Transcript Slide 1

Preventing Surgical Site Infections
in the Diabetic Cardiac Surgical
Patient
Paula Pintar BSN, RN
Alverno College – MSN Student
Tutorial Project Spring 2010
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Learning
Objectives
Surgical
Site Infection
What is it?
Why are Surgical
Site Infections a
Problem?
Significance
Of
Diabetes Mellitus
“Bundle”
Elements &
Nsg. Interventions
Stages of Surgical
Wound Healing
Activation of
Stress Response
And Surgery
Age &
Wound Healing
Key Risks
With
Wound Healing
Case Study
Part 2
Case Study
Part 1
Tying It All
Together
Best Practice
Standards
“Bundle”
References
Inflammation
&
Wound Healing
Genetics
&
Wound Healing
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information about.
Learning Objectives
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The Learner Will:
Identify criteria used for classifying a surgical site infection (SSI).
Identify why Surgical Site infections are a problem.
Review of Diabetes Mellitus and the genetic link of incidence.
Identify what risk factors can put Diabetic patients at a higher risk to
developing a Surgical Site infection.
Review the three main stages of wound healing: Inflammation, Proliferation,
Remodeling.
Be able to correlate the factors of Age, Inflammation, and the Generalized
Stress Response in the diabetic patient; relate how these factors impact the
stages of wound healing.
Review Best Practice Standards and Nursing interventions for a Surgical Site
infection prevention plan.
Apply Nursing indicators to a case study.
Understand how applying “best practice guidelines” will support positive
outcomes for the patient, family, staff, health system, and community.
Surgical Site Infection (SSI)
What Is It?
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Source: 1
Clinical and laboratory signs of infection at the surgical site
within:
30 days of the surgery or
Within 1 year if an implant was used (heart valve/joint)
Criteria for Defining a Surgical Site Infection (SSI)
Documented at various tissue levels:
 Superficial (skin/subcutaneous)
 Deep (soft tissue/muscle)
 Deep/organ space (organ space)
Caused by:
 Endogenous bacteria – patients’ own skin flora
 Exogenous bacteria – environmental bacteria or surgical
material
SSI As Defined by the CDC
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Superficial
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Infection within 30 days after procedure
Involves the skin and subcutaneous tissue (and meets one of the following
criteria)
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Has purulent drainage
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Organisms cultured from fluid or tissue
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Displays at least 1 of the following pain, local swelling, redness, and
incision is opened by surgeon
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Diagnosis of superficial incision SSI by the surgeon or attending MD
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Source:1
SSI As Defined by the CDC
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Deep Incisional SSI
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Source: 1
Occurs within 30 days of procedure
1 year if implant
Involves deep soft tissue ( fascial and muscle layers)
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And patient displays at least one of the following
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Purulent drainage
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Spontaneously dehisces or opened by the surgeon and the
patient has at least one of the following:
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Fever, pain, abscess, or diagnosis by MD
SSI As Defined by the CDC
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Organ space
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Source: 1
Occurs with in 30 days
1 year if implant used
Includes any part of the body excluding skin, fascia, or muscle layer.
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Must meet the following criteria
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Purulent drainage from a drain that is place through a stab
wound
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Isolated organisms from an aseptic culture
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Abscess
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Diagnosis by MD
Lets Review
What are the 3 tissue levels of a Surgical Site
Infection?
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Deep
Acute
Organ
Space
Primary
Superficial
Scar
Surgical Site Infection
Why Is It A Problem?
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Source: 1
According to the Institute for Healthcare Improvement (IHI)
38% of all Healthcare Associated Infections are SSI’s
2 – 5% of patients operated on will develop an SSI
Developing an SSI will extend the hospital stay by 5 to 7 days
One SSI will increase cost by $2,734 - $26,019 (estimated on 1985
dollars)
Estimated national costs of 130 million to 845 million dollars spent a year
on SSI’s.
What Does this Mean at a Local
Level?
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Higher cost related to longer stays
Decreased patient turnover translates into less income for healthcare facility
Healthcare facility develops a reputation of poor patient outcomes.
Decreased reimbursement by The Centers for Medicare and Medicaid
(CMS) as of October 1, 2008 stopped reimbursement for hospital acquired
infections
Microsoft clipart
Source: 16
What Does this Mean at a Local
Level?
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Source: 16
Negative Outcomes Linked to SSI’s
Trend is toward public reporting of infection rates for healthcare facilities.
This will impact consumer decisions as to where they will go to have
procedures performed.
Consumers have greater access to information - Intranet
Milwaukee has number of facilities with duplicative resources. Patients
may begin shopping around for facility with lowest infection rates.
Microsoft Clipart
Lets Review
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According to the Institute for Healthcare Improvement
(IHI)
38% of all Healthcare Associated Infections are SSI’s.
True
Developing an SSI will extend
the hospital stay by 5 to 7 days.
True
False
Increased reimbursement by
The Centers for Medicare and Medicaid (CMS)
as of October 1, 2008 started for
hospital acquired infections.
True
False
Trend is toward public reporting
of infection rates for healthcare facilities.
True
False
False
Now With The Problem Identified…
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Lets take a closer look at a patient population (diabetes mellitus), and
apply nursing indicators and medical knowledge to decrease and prevent
the development of Surgical Site Infections.
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Significance of Diabetes Mellitus
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Diabetes mellitus affects approximately 2.8 million
people in the United States
The disease is a metabolic process that results from a
lack of insulin secretion or action.
Insulin is a hormone that is secreted by the beta cells in
the pancreas.
This hormone then allows the cells in our body to
absorb the glucose and convert it into energy to
maintain metabolic processes.
There are two main types of diabetes mellitus that the
majority of diabetics are classified into.
Source: 6
Microsoft Clipart
Diabetes Mellitus & Genetic Link
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Type 1:
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This is characterized by an complete lack of insulin
secretion and elevated blood sugar, related to
destroyed pancreatic beta cells (6)
Usually occurs at an early age (childhood)
5 to 10% of the diabetic population have this type
of diabetes (~ 1 million people) (6)
These individuals have been associated with an
autoimmune link to the disease. (4)
This autoimmune response is the cause of beta cell
destruction (4)
The other factor identified is an exposure to an
environmental mediator, such as having an
infection. (6)
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Source: 4, 6
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Diabetes Mellitus & Age Link
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Type 2 :
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This is characterized by having insulin resistance
Approximately 90 to 95% of diabetics present with this
type (~19 million people)
18 -20% of persons 65 and older have diabetes
40% have the disease or precursor to disease
Obesity and older individuals is commonly associated
with Type 2
There is multiple hypothesis as to the causal agents of
this form.
Due to the variability of the causal agents, it is difficult to
predict or identify specific factors that lead to disease.
It is known that autoimmune destruction of the beta cells,
as in Type 1 does not occur.
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Source: 6
Microsoft Clipart
Diabetes Mellitus & Link to
Developing an SSI
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Studies correlating elevated levels of hemoglobin A1C 6.5 (HgA1C) and
uncontrolled blood sugars in the postoperative period have had a higher
incidence of postoperative wound infections.
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Blood glucose levels >200mg/dL in immediate postoperative period
and up to 48 hours post operatively are a key link to SSI
development.
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Phagocyte activity is altered by the elevated blood glucose levels.
Source: 6
Lets Review
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What is the key reference data used to
monitor blood sugar stability over time?
K level
Amylase
Correct
In Correct
C reactive protein
Hgb A1C
Finger stick glucose
Blood pressure
Urine
glucose
Review of the Surgical Wound Healing
Process
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There are 3 main stages of wound healing
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1. Inflammation
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2. Proliferation
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3. Remodeling
Within each stage there is a complex system of
cellular functions that occur. (5)
Factors that can impede good wound healing
are:
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Poor diet/uncontrolled blood sugars
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Compromised blood flow
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Disruption of inflammatory response
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Infection
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Effects of age (14)
Source: 5,14
Microsoft Clipart
Surgical Wound Healing Stages
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Stage 1 Inflammatory (acute)
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Incision – initial vasoconstriction followed by platelet
aggregation to damaged endothelium (14)
Followed by a dilation of capillaries
Around 24 hours macrophages enter the area and remain
there to clean up cellular debris and stimulate the healing
process (5)
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Microsoft Clipart
Source: 5,15
Surgical Wound Healing Stages
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Stage 2 – Proliferation
24-48 hours after wound occurrence the
fibroblast and vascular endothelial cells
begin formation (5)
This is a fragile period for the wound due
to new capillary growth (14)
Then formation of new dermal layers
begins (14)
Microsoft Clipart
Source: 5,15
Review of Surgical Wound
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Source: 14
Stage 3 – Remodeling
Occurs post wound by about week 3
Formation of a scar develops
During this process the healing wound experiences a
decrease in vascularization with the continuing
development of scar tissue.
Lets Review
Stage Definition
Stages of Wound Healing
New capillary growth
Inflammation
Wound stabilization
Proliferation
Debris removal
Click on stage definition
Remodeling
Age & Wound Healing
Stages of Wound Healing
Inflammation
Proliferation
Remodeling
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Immunosenescence or age-related changes impact the
immune system, putting these individuals at a higher
risk for infection.
By age 50 the thymus gland has decreased in size.
The function of the helper T cells deteriorates
Which in turn prolongs the inflammation phase of
wound healing.
During cardiopulmonary bypass blood cells are
“bypassed” in normal circulation. This activates the
cytokine response and activation of the phagocyte cells.
Source:12
Microsoft Clipart
Inflammation & Wound Healing
Stages of Wound Healing
Inflammation
Proliferation
Remodeling
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Source: 14
The key mediators in inflammation are Cytokines & Chemokines
These proteins activate the macrophages and lymphocytes.
Other contributing risk factors are high blood pressure, altered platelet
function, systemic inflammation noted by elevated C-reactive protein.
There is a thickening of the blood vessel walls that supply nerves. This
causes a decreased blood supply to tissues.
Elevated blood glucose levels cause damage to small blood vessels. In
time this causes defects in the cell structure at the microcirculation level.
Genetics & Wound Healing
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Source: 14
Diabetes has the genetic disease link that
contributes to poor wound healing.
Hyperglycemia will affect phagocyte function by
lessening the chemotaxic and phagocytic action
of the neutrophils.
Microsoft Clipart
A Closer Look at the Generalized
Stress Response (GSR), DM and SSI
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During periods of stress such as surgery and
anesthesia
There is an increase release of growth hormones
With this response there is a mobilization of fatty
acids from the adipose tissue.
This decreases the cellular utilization of glucose
causing a rise in blood glucose levels
During periods of stress, diabetic patients react
with a variety of metabolic processes despite
optimal insulin management
Microsoft Clipart
Source: 7
Review of the GSR
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GSR – also known as “fight or flight response”
It is the sympathetic nervous system release of
Catecholamine's:
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epinephrine
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adrenalin
The elderly individual has a slower response to
epinephrine and it takes them longer to recover
from its effects.
Excretion of these catecholamine's is also slower.
Lets take a closer look at what happens to blood
sugar in response to stress response. (next slide)
Source: 15
Action of the (GSR)
Click on
each object in order
1
Stress
3
Maintaining
Blood Glucose is the
Body’s goal
2
Adrenal medulla
Releases Epinephrine
4
Liver releases glucose
into blood
5
Release of fatty acid
from the fat cells
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Increase muscle
breakdown
of glycogen stores
Source: 15
6
Stops insulin release
from beta cells
8
Decrease glucose
movement
into muscles
Microsoft Clipart
Generalized Stress Response & DM
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The Diabetic patient experiencing stress will have
added risk to SSI development
Sporadic, transient increases of cortisol can affect
blood sugar control
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There is an increased secretion of cortisol in response to stress, (it can
cause damage to brain neurons over time) if the levels become too
high.
This is a Positive feedback system – an example of this is when an
elderly person secretes cortisol in response to stress. Repeated
exposure to the neurons causes the damaged. Therefore the neurons
can no longer sense the level and the hypothalamus continues to
secrete the hormone.
To view graphic of Positive Feedback
System, click HERE
Source: 15
Graphic of Generalized Stress
Response
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Positive Feedback
System
Hypothalamus
measures cortisol.
In times of stress,
releases CRH
Source: 15
Over time and repeated
stress response
activation leads to
damage of neurons
Neurons in
hypothalamus
unable to sense
elevated cortisol level.
Cont. to release CRH
Wound Healing & Increased Risk of SSI
Occurrence
Stages of Wound Healing
Inflammation
Proliferation
Remodeling
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There is a 20% decrease in the dermal layer
This translates into less strength and elasticity
Blood vessels supplying the dermis are also more
fragile
These conditions translate into a decrease of vascular
circulation with a decrease in oxygen delivery to the
wound site.
Elderly persons have stiffer arteries and narrower
capillaries which will accentuate the effects of diabetes
Source: 14
Microsoft Clipart
A Closer Look at the Who, What, and
Why Of SSI Development
Stages of Wound Healing
Inflammation
Proliferation
Remodeling
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Source:13
Early detection of infection is difficult as aged (65 or older) individuals
present with atypical signs and symptoms: lack of elevated white blood
cell count and temperature
Persons with diabetes mellitus have neuropathic and peripheral vascular
disease which will impact circulation to the wound site.
Age is a predisposing factor resulting in decreased function of systems
with an increased susceptibility to stressors.
Case Study – Part 1
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Lets apply this knowledge to a case study:
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65 year old Caucasian, widowed female who is overweight (101 kg.) has a
sedentary life style and lives alone.
She has had poor medical care due to lack of financial resources.
She thinks she recalls a doctor telling her in the past that she may have
diabetes or “something.”
The patient is now in the Cardiovascular Surgical Intensive care unit
following surgery of a 4 vessel myocardial revascularization.
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Microsoft Clipart
Case Study – Part 1
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Post operative day #1 Patient presents with the
following:
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Elevated blood glucose for the last 4 assessments: 190,
200,207,195
Fatigue and difficult to arouse
Low blood pressure :100/60
Sinus tachycardia: 120 bpm
Urine output: 25-30cc/hr
Low grade temperature: 99.1 blood temp
Slight elevated white blood cell count: 11,000
Elevated C-reactive protein (CRP) level: 2
Decreased bilateral pedal pulses: + 1
Cool bilateral lower leg extremities: new on
assessment
Microsoft Clipart
Case Study – Part 1
Indicators that may lead to an
SSI
Diabetes
Mellitus
Inflammation
Lack of family support
Low grade temperature
Risk Factors
of
SSI?
GSR
Unstable blood sugars
Fatigue
Decreased pedal pulses
Cool lower leg extremities
Obesity
Temperature
Age
Sinus tachycardia
Increased WBC
Decreased urine output
Increased CRP
Click an indicators on the right to see what
Physiological system they belong to.
Best Practice Standards – “Bundle”
Elements
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Source: 2
A “Bundle” is a group of researched based best practice
interventions.
It is shown that when bundle elements are implemented
together patient outcomes improve.
Best Practice Standards – “Bundle”
Elements
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Source: 2
Strict adherence to hand hygiene www.cdc.gov/handhygiene/Patient_Admission_Video.html
Treat all remote infections to the elective surgical site prior surgery
Do not shave hair at surgical site, but use clippers. This will cause less
microabraisions to the skin.
Control serum blood sugar levels, avoid hyperglycemic states.
Recommend stopping tobacco use
Antiseptic showers prior surgical procedure
Use appropriate surgical skin prep
Surgical team hand & forearm antisepsis
Administration of appropriate antimicrobial prophylaxis drug at the correct
time, and dose prior surgical incision (30min.)
Bundle Elements & Nursing
Interventions
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Source: 2
Pre-surgical baths have shown to decrease skin flora and multi-drug
resistant bacteria (MDRO's) such as Methicillin resistant Staphaureus,
vancomycin resistant Enterococci that may lead to surgical site
infections.
Most SSI’s are caused by the patients own bacterial flora
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20% Staphylococcus aureus
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14% Coagulase negative staphylococcus
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12% Enterococci
Bundle Elements & Nursing
Interventions
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Glucose control intra-operative and postoperative
(target less than 200 mg/dL)
Unstable blood sugars affect the neutrophils ability
to provide adequately functioning phagocytes
Maintaining the postoperative dressing for 24-48
hours
This is a critical time period when wound site is
gaining stability in cellular repair and
revascularization.
Source: 10
Bundle Elements & Nursing
Interventions
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Appropriate surgical antimicrobial
prophylaxis given at:
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Source: 1, 3
The appropriate time – 30 minutes prior cut time
Provides a therapeutic blood & tissue level of antibiotic at
time of surgery
Appropriate dosage – weight based. Repeat dose if
surgery extends past the ½ life of the drug
Appropriate agent – for gram negative and gram positive
organisms
Discontinue antibiotic 24 hours post surgery – assists in
decreasing resistance. Doses past 24 hour time frame of
wound closure have not proven beneficial.
Bundle Elements & Nursing
Interventions
Clipping surgical site in place of
shaving
Eliminates micro abrasions to the skin
that provides an entry portal for
microorganisms
Microsoft Clipart
Source: 2
Bundle Elements & Nursing
Interventions
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Maintain normothermia (greater that 36.0
Celsius) pre, intra, and postoperatively
Decreases vasoconstriction in blood vessels.
Normothermia will promote the blood flow
and oxygen delivery to the cells
Fosters immune function preservation
If normothermia maintained produces less
overall stress to diabetic patient
Microsoft Clipart
Source: 9
Let’s Review
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Bundle elements produce better
patient outcomes.
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True
False
Application of bundle practices
are researched based.
True
False
Using appropriate antibiotic
therapy is a key bundle
True
component.
False
What’s New?...Not Much!
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Source: 3
Decreased emphasis and incentive for drug manufactures to develop new
generations of antimicrobials to treat infections.
More deaths related to Methicillin-resistant Staphylococcus aureus
(MRSA) in U.S. facilities than from HIV/AIDS & Tuberculosis
combined.
Only 83 antibacterial in clinical trials – very small number in late stage
testing
Only 5 pharmaceutical companies still support antibacterial programs.
Antibiotic Manufacturing Strategies
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Source: 3
Infectious Disease Society of America (ISDA) is working on a plan in
cooperation with the pharmaceutical industry and academia to create and
sustain research and a long term plan.
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Incorporate big pharmacies, and small entities
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Create incentives for pharmaceutical companies to participate in
antibiotic research and development.
Case Study – Part 2
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Lets apply this knowledge to our case study:
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Post operative surgical day #3 Assessment findings:
Blood Sugar range 185-220 over last 48hours
Temp. 99.1-100.9(oral ranges)
WBC 11,000
CRP level 3
Sternal incision warm, red, small opening at bottom draining
creamy white fluid
Wound culture showing Moderate PMS’s & Moderate colonies
of Staphylococcus aureus
Fatigues easily
Stable SBP, Sinus tachycardia (105-110bpm), U.O. 30cc/hr
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Microsoft Clipart
Case Study – Part 2
1.
2.
3.
4.
5.
6.
Diabetes affect 2.8 million people in the United States. Identify three case study laboratory
results that may be indicators of an SSI.
Temperature, WBC, CRP, U.O., Positive wound culture, Fatigue
What assessment finding is a response to activation of the Generalized Stress Response?
Increased Heart Rate, Warm draining wound, Positive wound culture
During cardiovascular revascularization surgery, what process causes a cytokine response?
The process of “bypass”, anesthesia, maintaining normothermia
In reference to question 3, what stage of wound healing is critical to a diabetic with
uncontrolled blood sugars?
Inflammation, Proliferation, Remodeling
How is the proliferation stage of wound healing affected by diabetes?
Microcirculation, cellular regeneration , decrease in metabolic needs
What three nursing interventions can be initiated to help decrease the risk of
patients developing an SSI?
Hand Hygiene, Blood glucose control, Maintaining normothermia, quick ventilator
weaning, frequent turning of patient
Tying It All Together
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Surgical Site Infections affect patients, families, hospital systems,
and communities.
They add to personal pain and suffering, mortality and financial
burdens.
Research has identified that using the “Bundle” method of
preventive measures is more effective in preventing SSI’s than
when elements are applied inconsistently and individually.
Diabetics are at a higher surgical risk due to the inflammation
correlation process of their disease.
Tying It All Together
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Nursing Interventions
Key “take away” – Astute assessments and documentation of
subtle indicators
 Hand hygiene before all patient cares, tight control of
blood sugars, slight elevated WBC, mental status changes,
low grade temps, maintain surgical wound dressing in
place for 24 – 48 hours.
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
Barnard, B. (2003). Best practices prevention of surgical site infections. Infection Control Today, 1-6.
Retrieved February 23, 2010 from http://www.infectioncontroltoday.com/articles/341bpract.html
Beaver, M. (2008). CABG wound are best practices are elusive. Infection Control Today, 1-4. Retrieved
February 23, 2010 from http://www.infectioncontroltoday.com/articles/cabg-wound-care-best.html
Boucher, H.W., Talbot, G.H., Bradley, J.S., Edwards, J.E., Gilbert, D., Reice, L.B., etal. (2009). Bad
bugs, no drugs: no ESKAPE! An update from the infectious diseases society of america, 48, 1-12.
Infectious Disease Society of Americal
Connection diabetes and inflammation. Science Daily, 1-2. Retrieved March 22, 2010, from
http://www.sciencedaily.com/released/2007/07/070722105802.htm
De la Torre, J. & Chambers, J.A. (2008). Wound healing, chronic wounds. Plastic Surgery, 1-5.
Retrieved March 21, 2010, from the Medsape database.
Diagnosis and classification of diabetes mellitus. American Diabetes Association, 1-11. Retrieved
March 15, 2010, from http://care.diabetesjournals.org/content/33/supplement_l/s62.full
Engelic, G., Wright, D.G., Hartshorn, K.L. (2001). Acquired disorders of phagocyte function
complicating medical and surgical illness. Clinical Infectious Diseases, 33, 2040-8.
http://en.wikipedia.org/wiki/Diabetes
Kurz, A. Sesslelr, D.I., Lenhardt, R. (1996). Perioperative normothermia to reduce the incidence of
surgical wound infection and shorten hospitalization. New England Journal of Medicine, 334, 13091216. Retrieved March 26, 2010, from http://www.endo.gr/cgi/content/full/334/19/1209
References
10.
11.
12.
13.
14.
15.
16.
17.
Mercandetti, M. & Cohen, A.J. (2008) Wound healing, healing and repair. Plastic Surgery, 1-5.
Retrieved March 26, 2010, from Medscape database.
Microsoft clipart online.
Porth, C.M. & Matfin, G. (2009). Pathophsiology concepts of altered health states. In. H. Surrena, et al
(Ed.), Concepts of altered health in order adults (pp.36-55). Philadelphia, PA:Wolters Kluwer
Health/Lippincott Williams & Wilkins.
Porth, C.M. & Matfin, G. (2009). Pathophsiology concepts of altered health states. In. H. Surrena, et al
(Ed.), Diabetes mellitus and the metabolic syndrome (pp. 1047-1077). Philadelphia, PA:Wolters Kluwer
Health/Lippincott Williams & Wilkins.
Porth, C.M. & Matfin, G. (2009). Pathophsiology concepts of altered health states. In. H. Surrena, et al
(Ed.), Inflammation, tissue repair, and wound healing (377-399). Philadelphia, PA:Wolters Kluwer
Health/Lippincott Williams & Wilkins.
Porth, C.M. & Matfin, G. (2009). Pathophsiology concepts of altered health states. In. H. Surrena, et al
(Ed.), Stress and adaptation (198-238). Philadelphia, PA:Wolters Kluwer Health/Lippincott Williams &
Wilkins.
Stone, P.W., (2009). Changes in medicare reimbursement for hospital-acquired conditions including
infections. Association for Professionals in Infection Control and Epidemiology, 37, 12!-18A.
Swenson, B.R., Hedrick, T.L., Mezger, R., Bonartt, H., Ruett, T.L., Sqwyefr, R.G. (2009). Effects of
preoperative skin preparation on postoperative wound infection rates: a prospective study of 3 skin
prparitn protocols. Infection Control and Hospital Epidemiology, 30, 964-971.
The End
Thank you for your attention and participation!