2

U N IT

PROMOTING SAFETY

7 Controlling the Spread of Infection

8 Preventing Injuries
9 Responding to Emergencies
 7
CHAPTE R

Controlling the Spread

of Infection

Goals
After reading this chapter, you will have the information needed to:

• Describe how infections can be spread from one

person to another.
• Apply standard precautions and transmission-based
precautions.
• Recognize the signs and symptoms of an infection. • Understand your role and your employer’s role
• Take measures to control the spread of microbes that
can cause infection.
in protecting you from exposure to bloodborne
pathogens on the job.

After practicing the corresponding skills, you will have the information needed to:

• Wash your hands in a way that controls the spread of

microbes that can cause infection.
• Open and close a trash bag correctly and
double-bag contaminated trash and laundry.
• Put on and take off personal protective equipment
(PPE) correctly.
 During morning report at Metropolitan and flus also are diseases that people can get from
Hospital Center, your supervising nurse tells one another. Have you ever caught a cold or flu from
you about your new patient, Louise Wang, a someone? You can lessen your chances of getting
53-year-old woman who was admitted through the sick and avoid passing on an illness to someone else
emergency room from Morningside Nursing Home by learning about what causes infections and how
last night. Because she was diagnosed with highly infections can spread.
contagious staph pneumonia, she is in isolation
in Room 117. Last year, she had part of her bowel Microbes (microorganisms) are tiny living things
removed because of colon cancer, and she uses that are too small to see but are all around us.
an ostomy appliance (a bag worn on the outside Microbes can only be seen using a microscope.
of the body) for the elimination of feces. The feces Examples of microbes include bacteria, viruses,
pass through a surgically made opening in her fungi, yeasts and molds. Most microbes grow rapidly
abdomen and into the ostomy appliance. In addition wherever they have warm temperatures, moisture,
to assisting Mrs. Wang with emptying her ostomy darkness and food. These characteristics make the
appliance, you will need to help her with a complete human body an ideal place for microbial growth!
bed bath and with transferring from the bed to the Some microbes are harmful to humans and some are
chair, because she is very weak. The nurse also not. Harmful microbes that cause disease are called
tells you that Mrs. Wang is originally from China but pathogens. A disease caused by a pathogen is called
speaks and understands English very well. an infection.
You decide to visit Mrs. Wang immediately because Microbes are everywhere, even in and on our bodies.
you think she might be afraid. Before going into Many of the microbes that live in and on our bodies
her room, you wash your hands and put on a gown,
are harmless, and some even perform useful functions.
mask and gloves. Outside her room, you notice the
However, even microbes that are useful and necessary
sign posted on her closed door. The sign requests
in certain areas of the body can cause disease if they
visitors to report to the nurses’ station.
spread to another part of the body where they are not
You knock gently, then a little louder when you hear normally found. For example, certain bacteria in the
no response. When you finally hear a faint “Come stomach and bowel help to digest food. But if these
in,” you open the door to see the back of a small same bacteria are present in the kidney or bladder,
woman lying in bed. You walk toward the bed, gently they can cause an infection.
calling Mrs. Wang’s name and telling her who you
The body has many natural defenses against infection.
are. When she turns toward you and sees your
Healthy, intact skin and mucous membranes help
masked face, her eyes open wide before she turns
to prevent microbes from entering the body. Mucous
back to face the wall.
membranes are sticky, moist membranes that line
the respiratory, genitourinary and digestive tracts.
What Causes Infection? Reflexes, such as coughing and sneezing, help to
Louise Wang is in a room by herself because she has expel microbes from the body. Finally, white blood cells
Staphylococcus pneumonia (staph pneumonia), a carried in the blood are able to destroy pathogens that
disease that other people could catch from her. Colds enter the body. These natural defense mechanisms

K EY TE R M S

• acquired • hand hygiene • microbes • respirator

immunodeficiency (microorganisms)
syndrome (AIDS) • healthcare-associated • sharps container
infection • mucous membranes
• bloodborne pathogens • standard precautions
• hepatitis • occupational exposure
• body fluids • sterilization
• human • other potentially
• chain of infection immunodeficiency virus infectious materials • transmission-based
(HIV) (OPIM) precautions
• contaminated
• infection • pathogens • tuberculosis
• disinfectant
• infection control • personal protective
• double-bagging equipment (PPE)

76 | | Nurse Assistant Training

help to keep us healthy. In addition, modern medicine
has made other tools available to help us fight and
prevent infections, such as antibiotic medications and
vaccinations. Even though our bodies have ways of
protecting us from infection and there are medications
available to treat some infections, prevention is still the
optimal goal. Some infections can be fatal, especially
in people who are not otherwise healthy, and some
infections cannot be treated with medication.

The Chain of Infection

Many infections can be passed from one person to
another. However, for this to occur, six requirements
must be met. These six requirements are called the
chain of infection (Figure 7-1). Eliminating just
one link in the chain can prevent an infection from
spreading. Let’s take a closer look at the six links in
the chain of infection:
1. Pathogen. For an infection to occur, a microbe Figure 7-1 The chain of infection. Breaking just one link in this chain
capable of causing disease must be present. can stop an infection from occurring.

2. Reservoir. Reservoir is a French word that means

“storehouse.” Here, we are using it to mean a
place where microbes can grow and multiply. 5. Portal of entry. Just as the pathogen must have a
Possible reservoirs for microbes include the way of leaving the reservoir, it must also have
bodies of people and animals, bodies of water, a way of gaining entry to a new reservoir. This is
and food. called a portal of entry. In the case of person-
3. Portal of exit. Portal comes from the Latin word to-person (or animal-to-person) transmission,
for “gate.” For an infection to occur, the microbe potential portals of entry include the respiratory
must have a way of leaving the reservoir, or a tract, the digestive tract, the genitourinary tract,
portal of exit. The portal of exit varies depending the eye and breaks in the skin.
on the pathogen and the reservoir. When the 6. Susceptible host. Finally, the pathogen must
reservoir is a human or animal body, the portal enter a susceptible host, or a person who is
of exit may be the respiratory tract, the digestive capable of becoming infected with that particular
tract, the genitourinary tract or breaks in the skin. pathogen. Some factors increase a person’s
4. Method of transmission. The way a pathogen susceptibility to infection, including very young
gets from one person to another is called the or very old age, poor general health, and the
pathogen’s method of transmission. The method presence of medical devices that are placed in
of transmission may be direct or indirect. In direct the body (such as urinary catheters). Many of the
transmission, the pathogen is passed from one people you will care for will have risk factors that
person to another through close physical contact, increase their susceptibility to infection.
such as touching, kissing, having sex or breathing
infected air. Indirect transmission means that Healthcare-Associated
pathogens are spread by way of a contaminated
surface or object. A contaminated surface or Infections
object has been soiled with pathogens. Usually A healthcare-associated infection is an infection
this situation occurs when an infected person that a person gets while receiving care in a healthcare
touches something and then someone else facility. You may also hear healthcare-associated
touches that same object. For example, if you infections referred to as nosocomial infections.
have a cold and blow your nose into a tissue, and Healthcare organizations that seek to provide quality
someone else picks up the tissue to throw it away care make it a priority to prevent healthcare-associated
without wearing gloves, that person can get your infections from occurring. If a person develops an
cold by indirect contact. The germs will spread infection while in a healthcare facility, he may need
from your nose secretions to the tissue to the to stay in the facility longer so that the infection
other person’s hand. can be treated, delaying the person’s recovery and

Chapter 7 | Controlling the Spread of Infection | 77

 driving up healthcare costs. In addition, developing a
healthcare-associated infection can put the person
• Vancomycin-resistant enterococcus (VRE).
This microbe can infect wounds, the intestinal tract
at risk for serious complications and even death. As and the urinary tract.
noted earlier, many people who are receiving care in
The basic infection control measures that you will
healthcare facilities are more susceptible to developing
learn about in this chapter are extremely effective
infections, and if they do develop an infection, it is
for preventing the spread of these very dangerous
harder for their bodies to overcome it. In addition,
microbes, as well as other microbes that can cause
some of the microbes that commonly cause
healthcare-associated infections. The key is to
healthcare-associated infections are very difficult
use these infection control methods properly and
to treat. Over time, these microbes have become
consistently.
resistant to the antibiotics (such as methicillin and
vancomycin) used to treat the infections they cause,
which means that these medications are no longer How to Recognize
effective for eliminating the infection. Examples of
these hard-to-treat super bugs include the following: an Infection
• Methicillin-resistant Staphylococcus aureus
(MRSA). Staph infections are spread by direct
An infection occurs when pathogens grow inside
the body. Almost any part of the body can become
infected. You can recognize a possible infection
contact and can cause serious skin infections. If the
in a person’s body by certain signs and symptoms
bacterium enters the body (for example, through
(Box 7-1). The signs and symptoms of infection vary
a cut on the skin), the person can develop serious
according to the pathogen and the place in the body
infections of the blood, lungs, heart or bone.
where the infection is occurring. If you notice that
• Clostridium difficile, or C-diff. C. difficile is
a microbe that is passed from the body in feces.
someone in your care has one or more of the signs
and symptoms in Box 7-1, report your observations
Contact with surfaces or hands contaminated to the nurse. By recognizing infections early, you help
by the microbe spreads the infection to others. to ensure that the person receives prompt treatment,
The bacteria invade the bowel, causing diarrhea which in turn helps to prevent the spread of infection
and abdominal pain. C. difficile produces spores to other people. Remember that not all people with
that can live on hands and surfaces for a long infections will show common signs and symptoms
time. When a person is known to have C. difficile of infection. This is why it is important to practice
infection, you must always wash your hands with infection control with every person in your care, even
soap and water, because alcohol-based hand when you do not observe any signs or symptoms of
sanitizers are not effective for removing C. difficile infection. Remember, infection control is one of the six
from the hands. In addition, a disinfectant containing principles of care.
bleach must be used to clean hard surfaces.

Box 7-1 Common Signs and Symptoms of Infection

High body temperature Diarrhea

Red or draining eyes Vomiting
Nasal congestion Cloudy or smelly urine
Coughing Joint pain
Headache Muscle ache
Sore throat Skin rash
Flushed face Sores
Loss of appetite Redness around a wound or incision
Nausea Drainage from a wound or incision
Stomach pain Swelling

78 | | Nurse Assistant Training

 ELDER CARE NOTE. In older adults,
fever may not be present even if an
infection is present. That’s because
many older adults have other chronic conditions,
are taking medications, or have changes in
their immune system that can interfere with the
body’s ability to produce a fever.
Be alert for other possible signs and symptoms
in older adults, such as:
●●
New onset of confusion or increased
confusion (if the person is already confused).
●●
Changes in eating or appetite.
●●
New onset of the loss of bladder or bowel
Figure 7-2 Hand hygiene is one of the most important things you can
control or more frequent episodes of
do to protect yourself and others from infection.
incontinence.
●●
Loss of the ability to complete tasks the
person is usually able to do. to ensure that all surfaces are clean. You should wash
●●
Fatigue or lethargy. your hands whenever they are visibly soiled with dirt,
●●
Flu-like symptoms. blood or body fluids, and at specific times throughout
the day (Box 7-3). Body fluids include urine, feces,
saliva, mucus, vomit, semen, vaginal secretions, breast
milk and wound drainage. Guidelines for proper hand
How to Control the Spread washing are given in Box 7-4. The specific procedure
of Microbes for hand washing is explained step-by-step in Skill 7-1.
Healthcare workers take certain actions to control When your hands are visibly soiled, you must wash
the spread of microbes that can cause disease. This them with soap and water. You should also wash with
practice is called infection control and it is one of soap and water before eating or handling food, after
the six principles of care. Protecting those in your care using the bathroom, and if you have had contact with
from infections is an important part of providing quality organisms that cause certain types of diarrhea. In most
care. You probably already practice some types of other circumstances, you may use an alcohol-based
infection control in your daily life without thinking much hand sanitizer to clean your hands instead of washing
about it. If you cough or sneeze, for example, do you with soap and water. The sanitizer should contain at
cover your mouth with a tissue or cough or sneeze into least 60% alcohol. When using an alcohol-based hand
your elbow to control the spread of germs? If someone sanitizer, use the amount of product recommended
you know has a cold or flu, do you try to keep your by manufacturer. Rub it thoroughly over all surfaces
distance from that person so that you will not catch the of the hands, including the nails and between the
cold or flu yourself? Do you always wash your hands fingers, until the product dries (at least 20 seconds)
after using the bathroom? If you do these things, you (Figure 7-3). Always follow your employer’s policy
already are using infection control methods. Box 7-2 about using an alcohol-based hand sanitizer.
summarizes general actions that can be taken to help
control the spread of microbes. Four common methods Sometimes you may think that hand hygiene is an
of infection control used in healthcare settings include inconvenience when you have so much else to do. But
using hand hygiene (which includes hand washing the one time you decide to skip it may be the time you
with soap and water or use of an alcohol-based hand infect yourself or someone else with microbes from
sanitizer), decontaminating objects and surfaces, another person.
using personal protective equipment (PPE) and taking
isolation precautions. Keeping Objects and Surfaces
Clean
Hand Hygiene When you work in any healthcare setting, you can
Hand hygiene is an important part of everyday life, help control the spread of infection if you understand
especially in your role as a nurse assistant, and it is exactly what is meant by clean and what is meant by
one of the most important things you can do dirty. Clean items or surfaces are considered to be
to control the spread of microbes (Figure 7-2). As a free of dirt and pathogens. Dirty items or surfaces are
nurse assistant, you clean your hands in a special way considered contaminated because they contain dirt or

Chapter 7 | Controlling the Spread of Infection | 79

 Box 7-2 General Actions That Help to Control the Spread of Microbes

• Cleanse your hands frequently, using

soap and water or an alcohol-based hand
room before you carry the bag to the laundry
hamper outside the room. Place wet and soiled
sanitizer. linens in a plastic or leakproof laundry bag.
• Take care of your body. Eat well, exercise and
get enough rest to keep your immune system
• Cover bedpans and urinals. To contain fluids
when carrying them from one place to another,
healthy. always cover bedpans and urinals.
• Get vaccinated. Vaccines are available to prevent
many infectious diseases, including influenza and
• Prepare food carefully. When preparing food
for yourself or for those in your care:
hepatitis B. Receiving appropriate vaccinations {{ Wash your hands first.

and keeping them up-to-date helps to protect you {{ Rinse off the tops of cans before opening
from getting these infectious diseases.
them.
• Stay home if you are sick. If you must report
to work when you are not feeling well, be sure to
{{ Wash fruits and vegetables before using them.

{{ Ensure that cooked foods (especially meat)

discuss your illness with your supervising nurse
so that your supervisor can make decisions about reach the proper temperature.
{{ Wash, dry and store dishes and utensils after
what tasks you can do and what care you can
safely provide to others. each use.

• Recognize and report signs and symptoms

of infection. Be on the lookout for any signs of
{{ Wash cutting boards used to prepare meat

and poultry with hot soapy water immediately

infection and report any findings immediately to after use. Use separate cutting boards
the nurse. for cutting meat or poultry and for cutting

• Maintain cleanliness. Keep yourself, those in

your care, and the environment clean. •
vegetables that are not going to be cooked.
Serve meals immediately. After food arrives

• Ensure single use of personal equipment.

Make sure each person in your care has their
from the dietary department of a hospital or
nursing home, or as soon as you prepare food in
own personal items such as bedpans, urinals, a person’s home, serve it immediately.
washbasins, emesis basins, toothbrushes,
toothpaste, lotion and soap. These items should
• Store foods carefully. Make sure people do
not store food in their rooms, unless the food is
never be shared. nonperishable and is stored in a tightly sealed

• Handle linens properly. When handling bed

linens, be sure to keep dirty linens away from your
container. If a person wants to save part of a meal
for later, explain to the person that unrefrigerated
uniform. Avoid shaking dirty linens, because this food can grow bacteria that can make the person
can spread microbes into the environment. Place ill, and tell the person that you will bring a fresh
dirty linens in the laundry bag in the person’s serving of the food later, if the person wants it.

Box 7-3 When to Use Hand Hygiene

• As you are coming on duty • Before eating or handling food

• Before and after contact with a person in your • Before handling clean supplies or equipment

•
care
• Before going home

•
Before and after putting on gloves
After using the bathroom
• After any possible contact with infectious
organisms that might cause diarrhea
• After coughing, sneezing or blowing your nose • Any time they become visibly soiled with dirt or
• After smoking
•
body fluids

• After handling dirty supplies or equipment Any other time you think it may be important

80 | | Nurse Assistant Training

 pathogens. An unused item is considered clean until
Box 7-4 it comes in contact with a person or his environment.
It is then considered dirty and cannot be reused for
Nurse Assistant another person. In a hospital or nursing home, clean,
unused supplies (such as linens and dressings) are
DOs and DON’Ts stored in the clean utility room. Used supplies that
must be cleaned or laundered are returned to the
dirty utility room. The dirty utility room also has trash
Hand Washing containers for disposing of disposable supplies.

DO keep your fingernails trimmed short and use As a nurse assistant, one of your responsibilities is
a nailbrush or orange stick to remove dirt and to help keep the person’s environment clean. You
microbes from underneath them. may also be responsible for cleaning some types of
equipment after you use it. Healthcare workers use
DO push your watch above your wrist, put it in many strategies to remove microbes from objects
your pocket or pin it to your uniform. This enables and surfaces. Simply washing the object or surface
you to wash your wrists along with your hands. with soap and water will remove dirt and some
DO apply hand lotion to help prevent the microbes. Or you can use disinfectant, a chemical
chapping and dryness that can occur with solution used to kill microbes on an object or surface
frequent hand washing. (Figure 7-4). The facility will specify which disinfectant
solution to use, or you may make a disinfectant
DON’T wear artificial nails or nail polish. solution by mixing a solution of 1½ cups bleach to
Microbes can be very difficult to remove from 1 gallon of water. When using a bleach solution,
the spaces created when artificial nails lift or nail always ensure good ventilation and wear gloves and
polish peels and cracks. eye protection. Let the disinfectant or bleach solution
DON’T wear rings to work. The tiny spaces stand on the surface for the recommended amount
in jewelry are difficult to clean and can harbor of time (for example, 1 to 3 minutes for a disinfectant
microbes. In addition, it is difficult to remove solution, 10 to 15 minutes for a bleach solution).
microbes from underneath the jewelry. When it is necessary to destroy all the microbes on
an object or surface, sterilization is used. Objects
that are going to be placed inside a person’s body
(for example, indwelling urinary catheters) must be
sterile. Sterilization is a technique that uses gas,
chemicals, dry heat or pressurized steam to destroy
all microbes on an object or surface. In facilities, a
special department (often called Central Supply) is
usually responsible for sterilizing objects. In the home
setting, boiling an object in water, if the object can
be boiled, for 20 minutes is an effective means of
sterilization.

B
Figure 7-3 An alcohol-based hand sanitizer may be used as an
alternative to washing with soap and water if your hands are not
visibly soiled. (A) To use an alcohol-based hand sanitizer, dispense
the recommended amount of product into the palm of one hand. Figure 7-4 One of your responsibilities as a nurse assistant is to
(B) Rub your hands together, covering all surfaces, until the product keep the person’s environment clean. Here, a nurse assistant is using
dries (at least 20 seconds). a disinfectant solution to clean an over-bed table.

Chapter 7 | Controlling the Spread of Infection | 81

 Using Personal Protective Box 7-5
Equipment
Personal protective equipment (PPE) is
protective gear that is worn to prevent microbes
Nurse Assistant
from contaminating your uniform, skin or mucous
membranes. PPE includes gloves, gowns, masks and
DOs and DON’Ts
eyewear (Figure 7-5). Properly using PPE eliminates
a portal of entry for potential pathogens and helps to Using Personal Protective
keep you safe from infection.
Equipment (PPE) Properly
PPE is usually put on outside of the person’s room
and removed and discarded inside the person’s room. DO choose gloves that fit your hands properly.
When it is necessary to put on multiple types of PPE, DO change masks and gowns if they become
items are put on in the following order: gown, mask, moist.
protective eyewear, gloves. When it is necessary
to remove the PPE, the order is as follows: gloves, DO put on and take off PPE in the proper order.
protective eyewear, gown, mask. Removing PPE in the DON’T wear gloves as a “second skin”
proper order helps to protect you from contaminating throughout the day. Replace your gloves as often
yourself or your uniform. Guidelines for the proper use as necessary throughout a procedure to avoid
of PPE are given in Box 7-5. Skill 7-2 describes step- contaminating clean surfaces with dirty gloves,
by-step how to put on and remove each article of PPE. and always discard your gloves and wash your
See also Appendix C, Skill C-4 for information about hands when you have finished the procedure.
how to put on and remove PPE when only a gown and
gloves are needed. DON’T wash or disinfect disposable gloves for
re-use. They are meant to be worn once and
Gloves discarded.
Disposable gloves are typically made of vinyl, nitrile DON’T use gloves that have rips, tears or
or latex. These gloves are meant to be worn once and punctures or that appear discolored.
then discarded. Gloves should fit properly and be
free of rips or tears. Gloves are worn whenever there
is a possibility that you will come into contact with a
person’s blood or body fluids (Box 7-6). For example, You may need to change gloves several times during
you wear gloves when you provide mouth care, perineal one procedure to avoid contaminating clean surfaces
care or care for someone who has a draining wound by touching them with dirty gloves. Always wash your
or open sores on the skin. You also wear gloves when hands after removing your gloves and before putting
there is a break in the skin on your own hands. on a new pair. When you are finished caring for one
person, always remove and discard your gloves and
wash your hands before leaving the room or assisting
another person.
Most facilities do not use latex gloves, since some
people are allergic to latex. If you or the person you are
caring for develops skin redness, a rash, hives, itching,
a runny nose, sneezing, itchy eyes, a scratchy throat or
difficulty breathing while you are providing care using
latex gloves, wash the area in contact with the gloves
immediately, and notify the nurse. In the future, you will
need to use disposable gloves made of vinyl or nitrile
when providing care.

Gowns
A gown is worn to protect your clothes and body
from splashes and sprays of blood and body fluids.
The gown must completely cover you from your neck
Figure 7-5 Personal protective equipment (PPE) helps to protect
your skin, mucous membranes and uniform from becoming to your knees. A gown is worn only once and then is
contaminated with microbes. placed in a laundry hamper (if it is made of fabric) or

82 | | Nurse Assistant Training

 Box 7-6 When to Wear Gloves

• When there is a possibility that you will touch

blood or other body fluids
• When the person in your care has broken skin or
you have broken skin on your hands
• When you are providing care that requires you to
touch mucous membranes
• When you must handle items or surfaces soiled
with blood or other body fluids

thrown away (if it is made of paper). Because a damp or disposing of fluids. Protective eyewear may be
or wet gown will not protect you, you must change reusable or disposable.
your gown if it becomes wet.

Masks Taking Isolation Precautions

Isolation precautions are actions taken to isolate
A mask covers your nose and mouth to protect you
pathogens to prevent them from spreading throughout
from inhaling pathogens into your lungs. You may also
the facility. Isolation precautions are based on the
wear a mask when it is important to protect the person
pathogen’s method of transmission. The goal of
from pathogens you may exhale. The mask should fit
these precautions is to contain the pathogen and
snugly over your nose and mouth. Use a mask only
limit others’ exposure to it as much as possible.
once. Change your mask if it becomes moist, because
There are two major types of isolation precautions:
moisture reduces the effectiveness of the mask.
standard precautions and transmission-based
There are two types of masks you may use. A surgical precautions.
(face) mask is most commonly used. These masks
are effective for providing a barrier that large droplets Standard Precautions
cannot pass through. When a person is known to Standard precautions (sometimes called universal
have a disease that is caused by very small droplets precautions) are precautions that healthcare workers
suspended in the air (called aerosols) a respirator take with every person to protect themselves
must be worn (Figure 7-6). A respirator is a mask that and others from pathogens that are transmitted
filters the air to prevent aerosols from passing through, through blood, body fluids, broken skin and mucous
and must be specifically fitted to the person who will membranes. You must practice standard precautions
be wearing it. whenever you expect this type of contact, such as
when assisting with a medical procedure or when
Protective Eyewear providing personal care—even if you think the person
Wear protective eyewear, such as goggles or a in your care is not infected. Box 7-7 lists standard
face shield, to keep blood and other body fluids precautions. Memorize these precautions and make
from splashing into your eyes when cleaning items them a way of life as you work as a nurse assistant.

Transmission-Based Precautions
When a person’s primary care provider suspects
or confirms that the person has an infection that
can be spread to others, you must take additional
precautions to prevent the spread of the infection
to other people. These precautions are referred to
as transmission-based precautions. The primary
care provider decides which transmission-based
precautions must be followed. This decision is based
on two things: the pathogen and how that pathogen
spreads. When transmission-based precautions are
in effect, you will usually put on the appropriate PPE
before entering the person’s room and remove it at the
doorway right before leaving the person’s room. The
three types of transmission-based precautions are
Figure 7-6 A respirator is needed to filter very small droplets airborne precautions, droplet precautions and contact
suspended in the air. precautions.

Chapter 7 | Controlling the Spread of Infection | 83

 Box 7-7 Standard Precautions

1. Wear disposable gloves whenever the 5. Clean up blood or body fluid spills
possibility exists that you could come into promptly, using an approved disinfectant or a
contact with blood or other body fluids, broken freshly mixed solution made by adding 1½ cups
skin and mucous membranes. This includes of bleach to 1 gallon of water. Be sure to wear
when you are providing care and situations appropriate PPE when cleaning up the spill.
where you must handle items soiled with blood 6. Handle contaminated articles carefully.
or other body fluids. Also wear gloves whenever Follow your facility’s guidelines regarding any
you have broken skin on your hands. item contaminated with blood or body fluids.
2. Wash your hands and skin surfaces thoroughly You will be required to put certain contaminated
and immediately if your skin becomes soiled articles into a puncture-resistant, labeled
with blood or other body fluids or if you have biohazard bag. One bag is usually enough,
handled potentially soiled items. Also wash your but sometimes you will need two bags. If the
hands after removing gloves and before putting outside of a bag is soiled or may have become
on gloves. If your hands are not visibly soiled contaminated, place the contaminated bag into
with blood or other body fluids, you may use an a second (clean) bag. This is called double-
alcohol-based hand sanitizer to decontaminate bagging. Double-bagging is also used if a
your hands after removing gloves and before contaminated article could puncture the first
putting on a clean pair. biohazard bag. You will need a co-worker to
3. Wear personal protective equipment (PPE) help with this. Skill 7-3 describes step-by-step
as indicated by the situation. A gown must be how to handle a plastic trash bag and how to
worn whenever the possibility exists that your double-bag contaminated waste.
uniform could be soiled by the splashing of 7. Practice respiratory hygiene and cough
blood or other body fluids. Protective eyewear, etiquette. Take measures to contain respiratory
a mask, or both must be worn whenever the secretions that can spread infections such as
possibility exists that blood or other body fluids influenza. Encourage people who enter the
could splash into your eyes, nose or mouth. facility with visible signs of a respiratory illness
4. Handle sharp objects carefully. Protect to cough or sneeze into a tissue to contain
yourself and others from injury caused by sharp respiratory secretions, dispose of tissues
objects that may be soiled by blood or other properly and clean their hands with soap and
body fluids (such as razors and needles) by water or an alcohol-based hand sanitizer after
disposing of them in a sharps container. sneezing, coughing or handling dirty tissues.
A sharps container is a sturdy, puncture-proof People with signs of respiratory illness may also
plastic box with a tight-fitting lid used for the be provided with masks or physically separated
disposal of sharp objects. Never recap a sharp from other people (for example, in common
object before disposing of it, because you could waiting areas) to further limit the spread of
cut yourself while trying to replace the cap. infections carried by respiratory secretions.

• Airborne precautions are used when caring for a

person who is known or thought to have an illness
• Droplet precautions are used when caring for a
person who is known or thought to have an illness
that is transmitted through the air. For example, that is transmitted by large droplets in the air, such
tuberculosis (Box 7-8) and measles are spread as a respiratory virus or meningitis. These droplets
in this manner. Airborne pathogens (pathogens are spread by sneezing, coughing, laughing, singing
expelled into the air when an infected person and talking. The droplets do not travel far. Droplet
breathes, coughs or sneezes) can travel a long precautions are similar to airborne precautions,
distance on air currents and through ventilation except a surgical (face) mask can be worn instead
systems. Therefore, airborne precautions include of a respirator.
placing the person in a private room and keeping
the door closed, wearing a respirator when • Contact precautions are used when caring for a
person who is known or thought to have an illness
providing care, and having the person wear a mask that can be spread by direct or indirect contact.
when the person must leave the room. Some types of wound infections and skin infections

84 | | Nurse Assistant Training

 can be spread in this way. Contact precautions Make a special effort to check in on the person often,
include wearing a gown and gloves when providing and take time to talk with the person. Spending time
care and containing and disposing of contaminated with the person and offering reassurance can help the
items properly. person feel better about the time spent in isolation and
the need for the transmission-based precautions.
When transmission-based precautions are in effect, a
sign may be posted outside the person’s room so that all
healthcare workers and visitors (if permitted) are aware Bloodborne Pathogens and
of the precautions that must be taken. Make sure visitors
and other healthcare workers follow these precautions.
Workplace Safety
As a nurse assistant, you are responsible for keeping
Having transmission-based precautions in effect can yourself and others safe from all infections. However,
be very difficult for the person. How would you feel some infections pose particular risk to you as a
if the door to your room had to be closed all the time healthcare worker because of their long-term effects
for isolation? Perhaps you would feel as if no one on your health if you become infected. Many of the
wanted to be near you or that no one liked you. You most serious infections that healthcare workers may be
might feel lonely, angry, depressed, embarrassed, exposed to are caused by bloodborne pathogens
afraid or all of these things! What if the people caring (disease-causing microbes that are in human blood
for you could not come near you without wearing and can cause disease in humans). Infection occurs
gowns, masks and gloves? Even though you must when blood from an infected person enters the
follow transmission-based precautions as ordered, you bloodstream of a person who is not infected. In the
can also be sensitive to the person’s feelings. Make workplace, this could happen if you stick yourself with
sure the person knows why the transmission-based a contaminated needle (a needlestick injury) or cut
precautions are being taken, and stress that these yourself with broken glass that has been soiled with
precautions will help to speed the person’s recovery blood. You could also become infected through direct
and prevent others from getting sick. Explain the contact with another person’s blood if it comes in
purpose of the PPE you are wearing. This can help the contact with your eyes, mucous membranes or an area
person get used to seeing you in protective clothing. of broken skin on your body.

Box 7-8 Tuberculosis and the Healthcare Worker

As a nurse assistant, you may care for people with Because healthcare workers are at risk for
tuberculosis, a bacterial infection of the lungs that is exposure to the pathogen that causes tuberculosis,
spread through the air from one person to another. healthcare facilities routinely screen employees
People with tuberculosis are most likely to spread for infection. Many states also require healthcare
the disease to people they spend time with every workers to be screened for tuberculosis infection
day. The bacteria are put into the air when the as a requirement for employment. Screening can
person with tuberculosis coughs, sneezes or talks. be done using a skin test called the Mantoux test,
which involves placing a small amount of tuberculin
In most people who become infected with the
(a protein made from the bacteria that causes
pathogen that causes tuberculosis, the body is able
tuberculosis) under the skin using a needle. After
to fight the pathogen and keep it from growing and
a few days, the area will become red and swollen
multiplying in the body. The pathogen becomes
if the person is infected with the pathogen that
inactive but remains alive in the body and can
causes tuberculosis. A blood test may also be
become active later. Many people with tuberculosis
used to screen for tuberculosis. Remember that a
infection never develop active tuberculosis
positive result on a screening test does not mean
disease. However, in others, the pathogen that
that you have active tuberculosis. The pathogen that
causes tuberculosis becomes active later in life,
causes tuberculosis may be alive in your body but
and the person develops tuberculosis. Although
inactive. If a screening test indicates exposure to
tuberculosis primarily affects the lungs, it can affect
tuberculosis, other follow-up tests, such as sputum
the bones, brain, kidneys and other organs as well.
testing or chest x-rays, are ordered to rule out active
If not treated, tuberculosis can be fatal. Treatment
tuberculosis.
is complex and involves taking many different
medications over an extended period of time.

Chapter 7 | Controlling the Spread of Infection | 85

 Bloodborne diseases that pose particular risk to against hepatitis B virus (HBV). Vaccination for
healthcare workers are human immunodeficiency HBV also offers protection from hepatitis D virus
virus (HIV) infection and hepatitis B, C and D. (HDV). However, there is no vaccine to protect

• HIV is a virus that that invades and destroys the

cells that help us to fight off infections. A person
against hepatitis C virus (HCV).
You and your employer share the responsibility for
who is infected with HIV may look and feel healthy protecting you from occupational exposure to
for many years. However, during this time, the virus bloodborne pathogens. Occupational exposure is
is breaking down the person’s immune system. exposure to disease in the workplace. Remember that
Eventually, most people who are infected with the standard precautions we take with every person
HIV develop acquired immunodeficiency (see Box 7-7) are designed to prevent accidental
syndrome (AIDS). A person with AIDS is unable exposure to blood and other body fluids. This is
to fight off infections that a healthy person would because you may not know whether a person is infected
be able to resist or control. The person dies from with a bloodborne pathogen or not, and it is important
one of these infections or another complication to protect yourself and others from accidental exposure.
of HIV infection. Although medications have been To effectively limit your risk for exposure to bloodborne
developed to help slow the progression of HIV pathogens while you are on the job, you must practice
infection, currently there is no cure. standard precautions consistently and correctly. Your
• Hepatitis is inflammation of the liver, an organ that
performs many vital functions for the body. There
employer also has responsibility for keeping you safe
from bloodborne pathogens on the job by making sure
are many different types and causes of hepatitis. you have the equipment and training you need to lower
Hepatitis B, hepatitis C and hepatitis D are caused your risk. Standards that employers must follow to keep
by infection with bloodborne viruses. Chronic their employees safe from occupational exposures to
infection with the viruses that cause hepatitis B, C bloodborne pathogens are outlined in the Bloodborne
or D can lead to liver failure, liver cancer and other Pathogens Standard issued by the Occupational Safety
serious conditions. A vaccine is available to protect and Health Administration (OSHA) in 2001 (Box 7-9).

Box 7-9 Bloodborne Pathogens Standard

To protect healthcare workers from exposure on during employee orientation and then at regular
the job to bloodborne pathogens, employers are intervals thereafter.
required to adhere to the following standards:
• Proper equipment. Employers are responsible
• Exposure control plan. The facility must have
a plan that outlines actions that will be taken
for providing personal protective equipment
(PPE) for employee use.
if an employee is exposed to blood or other
potentially infectious material (OPIM).
• HBV vaccination. Employers must offer
employees who have a risk of exposure to blood
OPIM includes certain body fluids such as an opportunity to receive at no cost a vaccination
cerebrospinal fluid, synovial fluid, pleural fluid, that protects against hepatitis B. An employee
pericardial fluid, peritoneal fluid, amniotic fluid, may refuse the vaccination, but if at any time the
saliva in dental procedures, any body fluid that is employee later decides to accept the vaccination,
visibly contaminated with blood, semen, vaginal the employer must provide it.
secretions and all body fluids in situations where
it is difficult or impossible to differentiate between • Work practice controls. The employer is
responsible for establishing and enforcing
body fluids. The plan must be reviewed annually procedures for handling contaminated waste,
and made available to all employees in written laundry and so on, and supplying the equipment
form. Employees are responsible for reporting needed to follow these procedures. The employer
exposure incidents so that proper follow-up (for must also ensure that necessary systems
example, medical testing) can be provided. are installed and running to maintain a safe
• Proper training. Employers must provide environment (for example, ventilation systems).
training about risks associated with bloodborne
pathogens and how to minimize these risks to all • Engineering controls. The employer is
responsible for making equipment available that
employees who may be exposed to bloodborne limits the employee’s risk for needle-stick injuries,
pathogens on the job. Training usually occurs such as sharps containers.

86 | | Nurse Assistant Training

Check Your Understanding Questions to Ask Yourself
1. How can you control the spread of infection
Questions for Review when you provide care for a person with an
1. When you take dirty linens to the laundry open wound?
hamper, you should: 2. How can you spread infection if you have a cold?
a. Shake them first. 3. In the past, how have you possibly spread
b. Hold them away from your uniform. pathogens through direct and indirect contact?
c. Take only one sheet at a time to prevent Think of three ways.
contamination. 4. What will you do in the future to avoid spreading
d. Save steps by tossing them into the laundry pathogens by direct and indirect contact? Think
hamper from a short distance. of three ways.
2. What is the most important thing you can do to 5. Airborne precautions are in effect for
control the spread of microbes? Mr. Thompson. You are changing Mr. Thompson’s
linens when you realize that you brought only
a. Bag all contaminated linens.
one sheet instead of two. How would you handle
b. Wash your hands. this problem? What would you do first?
c. Always cover bedpans and urinals when
carrying them from place to place. 6. When you put on gloves to help Mr. Wilson with
mouth care, he eyes the gloves and says, “I don’t
d. Eat a well-balanced diet and stay healthy.
have AIDS, you know. Why are you wearing those
3. You should practice standard precautions: things?” How should you respond?
a. When you provide care for any person. 7. Emma Jones, who works as a nurse assistant,
b. Only when you provide care for people became engaged over the weekend. She wants
infected with HIV or HBV. to wear her new engagement ring to work on
c. Only when a person is in isolation. Monday so that she can show it off. What does
she need to consider when deciding whether to
d. Only when you need to wash your hands.
wear the ring?
4. What is one time when you must wear gloves? 8. The nurse asks for your help to position a person
a. When you give someone a back rub on their side. The person has a large, open,
b. When you cough or sneeze draining wound that needs cleaning. The nurse
c. When you serve meal trays explains to you that a great deal of solution will
be used to clean the wound and that it is likely
d. When you touch blood or other body fluids
to splash. What personal protective equipment
5. If you have a cut or open sore on your hand, (PPE) should you put on and why?
what must you do to protect yourself and
others from infection?
a. Avoid providing care for people with infections. What Would You Do?
b. Stay away from work until the wound heals.
c. Wear gloves while providing care. Think back to your new patient, Mrs. Wang.
d. Handle only clean items. Recall that you will be responsible for helping
Mrs. Wang with emptying her ostomy appliance
6. Which of the following is a reason to place and with bathing.
someone in isolation? 1. Should you wear gloves when assisting Mrs.
a. The person has a contagious disease. Wang with these activities? Why or why not?
2. What would you do if the ostomy bag began to
b. The person had surgery. leak, spilling feces on Mrs. Wang’s abdomen?
c. The person is demanding and cannot get You know from the nurse’s report that droplet pre-
along with others. cautions are in effect for Mrs. Wang because staph
d. The person wants the privacy of a single room. pneumonia is contagious. As you enter Mrs. Wang’s

Chapter 7 | Controlling the Spread of Infection | 87

 room, she turns her face away and covers her eyes 2. What would you do to provide emotional support
so that you can’t see her tears. “Good morning, to Mrs. Wang, in addition to providing physical
Mrs. Wang,” you say and then introduce yourself. care?
You explain that you will be taking care of her today. 3. What information would you give Mrs. Wang
Mrs. Wang looks at you and smiles sadly. about the transmission-based precautions that
1. What might be bothering Mrs. Wang? are being used?

88 | | Nurse Assistant Training

 SKILLS

Skill 7-1
Hand Washing

PREPARATION
1. Gather your supplies:
• The nails (rub against the palms of your hands,
or use an orange stick or nail brush to clean

• Soap
underneath them).

• Paper towels
• Orange stick or nail brush (optional)
• Lotion (optional)
2. Remove your watch or push it up on your
forearm. If you are wearing long sleeves, push
them up.

PROCEDURE
3. Turn on the water and adjust the temperature until
it is comfortably warm.
4. Put your hands under the running water to wet
your hands and wrists, keeping your hands and Figure 1B
wrists below the level of your elbows.
5. Apply soap from the dispenser.
6. Rub your hands together vigorously to work up a
lather.
7. Wash vigorously for at least 20 seconds (Figure 1,
A–D), paying particular attention to:
• The wrists (grasp and circle with your other
hand).
• The palms and backs of your hands.
• The areas between the fingers.
Figure 1C

Figure 1A Figure 1D

(CONTINUED)

Chapter 7 | Controlling the Spread of Infection | 89

 SKILLS

Skill 7-1
Hand Washing CONTINUED
8. Rinse your hands and wrists under the running 10. Use another clean, dry paper towel to turn off the
water, keeping your hands lower than your elbows faucets (Figure 4). Discard the paper towel in a
and the fingertips down (Figure 2). facility-approved waste container.

Figure 2 Figure 4

9. Using a clean, dry paper towel, dry your hands 11. Exit the hand-washing area by pushing the door
thoroughly, beginning at the fingertips and moving open with your shoulder and hip. If the door has
back toward the elbow (Figure 3). Drying your a handle, turn the handle using a paper towel to
hands thoroughly keeps them from becoming avoid contaminating your clean hands.
chapped. Discard the paper towel in a facility- 12. If desired, apply a small amount of hand lotion to
approved waste container. prevent chapping and dryness.

Figure 3

90 | | Nurse Assistant Training

 SKILLS

Skill 7-2
Using Personal Protective Equipment (PPE)—Gown,
Mask, Eyewear, Gloves

PREPARATION Putting on a Mask

1. Gather your supplies: 5. Put the mask over your mouth and nose.

• Gown 6. Tie the top strings behind your head, then tie the
• Mask bottom strings or place the elastic loops around

• Protective eyewear your ears (Figure 2).

• Gloves
2. Wash your hands.

PROCEDURE
Putting on a Gown
3. Slide your arms through the armholes, keeping the
opening of the gown in the back.
4. Fasten the ties at the back of your neck and at your
waist, making sure the edges of the gown overlap
so that your back is completely covered (Figure 1).

Figure 2

7. Adjust the mask for comfort. If necessary, bend the

nose wire to fit.
Putting on Protective Eyewear
8. Place the earpieces over your ears or the
headband around your head and adjust the fit.
Putting on Gloves
9. Inspect both gloves carefully for tears.
10. Put the gloves on carefully so that they do not tear.
Figure 1 Pull the gloves up over the gown cuffs (Figure 3).

Figure 3

(CONTINUED)

Chapter 7 | Controlling the Spread of Infection | 91

 SKILLS

Skill 7-2
Using Personal Protective Equipment (PPE)—Gown,
Mask, Eyewear, Gloves CONTINUED
Taking off Gloves 14. Carefully slip two fingers under the wrist of the
11. Pinch the palm sides of one glove on the outside other glove. Avoid touching the outside of the
near your wrist (Figure 4). glove (Figure 7).

Figure 7
Figure 4
15. Pull the glove toward your fingertips, turning it
12. Pull the glove toward your fingertips, turning it inside out as your pull it off your hand. The other
inside out as you pull it off your hand (Figure 5). glove is now contained inside (Figure 8).

Figure 5 Figure 8

13. Hold the glove in the palm of your other (still- 16. Dispose of the gloves in a facility-approved waste
gloved) hand (Figure 6). container.
Taking off Protective Eyewear
17. Touch only the earpieces or the head band.
18. Place the eyewear in the appropriate container
for reprocessing or discard in a facility-approved
waste container.

Figure 6
(CONTINUED)

92 | | Nurse Assistant Training

 SKILLS

Skill 7-2
Using Personal Protective Equipment (PPE)—Gown,
Mask, Eyewear, Gloves CONTINUED
Taking off a Gown 23. Fold the outer, contaminated surface inward and
19. Untie the neck and waist strings. roll up the gown (Figure 11).
20. Pull off one gown sleeve by slipping your fingers
under the cuff and pulling the sleeve just over your
fingertips.
21. Grasp the other sleeve with the covered hand
(Figure 9) and pull it off.

Figure 11

24. Discard the gown in a facility-approved waste

container, or place the gown in the laundry
hamper, if it is not disposable.
Figure 9 Taking off a Mask
22. Continue holding that sleeve in your covered hand. 25. Untie the bottom strings and then the top strings,
Grasp the inside of the first shoulder of the gown or pull the elastic loop from around one ear and
with your uncovered hand and pull the gown off then the other.
the shoulder (Figure 10). Continue to bring the 26. Hold the mask by the strings (Figure 12) and
gown forward and turn it inside out as you pull it discard it in a facility-approved waste container.
over your covered hand.

Figure 10 Figure 12

COMPLETION
27. Wash your hands.

Chapter 7 | Controlling the Spread of Infection | 93

 SKILLS

Skill 7-3
Handling a Plastic Trash Bag

PREPARATION 8. Put the bag with contaminated items into the clean
Gather supplies: bag that your co-worker is holding under the cuff

•Plastic trash bag(s) (Figure 2).

PROCEDURE
Opening a Plastic Trash Bag
1. Open the plastic trash bag and make a cuff around
the opened edge.
2. Put the opened bag on a clean surface within easy
reach of your work area.
Closing a Used Plastic Trash Bag
3. Put your fingers under the cuffed edge of the used
plastic trash bag.
4. Pull the cuffed edges together and close the bag
Figure 2
by tying a knot. Touch only the outside of the bag
because the inside of the bag is contaminated. 9. Have your co-worker close the outside bag by
Double-Bagging a Bag That Is raising the cuffed area and tying a knot.
Contaminated with Body Fluids 10. Have your co-worker take the bag to the
5. Arrange for a co-worker to assist you at a certain area designated for disposal or laundering of
time. contaminated items.
6. Remove the bag from the trash or laundry 11. Wash your hands.
container inside the person’s room, close it and
carry it to the door of the person’s room.
7. Have your co-worker prepare a clean bag by
folding down a cuff at the top of the clean bag
(Figure 1). Have your co-worker hold the clean
bag under the cuff and stand by the doorway.

Figure 1

94 | | Nurse Assistant Training