Considerations for Nurses

Some other important considerations for nurses are that they should use universal precautions when dialyzing all patients. Pregnant health care workers are at no greater risk of contracting HIV infection than other staff. However, if the pregnant health care worker develops HIV infection during pregnancy, the infant is at risk of HIV infection due to perinatal transmission.

Post-exposure Protocol

The Centers for Disease Control have put forth the following suggestions for exposure to HIV: If an accidental needle-stick injury occurs, or if there is significant contact of a patient's blood with mucous membranes or non-intact skin surfaces, the health care worker should wash the affected area thoroughly. (This includes a splash in the eye or mouth.) The exposure should then be reported to the employee health service or infection control practitioner. If the source (patient) does not have a previous diagnosis of AIDS or a positive HIV antibody test, a clinical and social assessment of the patient's risk factors for AIDS should be undertaken. In the presence of any such factor, the patient should be told of the health care worker's exposure and an informed consent should be obtained for taking an HIV antibody test. The patient and the health care worker should be counseled regarding the implications of positive or negative results. Whether or not the test is obtained from the patient, the health care worker should consider obtaining a test himself or herself. In order to ensure complete confidentiality of test results, it might be preferable for physicians and nurses to be tested at an off-site test center rather than at their own institution. If the initial test is negative, the health care worker should be followed for a "'flu like" illness for 12 weeks after the exposure. This has been the usual time for HIV infection to develop after a known exposure. Repeat HIV tests at 1 3, and 6 months are recommended. Most infected persons are expected to seroconvert within the first 12 weeks after exposure.

The usual protocol for possible concomitant hepatitis B exposure should also be observed. The risk of work-related HIV conversion has been less than 1% in contrast to hepatitis B conversion, which is considerably higher, between 20% and 30%.

There is increasing evidence that HIV antibody conversion may not occur for up to 36 months after injection. at least in homosexual men. Therefore, many infectious patients may have a false negative test result; a negative antibody test does not definitively rule out infectivity.

Engineering and Work Practice Controls

Wherever there is a likelihood of exposure to HIV, HBV, and other blood borne pathogens, it is strictly prohibited for an employee to eat, drink, smoke, apply cosmetics or lip balm, handle contact lenses, or store food and drink. All contaminated surfaces must be cleaned immediately as soon as feasible.. Protective coverings must be replaced if overtly contaminated. Personal protective equipment should be removed immediately upon leaving the work area and placed in an appropriately designated area or container for storage, washing, decontamination, or disposal. All bins, pails, cans, and reusable receptacles must be decontaminated regularly. Sharps must be stored so that employees do not reach by hand into the container. Broken glassware cannot be picked up with the hands. Contaminated laundry has to be handled with a minimum of agitation and moved in labeled or color-coded bags or containers. Wet laundry requires leak-proof containers. Fluorescent orange or orange-red warning labels must be affixed to containers of "regulated" waste, refrigerators, and freezers containing infections materials and containers used to transport them. Labels must include the official BIOHAZARD legend.

Infection Control Precautions for Care Of the Patient with Acquired Immunodeficiency Syndrome (AIDS)

1. Patients with AIDS or AIDS-related complex (ARC) are at risk to acquire infection; therefore do not place them in a mom with an infected patient.
2. A single room is not required unless the AIDS patient is immunocompromised, has poor hygiene, is incontinent, or has diarrhea.
3. Isolation procedures beyond universal precautions are not warranted for patients with AIDS or ARC unless they have another infection that requires isolation precaution (e.g. tuberculosis, Herpes Simples, or Cryptosporidia).
4. Hand washing before and after patient contact as well as after being soiled with any body secretions or excretions is the most important means of preventing infection among patients and staff.
5. Visitors should be advised not to share razors or toothbrushes with the patient.

Exposure of Nursing Staff to Infectious Diseases

Nursing staff are at some risk for latrogenic infection. LIatrogenic disorders are conditions caused by medical personnel or procedures or through exposure to the environment of a health-care facility. The infections most common in ICU nurses are hepatitis B virus (HBV) and herpes simplex. The most common type of occupational injury for nurses surpassing even sprains and strains, are injuries that occur as a result of being stuck by a needle. ICU nurses will need to be familiar with the following list of communicable diseases to which they may be exposed at work.

Hepatitis B Virus (HBV)

The highest percentage of HBV is found In blood and blood-derived body fluids and is transmitted parenterally, through mucous membranes or non-intact skin, sexually, and perinatally. Hepatitis B poses a serious threat to ICU nurses. The greatest blood borne risk healthcare workers face is the HBV. The HBV can be transmitted from environmental surfaces (countertops, machines. etc.). These are a major source of HBV infection on certain units, such as hemodialysis units. A single needle-stick injury of contaminated blood has as much as a 30% chance of transmitting the disease. Up to 7,400 health-care workers every year acquire HBV Infections through occupational exposure. Universal precautions should be taken to protect against HBV. Nurses at high risk should be immunized with one of the HBV vaccines. The three-dose series of injections costs up to $150. Employers are now required by an Occupational Safety & Health Administration rule to offer free HBV vaccine to every employee who can be reasonably anticipated to have skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious material.

Herpes Simplex Virus (HSV)

Critical care patients frequently have HSV infections especially if they are immunosuppressed. Nurses are at risk for HSV unless they practice careful hand washing and wear gloves on both hands when handling respiratory tract secretions or placing their fingers in patients' mouths. If the nurse has a break in the skin on a finger or around a cuticle the virus can invade and cause an infection called a herpetic whitlow. This infection causes vesiculopustular lesions at the junction of the nail bed and the skin. Since it is usually too painful to cover the lesions with a glove or dressing, the nurse cannot perform patient care duties. Before returning to work clearance should be given by the employee health service.

Cytomegaiovirus (CMV)

A member of the herpes virus family, CMV is found in blood and body fluids and is transmitted by cutaneous or mucous membrane contact with Infectious secretions. Hand washing is sufficient for prevention of transmission. Pregnant nurses should avoid contact with patients known to be infected with CMV because it causes obvious infection in newborns. Patients most likely to have CMV infection are those who are immunosuppressed, such as those having organ transplants, AIDS, or cancer.

Chickenpox (Varicella)

Employees who have not had chickenpox may acquire it from contact with a person who has active chickenpox or disseminated varicella zoster (shingles). The patient is also contagious in the last 48 hours of incubation before the typical vesicular rash occurs. If a nurse has had chickenpox as a child, he or she can usually be safely considered immune.

Rubella

Rubella is transmitted through inhalation of infected droplets of respiratory secretions. Nurses at the highest risk for acquiring rubella are those who work with infants and children and who are not immune to the rubella virus. If a pregnant woman contracts rubella during the first trimester of pregnancy, her fetus may develop major organ systems malformations. All nurses should be tested by their employers to determine rubella immunity. Non-pregnant nurses without immunity should be given a rubella vaccination.

Meningitis

Several viral and bacterial agents can cause meningitis, but only one requires hasty identification and follow up of exposed health care workers - Neisseria meningitis. Meningococcal disease is transmitted via inhalation of infected droplets of respiratory secretions. Exposure can occur if a staff member comes from within three feet of a patient without wearing a face mask. Staff members have had high-risk exposure to meningococcal meningitis if they have provided the following care to an infected patient:

• mouth-to-mouth resuscitation
• intubation or suctioning
• Oral or fundoscopic exam
• Assistance during vomiting or when coughing directly at staff member
• Close patient care where the patient breathed directly on staff member

Prophylactic treatment for high-risk exposure is with rifampin, 600 mg orally twice daily for four doses. Staff members who choose not to take rifampin should be alert for signs of meningitis which include: upper respiratory tract infection, nausea, vomiting, fever, headache, malaise, lethargy, confusion, stiff neck, and petechiae.

Pertussis

Exposure to pertussis (whooping cough) may occur through respiratory secretions from face-to-face contact. A nurse who has been exposed will require Erythromycin prophylaxis because past immunization wanes with age and cannot ensure protection.

Tuberculosis (TB)

Tuberculosis infection occurs when aerosolized droplets containing viable organisms are inhaled by a person susceptible to the disease. A nurse may be exposed to TB if there has been face-to-face contact (without a mask) with a patient who has active laryngeal or pulmonary infection caused by Mycobacterium tuberculosis. If exposure is suspected, a purified protein derivative (PPD) skin test should be performed. If a change in PPD status has occurred, one year of isoniazid (INH) therapy may be recommended.

Infectious Diarrhea

Acute diarrhea is transmitted via the fecal-oral route. Most infectious diarrhea is caused by viruses and is of short duration. If the diarrhea persists, it may be bacterial (e.g. Salmonella, shigella). In such cases diagnosis will be confirmed by stool cultures.

Acquired Immunodeficiency Syndrome (AIDS)

AIIDS is caused by the Human Immunodeficiency virus (HIV). The occupational risk for HIV infection among health care workers is minimal, although it does exist. By far, the most prevalent exposure has been through injury when stuck by a needle. A health-care worker has less than a 1% chance of infection from an HIV-contaminated needle-stick. Legislation has been passed directing the states to adopt new CDC guidelines that call on heath-care workers to know their HIV status and to stop doing exposure-prone procedures if they are infected.

Methicillin-Resistant Staphylococctits aureus (MRSA)

MRSA and other resistant strains of aureus have become one of the most common causes of hospital and community acquired infections. MRSA is resistant to many antibiotics. It is likely that hospital staff carry MRSA from one patient to another on their unwashed hands. Another reservoir for MRSA is the inanimate environment. Everything in the room of a patient infected with MRSA can become infected. Nurses who care for patients infected with MRSA risk becoming carriers of the bacteria. In some hospitals nurses who become colonized with MRSA are assigned to care only for patients with MRSA or are removed from patient care until they are no longer colonized. Treatment of colonized (not infected) carriers include regimens such as: (1) oral antibiotics, (2) topical antibiotic ointments for the anterior nasal passages, and (3) bathing and shampooing with skin disinfectants.