Medic-CE

Infection Control on the Job: Approach to the Patient

General Approach:

Once you have surveyed the scene and are wearing the proper personal protective equipment, you can now approach the patient. Be highly suspicious of infectious diseases in all patients, and do not be afraid to acknowledge intuition that an emergency call may involve exposure to infectious substances.

Make sure that you have observed appropriate hand hygiene measures before making contact with the patient. When working in pairs, contact with the patient should be limited to the individual involved in direct patient care, so as to limit exposure. If possible, use disposable equipment when assessing and managing a patient.

Once physical contact has been made with the patient or his or her surroundings, DO NOT expose your mucous membranes to infectious material. In other words, do no rub your nose or mouth, handle contact lenses, apply lip balm, or itch your eyes, for example.

If using sharps, be sure to exercise caution. Use them only for the purpose intended and dispose of them immediately in a labeled, puncture-proof container.

Finally, NEVER smoke, eat, or drink while caring for or transporting a patient. Not only is this disrespectful, but it is also a great way to contract and transmit infectious diseases!

Key Aspects of the Patient History:

When evaluating a patient suspected of having an infectious disease, the following aspects of the patient history are important.

-Primary Complaint: Ask the patient to describe the primary complaint in his or her own words.

-Associated Symptoms: Does the patient have a fever, headache, cough, muscle aches, or difficulty swallowing? Does the patient have any focal areas of swelling, such as enlarged lymph nodes? All of the aforementioned symptoms are general indicators of infection.

-Additionally, ask the patient if he or she has any neck pain, especially when flexing the chin toward the chest. This may indicate an infection of the brain, or the membranes that line the brain.

-Onset: When did the pain/complaint begin?

-Duration: How long have the symptoms been present?

-Severity: Assess the severity of each symptom. How high is the fever? How severe is the headache, etc.?

-History of Similar Events: Is this the first time the patient has experienced this particular complaint, or has it occurred before? If so, what happened then? Did the patient seek medical treatment? Why or why not?

-Past Medical History: It is very important to obtain the past medical history from potentially infectious patients. In many cases, if a patient harbors a dangerous infectious disease, he or she will tell you immediately. In some cases, you will need to directly ask the patient about any history of HIV or hepatitis.

-It is also important to focus questions on the immune status of an individual.

-Ask about a history of endocrine disorders, such as diabetes, or respiratory conditions, such as COPD, that place a patient at an increased risk for infectious diseases.

-Ask about any organ transplants, autoimmune disorders, or severe respiratory conditions for which a person may be taking immunosuppressive medications.

-Ask if the patient was born with any immune system deficiencies.

-It may also help to ask about alcoholism, malnutrition, IV drug use, surgery for spleen removal, heart surgery with valve replacement, or malignancy, as these conditions can increase the risk of development of an infectious disease.

-Medications: Ask about general medications the patient is taking. Has the patient been taking any medications to relieve the symptoms, such as a decongestant, or anti-pyretic? This is helpful because medications may mask symptoms.

-In addition, identify if the patient has recently taken antibiotics for an infection and if the complete course was taken. A recent infection that did not resolve with antibiotics, or that persisted without completion of an antibiotic regimen may signal a resistant strain. You should also specifically inquire about steroids and immunosuppressive medications.

-It may be helpful to take the patient’s medications with you to the destination facility.

-Other: As always, if time and circumstances allow, obtain a complete SAMPLE history, with a focused OPQRST analysis of the chief complaint.

Key Aspects of the Physical Exam:

-General Appearance: You may learn much about a patient’s health status just by observation. Identify if the patient is writhing in pain or resting comfortably. Is the patient able to communicate with you in a coordinated and coherent manner? Is the patient yellow in color (known as jaundice)? Are the whites of the eyes yellow in color (known as scleral icterus)? These last two findings may signify liver disease.

-Skin Exam: Carefully examine the skin, paying close attention to temperature, hydration status, color, rashes, and focal areas of swelling, such as lymph nodes.

-Neurologic Exam: Assess the patient’s level of consciousness. Is the patient Alert? Does the patient respond to Verbal stimuli? Does the patient respond to Painful stimuli? Is the patient Unresponsive?

-In addition, identify any sensory or motor deficits. Also, assess whether the patient has any pain on neck flexion. These signs may indicate infection of nervous system structures.

-Respiratory Exam: Evaluate for signs or symptoms of respiratory distress. Listen for wheezing, stridor, or crackles during respiration. Also, listen for any areas over the lung fields where breath sounds are diminished. These signs may help you determine if there is a respiratory infection.

-Abdominal Exam: Palpate for abdominal tenderness. Also, if the patient’s condition allows, palpate deeply in the right upper quadrant for the liver and in the left upper quadrant for the spleen. Certain infections can result in these organs enlarging or shrinking.

-Vital Signs: Record vital signs, at frequent intervals, if possible. Be sure to obtain an accurate temperature (see below).

****NOTE: Vital signs and infection.

-The patient’s HR will likely be increased if the temperature is elevated.

-Very ill elderly patients may not have a fever or may be hypothermic.

Evaluating Body Temperature:

There are several anatomical options for measuring temperature including the use of the rectum, mouth, armpit, eardrum, and skin.

-The Rectum:

Rectal temperature provides the most accurate method of estimating a patient’s core body temperature. However, most adults will object to having their temperatures checked via the rectum. Therefore, it is important to have other methods for estimating core body temperatures.

-The Mouth:

The floor of the mouth, below the tongue, provides such a solution. Unfortunately, this measurement is roughly one degree below the rectal temperature, and it also requires that the patient hold the thermometer under his or her tongue for several seconds while the digital probe measures the temperature.⁴

-The Axilla:

The axilla (also known as the armpit) provides yet another avenue for measuring temperature. However, the axilla is less reliable than the oral cavity – the axillary temperature is estimated to be roughly two degrees below normal core temperature.⁴

-The Eardrum:

Yet another way to measure temperature is by using an infrared tympanic temperature probe. The probe slides into a patient’s ear and uses infrared signals to identify the patient’s core body temperature. Although these devices were initially controversial, they have been shown to accurately track core body temperature if calibrated appropriately.⁵

-The Skin:

As a final example, one can apply his or her hands to the patient’s skin and “feel” for the patient’s temperature; however, this provides only a rough estimate.