation of clotting factor (6). A platelet “plug” is formed as fibrinogen converts to fibrin and binds to itself. Vasoconstriction occurs at this time, decreasing blood loss and allowing clot formation.  

The inflammatory phase begins right after the injury and the injured blood vessels leak and cause localized swelling. The swelling, warmth, pain, and redness present during this stage of wound healing are related to the release of white blood cells, growth factors, nutrients, and enzymes to help control bleeding and prevent infection (6).  

The proliferative phase of wound healing involves “rebuilding” with new tissue made up of collagen and extracellular matrix; granulation tissue is built stronger with proper oxygen and nutrients.  

Key nursing knowledge: Dark granulation tissue can indicate infection, ischemia, or poor perfusion. The maturation phase of wound healing is when collagen is remodeled, aligns along tension lines, water is reabsorbed so the collagen fibers can lie closer together and cross-link, and the wound fully closes (1). 

There are three types of wound healing: primary intention, secondary intention, and tertiary intention.  

Primary intention means that the wound healing is supported by sutures, staples, glue, or otherwise closed so the wound heals beneath the closure (6).  

Secondary intention must happen when the edges of a wound cannot be approximated, or “brought together,” so the wound heals with the production of granulation tissue from the bottom up (6).  

Wounds that heal by secondary intention are at higher risk for infection, so contamination prevention is essential. Pressure ulcers are an example of wounds that heal by secondary intention.  

Tertiary intention refers to a wound that needs to remain open, often due to severe infection. Wounds with secondary and tertiary intention have longer healing times (2). 

Alternatives when NPWT fails 

• Hyperbaric Oxygen Therapy (HBOT):