


Introduction to Physical Therapy and Patient Skills?

CHAPTER 8: Preparation for Patient Care



CHAPTER OBJECTIVES
At the completion of this chapter, the reader will be able to:
1. Discuss the differences between values and beliefs
2. List some of the most common negative biases of healthcare workers
3. Provide some examples of nonverbal communication
4. Define empathy
5. Discuss the importance of health equity and cultural competency among healthcare providers
6. Describe what health disparity is
7. List the five steps to achieving cultural competence
8. Discuss the importance of infection control in healthcare
9. Describe some of the microorganisms that can be encountered in healthcare and their various modes of transmission
10. List some of the precautions that must be used with special populations
OVERVIEW
Patient care is a partnership between a patient and the clinician it is something a clinician does with a patient, not to a patient. The primary focus of patient care is to enhance a patient's function through positive interactions, with each interaction having an objective. In some cases, this involves helping a patient to regain former skills, whereas in other cases, it may involve teaching a patient ways to compensate for the loss of a physical or mental attribute. Generally speaking, most interventions involve increasing either a patient's mobility or a patient's stability. Determining what the focus or objective will be requires clinical decision making and preparation.

THE HEALTHCARE TEAM
In many physical therapy settings, a physical therapist does not work in isolation. Often, a healthcare team made up of many different professions plays a role in reviewing a patient's condition and making decisions (see Chapter 1). This patient centered interprofessional collaboration, which is



more common outside the outpatient work areas, serves to enhance problem solving and the coordination of care. In most cases, team conferences involving members from each of the disciplines (nursing, social services, etc.) are held on the patient's behalf. In addition to these discussion meetings, it is not unusual for fellow professionals to co treat a patient. For example, a patient who has undergone hip replacement is often co treated by a physical therapist and an occupational therapist. The advantage of co treatment is that it reduces duplication of treatments, enhances input from different professionals, and often results in interventions for complex problems that exceed what an individual could accomplish. Another example of co treatment occurs when a physical therapist and a physical therapist assistant work together with the same patient. The physical therapist evaluates the patient, provides a plan of care, establishes the goals or desired outcomes, and determines the therapeutic interventions to be used. The physical therapist assistant performs the treatment activities for which he or she is qualified and communicates frequently, both orally and in writing, with the physical therapist, who evaluates the results of the treatment and the patient's responses to it so that alterations or adjustments to the plan of care can be made as necessary.
INITIAL PREPARATION
A significant component of the clinician patient interaction takes place before the clinician ever comes into contact with the patient. Before the start of any procedure, the clinician must prepare for the steps ahead, both mentally and physically. For example, the treatment area must be organized with safety in mind, as well as for efficient use. This may include the removal of any obstacles, adjusting the height of the treatment table, or checking the availability of a particular piece of equipment. Enough room must be allowed for unimpeded movement. Before meeting the patient, the clinician should perform a comprehensive review of the patient's medical record or chart, including all of the following:
 Diagnosis or reason for admittance  Past medical history
 Past surgical history
 Current history and physical findings  Imaging test results, as appropriate
 Laboratory test results, as appropriate  Prescribed medications
 Other consultations prescribed
 Confirmation that orders for physical therapy exist
After the chart review, the clinician enters the patient's room, performs a personal introduction, and then informs the patient about the reason that physical therapy has been ordered. This can include the treatment goals and the desired outcomes, as well as a review of any pertinent precautions (e.g., physician ordered restrictions of motion). The patient should be asked if he or she has any questions before the clinician proceeds with the more formal part of the examination (see Chapter 5).
COMMUNICATION
Patient clinician interactions can take place in a number of environments, including hospital rooms, outpatient clinics, and the home. Much about becoming a clinician relates to an ability to communicate with the patient, the patient's family, and the other members of the healthcare team. It is important to remember that listening is often more critical than speaking. Nonverbal cues are especially significant, because they often are performed subconsciously. Even when performing a dependent mobility task, the clinician can engage the patient both physically and cognitively to some degree. Special attention needs to be paid to cultural diversity and to nonverbal communication such as:
 Facial expression. The facial expression should be one of interest and concern.
 Voice volume. The voice volume should be at a level that is sufficient for the patient to hear. Avoid speaking loudly when possible, especially to



those who are hard of hearing.
 Posture. An upright and attentive posture is preferable (Figure 8 1).
 Touch. Any touch, based on respect of the patient's cultural preferences and personal boundaries, should be confident and firm.
 Gestures. Gestures should be limited to those describing a particular activity.
 Physical closeness. Comfort with physical closeness varies according to culture. In the United States a distance of 18 inches to 4 feet is considered normal for a professional distance.
 Eye contact. Maintaining eye contact enhances trust and demonstrates attentiveness (see Figure 8 1).
 Eye level. Whenever possible, the clinician should alter his or her position so that the eye level between patient and clinician is the same. For example, if the patient is sitting, the clinician should assume a sitting position (see Figure 8 1).

FIGURE 8 1


Clinician patient interaction

The appearance of the clinician should convey an air of professionalism (see Figure 8 1). Most institutions have a dress code that should be adhered to.

 Communication between the clinician and the patient begins when the clinician first meets the patient and continues throughout any future sessions.	



Communication involves interacting with the patient using terms he or she can understand. The introduction to the patient should be handled in a professional yet empathetic tone. Listening with empathy involves understanding the ideas being communicated and the emotion behind the ideas. In essence, empathy is seeing another person's viewpoint, so that a deep and true understanding of what the person is experiencing can be obtained.
Particularly important aspects of empathy are the recognition of patients' rights, potential cultural differences (see Cultural Competence), typical responses to loss, and the perceived role of spirituality in health and wellness to the patient.

Given the nature of the physical therapy profession, physical therapists interact frequently with people with disabilities. When writing or speaking about people with disabilities, it is important to put the person first. Group designations such as "the blind" or "the disabled" are inappropriate because they do not reflect the individuality, equality, or dignity of people with disabilities. Similarly, words such as "normal person" imply that the person with a disability is not normal, whereas "person without a disability" is descriptive but not negative. Etiquette considered appropriate when interacting with people with disabilities is based primarily on respect and courtesy. Outlined next are tips to help when communicating with persons with disabilities, provided by the Office of Disability Employment Policy; the Media Project, Research and Training Center on Independent Living, University of Kansas, Lawrence, KS; and the National Center for Access Unlimited, Chicago, IL.
General Tips

When introduced to a person with a disability, it is appropriate to offer to shake hands. People with limited hand use or who wear an artificial limb can usually shake hands (shaking hands with the left hand is an acceptable greeting). If you offer assistance to a person with a disability, wait until the offer is accepted, then listen to or ask for instructions. Address people who have disabilities by their first names only when extending the same familiarity to all others.
Communicating with Individuals Who Are Blind, or Visually Impaired

The clinician should speak to the individual when approaching him or her, and should speak in a normal tone of voice. When conversing in a group, remember to identify yourself and the person to whom you are speaking. The clinician should not attempt to lead the individual without first asking; allow the person to hold your arm and control her or his own movements. Direct action should be given using descriptive words giving the person verbal information that is visually obvious to individuals who can see. For example, if you are approaching a series of steps, mention how many steps. If you are offering a seat, gently place the individual's hand on the back or arm of the chair so that the person can locate the seat. At the end of the session, the clinician should tell the individual that he or she is leaving.
Communicating with Individuals Who Are Deaf or Hard of Hearing

The clinician should gain the patient's attention before starting a conversation (e.g., tap the person gently on the shoulder or arm), and then look directly at the individual, face the light, speak clearly, in a normal tone of voice, and keep the hands from obstructing the mouth. Short, simple sentences should be used. If the patient uses a sign language interpreter, the clinician should speak directly to the person, not the interpreter. If the clinician places a phone call, he or she should let the phone ring longer than usual. If a Text Telephone (TTY) is not available, the clinician should dial 711 to reach the national telecommunications relay service, which will facilitate the call.
Communicating with Individuals with Mobility Impairments

Whenever possible, the clinician should position himself or herself at the wheelchair user's eye level without leaning on the wheelchair or any other assistive device. Never patronize people who use wheelchairs by patting them on the head or shoulder. Do not assume that an individual wants to be pushed ask first.
Communicating with Individuals with Speech Impairments



If the clinician does not understand something the patient said, he or she should not pretend that they did but should ask the individual to repeat what was said and then repeat it back. To help the patient, the clinician should try to ask questions that require only short answers or a nod of the head. The clinician should not speak for the individual or attempt to finish her or his sentences. If the clinician is having difficulty understanding the individual, writing should be considered as an alternative means of communicating, but only after asking the individual if this is acceptable.
Communicating with Individuals with Cognitive Disabilities

Whenever possible, the clinician and patient should communicate in a quiet or private location and should be prepared to repeat what is said, orally or in writing. It is important that the clinician be patient, flexible, and supportive. The clinician should wait for the individual to accept an offer of assistance; do not "overassist" or be patronizing.
At the end of the first visit and at subsequent visits, the clinician should ask if there are any questions. Each session should have closure, which may include a handshake, if appropriate.
VALUES AND BELIEFS
Every individual has an internalized system of values and beliefs that have developed throughout life. Consciously or otherwise, a clinician brings a set of values and beliefs to every patient interaction. These values and beliefs have been honed by prior experiences. Values and beliefs not only guide actions and behavior but also help to form attitudes toward different things and situations.
 Values. Values are characteristics that are deemed important. Examples include honesty, effort, perseverance, and loyalty. Numerous studies have demonstrated that both conscious and unconscious values can have an impact on interactions with others.
 Beliefs. Beliefs are assumptions that are made based on life's experiences. Examples include religion, gender bias, and racial equality. Belief bias occurs when someone's evaluation of the logical strength of an argument is biased by their belief in the truth or falsity of the conclusion. People tend to accept any and all conclusions that fit in with their systems of belief. A bias can be negative or positive. The most common negative biases of healthcare workers involve:
 Race/ethnicity. In the United States, patients of racial and ethnic minorities tend to receive healthcare interventions that are inferior to those received by White patients even when income and insurance levels are similar.
 Gender. Research is commonly conducted on male subjects, and the conclusions from this research have been generalized and applied to women without consideration of structural or biochemical differences.
 Ageism. Older patients are often considered to be senile, hard of hearing, frail, lonely, and incapable of learning new things.
 Obesity. Assumptions are made that this population is lazy, lacking in self discipline and motivation, and ugly, and that they have brought their weight problems on themselves.
 Disability. Although patients with disabilities are often viewed positively, they are often treated with pity.
 Substance abuse. It is a generally held belief that substance abuse is the fault of the individual because of a lack of willpower.
As clinicians, we are likely to interact frequently with individuals whose values and cultural practices differ from our own. These differences can result in a judgmental response that will either validate or invalidate those values and cultural practices. It is important that the judgmental response not be critical, biased, or one of disapproval, but that every conscious effort be made to accept differences as long as those differences serve the well being of the patients.




CULTURAL COMPETENCE
In today's healthcare, a clinician will encounter people of racial, ethnic and cultural minorities, immigrant and refugee communities, those with disabilities, and lesbian, gay, bisexual, and transgender populations. In addition, within these populations can be economically and socially disadvantaged groups. One of the goals of the U.S. government is to create health equity and to promote cultural competency among healthcare providers so as to increase positive outcomes for all people.

In 2010, according to the U.S. Census Bureau, about 30% of the nation's population identified themselves as members of racial or ethnic minority groups. By 2050, these groups are expected to account for almost half of the country's population. It is widely accepted that racial and ethnic minority populations on average receive lower levels of care and have higher rates of certain conditions and diseases than Whites. It has also become clear that economic and social conditions under which people live can affect a person's health and well being. The World Health Organization recently published a final report and recommendations for creating health equity through action on the social determinants of health (http://www.who.int/social_determinants/en).
A precise definition of "culture" has been widely debated and broadly described, with certain common characteristics including an integrated pattern of learned beliefs and behaviors that can be shared among groups. Included in the pattern are thoughts, styles of communicating, ways of interacting, views on roles and relationships, values, practices, and customs. In essence, culture serves to help individuals to shape and explain their values and to provide meaning. Too often, a different culture is considered to be "exotic" or about "other people" and has been associated with socioeconomic status, religion, gender, and sexual orientation.
Cultural competence can be viewed as a set of congruent behaviors, attitudes, and policies that blend together to form effective interactions within a cross cultural framework. To be culturally competent, an individual must be aware of, respect, and accept different cultures and must resist the temptation to make assumptions about people and situations.




Examples of how culture can affect healthcare include differences in languages and nonverbal communication patterns, cultural differences in the perception of illness, disease, medical roles and responsibilities, and cultural preferences for treatment of illnesses. Overcoming these barriers requires the cooperation of the patient, the organization, and the clinician.

Wherever possible, questions should be asked to help with patients and families from culturally diverse backgrounds. Such questions can include:  Can you tell me the languages that you understand and speak?
 Do you use any traditional health remedies to improve your health?
 Is there someone, in addition to yourself, with whom you want us to discuss your medical condition? Are there certain healthcare procedures and tests that your culture prohibits?
Are there any situations where you would prefer to be treated by a clinician of a specific gender?
To minimize the level of difficulty encountered by patients with limited or no English proficiency, systemwide procedures or resources can be put in place. Resources to support this capacity may include:
Trained interpreters
Bilingual/bicultural or multilingual/multicultural staff
Materials developed for specific cultural, ethnic and linguistic groups, including culturally and linguistically appropriate signage
The National Standards on Culturally and Linguistically Appropriate Services (CLAS) (http://clas.uiuc.edu/) are directed at healthcare organizations.



The 14 CLAS standards are organized by themes: culturally competent care, language access services, and organizational supports for cultural competency.
PATIENT COMFORT AND SAFETY
The patient's well being is always the central focus of any interaction or procedure. Treatment tables, mats, or beds should be prepared with linens and pillows before the patient arrives in the treatment area. Additional sheets may be required as pull sheets for transfers or for draping. Pillows can be used for patient positioning and/or comfort. Call bells must be within reach of patients in areas where patients will be left unattended. Finally, the clinician should always emphasize cleanliness, particularly hand hygiene (see Infection Control).
INFECTION CONTROL
A major focus of healthcare is the prevention of the spread of infection by fostering a clean environment. The degree of cleanliness required depends on the level of the contamination threat. A pathogen, commonly referred to as a germ, is a microorganism that causes disease in (infects) its host.
Some healthcare environments and situations can increase the potential for infection. Nosocomial infections are those that originate or occur in a hospital or hospital like setting. These infections are responsible for about 20,000 deaths per year in the United States.1


Approximately 10% of American hospital patients (about 2 million every year) acquire a clinically significant nosocomial infection.1 Nosocomial infections are due to a number of factors occurring in tandem:
 A high prevalence of pathogens
 A high prevalence of immunocompromised hosts
 High potential of the chains of transmission from patient to patient
Although the purpose of hospitals is to corral the sick and injured into one place in order to efficiently treat them, this environment increases the potential for the movement of pathogens from individual to individual via various routes. In addition to the higher likelihood of pathogen transmission, the high prevalence of pathogens provides an environment for the potential evolution of new microorganisms that are resistant to conventional methods of treatment. Hospitals or hospital like settings are hosts to a number of opportunistic microorganisms. An opportunistic microorganism is one that takes advantage of certain opportunities (e.g., compromised host) to cause disease. Compromised hosts include:
 Those with broken skin or mucous membranes (wounds)  The immunocompromised
  The most common sites of nosocomial infections are as follows:  Urinary tract
 Surgical wounds  Respiratory tract
 Skin (especially after a serious burn)
 Blood (bacteremia)



Gastrointestinal (GI) tract Central nervous system
Infection is the process by which this microorganism establishes a parasitic relationship with its host. This invasion and multiplication of microorganisms produces an immune response and subsequent signs and symptoms.2


For an infection to occur a chain of events that involves several steps must occur in a chronological order (Table 8 1). These steps include the infectious agent encountering a reservoir (host), entering a susceptible reservoir, exiting the reservoir, and then being transmitted (by a vehicle) to new hosts. Examples of how the infectious agent can exit the reservoir include:
 The nose
 The mouth and throat  The eyes
 The intestinal tract  The urinary tract
Multiple body fluids
Examples of the vehicle of transmission include the following:
Air: droplets of body fluid from a cough or sneeze
Indirect contact: occurs when an uninfected person comes into contact with pathogens on a person or object (e.g., clothing, equipment, patient care items, toys)
Direct contact: with another person's skin, body fluids such as blood, semen, and saliva, and eating utensils



TABLE 8 1
The Chain of Infection

Element 
Description
Pathogen reservoir
A pathogen can be found in food, water, people, and inanimate objects.
An individual may carry a pathogen without showing any signs or symptoms of disease. In addition, healthcare workers who are sick can put both co workers and patients at risk and so may be required to wear a face mask.
A common pathogen reservoir is the nails of the hand, including artificial nails. The CDC recommends keeping natural nail length to less than one quarter of an inch.
Visitors can be significant pathogen reservoirs. Good hand hygiene is encouraged and, on occasion, the use of face masks.
Portal of exit
Pathogens can exit their host through bodily excretions and secretions through openings in the skin.
Means of transmission
Pathogens are transmitted primarily by three modes:
Contact (direct and indirect). Direct contact transmission involves physical transfer of pathogens directly from one person to another through physical contact. An indirect transmission occurs when an uninfected person comes into contact with pathogens on a person or object, and then passes those pathogens on to another person through physical contact.
Droplet. This involves large pathogenic particle droplets coming into contact with either the host's. conjunctivae or the mucous membranes of the nose or mouth, usually through coughing or sneezing.
Airborne. This involves small pathogenic particle droplets being either inhaled or deposited on a susceptible host.
Mode of entry
The most common modes of entry are the mucous membranes of the nose, the eyes, and openings in the skin.
Susceptibility
The risk of infection increases based on both the virulence of the pathogen and the susceptibility of the host.


Without this transmission, the infection cannot take place. Once the infectious agent has left the host, it must be able to enter another host in order for the infection to spread. An infectious agent can enter a host through a break in a person's skin barrier, mucous membranes, eyes, mouth, nose, or genitourinary tract.

Entry into a host does not guarantee that the infection will spread. For that to occur, the host must be susceptible or the organism must be difficult to destroy. Multidrug resistant organisms (MDROs) are organisms that have developed resistance to one or more antibiotics. Most healthy individuals are not susceptible to the majority of infections, but those who are sick, at either end of the life span, malnourished, or immunocompromised are at a greater risk.




A great variety of microorganisms are responsible for infectious diseases, including fungi (yeast and molds); helminths (e.g., tapeworms); viruses; bacteria, protozoa; and prions.
 Fungi. Certain types of fungi (such as Candida) are commonly present on body surfaces or in the intestines. Although generally innocuous, these fungi sometimes cause local infections of the skin and nails, vagina, mouth, or sinuses in immunocompromised individuals. In these individuals, fungal infections can be aggressive spreading quickly to other organs and often proving fatal. Some fungi reproduce by spreading microscopic spores. These spores are often present in the air, where they can be inhaled or contact the body surfaces. Of the wide variety of spores that land on the skin or end in the lungs, most do not cause infection.

Even in otherwise healthy people, some fungal infections (for example, blastomycosis and coccidioidomycosis) can have serious outcomes.
 Bacteria. Bacteria are microscopic, single celled organisms, which are encountered in the environment, on the skin, in the airways, in the mouth, and in the digestive and genitourinary tracts of people and animals.
Bacteria can be classified according to shape (cocci [spherical], bacilli [rod like], and spirochetes [spiral or helical]), their use of oxygen (aerobes, those that can live and grow in the presence of oxygen, and anaerobes, those that can tolerate only low levels of oxygen such as those found in the intestine or in decaying tissue), or by color after a particular chemical (Gram) stain is applied (the bacteria that stain blue are called gram positive, whereas those that stain pink are called gram negative). Gram positive and gram negative bacteria differ in the types of infections they produce and in the types of antibiotics that are required to manage them.
 Gram negative bacteria. These bacteria possess a unique outer membrane that is rich in molecules called lipopolysaccharides (endotoxins) that make them more resistant to antibiotics than gram positive bacteria. The lipopolysaccharides can potentially cause high fever and a life  threatening drop in blood pressure. Gram negative bacteria have a great facility for mutation the capacity to exchange genetic material (DNA) with other strains of the same species and even with different species.
 Gram positive bacteria. These bacteria are usually slow to develop resistance to antibiotics but some (e.g., Bacillus anthracis and Clostridium botulinum) can produce toxins that cause serious illness. Disease causing anaerobes include clostridia and peptococci and peptostreptococci, the latter two of which are part of the normal bacterial population (flora) of the mouth, upper respiratory tract, and large intestine.
Mycoplasmas. Mycoplasmas are unusual, self replicating bacteria that have no cell wall component and very small genomes.2 For this reason, antibiotics that are active against bacterial cell walls have no effect on mycoplasmas.2
Clostridia. Clostridia, which normally inhabit the human intestinal tract, soil, and decaying vegetation, are toxin producing anaerobes that can cause tetanus, botulism, and tissue infections. Clostridia, particularly Clostridium perfringens, also infect wounds. Clostridial wound infections, including skin gangrene, muscle gangrene (clostridial myonecrosis), and tetanus, are rather uncommon but may be fatal.
Rickettsiae. Rickettsiae are small, gram negative, obligate intracellular organisms that cause several diseases, including Rocky Mountain spotted fever and epidemic typhus. Like viruses, rickettsiae require a host for replication and cannot survive on their own in the environment.



In humans, rickettsiae infect the cells lining small blood vessels, causing the blood vessels to become inflamed or choked or to bleed into the surrounding tissue. The various types of rickettsial infections produce similar symptoms, which include fever, severe headache, a characteristic skin rash, and a general feeling of malaise. As rickettsial disease progresses, a person typically experiences confusion and severe weakness often with cough, dyspnea, and sometimes vomiting and diarrhea. In some people, the liver or spleen enlarges, the kidneys fail, and blood pressure falls dangerously low. Death can occur.
Because ticks, mites, fleas, and lice transmit rickettsiae, a report of a bite from one or more of these vectors is a helpful clue particularly in geographic areas where rickettsial infection is common.
 Ehrlichioses. Ehrlichiae are similar to rickettsiae: they are microorganisms that can live only inside the cells of an animal or person. Unlike rickettsiae, however, ehrlichiae inhabit white blood cells (such as granulocytes and monocytes). Ehrlichioses occur in the United States and Europe, but are most common in the midwestern, southeastern, and south central United States. Ehrlichioses are most likely to develop between spring and late fall, when ticks are most active.
Virus. A virus is a subcellular organism made up only of a ribonucleic acid (RNA) or a deoxyribonucleic acid (DNA) nucleus covered with proteins.2 Viruses are completely dependent on host cells and cannot replicate unless they invade a host cell and stimulate it to participate in the formation of additional virus particles.2 The virus can either kill the cell it enters or alter its function. Some viruses leave their genetic material in the host cell, where it remains dormant for an extended time (latent infection; e.g., herpesviruses). Viruses are not susceptible to antibiotics and cannot be destroyed by pharmacologic means.2 However, antiviral medications can mitigate the course of the viral illness.2


Probably the most common viral infections are upper respiratory infections. In small children, viruses also commonly cause croup, laryngitis, bronchiolitis, or bronchitis.
Some viruses (for example, rabies, West Nile virus, and several encephalitis viruses) infect the nervous system. Viral infections may also develop in the skin, sometimes resulting in warts or other blemishes.
 Prions. Prions are newly discovered proteinaceous, infectious particles consisting of proteins but without nucleic acids.2 These particles are transmitted from animals to humans and are characterized by a long, latent interval in the host. Examples include Creutzfeldt Jakob disease and bovine spongiform encephalopathy or "mad cow disease."2
 Parasite. A parasite is an organism that resides on or inside another organism (the host) and causes harm to the host. Parasitic infections are common in rural parts of Africa, Asia, and Latin America and less prevalent in industrialized countries.
Parasites enter the body through the mouth or skin. Parasites that enter through the mouth are swallowed and can remain in the intestine or burrow through the intestinal wall and invade other organs. Parasites that enter through the skin bore directly through the skin or are introduced through the bites of infected insects (the vector). Some parasites enter through the soles of the feet when a person walks barefoot or through the skin when a person swims or bathes in water where the parasites are present.
The diagnosis of a parasitic infection can be made from samples of blood, tissue, stool, or urine for laboratory analysis.
Some parasites, particularly those that are single celled, reproduce inside the host. Other parasites have complex life cycles, producing larvae that spend time in the environment or as an insect vector before becoming infective. If egglaying parasites live in the digestive tract, their eggs may be found in the person's stool when a sample is examined under a microscope. Antibiotics, laxatives, and antacids can substantially reduce the number of parasites, making their detection in a stool sample more difficult.



Food, drink, and water are often contaminated with parasites in areas of the world with poor sanitation and unhygienic practices.

Infectious Diseases
Infectious agents are now suspected in the origins of chronic diseases such as sarcoidosis, various forms of inflammatory bowel disease, scleroderma, rheumatoid arthritis, systemic lupus erythematosus, diabetes mellitus, Kawasaki disease, Alzheimer's disease, and many forms of cancer. All healthcare professionals need to have an understanding of the infectious process, the sequence of transmission, and approaches to lessen the spread of infections.
Staphylococcal Infections

Most infections caused by staphylococci are because of Staphylococcus aureus. However, the prevalence of infections because of Staphylococcus epidermidis and other coagulase negative staphylococci has been steadily increasing in recent years.
Staphylococcus aureus (S. aureus)

S. aureus is a gram positive coccus that is catalase positive and coagulase positive. S. aureus produces a wide variety of toxins, including enterotoxins; Panton Valentine leukocidin (PVL), associated with necrotic skin and lung infections; and toxic shock syndrome toxin 1 (TSST 1).

S. aureus occurs worldwide. Healthcare workers, anyone with diabetes, and patients on dialysis all have higher rates of colonization. The anterior nares are the chief site of colonization in adults; other potential sites of colonization include the axilla, rectum, and perineum.4
Common expressions of staphylococcal infections include skin, wound, and soft tissue infections (burns, surgical wounds, pyomyositis, septic bursitis), toxic shock syndrome, endocarditis, osteomyelitis, food poisoning, and infections related to prosthetic devices (prosthetic joints and heart valves and vascular shunts, grafts, and catheters).4 The clinical manifestations vary enormously according to the site and type of infection.2
Many antibiotics are effective against S. aureus. Methicillin resistant S. aureus (MRSA) are resistant to most agents other than vancomycin or non  beta lactam antibiotics. Many coagulase negative staphylococci are resistant to all antimicrobials other than vancomycin.



Streptococcal Infections

Streptococcus pyogenes (group A Streptococcus) is one of the most common pathogens faced in clinical practice. It causes many diseases in diverse organ systems, ranging from skin infections to infections of the upper respiratory tract.
Signs and symptoms of streptococcus contamination are varied. Classic acute disease involves the skin and oropharynx, but any organ system may be involved. Spread is by skin contact, not by the respiratory tract, although impetigo serotypes may colonize the throat. Respiratory droplet spread is the major route for transmission of strains associated with upper respiratory tract infection. Fingernails and the perianal region can harbor streptococci and play a role in spreading impetigo.
Diagnosis is by culture of streptococci from pharyngeal secretions, blood, cerebrospinal fluid, joint aspirate, skin biopsy specimen, sputum, bronchoalveolar lavage fluid, or thoracocentesis fluid. Types include:
 Group A (S. pyogenes) responsible for pharyngitis, rheumatic fever, scarlet fever, impetigo, necrotizing fasciitis, cellulitis, myositis  Group B (S. agalactiae) responsible for neonatal and adult infections
 Group C (S. pneumoniae) responsible for pneumonia, otitis media, meningitis, endocarditis
The interventions for streptococcal infections vary depending on the clinical syndrome. In general, penicillin therapy remains the intervention of choice in most situations (except in penicillin allergic individuals). Remarkably, no penicillin resistant strains of S. pyogenes have yet been encountered in clinical practice.
Hepatitis

Hepatitis is defined as an inflammation of the liver. Several different viruses cause viral hepatitis. They are named the hepatitis A, B, C, D, and E viruses. Some cases of viral hepatitis cannot be attributed to the hepatitis A, B, C, D, or E viruses. These types are called non A E hepatitis.
The hepatitis A, B, C, D, and E viruses cause acute, or short term, viral hepatitis. The hepatitis B, C, and D viruses can also cause chronic hepatitis, in which the infection is prolonged, sometimes lifelong.
Signs and symptoms (some people do not have symptoms) include:
 Low grade fever usually an early sign (preicteric phase), with anorexia, nausea, headache, malaise, fatigue, vomiting, abdominal pain, loss of appetite
 Jaundice (yellowing of the skin and eyes) usually a sign of the icteric phase, with an enlarged liver with tenderness and abatement of the earlier symptoms
 Elevated lab values (hepatic transaminases and bilirubin)
Hepatitis A (HAV, Acute Infectious Hepatitis)

Hepatitis A spreads mostly through food or water contaminated by feces from an infected person. Rarely, it spreads through contact with infected blood. People at risk include international travelers; people living in areas where hepatitis A outbreaks are common; people who live with or have sex with an infected person; and, during outbreaks, day care children and employees, men who have sex with men, and injection drug users. The best methods of prevention are:
 The hepatitis A vaccine
 Avoiding tap water when traveling internationally
 Practicing good hygiene and sanitation handwashing



Hepatitis A is usually self limiting, lasting several weeks.
Hepatitis B (HBV, Serum Hepatitis)

Hepatitis B is spread through contact with infected blood, through sex with an infected person, or from mother to child during childbirth. People at risk are those who have sex with an infected person, gay men, injection drug users, children of immigrants from disease endemic areas, infants born to infected mothers, people who live with an infected person, healthcare workers, hemodialysis patients, people who received a transfusion of blood or blood products before July 1992 or clotting factors made before 1987, and international travelers. The best method of prevention for this type is the hepatitis B vaccine.
Acute hepatitis B is usually self limiting. The intervention for chronic hepatitis B includes drug treatment with alpha interferon, peginterferon, lamivudine, or adefovir dipivoxil.
Hepatitis C (HCV, non A, non B)

This type of hepatitis spreads mostly through contact with infected blood and, less commonly, through sexual contact and childbirth. People at risk include injection drug users, people who have sex with an infected person, people who have multiple sex partners, healthcare workers, infants born to infected women, hemodialysis patients, and people who received a transfusion of blood or blood products before July 1992 or clotting factors made before 1987. The best method for prevention is through a reduction in the risk of exposure to the virus (there is no vaccine for hepatitis C) avoiding behaviors such as sharing drug needles or sharing personal items like toothbrushes, razors, and nail clippers with an infected person. The intervention for chronic hepatitis C is pharmacology: peginterferon alone, or combination treatment with peginterferon and the drug ribavirin.
Hepatitis D

Hepatitis D spreads through contact with infected blood. This disease occurs only in people who are already infected with hepatitis B. People at risk include anyone infected with hepatitis B injection drug users who have hepatitis B have the highest risk. People who have hepatitis B are also at risk if they have sex with a person infected with hepatitis D or if they live with an infected person. Also at risk are people who received a transfusion of blood or blood products before July 1992 or clotting factors made before 1987. The best method of prevention for this type is:
 Immunization against hepatitis B for those not already infected
   Avoiding exposure to infected blood, contaminated needles, and an infected person's personal items (toothbrush, razor, nail clippers) The intervention for chronic hepatitis D is alpha interferon.
Hepatitis E

This type of hepatitis spreads through contaminated food or water (by feces from an infected person). The disease is uncommon in the United States. People at risk include international travelers; people living in areas where hepatitis E outbreaks are common; and people who live with or have sex with an infected person. The best way to prevent hepatitis E is to reduce the risk of exposure to the virus (there is no vaccine for hepatitis E) avoiding tap water when traveling internationally and practicing good hygiene and sanitation.
Hepatitis E is usually self limiting, lasting several weeks to months.
Acquired Immunodeficiency Syndrome (AIDS)

In 1984, 3 years after the first reports of a disease that was to become known as AIDS, researchers discovered the primary causative viral agent, the human immunodeficiency virus type 1 (HIV 1).5 In 1986, a second type of HIV, called HIV 2, was isolated from AIDS patients in West Africa, where it may have been present decades earlier.5 Both HIV 1 and HIV 2 have the same modes of transmission and are associated with similar opportunistic infections and AIDS.6 In persons infected with HIV 2, immunodeficiency seems to develop more slowly and to be milder. Compared with persons infected with HIV 1, those with HIV 2 are less infectious early in the course of infection.6
The primary cause of AIDS is through transmission of the HIV retrovirus by body fluid exchange (in particular blood and semen), which is associated



with high risk behaviors:
 Unprotected sexual contact
 Contaminated needles: sharing, frequent injection of Institute for Applied Biomedicine drugs, transfusions (although no longer a major risk)  Maternal fetal transmission in utero or at delivery or through contaminated breast milk
Low risk behaviors for HIV transmission include:
 Occupational transmission: needle sticks
 Casual contact: kissing
The HIV retrovirus chiefly infects human T4 (helper) lymphocytes, the major regulators of the immune response, and destroys or inactivates them.6 Once HIV enters the body, cells containing the CD4 antigen, including macrophages and T4 cells, serve as receptors for the HIV retrovirus.6 After invading a cell, a virus particle (virion) injects the core proteins and the two strands of viral RNA into the cell. HIV contains reverse transcriptase, an enzyme that allows for successful replication of the virus in reverse fashion, transcribing the RNA code into DNA.5
HIV infection manifests itself in many different ways and differs between adult and pediatric populations. The clinical expressions of HIV infection are classified into three stages5,6:
 Asymptomatic stage: although positive for laboratory tests, a patient in the early stages remains asymptomatic. Some individuals can develop an acute, self limiting infectious mononucleosis like condition.
 Early symptomatic stage: AIDS related complex (ARC), as the infection progresses and the immune system becomes increasingly compromised. This stage may last for weeks or months and is a forerunner to full blown AIDS. Symptoms and conditions during this stage involve:
 Generalized adenopathy, deconditioning, anxiety and depression.
 Nonspecific symptoms, including weight loss, fatigue, night sweats, swollen lymph glands, loss of appetite, apathy and fevers.  Neurologic symptoms, including encephalopathy, headache, blurred vision, mild dementia, seizures, focal neurologic signs.
 Opportunistic infections: the most common are Pneumocystis jirovecii pneumonia, oral and esophageal candidiasis, cytomegalovirus infection, Cryptococcus, herpes simplex, Mycobacterium tuberculosis.
 HIV advanced disease: this stage can include:
 Neurologic manifestations of central, peripheral, and autonomic nervous systems, including:  AIDS encephalopathy (HIV associated dementia).
 Peripheral neuropathy: distal, symmetric, and mainly sensory.
 Neuromusculoskeletal diseases: osteomyelitis, bacterial myositis, non Hodgkin's lymphoma, and infectious arthritis.
 HIV wasting syndrome: characterized by a disproportionate loss of metabolically active tissue, specifically body cell mass secondary to weight loss, chronic diarrhea, unexplained weakness, and malnutrition.
 Rheumatologic manifestations.
 HIV associated myopathy: a progressive painless weakness in the proximal limb muscles.
 Malignancies: the most common are Kaposi's sarcoma, non Hodgkin's lymphoma, and primary brain lymphoma.



The diagnosis is by clinical findings and systemic evidence of HIV infection and nonexistence of other known causes of immunodeficiency. Early identification is important so that early and preventive therapies may be introduced.
Controlling the Transmission of Infection

Contamination refers to any instance when an object, surface, or field comes into contact with anything that is not sterile. The most effective ways of preventing contamination and the spread of infection include effective personal and hand hygiene, and effective cleaning and handling techniques.

The best way of preventing or controlling the transmission of infection is through the use of sterile techniques and an emphasis on cleanliness.

In 1985, the Centers for Disease Control and Prevention (CDC) introduced the use of Universal Precautions to protect healthcare workers and to reduce the transmission of diseases.
The CDC has since revised its previous information and currently recommends the use of Standard Precautions by healthcare workers when they have contact with any patient's body fluid (secretions or excretions) or blood, and Transmission Based Precautions when in contact with special patient populations that have highly transmissible pathogens.

In addition to these recommendations, most institutions and agencies have enacted additional policies and procedures to control the transmission of infection and disease (Table 8 2). These policies and procedures emphasize good hand hygiene, good respiratory hygiene, a clean environment, the correct disposal of soiled articles (e.g., patient linens, wound dressings), and the safe disposal of needles and other sharps (Table 8 3).



TABLE 8 2
Basic Precautions

Hand hygiene
The single most effective way to protect the patient and the caregiver.
Should be performed by every caregiver and hospital visitor before or after a treatment or contact with a patient.
Hand rubbing: advantages include requires less time to use, is more effective than soap and water, is more accessible than sinks, significantly reduces bacterial counts on hand, and causes less damage to the skin than soap and water.
Handwashing: not the most effective method to decontaminate the hands except when hands are visibly dirty, soiled, or considered to be contaminated. The soap typically includes an antimicrobial or germicidal agent. Many handwashing stations have knee  or foot operated controls for the faucet. Warm water promotes lather and is less irritating than hot or cold water.
Respiratory hygiene
Often referred to as "cough etiquette." Includes:
Covering of the mouth and nose with a tissue during a cough or sneeze.
Coughing or sneezing into the upper sleeve or elbow rather than into the hands, if no tissue is available. Hand hygiene after contact with respiratory secretions.
Maintaining a distance of more than 3 feet from persons with respiratory infections in common waiting areas.
Wearing a face mask on entering a healthcare facility if one has increased production of infectious respiratory secretions.
Clean environment
Treatment tables or mat tables require regular cleaning, ideally between each use (except in the case where a linen covering or paper sheet is used).
Linens, including sheets, pillowcases, and towels, should be changed after each use and should be properly laundered and stored. Equipment that comes into contact with a patient or with a contaminated area, including such things as goniometers, ambulation devices, ankle weights, and exercise machines, must be cleaned regularly.
Toys are common clinical items that can serve as pathogen reservoirs; therefore, only toys that can be easily cleaned and disinfected should be provided (avoid the use of stuffed or furry toys). Containers should be designated for toys that have been cleaned and for those that require cleaning.
Disposal of soiled items
All items that have been used by or with a patient are considered soiled, even if no contamination is visible. Linens should be placed in an appropriate laundry container, and gloves should be worn when handling soiled items. Soiled items that have come in contact with the patient's blood or suspected infectious material require special handling and should be disposed of in specially labeled biohazard containers. Hand hygiene should always be performed after disposing of used and soiled items.
Sharps containers
Any instrument capable of puncturing the skin, such as needles and scalpels, must be discarded in a specific container, typically referred to as a "sharps container."



TABLE 8 3
Correct Disposal of Clinical Items

Item 
Disposal Method 
Instruments and equipment
Cleaned or disposed of according to institutional or agency policies and procedures.
Contaminated reusable equipment should be placed carefully in a container, labeled, and returned to the appropriate department for sterilization.
Contaminated disposable items should be placed carefully in a container, labeled, and discarded.

Staff members who handle contaminated instruments or equipment should wear gloves and wash or rub the hands before and after the gloves have been applied and removed.
Needles, scalpels, and other sharp instruments
Should be placed in puncture proof containers.
No attempt should be made to bend, or break the needle before it is discarded according to institutional or agency policies and procedures.
Departmental stethoscope
The ear tips should be wiped with alcohol before and after each use.
Contaminated or soiled linen
Should be disposed of with minimal handling, sorting, and movement according to institutional or agency policies and procedures.
Contaminated dressings, bandages, and other disposable materials
Should be properly placed in a nonporous container or bag, labeled, and discarded according to institutional or agency policies and procedures.



Standard Precautions

Standard Precautions (Table 8 4) are required when working with all patients and clients in any healthcare setting, including the patient's home. Generally, the clinician should:
 Avoid direct contact with patients, fomites, or, especially, body fluids  Wear barriers such as gloves when contact is necessary or expected
 Avoid puncturing himself or herself with anything and therefore should minimize exposure to sharp instruments, especially body fluid  contaminated sharp instruments
   Avoid exposing patients to any body fluids (or substances, e.g., "weeping dermatitis") of others, such as that of healthcare workers The most basic standard precaution is hand hygiene. There are two primary methods of hand hygiene: hand rubbing and handwashing.
 Hand rubbing. This technique uses an alcohol based (60% to 95% alcohol [isopropyl, ethanol, n propanol]) and skin conditioner product (to prevent skin irritation and dryness) dispensed from a wall mounted unit, or an antimicrobial/antiseptic hand wipe. Hand rubbing is used to decontaminate hands in lieu of handwashing. After performing several hand rubs, the hands may become sticky, and handwashing should be used to cleanse them.
 Handwashing. Handwashing with soap and water is necessary when organic material such as blood or dirt is visible, when the pathogen is known to be C. difficile, in between patients, or after multiple applications of hand rubbing. It is important to avoid touching any potentially contaminated surface during or at the conclusion of the handwashing process. It is important to remember that the sink, soap dispenser, and towel container are considered to be contaminated.



TABLE 8 4
Standard Precautions


Handwashing
1. Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves were worn.
2. Wash hands immediately after removing gloves, between patient contacts, and when otherwise indicated to reduce transmission of microorganisms.
3. Wash hands between tasks and procedures on the same patient to prevent cross contamination of different body sites.
4. Use plain (non antimicrobial) soap for routine handwashing.
5. An antimicrobial agent or a waterless antiseptic agent may be used for specific circumstances (hyperendemic infections) as defined by infection control.

Gloves 
1. Wear gloves (clean, unsterile gloves are adequate) when touching blood, body fluids, secretions, excretions, and contaminated items; put on clean gloves just before touching mucous membranes and nonintact skin.
2. Change gloves between tasks and procedures on the same patient after contact with materials that may contain high concentrations of microorganisms.
3. Remove gloves promptly after use, before touching uncontaminated items and environmental surfaces, and before going on to another patient; wash hands immediately after glove removal to avoid transfer of microorganisms to other patients or environments.
Mask and Eye Protection or Face Shield
1. Wear a mask and eye protection or a spray shield to protect mucous membranes of the eyes, nose, and mouth during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions.
Gown 
1. Wear a gown (a clean, unsterile gown is adequate) to protect skin and prevent soiling of clothing during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions.
2. Select a gown that is appropriate for the activity and the amount of fluid likely to be encountered.
3. Remove a soiled gown as soon as possible and wash hands to avoid transfer of microorganisms to other patients or environments.

Patient Care Equipment
1. Handle used patient care equipment soiled with blood, body fluids, secretions, and excretion in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients or environments.
2. Ensure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately.
3. Ensure that single use items are discarded properly.

Environmental Control 
1. Follow hospital procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bed rails, bedside equipment, and other frequently touched surfaces.
Linen 
1. Handle, transport, and process used linen soiled with blood, body fluids, secretions, and excretion in a manner that prevents skin and mucous membrane exposures and contamination of clothing, and avoids transfer of microorganisms to other patients or environments.
Occupational Health and Blood Borne Pathogens
1. Prevent injuries when using needles, scalpels, and other sharp instruments or devices; when handling sharp instruments and procedures; when cleaning used instruments; and when disposing of used needles.
2. Never recap used needles, or otherwise manipulate them using both hands, or use any other technique that involves directing the point of the needle toward any part of the body; rather, use either a one handed "scoop" technique or mechanical device designed for holding the needle sheath.
3. Do not remove used needles from disposable syringes by hand, and do not bend, break, or otherwise manipulate used needles by hand.
4. Place used disposable syringes and needles, scalpel blades, or other sharp items in an appropriate puncture resistant container for transport to the reprocessing area.
5. Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth to mouth resuscitation.


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From Centers for Disease Control, Hospital Infection Control Practices Advisory Committee. Part II. Recommendations for Isolation Precautions in Hospitals. February 2007.


FIGURE 8 2


Handwashing procedure adjusting the faucet to correct temperature




FIGURE 8 3


Handwashing procedure applying the soap


FIGURE 8 4


Handwashing procedure adding water




FIGURE 8 5


Handwashing procedure rubbing motions


FIGURE 8 6


Handwashing procedure friction motions




FIGURE 8 7

Handwashing procedure between the fingers


FIGURE 8 8


Hand rinsing procedure hands are directed downward


FIGURE 8 9


Hand rinsing procedure maintaining no contact with the sink rim or basin




FIGURE  8 10


Hand drying


FIGURE  8 11


Hand drying




FIGURE  8 12

Hand drying


FIGURE  8 13


Turning off the faucet


FIGURE  8 14


Turning off the faucet




Transmission Based Precautions

Transmission based precautions (Table 8 5) are required for patients known to be at risk for the presence of pathogens. Transmission based precautions are standard precaution procedures that include additional practices specific to the infectious microorganism's mode of transmission.



TABLE 8 5
Transmission Based Isolation Precautions


Airborne Precautions
In addition to Standard Precautions, use Airborne Precautions, or the equivalent, with all patients known or suspected to be infected with serious illness transmitted by airborne droplet nuclei (small particle residue) that remain suspended in the air and that can be dispersed widely by air currents within a room or over long distance (for example, Mycobacterium tuberculosis, measles virus, chickenpox virus).
1. Respiratory isolation room.
2. Wear respiratory protection (mask) when entering room.
3. Limit movement and transport of patient to essential purposes only. Mask patient when transporting out of area.

Droplet Precautions 
In addition to Standard Precautions, use Droplet Precautions, or the equivalent, for patients known or suspected to be infected with serious illness due to microorganisms transmitted by large particle droplets that can be generated by the patient during coughing, sneezing, talking, or the performance of procedures (for example, mumps, rubella, pertussis, influenza).
1. Isolation room.
2. Wear respiratory protection (mask) when entering room.
3. Limit movement and transport of patient to essential purposes only. Mask patient when transporting out of area.

Contact Precautions
In addition to Standard Precautions, use Contact Precautions, or the equivalent, for specified patients known or suspected to be infected or colonized with serious illness transmitted by direct patient contact (and or skin to skin contact) or contact with items in patient environment.
1. Isolation room. Complete isolation precaution policies can be found in a healthcare facility's infection control manual.
2. Wear gloves when entering room; change gloves after having contact with infective material; remove gloves before leaving patient's room; wash hands immediately with an antimicrobial agent or waterless antiseptic agent. After glove removal and handwashing, ensure that hands do not touch contaminated environmental items.
3. Wear a gown when entering room if you anticipate your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room, or if the patient is incontinent or has diarrhea, ileostomy, colostomy, or wound drainage not contained by dressing. Remove gown before leaving patient's room; after gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces.
4. Single patient use equipment.
5. Limit movement and transport of patient to essential purposes only. Use precautions when transporting patient to minimize risk of transmission of microorganisms to other patients and contamination of environmental surfaces or equipment.


Data from Guideline for isolation precautions in hospitals. Part II. Recommendations for isolation precautions in hospitals. Hospital Infection Control Practices Advisory Committee 2008.

Personal Protective Equipment

The use of personal protective equipment (PPE) may be necessary to protect the clinician from the patient, although in some cases PPE can be worn by patients. The amount and type of PPE worn is determined by the likelihood of encountering body fluids and contaminated areas and by the modes in which known or suspected pathogens are transmitted. The various types of PPE are described in Table 8 6. Special procedures must be followed when donning and doffing PPE so that the items are donned and doffed in a particular order to avoid contamination.



TABLE 8 6
Personal Protective Equipment

Equipment 
Description of Use
Purpose and Precautions
Gloves
Two types:
Exam the gloves are clean but have not undergone sterilization. Dispensed singly from a box.
Sterile have been treated to remove microorganisms. Packaged in pairs and sealed to prevent contamination.
Used when there is a potential for coming in contact with a patient's body fluids, direct contact with someone who has an infection, handling equipment or touching surfaces that may be contaminated, or when there is a cut, wound, or break in the skin.
To prevent pathogens entering small cuts, wound, or breaks in the skin.
Latex sensitivity is common in healthcare workers. Nonlatex and nonvinyl gloves are available for those who have latex sensitivity.
Gowns
Disposable gowns that are designed to cover the arms and the front of the clinician's body to at least the mid thigh.
Used to protect the clinician skin and clothing from possible contact with pathogens.
Face protectors
These come in a variety of designs:
Facemask: fits over the clinician's nose and mouth. Goggles: often worn with facemasks.
Face shield: a combination of a face mask and goggles.
Face masks help protect against the spray of body fluids and secretions but also to prevent the dispersal of potentially infectious respiratory particles.
Goggles protect the eyes against splashes from body fluids or chemicals.
Particulate respirators
Fully disposable or reusable face masks designed to filter particulate matter in the air at a higher level than standard surgical masks. The CDC recommends N95 (95% filter with no resistance to oils).
Typically used in the presence of tuberculosis (TB), and severe acute respiratory syndrome (SARS).



Hand hygiene should be performed before donning PPE and immediately after removal of PPE. Although each facility has its own specific protocols related to donning and doffing of PPE, an example of such a method follows.
Donning and doffing gloves. If exam gloves are donned, no specific techniques are required (Figures 8 15, 8 16 and 8 17). However, if sterile gloves are being used, a specific (clean) technique must be used (see Clinical Pearl). In either situation, if a tear develops while donning a glove, it should be disposed of and replaced with a new one. Depending on the procedure, the clinician may go through several pairs of sterile gloves in one session. For example, one pair must be used for the removal of the soiled dressings, then a new set is needed to examine and treat the wound, and then a further pair is used to apply a new dressing. Each separate wound is treated as a separate treatment site to prevent cross contamination.



FIGURE  8 15

Donning nonsterile gloves


FIGURE  8 16


Donning nonsterile gloves


FIGURE  8 17


Donning nonsterile gloves




After treating the patient, the gloves can be removed in any sequence, after which good hand hygiene is performed. The most common method to remove gloves is as follows (Figures 8 18, 8 19, 8 20 and 8 21): using one gloved hand to pull the opposite glove away from the hand, then placing the fingers of the bare hand under the remaining glove and using them to remove the glove without touching the outside of the gloves with the bare hands. The gloves are then disposed in the appropriate receptacle (Figure 8 22).

FIGURE  8 18


Doffing nonsterile gloves




FIGURE  8 19


Doffing nonsterile gloves


FIGURE  8 20


Doffing nonsterile gloves




FIGURE  8 21

Doffing nonsterile gloves


FIGURE  8 22


Disposing of gloves


 Donning and doffing a face mask or respirator. If a face mask or respirator is to be used, the clinician applies it while holding it by its ties or edges (Figure 8 23). The mask or respirator should be positioned on the face so that it fits over the nose and under the chin. The upper ties are tied at the middle of the back of the head. The lower ties are tied at the neck while ensuring that the neck or cap is not touched as the mask is being tied. If the mask has a flexible piece designed to fit on the bridge of the nose, the clinician can gently press on the nose piece to contour it for a better fit once the face mask has been donned (Figure 8 24). A mask or respirator can be removed by carefully untying each of the ties and then handling it by the ties while avoiding touching the center of the mask with the hands before being disposed of in an appropriate receptacle.
 Donning and doffing eye or face shields. If eye protection is necessary, the clinician can apply goggles or a face shield (Figure 8 25). Modern goggles are similar to glasses and are worn accordingly, but some goggles have elastic straps that fit snugly around the head. It is important that



the goggles be comfortable, provide good peripheral vision, and ensure a secure fit. In place of a face mask and goggles, a chinlength face shield may be used, although it is important to remember that face shields do not protect against airborne transmission and, therefore, often have to be used in conjunction with a surgical mask, or respirator. Goggles are removed by handling the earpieces or headbands, and not the front of the goggles. Face shields are removed in a similar fashion by touching only the earpieces or headbands at the side of the head before they are disposed of in an appropriate receptacle (Figure 8 26).
 Donning and doffing a disposable gown. If a gown is required, once the inside of the gown comes into contact with the clinician's clothing it is considered contaminated. The clinician picks up the gown with one hand by grasping the center or neck of the gown and allows it to unfold without letting it touch the body (Figure 8 27). The clinician may need to gently shake the gown, which is folded inside out, so that it opens fully. Once opened fully, the clinician inserts one hand and arm through one sleeve inside the gown (Figure 8 28), maintaining gown to gown contact, but not allowing the hand to extend through the gown cuff (if a closed glove technique is to be used) (Figure 8 29). The clinician then places the other arm through the other sleeve in the gown (Figure 8 30), again maintaining gown to gown contact and keeping that hand inside the cuff (if a closed glove technique is to be used). Once the clinician has checked to be sure that the gown covers the arms on the front of the body to at least mid thigh level (Figure 8 31), the straps are tied behind the clinician at the neck (Figures 8 32, 8 33, 8 34 and 8 35) and waist (Figures 8 36 and 8 37). After treating the patient, the gown can usually be removed in any sequence such as the one outlined in Figures 8 38, 8 39, 8 40, 8  4 1, 8 42, 8 43, 8 44, 8 45 and 8 46, and then good hand hygiene is performed. To remove a gown following isolation precautions, the clinician unties the waist tie of the gown and then carefully unties the neck tie while avoiding touching the neck, cap, or outer side of the gown. The clinician then slips both hands under the gown at the neck and shoulders and peels the gown away from the body, turning the sleeves inside out. Grasping the cuffs one of the time by slipping the fingers underneath each of them, each arm is then pulled out of the gown. Then, while holding the inside surface of the gown at the shoulders, the clinician folds or rolls the gown in on itself so that the inner surface of the gown is exposed and the contaminated surfaces are contained within. The gown is then discarded into an appropriate receptacle.
 Donning and doffing a cap. If a cap is to be used, the clinician should apply it before donning the gown. The cap should be applied while avoiding touching the head as much as possible, and including all of the head and ears in the cap. To remove a cap, the clinician handles it by its ties or gently grasps the center at the top and lifts it from the head.

FIGURE  8 23


Applying a face mask


FIGURE  8 24


Pressing on the nose piece to contour it for a better fit




FIGURE  8 25


Donning a face shield


FIGURE  8 26

Disposing of a face shield




FIGURE  8 27

Allowing the gown to unfold without letting it touch the body


FIGURE  8 28


Inserting one hand and arm through one sleeve inside the gown




FIGURE  8 29


Inserting one hand and arm through one sleeve inside the gown




FIGURE  8 30


Placing the other arm through the other sleeve in the gown




FIGURE  8 31


Ensuring that the gown covers the arms on the front of the body




FIGURE  8 32


Sequence of applying and tying the straps behind the clinician at the neck




FIGURE  8 33


Sequence of applying and tying the straps behind the clinician at the neck


FIGURE  8 34


Sequence of applying and tying the straps behind the clinician at the neck




FIGURE  8 35


Sequence of applying and tying the straps behind the clinician at the neck


FIGURE  8 36


Tying the straps at the waist




FIGURE  8 37

Tying the straps at the waist


FIGURE  8 38


Sequence for doffing gown


FIGURE  8 39


Sequence for doffing gown




FIGURE  8 40


Sequence for doffing gown


FIGURE  8 41


Sequence for doffing gown




FIGURE  8 42

Sequence for doffing gown


FIGURE  8 43


Sequence for doffing gown




FIGURE  8 44

Sequence for doffing gown


FIGURE  8 45


Sequence for doffing gown


FIGURE  8 46


Sequence for doffing gown




Precautions for Special Populations

Certain populations with impaired resistance to infection require extra precautions to protect the patient. These populations include patients who are transplant recipients, including bone marrow transplants, and those undergoing chemotherapy. These precautions include, but are not limited to8:
 Placing a patient in a private room with the air pressure positive in relation to the corridor outside.
 Performing good hand hygiene using an antimicrobial soap before either entering the patient's room or before providing direct patient care.
 Permitting only essential personnel and visitors to enter the patient's room and preventing anyone who is ill, or feels like they may be getting sick, from entering.
 Permitting no live plants, fresh fruits, or uncooked vegetables without the approval of the attending physician.
 Allowing the patient to leave his or her room only for essential purposes with the attending physician's permission. If allowed to leave, the patient must wear a surgical mask.
In addition to those populations already mentioned, pediatric and geriatric patients bring their own set of challenges. This is because these populations tend to be at higher risk of infection than other patients, especially when potentially having weakened immune systems as a result of an acquired or congenital health problem. Key precautions with these populations in addition to standard precautions include the implementation of respiratory hygiene and coughetiquette strategies for patients with suspected influenza or infection with another respiratorytract pathogen to the extent feasible; separation of infected, contagious children from uninfected children when feasible; and appropriate sterilization, disinfection, and antisepsis.




THE CRITICAL CARE ENVIRONMENT
Critical care environments have different names depending on the area of specialization:
 ICU intensive care unit or intermediate care unit  CCU coronary care unit or critical care unit
 MICU medical intensive care unit  SICU surgical intensive care unit
 NICU neurologic intensive care unit or neonatal intensive care unit  PACU Postanesthesia care unit
Physical therapists who practice in these critical care settings face a variety of complex challenges. The amount of preparation required to treat patients in this environment requires is more than for a typical hospital setting. Critically ill patients have limited mobility because of tenuous hemodynamic status, multiple central catheters, life support monitors, artificial airways, sedative medication, impaired levels of alertness, electrolyte imbalances, multiple medical problems, deconditioning, sleep disturbances, and muscle weakness. The benefits of early mobilization of this population include weaning from mechanical ventilation, improving tissue perfusion, promoting better rest periods, improving emotional state, decreasing the incidence of acquired pressure ulcers, restoring function and mobility, relieving pain, and decreasing the length of stay (thereby reducing healthcare costs). However, mobilizing patients in this environment is not without risk. Catheters and supportive equipment attached to patients can become dislodged and cause injury, and reinsertion of catheters can increase infection risk and cause unwanted stress and pain for patients and families.9 The treating clinician may find the highly technical environment somewhat daunting, especially as the stakes are high. However, provided that the clinician approaches these situations in a logical and organized manner, a degree of comfort level will be reached fairly quickly. In most cases, orientation is provided to new clinicians, which includes a formal introduction to the nursing staff and other key members of the healthcare team as well as information regarding the equipment and the various treatment protocols. Most critical care environments consist of a series of individualized cubicles, with one patient to each cubicle. Typically, before entering an intensive care unit, the clinician reviews the patient's medical record for any changes in the patient status, any procedures that are scheduled, any special precautions that need to be taken (e.g., respiratory isolation), or any changes in the orders for the patient.
Contained within the medical chart are laboratory values, which provide information about the patient's blood chemistry, blood gases, and urinalysis depending on the patient's diagnosis. Reference laboratory values are provided in Table 8 7.
TABLE 8 7
	Reference Laboratory Values	







Profile 

Component 

Related Physiology 
Reference Value 

Significance


Arterial blood gases (ABGs)
Arterial PaO2
Reflects the dissolved oxygen level based on the pressure it exerts on the bloodstream.
80 100 mm
Hg
A decrease indicates pulmonary dysfunction, e.g. hypoventilation.



Arterial PaCO2
Reflect the dissolved carbon dioxide level based on the pressure it exerts on the bloodstream.
35 45 mm
Hg
Indicates pulmonary dysfunction hypoventilation leads to an elevation.



Arterial pH
Reflects the free hydrogen ion concentration.
7.35 7.45
<7.35 = acidosis >7.45 = alkalosis Collectively this test and the arterial PO2 and arterial PCO2 tests






help reveal the acidbased status and how well oxygen is being delivered to the body.



Oxygen saturation (SAO2)
Usually a bedside technique (pulse oximetry) is used to indicate the level of oxygen transport.
95% 98%
During exercise or physical activity, a minimum of 90% saturation should be maintained to avoid hypoxemia.


Fluids and electrolytes
Sodium (Na)
Major extracellular cation that serves to regulate serum osmolality, fluid, and acid base balance; maintains transmembrane electric potential for neuromuscular functioning.
135 145
mEq/L
Increased values found with excessive sweating, hypothalamus disease, diabetes insipidus, hypoadrenalism, excess sodium intake.
Decreased values found with diuretic medication, kidney disease, congestive heart failure, diabetic ketoacidosis, sweating, severe vomiting and diarrhea.



Potassium (K)
Major intracellular cation: maintains normal hydration and osmotic pressure.
3.5 5.0
mEq/L
Increased values with tissue damage, urinary obstruction, primary adrenal insufficiency, diabetes mellitus.
Decreased values with prolonged vomiting and diarrhea, diuretic medication, corticosteroid excess.



Calcium (Ca)
Transmission of nerve impulses, muscle contractility; cofactor in enzyme reactions and blood coagulation.
8.5 10.8
mg/dL; inversely related to phosphorus level
Increased values with hyperparathyroidism, carcinoma metastatic to bone, multiple myeloma; loss of neuromuscular excitability and muscle weakness may be seen.
Decreased values with vitamin D deficiency, malabsorption, kidney disease, hypoparathyroidism; muscle tetany may be observed.



Phosphorus (PO4)
Integral to structure of nucleic acids, in adenosine triphosphate energy transfer, and in phospholipid function. Phosphate helps to regulate calcium levels, metabolism, base balance, and bone metabolism.
2.6 4.5
mg/dL; inversely related to calcium level
Increased values with renal disease, hypoparathyroidism, hyperthyroidism. Decreased values with malabsorption, hyperparathyroidism.












Blood Enzymes
Creatine kinase (CK)
An enzyme found predominantly in the heart, brain, and skeletal muscle. Aids in protein catabolism. Can be separated into subunits or isoenzymes, each derived from a specific tissue; CPK MB = cardiac
CPK MM = skeletal muscle.
Blood levels of CPK MB typically rise within 2 to 6 hours after a heart attack, reach their highest levels within 12 to 24 hours, and fall to normal levels within 3 days.
CK Total = 25 255 ?L/L
CK MB = 0 
5.9 mL/L
CK MM = 5 
70 ?L/L
CK Total: severe hypokalemia, carbon monoxide poisoning, seizures, pulmonary and cerebral infarctions.
CPK MB: myocardial infarction (an ongoing high level of CPK MB levels after 3 days may mean that an MI is progressing and more heart muscle is being damaged), post cardiac surgery, muscular dystrophies, polymyositis.
CPK MM: trauma, muscular dystrophy, dermatomyositis, hypothyroidism, seizures.





Lactate dehydrogenase (LDH)
Present in all body tissues and is abundant in red blood cells. Acts as a marker for hemolysis. Isoenzymes are LDH 1 5.
105 333
IU/L
LDH 1 2: myocardial infarction, myocarditis, shock, hemolytic and sickle cell anemia.
LDH 3: shock, pulmonary infarction. LDH 4: shock.
LDH 5: congestive heart failure, shock, hepatitis, cirrhosis, liver congestion.





Alkaline phosphatase
An enzyme most effective in an alkaline environment. Associated with bone metabolism/calcification and lipid transport.
Adults: 20 
140 IU/L
Infants to adolescents: Up to 104 IU/L
Increased = severe biliary obstruction, cirrhosis, hepatitis. Indicates increased osteoblastic activity: 150 250 IU/L indicates a fracture.
350 700 IU/L indicates active heterotrophic ossification.
Used as an indicator for Paget's disease, bone metastasis, osteomalacia, and hyper  parathyroidism.
Decreased = the healing of bone has ceased (nonunion fracture), or normal finding indicating bone growth has stopped with skeletal maturity.




Cellular blood elements
White blood cells (WBCs)
Produced in bone marrow; provide defense against foreign agents/organisms.
4.3 10.8  
109/L
Increased values with infection (bacterial), most illnesses, inflammation, allergic reactions, parasitic infections, leukemias, stress, overall stimulation of bone marrow.
Decreased values with chemotherapy, bone marrow failure, viral infections, alcoholism, AIDS.





Red blood cells (RBCs)
Produced in bone marrow, carry oxygen to tissues.
4.6 6.2  
1012/L
(male)
4.2 5.4  
1012/L
(female)
Increased values with lack of oxygen, smoking, exposure to carbon monoxide, long term lung disease, diseases of kidney, heart, bone marrow; dehydration, vomiting, diarrhea, sweating, severe burns, diuretics.
Decreased values with anemia from blood loss (colon cancer), decreased in RBC production (tumor, medication, lack of nutrients), increased RBC destruction (sickle cell disease).





Hemoglobin (Hgb)
Reflects oxygen carrying capacity.
14 18 g/dL (male) 13 16 g/dL
Values of 8 10 g/dL typically result in decreased exercise tolerance, increased fatigue, and tachycardia, conditions that may contraindicate








(female)
aggressive therapeutic measures, including strength and endurance training.



Hematocrit
Measure of the ratio of packed red blood cells to whole blood.
40 54
mL/dL (male) 37 48
mL/dL (female)
By dividing the hematocrit level by 3, one can approximate the hemoglobin level.



Platelet count
Reflects potential to address injury to vessel walls, thus regulating homeostasis.

Increased values with severe bleeding, infection, strenuous exercise, pregnancy, splenectomy, iron deficiency, rheumatoid arthritis, leukemia.
Decreased values with infection, vitamin B12 or folic






acid deficiency, severe internal bleeding, cancer, and autoimmune conditions.


It is also worth noting whether the patient has a do not resuscitate (DNR) directive in the medical record.

Once the medical record has been reviewed, the clinician then communicates with the nursing staff to get the most recent update on the patient and to inform the nurse responsible for the patient about the activities planned for the patient.

On entering the patient's cubicle, the clinician should begin to systematically observe the equipment on the bed, on the wall, and on the floor. In addition, the clinician should observe the patient and determine the patient's level of arousal and overall condition before proceeding. In most cases, the patient's vital signs will be displayed on a monitor.




If the patient is conscious, the clinician should introduce himself or herself, explain the purpose of the visit, and describe what the patient can expect.

The following sections provide a description of the most common types of equipment and devices that are found in the critical care environment.
Bed Type

Standard Adjustable

The standard hospital bed has two motors: one for the legs and one for the back. These beds can also have a third motor as an option that allows the whole bed to go up and down. The lower portion of the bed is typically hinged so it can be adjusted to provide knee flexion/hip flexion (Fowler's position). The average size for this type of bed is 36 inches wide   80 inches long. In the interest of safety, these beds are fitted with side rails that can be lifted until a locking mechanism is engaged, and lowered to allow the patient to get out of bed. If a side rail is to be lifted or lowered, the clinician must check that such a movement will not compress or stretch any line, lead, or tube that is connected to the patient, and whenever the patient is returned to the bed, the clinician should ensure that the side rail is in its correct position. The majority of these beds have a device (call button) attached to the side rail that can be used to contact nursing personnel, or a similar device, attached to an electrical cord, is provided for the patient. These beds come with a standard vinylcovered innerspring or foam mattress, but designs are available for skin shear, reinforced borders to help a patient get in and out of bed, and several layers of foam for circulation, cushioning, pressure relief, and comfort. These beds are typically used with patients who do not require specialized equipment such as those in the late stages of dementia (bed rails can be used as a restraint method for short periods) and postsurgery patients. The benefits of this type of bed are that they ease caregiving, enhance patient comfort, are adjustable, and can help relieve various conditions including:
Respiratory difficulties
Patients susceptible to aspiration
Patients with digestive problems such as reflux Cardiac patients



The ability to raise the upper part of the bed aids with activities of daily living such as:
 Sitting up in bed. A person is more likely to slip down when in a sitting position in bed if a pillow or wedge is not under his/her knees.  Eating/drinking using a bed tray.
 Brushing teeth.
If the patient frequently sits up in bed, the clinician should make sure that the patient is educated on correct body alignment and posture. If the patient is unable to self support good body alignment, the clinician can use pillows to help prop him/her up. A small pillow placed under the head can also increase comfort.


Bariatric 

These hospital beds are electrically operated beds with reinforced frames and decks that are designed for people from 600 to 1000 lb depending on the design. The dimensions can be 42 inches wide (600 lb), 48 inches wide (750 lb), and 54 inches wide (1000 lb).
Air Fluidized (Clinitron)

These beds contain 1600 lb of silicone coated glass beads called microspheres through which heated and pressurized air flows through to suspend a polyester cover that supports the patient. The airflow combined with the microspheres develop the properties associated with fluids and provide a contact pressure to the patient's body of only 11 to 15 mm Hg. The indications for this type of bed include patients who have several infected lesions, obese patients with risk of skin deterioration, patients who require skin protection, and patients whose position cannot be altered easily (those with extensive skin grafts and those who require prolonged immobilization). The advantages of using this type of bed include:
 Reduced need for topical medication and dressings because the microclimate is favorable for the healing process  Ability to control the temperature of the bed
 Reduction in overall skin pressure
When the unit is turned off, the polyester cover becomes a firm surface, which may be beneficial for certain nursing procedures (turning a patient during dressing changes).
In addition to being very expensive, the disadvantages of using this type of bed include:
 The polyester cover can be easily punctured.
 The air flowing across the patient's skin may cause dehydration.  Tall or obese persons may be uncomfortable in this bed.
 The height of the bed surface from the floor is fixed.  These beds tend to be very noisy.
Circular Turning Frame (Circ O Lectric Bed or Stryker Wedge)

This type of bed has an anterior/posterior frame that is attached to two circular supports, which can move a patient vertically from supine to prone as



the circular supports rotate through 180  around a short axis. At any point within their half circle range during the rotation, the circular supports can be stopped. This type of bed is indicated when skeletal stability and alignment are required. The advantages of using this type of bed include:
 One person can safely and easily turn or position a patient.
 It provides easy access for a variety of therapeutic interventions.
 Attachments can be added to provide traction (cervical) or immobilization.  The unit can be elevated to several heights.
 Various patient positioning options are available (e.g., hip and knee flexion, and semirecumbent). In addition, it is possible to position a patient in the fully upright position to allow him or her to step off the bed onto the floor.
The disadvantages of using this type of bed include:
 The amount of space required to allow the frames to rotate.
 A doorway must be over 7 feet high to allow the bed to pass through.
 Increased axial compressive pressure through the patient as he or she is moved into the vertical position during transition.
The use of this bed is contraindicated for unhealed, unstable vertebral fractures, any patient whose skin is susceptible to shearing and pressure, and any patient who suffers from motion sickness, vertigo, nausea, or orthostatic hypotension.
Posttrauma Mobility (Keane, Rotorest)

This type of bed is designed to maintain a seriously injured patient in a stable position and to maintain proper postural alignment through the use of adjustable bolsters. The bed, which is designed to oscillate from side to side in a cradle like motion to reduce the amount of prolonged pressure on the patient's skin, is indicated for patients with restricted respiratory function, advanced or multiple pressure sores, severe neurologic deficits, and those who require stabilization and skeletal alignment after extensive trauma (spinal injuries, with or without the complication of paraplegia or quadriplegia, and also for head injuries and certain orthopedic cases to help manage patients at risk for pulmonary complications as a result of immobility).
The side to side motion provided by the bed improves upper respiratory function, reduces the need to turn the patient, provides environmental stimulation for the neurologically impaired patient, reduces urinary stasis, and improves bowel function. However, there are a number of disadvantages associated with this type of bed, including:
 The constant motion of the bed may induce motion sickness.
 Exercising may be restricted by bolsters and alignment supports.  The bed requires a lot of room to oscillate.
Low Air Loss (Alternating Pressure) Therapy

These mattresses feature air flow throughout the sacral and torso areas to help minimize skin maceration by reducing excess moisture under patient. These mattress systems are available to fit all standard hospital beds including pediatric, geriatric, and bariatric configurations and are a proven way to help prevent and treat pressure ulcers by suspending the patient on several segmental airfilled cells while circulating air across the skin to reduce moisture and help maintain a constant skin interface pressure. The user has the ability to electronically adjust the amount of air pressure in each cell and to electronically adjust the bed to several different positions, including hip and knee flexion, sitting, or a semirecumbent position. This type of bed is indicated for patients who require prolonged immobilization, patients who are high risk of developing pressure ulcers or who have existing ulcers, patients who are obese, and those patients whose condition requires frequent elevation of the trunk. The advantages of this type of bed are that the patient's weight is measured by the sensors in the bed and the air bladders are inflated or deflated automatically to correctly distribute the patient's weight. The disadvantages of this type of bed include:



 The air cells can be punctured or torn by sharp objects.
 The patient's position must be frequently altered to prevent pressure ulcers.
Lines, Leads, and Tubes

Intravenous (IV) Line

IV lines are used for a number of purposes:
 To infuse fluids, nutrients, electrolytes, and medications via a plastic bag that measures the number of drops of fluid administered per minute  To obtain venous blood samples
 To insert catheters into the central circulatory system
IVs are most commonly placed in the forearm or back of the hand. Complications associated with IV administration include cellulitis, phlebitis, thrombosis, sepsis, air embolus, and pulmonary thromboembolism.
Hickman Line

A central venous line/catheter most often used for the administration of chemotherapy or other medications, measurement of central venous pressure, or for the withdrawal of blood. Unlike the single entry point of an IV line, the Hickman has both an entry and exit point. The entry is usually through the jugular vein in the neck, and the catheter is then run through part of the body until it reaches the tip of the right atrium. It emerges from there and is attached to two or three tubes that are exterior to the chest. As with most permanent IV lines or catheters, the Hickman can be prone to infection. Because the line is inserted into the major veins, this can be very serious.
Nasogastric (NG) Tube

A flexible tube connected to an electric pump is passed through the nose and down through the nasopharynx and esophagus into the stomach, which provides access to the stomach for diagnostic and therapeutic purposes (feeding and administering drugs and other oral agents directly into the GI tract). Before treating a patient who is on an NG tube, the pump must be stopped and the patient positioned in an upright or semiupright position for at least 30 minutes (1 hour for pediatric patients) before supine activities.
Enterostomy Feeding Tube

A flexible feeding tube (percutaneous endoscopic gastrostomy/jejunostomy [PEG/PEJ]) that is inserted by endoscopic or a small surgical opening in the abdomen so that nutritional solutions can be conveyed directly into the stomach or jejunum through a tube. The main difference between a PEG and a PEJ is that the physician inserts the PEG tube percutaneously into the stomach with an endoscope, whereas the PEJ tube is inserted into the intestine to the jejunum.
Endotracheal Tube

An endotracheal tube is a specific type of artificial airway for a patient who is unable to oxygenate/ventilate independently. A large diameter flexible tube can be inserted through the mouth (orotracheal) or nose (nasotracheal). Verification of correct placement is done by x ray. Once correctly placed, the tube must not be moved unless there is a written order from the physician.
Chest Tube (Pleur Evac)

This is a flexible plastic tube that is surgically inserted through an incision on the side of a patient's chest and into the pleural space. It is used to remove air (pneumothorax) if placed in the anterior or lateral chest wall, fluid (pleural effusion, blood, chyle) if placed inferiorly and posteriorly, or pus (empyema) from the intrathoracic space, using mediastinal tubes. The chest tube is connected to one to three large bottles, which are responsible for collecting air/fluid without permitting the lung to collapse. The clinician should avoid activities that pull on these tubes because if they are accidentally



dislodged or disconnected from the bottle, the patient's lung will collapse completely.
Jackson Pratt Drain

A drainage device, which consists of a surgical tube connected to a suction bulb, that is used to pull excess fluid from the body by constant suction.
Autofusion Surgical Drain (Hemovac or Autovac)

A disposable, self contained postsurgical drain that is used to remove pus, blood, or other fluids from a wound. Before a treatment session, the clinician should ask the nursing staff to empty any drain that is more than half full.
Patient controlled Analgesia (PCA)

PCA is commonly assumed to imply on demand, intermittent, IV administration of opioids under patient control a sophisticated microprocessor  controlled infusion pump delivers a prepro grammed dose of opioid when the patient pushes a demand button.
Catheters

Indwelling Urinary (Foley) Catheter

This type of catheter is inserted into the bladder via the urethra. Urinary catheters are used to drain the bladder in cases of:  Urinary incontinence (leaking urine or being unable to control urination)
 Urinary retention (being unable to empty the bladder on demand)  Surgery on the prostate or genitals
 Other medical conditions such as multiple sclerosis, spinal cord injury, or dementia
An indwelling urinary catheter is one that is left in the bladder. It is held in place in the bladder by a small balloon. The urine drains through plastic tubing into a collection bag, bottle, or urinal. Complications associated with urinary catheters include infection of the urinary tract or bladder, development of a urethral fistula, and kidney failure. Before starting a treatment session, the clinician should drain urine from the catheter tubing. During treatment sessions, the clinician should ensure that the collection bag is always placed below the level of the bladder. Any signs of foul smelling urine, cloudy dark urine, or urine with blood in it should be reported to the patient's physician or nurse.
Suprapubic Catheter

This type of catheter is inserted directly into the bladder through a small incision in the stomach and the bladder. Indications for a suprapubic catheter include:
 Failed trial using a urethral catheter
 Long term use (if left in for long periods, urethral catheters can lead to acquired hypospadias and recurrent/chronic urinary tract infections [UTIs])
Contraindications include:
 Lower abdominal incisions, which can lead to adhesions  Pelvic fracture
Complications associated with this type of catheter include:  UTIs



 Blockages
 Bladder stones  Bladder cancer
The clinician should use caution to avoid placing a gait or transfer belt directly over the insertion site.
Colostomy Bag

A colostomy is a surgical procedure in which a stoma is formed by drawing the healthy end of the large intestine or colon through an incision in the anterior abdominal wall and suturing it into place via an ostomy. This opening, in conjunction with the attached stoma appliance, provides an alternative channel for feces to leave the body. People with colostomies must wear an ostomy pouching system to collect intestinal waste. Ordinarily the pouch must be emptied or changed a couple of times a day depending on the frequency of activity; in general the further from the anus (i.e., the further "up" the intestinal tract) the ostomy is located, the greater the output and more frequent the need to empty or change the pouch.
Rectal Tube

The purpose of a rectal tube is to remove gas from the lower intestines or to remove or contain fecal matter. The collection bag should be kept below the level of the tube.
Life Support Equipment

Mechanical Ventilator

A machine that generates a controlled flow of gas into a patient's airways using positive pressure from oxygen and air received from cylinders or wall outlets. The incoming gas is pressure reduced and blended according to the prescribed inspired oxygen tension (FiO2), accumulated in a receptacle
within the machine, and then delivered to the patient using one of many available modes of ventilation. Flow is either volume targeted and pressure variable, or pressure limited and volume variable. There are two phases in the respiratory cycle, high lung volume and lower lung volume (inhalation and exhalation). Gas exchange occurs in both phases. Inhalation serves to replenish alveolar gas. Prolonging the duration of the higher volume cycle enhances oxygen uptake, while increasing intrathoracic pressure and reducing time available for CO2 removal. A variety of mechanical ventilators exist
including:
 Positive pressure. These ventilators require an artificial airway (endotracheal or tracheostomy tube) and use positive pressure to force gas into a patient's lungs. Inspiration can be triggered either by the patient or the machine. There are four types of positive pressure ventilators:
 Volume cycled. This type, which is the most commonly used in critical care environments, delivers a preset tidal volume then allows passive expiration. This is ideal for patients with acute respiratory distress syndrome (ARDS) or bronchospasm, since the same tidal volume is delivered regardless of the amount of airway resistance.
 Pressure cycled. These ventilators, which are also commonly used in the critical care environment, deliver gases at a preset pressure, then allow passive expiration. The benefit of this type is a decreased risk of lung damage from high inspiratory pressures, which is particularly beneficial for neonates who have a small lung capacity. The disadvantage is that the tidal volume delivered can decrease if the patient has poor lung compliance and increased airway resistance. This type of ventilation is usually used for short term therapy (less than 24 hours). Some ventilators have the capability to provide both volume cycled and pressure cycled ventilation.
 Flow cycled. This type delivers oxygenation until a preset flow rate is achieved during inspiration.
 Time cycled. This type delivers oxygenation over a preset time period. These types of ventilators are not used as frequently as the volume  cycled and pressure cycled ventilators.
 Negative pressure. Negative pressure ventilation is typically only used in a few situations. These units allow negative pressure to be applied only to the patient's chest by using a combination of a formfitted shell and a soft bladder. Rather than connecting to an artificial airway as with the



more modern ventilators, these ventilators were designed to enclose the body from the outside so that when the gas is pulled out of the ventilator chamber, the resulting negative pressure causes the chest wall to expand, which pulls air into the lungs. For exhalation to occur, cessation of the negative pressure causes the chest wall to fall. These devices can be used for patients with neuromuscular disorders, especially those with some residual muscular function, because they do not require a tracheostomy with its inherent problems.
Modes of Ventilation

The mode of ventilation refers to how a machine ventilates the patient in relation to the patient's own respiratory efforts (http://www.enotes.com/ventilators reference/ventilators).
Control Ventilation (CV)

CV, which delivers the preset volume or pressure regardless of the patient's own inspiratory efforts, is used for patients who are unable to initiate their own breath. If it is used with spontaneously breathing patients, they must be sedated and/or pharmacologically paralyzed so they do not breathe out of synchrony with the ventilator.
Assist control Ventilation (AC) or Continuous Mandatory Ventilation (CMV)

AC or CMV, which delivers a preset volume or pressure in response to the patient's inspiratory effort, initiates the breath if the patient does not do so within a preset amount of time. This mode is used for patients who can initiate a breath but who have weakened respiratory muscles. The patient may need to be sedated to limit the number of spontaneous breaths, as hyperventilation can occur in patients with high respiratory rates.
Synchronous Intermittent Mandatory Ventilation (SIMV)

SIMV, which delivers a preset volume or pressure and a preset respiratory rate while allowing the patient to breathe spontaneously, initiates each breath in synchrony with the patient's breaths. SIMV is used as a primary mode of ventilation as well as a weaning mode. (During weaning, the preset rate is gradually reduced, allowing the patient to slowly return to breathing independently.) The disadvantage of this mode is that it may increase the effort of breathing and cause respiratory muscle fatigue. (Breathing spontaneously through ventilator tubing has been compared to breathing through a straw.)
Positive end Expiratory Pressure (PEEP)

PEEP, which is positive pressure that is applied by the ventilator at the end of expiration, does not deliver breaths but is used as an adjunct to CV, AC, and SIMV to improve oxygenation by opening collapsed alveoli at the end of expiration. Complications from the increased pressure can include decreased cardiac output, lung rupture, and increased intracranial pressure.
Constant Positive Airway Pressure (CPAP)

CPAP is similar to PEEP, except that it works only for patients who are breathing spontaneously. The effect of CPAP (and PEEP) is compared to inflating a balloon but not letting it completely deflate before inflating it again. The second inflation is easier to perform because resistance is decreased. CPAP can also be administered using a mask and CPAP machine for patients who do not require mechanical ventilation but who need respiratory support (for example, patients with sleep apnea).
Pressure Support Ventilation (PSV)

PS is preset pressure that augments the patient's spontaneous inspiration effort and decreases the work of breathing. The patient completely controls the respiratory rate and tidal volume. PS is used for patients with a stable respiratory status and is often used with SIMV during weaning.
Independent Lung Ventilation (ILV)

This method is used to ventilate each lung separately in patients with unilateral lung disease or a different disease process in each lung. It requires a double lumen endotracheal tube and two ventilators. Sedation and pharmacologic paralysis are used to facilitate optimal ventilation and increase comfort for the patient in whom this method is used.




High frequency Ventilation (HFV)

HFV delivers a small amount of gas at a rapid rate (as many as 60 to 100 breaths per minute). It is used when conventional mechanical ventilation would compromise hemodynamic stability, during short term procedures, or for patients who are at high risk for lung rupture. Sedation and/or pharmacologic paralysis are required.
Inverse Ratio Ventilation (IRV)

The normal inspiratory: expiratory ratio is 1:2, but this is reversed during IRV to 2:1 or greater (a maximum of 4:1). This method is used for patients who are still hypoxic, even with the use of PEEP. Longer inspiratory time increases the amount of air in the lungs at the end of expiration (the functional residual capacity) and improves oxygenation by reexpanding any collapsed alveoli. The shorter expiratory time prevents the alveoli from collapsing again. This method requires sedation and therapeutic paralysis because it is very uncomfortable for the patient.
Monitoring Equipment

Arterial Line

The arterial line (A line) is connected to a pressure transducer that provides a way to constantly measure a patient's blood pressure and also provides access for frequent blood sampling, thereby avoiding repeated needle punctures. An A line is typically inserted into one of four arteries: radial, femoral, dorsal pedal, or axillary. Arterial lines are usually changed every 4 to 5 days to decrease the risk of infection. Accidental displacement of an A  line is a life threatening emergency, as significant blood loss can occur very quickly unless direct pressure is promptly applied to the insertion site.
Cardiac Leads

A series of 12 leads that are connected to the anterior chest to monitor electrical activity of the heart.
Pulse Oximeter

A noninvasive method allowing the monitoring of the saturation of a patient's hemoglobin levels in the blood. Usually, an external clip is attached to the patient's fingertip or earlobe.
Pulmonary Artery Catheterization (Swan Ganz)

Initially developed for the management of acute myocardial infarction, this catheter has gained widespread use in the management of a variety of critical illnesses and surgical procedures such as the diagnosis of idiopathic pulmonary hypertension, valvular disease, intracardiac shunts, cardiac tamponade, and pulmonary embolus (PE). The catheter is inserted into the internal jugular or the femoral vein and is then glided into the basilic or subclavian vein, before being passed into the pulmonary artery. The catheter is designed to provide accurate and continuous measurements of pulmonary artery pressure, which can detect even subtle changes in a patient's cardiovascular system. Accidental displacement of this device creates a life threatening emergency for the patient, as significant blood loss can occur very quickly unless direct pressure is promptly applied to the insertion site.
Intracranial Pressure (ICP) Monitor

Cerebrospinal fluid (CSF) is a colorless, clear fluid produced by the highly vascular choroid plexus in the lateral third and fourth ventricles that functions as a cushion for the brain and spinal cord. ICP monitoring, which calculates the pressure exerted against the skull by brain tissue, blood, or CSF, is a common practice when treating intracranial pathology with risk for elevated ICP, including patients who have sustained a closed head injury, a cerebral hemorrhage, or an overproduction of CSF. When the brain suffers an insult or injury, changes occur that affect cerebral hemodynamics, including changes in ICP, cerebral blood flow, and oxygen delivery. ICP data are very useful to help predict outcomes and worsening intracranial pathology, such as cerebral edema or hemorrhage. Intraventricular catheters, which are antibiotic impregnated and coated ventricular catheters to prevent infections, are considered the gold standard for measuring ICP because they are placed directly into the ventricle and are attached to a pressure transducer. An external ventricular device can assist with controlling increased ICP by allowing for therapeutic CSF drainage.



Oxygen Delivery Systems

Nasal Cannula

A device with two plastic prongs, which are inserted into each of the patient's nostrils, to deliver supplemental oxygen or airflow to a patient who requires low to moderate concentrations of oxygen.
Oronasal Mask

A triangular plastic device covered with small vent holes that covers the patient's nose and mouth and allows exhaled air to be expelled.
Tracheotomy/Tracheostomy

This is a method to provide a semipermanent, or permanent, oxygen delivery system to a patient via an incision on the anterior aspect of the neck to form a direct connection with the trachea and to allow a patient to breathe without the use of his or her mouth or nose. The tracheostomy tube is a 2  to 3 inch long (51  to 76 mm) curved metal or plastic tube that is connected to a wall unit via a long plastic tube that is inserted into a tracheostomy stoma to maintain a patent lumen. This type of procedure is usually not used unless the patient has had an endotracheal tube in for an extended period of time and is unable to be weaned from the ventilator. Indications in the acute setting include severe facial trauma, head and neck cancers, and large congenital tumors of the head and neck. Indications in the chronic setting include the need for long term mechanical ventilation and tracheal hygiene.
THE GRIEVING PROCESS
It is not uncommon for a healthcare provider to encounter a patient who has suffered the loss of someone or something close to them (loved one, pet, a job, or possibly a role entering retirement). Grief, itself, is a normal and natural response to a loss, so it is important to realize that acknowledging the grief promotes the healing process. There are a variety of ways in which individuals respond to loss, some healthy and some that may hinder the grieving process.



Invariably an individual passes through a series of stages during the grieving process. These stages reflect a variety of reactions that may surface as an individual makes sense of how a loss affects them. Experiencing and accepting all feelings remains an important part of the healing process. Elizabeth K bler Ross10 identified a number of stages that occur during the grieving process:
 Stage 1: Shock, numbness, and denial.
 Shock usually occurs as the initial reaction to a psychological trauma or severe and sudden physical injury.11 During stressful situations, individuals express themselves through physiologic and emotional responses. These reactions serve to protect the individual from an overwhelming experience.
 Numbness is a normal reaction to an immediate loss and should not be confused with "lack of caring."
 Denial is often used as a defense mechanism to alleviate anxiety and pain associated with a disability or illness.11 Denial, and feelings of disbelief, occur as a specific phase early in the adaptation process and serve to protect the person from having to confront the overwhelming implications of illness or injury at once.11 Denial and disbelief will diminish as the individual slowly acknowledges the impact of this loss and accompanying feelings.
It is common for people to avoid making decisions or taking action at this point.
Stage 2: Anger. This reaction usually occurs when an individual feels helpless and powerless. Anger may result from feeling abandoned, occurring in cases of loss through death. Feelings of resentment may occur toward one's higher power or toward life in general for the injustice of this loss. After an individual acknowledges anger, guilt may surface because of expressing these negative feelings.
Making decisions at this point is difficult because an individual's energy is focused on the emotion rather than on problem solving.
Stage 3: Depression and detachment. After recognizing the true extent of the loss, some individuals may experience depressive symptoms. Sleep and appetite disturbance, lack of energy and concentration, and crying spells are some typical symptoms. Feelings of loneliness, emptiness,



isolation, and self pity can also surface during this phase, contributing to this reactive depression. For many, this phase must be experienced in order to begin reorganizing one's life.
 Stage 4: Dialogue and bargaining. People become more willing to explore alternatives after expressing their feelings. At times, individuals may ruminate about what could have been done to prevent the loss. Individuals can become preoccupied with ways that things could have been better, imagining all the things that will never be. This reaction can provide insight into the impact of the loss; however, if not properly resolved, intense feelings of remorse or guilt may hinder the healing process. This phase may be marked by externalized hostility toward other people or objects in the environment.
 Stage 5: Acceptance. Time allows the individual an opportunity to resolve the range of feelings that surface. Acknowledgment is the first sign that the patient has accepted or recognized the permanency of the condition and its future implications.11 Decisions are much easier to make because people have found new purpose and meaning as they have begun to accept the loss. Adjustment is the final phase in adaptation and involves the development of new ways of interacting successfully with others and one's environment.11
Physical Therapy Approach During the Grieving Process

 Discuss quality of life issues with patient/family.  Make time for grief work.
 Focus on the positive: realize and maximize all clinical opportunities.
 Learn to deal with the patient's or family's anger during the discharge crisis.
 Realize the importance of comfort measures and pain management to patient/family.  Work with appropriate pastoral supports.
 Try to engage the patient's interest in things.
 Respect the needs of privacy, independence, and decathexis (the gradual weakening and separating of emotional ties) on the part of the patient.
REFERENCES

1. Decoster A, Grandbastien B, Demory MF et al.: A prospective study of nosocomial infection related mortality assessed through mortality reviews in 14 hospitals in Northern France. J Hosp Infect 80:310 315, 2012.
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