Introduction

Mortality related to opioid overdose has gradually increased over the past decade.  To put an end to this fatal epidemic, drug treatment centers are distributing naloxone in combination with administration training and resuscitation education (World Health Organization [WHO], 2018).  These innovative practices have been proven to be effective in decreasing the number of opioid-related deaths.

There are a variety of interventions that have been visited to decrease the number of overdose deaths within the United States, including identification of at-risk patients, improved inter-healthcare communication to prevent co-prescribing of opioids/narcotics, follow-up appointments for individuals with a substance use disorder, and limiting licit opioid distribution (Boscarino et al., 2016).  For individuals who have been on long-term opioid treatment or have a known opioid use disorder (OUD), offering education on the risks of overdose, signs/symptoms, and rapid opioid reversal with the proper use of naloxone, premature deaths related to opioid overdose can be reduced (Lynn & Galinkin, 2018).  The following paper discusses the effectiveness of combining an educational intervention with naloxone administration in preventing opioid overdose mortality.

Definition

There are several terms that form the PICOT question; the main terms of the PICOT question will be defined within this section, with a brief overview of opioid drug addiction.

Opioid drug addiction is a well-known issue, and with it, brings major health concerns, mainly overdose and death (Painter, 2017).  Daily, patients are admitted to emergency rooms and intensive care units across the country diagnosed with opioid-related overdose, resulting in potentially severe irreversible injury.  Nurse practitioners will be at the forefront of these trying times, caring for patients with addiction issues and having the obligation to connect them to resources and treatment options (Painter, 2017).

Listed below are key terms that will be used throughout the entity of this capstone project.

• Opioids are either opium poppy derivatives or synthetic equivalents, that have highly addictive properties of pain relief and euphoria (WHO, 2018).  Some of the more common types of opioids, include the illicit drug, heroin and the licit drugs, including codeine, morphine, oxycodone, and fentanyl (WHO, 2018).
• Overdose is the intentional or accidental use of a prescribed or illegal drug at an amount that is larger than the individual can safely tolerate, resulting in severe central nervous system adverse effects or fatality (Thanacoody, 2018).
• Naloxone is an opioid antagonist that can be safely administered via multiple routes to reverse the detrimental side effects of opioids (Lynn & Galinkin, 2018).

Epidemiology

Overuse of illicit and prescription opioids, resulting in addiction is becoming commonplace and unfortunately becoming an increasing issue worldwide.  Astonishing statistics show that approximately 275 million individuals worldwide between the ages of 15 and 64 years old, have attempted drugs at least once during 2016, and of those, 34 million people attempted opioids (WHO, 2018).  Because of this a longstanding dilemma of opioid-related overdose has occurred.  Opioid-related overdose is the leading cause of accidental deaths in the United States, taking nearly 50,000 lives in 2017 (National Institute on Drug Abuse [NIDA], 2018).  Because of the new laws in effect in certain states mandating the extreme limitation of prescription opioids, the current epidemic is bound to spiral out of control based on statistics alone.  One such statistic shows that 94% of respondents in a 2014 survey of individuals receiving treatment for opioid addiction progressed to heroin use because opioids were costly, and they were harder to acquire (American Society of Addiction Medicine, n.d.).

Clinical Presentation

Prescription opioids, heroin, and illicitly-manufactured synthetic opioids are contributing to the increase numbers in fatal overdoses (U.S. Department of Health & Human Services, 2018).  Prescription opioids and fentanyl are often prescribed to relieve moderate to severe acute or chronic pain (Centers for Disease Control and Prevention [CDC], 2017).   However, with the pain relief there are a variety of side effects that can occur that can increase in severity as more of the medication is ingested and accumulates in the system.  Side effects can include sweating, dry mouth, dizziness, constipation, hyperalgesia, sleepiness and progress to dependence and tolerance (CDC, 2017).

Complications

Although there are several complications that can occur form opioid use, this paper will focus on opioid use disorder and opioid overdose.  Opioid use disorder (OUD), commonly known as opioid addiction, is when the use of opioids consistently negatively affects activities of daily living, resulting in poor work performance, disturbance in homelife, and social ineptness/isolation (CDC, 2017).  Opioids are similar in that they all potentiate immense respiratory depression, bradycardia, hypotension, pupil constriction, pallor, and unconsciousness and if taken in large amounts can cause a nonfatal or fatal overdose (CDC, 2017).

Diagnosis

In diagnosing an opioid overdose, there are crucial diagnostic measures that need to be implemented to confirm accuracy of diagnosis and substance confirmation so that proper treatment can be instituted.  These measures include presence of central nervous system collapse accompanied by physical mutilation from needle injection, nearby drug accounterments, and thorough history from witnesses/bystanders, with confirmatory diagnostics of a therapeutic trial of naloxone, EKG, radiographic examinations, and opioid urine screen (Thanacoody, 2018).

Conclusion

The current opioid epidemic is calculated to increase in intensity within the upcoming years and strategic planning is underway to prevent future opioid-related deaths from occurring.  Areas of importance that lawmakers are addressing and incorporating into their policy changes relating to the current opioid predicament, include educating prescribers on the importance of co-prescribing naloxone to high-risk opioid users, increasing education and the availability of naloxone in the community, and implementing more effective treatment options for individuals suffering from an opioid use disorder (Kerensky & Walley, 2017).  Hopefully, by increasing society’s knowledge on opioid overdose and naloxone accessibility/administration will prove to be a resolution to the opioid epidemic.

The PICOT question that will be addressed within this project is:

Does offering an opioid educational intervention and naloxone instruction to individuals with an opioid use disorder decrease the number of opioid-related overdose deaths as compared to no educational intervention/instruction after an overdose incident?

One such plan, includes offering opioid education and teaching correct naloxone administration to individuals attending overdose rehabilitation programs (Lott & Rhodes, 2016).  Individuals with a known opioid use disorder (OUD) are at risk for an initial or repeated attempt of overdose.  For this reason, OUD individuals should be educated in the prevention, detection, and appropriate response to overdose.  Educational intervention should include signs of opioid overdose, proper   administration of the reversal agent, naloxone, and essential overdose after-care (American Society of Addiction Medicine [ASAM], 2016).  Overdose mortality can also be reduced by offering naloxone to the community by way of over the counter availability, third-party prescription, or dispensing it to bystanders at opioid overdose prevention programs (OOPP) (Neergaard, 2016).  The increase number of opioid-related overdoses has warranted a need for increased accessibility and naloxone education for the community, who are on the frontlines of America’s opioid epidemic.

References

• American Society of Addiction Medicine. (n.d.). Opioid addiction 2016 facts and figures. Retrieved from:
  
  https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf
  
• Boscarino, J., Kirchner, H., Pitcavage, J., Nadipelli, V., Ronquest, N., Fitzpatrick, M., & Han, J.  (2016).  Factors associated with opioid overdose: A 10-year retrospective study of patients in a large integrated health care system.
  
  
  
  Substance Abuse and Rehabilitation
  
  , 7: 131-141.  doi: 10.2147/SAR.S108302
• Centers for Disease Control and Prevention. (2017). Opioid basics. Retrieved from:
  
  https://www.cdc.gov/drugoverdose/opioids/index.html
  
• Kerensky, T. & Walley, A. (2017). Opioid overdose prevention and naloxone rescue kits: What we know and what we don’t know.
  
  
  
  Addiction Science & Clinical Practice
  
  , 12: 4. doi: 10.1186/s13722-016-0068-3
• Lynn, R. & Galinkin, J.  (2018).  Naloxone dosage for opioid reversal: Current evidence and clinical implications.
  
  Therapeutic Advances in Drug Safety
  
  , 9(1): 63-88. doi: 10.1177/2042098617744161
• National Institute on Drug Abuse.  (2018).  Overdose death rates.  Retrieved from: https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates
• Thanacoody, R.  (2018).  Opioid overdose.  Retrieved from:
  
  https://bestpractice.bmj.com/topics/en-gb/339
  
• U.S. Department of Health & Human Services. (2018). Surgeon General’s Advisory on naloxone and opioid overdose. Retrieved from: https://www.surgeongeneral.gov/priorities/opioid-overdose-prevention/naloxone-advisory.html
• World Health Organization. (2018). Information sheet on opioid overdose.  Retrieved from:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            https://www.who.int/substance_abuse/information-sheet/en/

Cardiogenic shock is a major and often fatal complication of a variety of acute and chronic disorders whereby the heart muscle fails to effectively pump blood forward and is unable to maintain adequate tissue perfusion. This ongoing clinical problem of cardiogenic shock often results from cardiac failure. Nurses and physicians need to work together to develop a rapid and well-organized treatment approach to this devastating condition. Acute myocardial infarction (AMI) is the most common cause and early recognition of cardiogenic shock is essential to saving the patient and functional organ perfusion. To help discuss the differences between right ventricular and left ventricular cardiogenic shock as a result of AMI, a case study format has been chosen. Priority nursing diagnoses, interventions and outcomes will also be addressed.

Case Study

Mrs. Rudd, a 53-year-old woman, is walking her two golden retrievers in Central Park when she starts to develop a nagging left arm pain radiating up her neck and down to her fingers along with diaphoresis, flushing and shortness of breath. She loses grip of the leashes and the dogs, sensing something wrong, get the attention of a young couple sitting under a tree. They see her in distress and call 911 to get an ambulance. Paramedics arrive on the scene within minutes and transport her to the emergency department at Mt. Sinai Hospital.

On arrival, Mrs. Rudd continues to complain of the pain getting more intense and a new onset of substernal pain. The paramedics note her to be pale and clammy with cool and mottled extremities. Her vital signs in the ED are heart rate 56 beats/minute, blood pressure 78/53, respiratory rate 24 breaths/min and labored, pain level of 9/10 and temperature 96.9* F orally. The nurse provides supplemental oxygen at 100% via non-rebreather mask and administers 325mg of chewable aspirin, but holds the nitroglycerin because of her already low HR and BP. Then the cardiac monitor leads are placed, which shows sinus bradycardia;18g IV access is obtained in both arms and blood chemistry, CBC and cardiac enzymes are drawn and sent to the lab. A stat 12-lead electrocardiogram is run which indicates that Mrs. Rudd is having ST elevations in leads II, III and aVF suggesting acute inferior wall myocardial infarction. This explains the bradycardia due to damage to the right ventricle and likely an occluded right coronary artery. Tachycardia is seen in anterior and lateral wall MI where the circumflex and/or LAD coronary arteries are blocked. The nurse may also see ST depression instead of elevation in leads II, III and aVF with either of these infarcts. Her signs and symptoms upon presentation to the hospital suggest that she is in the early stages of cardiogenic shock, a life-threatening complication of AMI associated with high mortality. Early and aggressive treatment is necessary for her to survive this condition (Lenneman, 2011).

Etiology and Pathophysiology

With cardiogenic shock, perfusion is affected and delivery of oxygen to the tissues is markedly decreased. Various conditions can lead to cardiogenic shock besides AMI. It can occur as a complication of open heart surgery, myocarditis, valve failure, severe dysrhythmias or from any disease or injury that leads to mechanical failure of the body’s pump. With AMI, the myocardium is starved of oxygen and nutrients and dies (Lenneman, 2011). This leads to diminished contractility, reduced ejection fraction (the percentage of blood present in the ventricle at end-diastole that is pumped out with each heart beat) and disruption of hemodynamic measurements including persistent hypotension, high filling pressures, such as PAWP, PAP, high CVP and SVR, and most importantly reduced stoke volume and cardiac output. As a result of the reduced ventricular emptying, pressure rises within the ventricles, causing dilation of the ventricles, eventually leading the one initially injured to fail and if not corrected both ventricles. In cases of heart failure in both ventricles, the patient will probably require transplantation and an LVAD to keep them alive while on the list awaiting a donor heart (Holcomb, 2002).

Signs and symptoms

Clinical signs and symptoms that are associated with cardiogenic shock depend on the ventricle affected. In right heart failure the nurse may observe jugular vein distension, peripheral edema and weak pulses, altered mental status, elevated ICP. Venous congestion and bradycardia are possible due to the heart slowing to allow adequate blood return and filling before pumping, which can be heard on auscultation as a split second heart beat. With left ventricular failure a pathological S3 or ventricular gallop can be auscultated, and pulmonary edema and congestion will likely be present, evidenced by labored breathing, dyspnea, course crackles and wheezing leading to ineffective gas exchange. To improve oxygenation, respiratory rate increases and the patient hyperventilates as manifested by hypocapnia and alkalosis (PaCO2 less than 35 or pH greater than 7.45) measured by arterial blood gases (Holcomb, 2002). Since the heart is unable to recover and maintain adequate perfusion to the kidneys, they also will fail and subsequent ABGs reveal a shift indicating a worsening condition of both respiratory and metabolic acidosis.

Sustained hypotension (systolic blood pressure less than 90mmHg for longer than 30 minutes) and adequate left ventricular filling pressure with signs and symptoms of tissue hypoperfusion are less common definitions for cardiogenic shock. This hypoperfusion may be exhibited by such signs as cool extremities, altered mental status, oliguria (urine output less than 30mL/hour or less than 0.5mL/kg/hour) or all three. Another helpful measurement utilized in assessing shock is drawing a serum lactic acid level, a diagnostic tool for detecting occult tissue hypoperfusion. Even if a patient does not exhibit low blood pressure at onset, a lactic acid value above 4mmol/L can identify organ dysfunction at the cellular level before the patient becomes hypotensive. This can be assessed by the nurse observing skin becoming cool, pale, and clammy as blood is shunted away from the periphery and skeletal muscles back to the vital organs. As a consequence, wasting and lactic acid buildup occur. The effects of blood being shunted away from the gastrointestinal tract initially lead to decreased bowel sounds and eventually progress to absent bowel sounds or paralytic ileus (Farwell, 2006).

Hemodynamics

In the case of Mrs. Rudd, her initial presentation reveals signs of the early compensatory phase of shock. The physicians and nurses need to collaborate and respond promptly to limit permanent damage to her organs and ensure her survival. In the early stage of cardiogenic shock the sympathetic nervous system is activated to respond to a failing heart. The renin-angiotensin-aldosterone system (RAAS) is stimulated to cause vasoconstriction and sodium and water retention to maintain blood pressure (Porth, 2006).

To evaluate the effectiveness of organ perfusion cardiac output needs to be monitored and controlled. This is initially sustained with fluid replacement and volume expanders in right heart failure resulting from inferior AMI, to in essence replace oil in the engine to keep it running. In response to heart failure from a lateral or anterior AMI, the patient will exhibit increases in heart rate and/or stroke volume defined as the amount of blood pumped out with each ventricular contraction or the difference between the end-diastolic and end-systolic volumes (Eliott, Aitken, & Chaboyer, 2007). The physician often prescribes vasopressors and inotropic medications such as milrinone or dobutamine to improve contractility and pumping efficiency of the damaged heart as well as reduce afterload.

In cardiogenic shock, the values of cardiac output (normal range of 4-8L/min) and the more accurate measurement, cardiac index (2.5-4.0L/min), can significantly drop in response to heart failure and the pump not being able to adequately circulate blood through the body. In some cases the physician may order a diuretic such as furosemide to be administered to decrease preload by reducing pulmonary (LV) or systemic (RV) congestion and stasis of blood. Another measurement of end organ perfusion that clinicians rely on is mean arterial blood pressure (MAP) which has a normal range of 60 to 110mmHg. When the body is in a state of shock, at first the body attempts to compensate, however as the condition prolongs the values gradually drop below 60 mm Hg along with a decreasing cardiac output (Holcomb, 2002). Together these hemodynamic values are used to determine if the patient has inadequate organ perfusion and to evaluate the adequacy of interventions by both the physicians and nurses.

Subsequently, the body attempts to compensate by increasing heart rate, which decreases diastolic filling time. This faster rate increases the oxygen demand of already damaged heart muscle, which negatively impacts cardiac output even further. Unable to keep pace with the increase in volume, hemodynamic values worsen as the heart fails to perfuse the body. This eventually leads to MODS and unfortunately, as a result, death in around 50% of all patients affected by cardiogenic shock (Babaev, Frederick, & Pasta, 2005). Even in cases where the patient is recovered and stabilized, sometimes the damage may be too great for the patient to overcome and within days or weeks they irreversibly deteriorate.

Treatments

The best chance of recovery for Mrs. Rudd relies on rapid percutaneous or surgical revascularization. While awaiting revascularization there are nursing interventions and pharmacologic measures that can be started to optimize her cardiac output. As mentioned earlier, rapid infusion of fluids is the first line of defense to improve cardiac output and stroke volume in right AMI. Diuretics may be used in left heart failure to decrease preload and improve the heart’s pumping ability, however it is contraindicated with right AMI as in the case of Mrs. Rudd. Tachycardia is a common compensatory mechanism of cardiogenic shock to improve perfusion, yet beta-blockers, although they can lower rapid heart rates, are another class of drugs that should be avoided for Mrs. Rudd since they also have a hypotensive effect and could counter the positive effects of fluid resuscitation and further perpetuate severe hypotension, having a bottoming out effect. Therefore beta-blockers should be used carefully and only in early stages of uncomplicated AMI without heart failure (Eliott, Aitken, & Chaboyer, 2007).

Providing inotropic support and improving systemic vascular resistance are important in the management of cardiogenic shock. To increase contractility and consequently cardiac output, inotropes, such as dobutamine, dopamine and milrinone, might be started and gradually increased to obtain adequate perfusion. However, because they can increase myocardial oxygen demand in an already ischemic heart, they must be used cautiously in patients, as they may lead to the incidence of fatal dysrhythmias. To treat life-threatening ventricular dysrhythmias (VT or VF), antiarrhythmic medications such as amiodarone or lidocaine are indicated. Additional considerations to treat dysrhythmias or heart block include defibrillators and transcutaneous pacing, or depending on the damage present, a permanent pacemaker (ECC Commitee, American Heart Association, 2005).

Another complication of cardiogenic shock that increases oxygen demand is hypoxemia from pulmonary edema and backflow; common in left AMI and often a secondary complication in right AMI. As the patient deteriorates and stops responding to compensatory mechanisms, mechanical ventilation may be warranted to provide adequate oxygenation. By instituting mechanical ventilation the workload of breathing is decreased as the machine takes over. Also anxiety and metabolic demands are decreased when the patient is sedated and intubated. Unfortunately, sedation may cause a further drop in blood pressure and needs to be closely monitored. Maintenance of adequate MAP is also vital to prevent end-organ damage.

To increase MAP, norepinephrine may be added to the medication regimen, but it may have a negative effect on cardiac output. Through means of combination therapy in severe hypotension, catecholamines are mainly administered in cardiogenic shock along with monitoring urinary output and calculating cardiac output, to sustain functioning of the patient’s organs and optimistically to buy time before revascularization and the return of adequate pump function (Eliott, Aitken, & Chaboyer, 2007).

Unless contraindicated, it is protocol to treat any patient admitted with a diagnosis of acute coronary syndromes, including patients in cardiogenic shock, with aspirin and IV anticoagulation (heparin) to slow the progression of the infarct. Fibrinolytics are not recommended in patients requiring percutaneous coronary intervention (PCI) or surgery, however, improvement in hospital mortality with the use of the glycoprotein IIb-IIIa inhibitor abciximab (ReoPro) has recently been shown to reduce mortality from 40% to 50% down to 18% to 26% in cardiogenic shock treated with stent implantation (ECC Commitee, American Heart Association, 2005). Hospitals have adopted the PTCA guidelines set forth by The American College of Cardiology and the American Heart Association aiming to provide reperfusion of the infarct artery within 90 minutes after arrival to the hospital. These new guidelines also assist in decision making regarding PCI, a nonsurgical coronary revascularization procedure that relieves the narrowing or obstruction of the coronary artery or arteries to allow more blood and oxygen to be delivered to the heart muscle. This ensures patient safety and improves patient quality of care (ECC Commitee, American Heart Association, 2005).

Another intervention that is used to prevent or manage cardiogenic shock is an intra-aortic balloon pump (IABP) which improves coronary artery perfusion and reduces afterload. This mechanical device consisting of a 34- to 40-mL balloon catheter, is placed during PCI and operates by using counterpulsation therapy. The IABP inflates during ventricular diastole (increasing coronary artery perfusion) and deflates during ventricular systole (decreasing afterload or the resistance against which the heart has to pump). By increasing coronary artery perfusion with this device, the patient’s cardiac output, ejection fraction, and MAP are increased, ultimately improving end-organ perfusion. Heart rate and pulmonary artery pressures, especially pulmonary artery diastolic and wedge pressures are lowered, which essentially decrease the heart’s oxygen consumption, blood volume and workload (Holcomb, 2002).

Now an hour and fifteen minutes from onset, Mrs. Rudd’s status continues to worsen and the physicians, noting that they are still within the 90 minute timeframe, rush her directly to the cardiac catheterization laboratory and she undergoes PCI with drug-eluting stent placement in the right coronary artery. During the procedure the surgeon places an IABP to increase coronary artery perfusion and decrease workload of the heart. She is transferred to the surgical intensive care unit for further management and monitoring with a pressure dressing to the femoral artery where the catheter was inserted. After recovery of her strength and hemodynamic stabilization, she is transferred to a medical-surgical unit, then discharged four days later on a new medication regimen prescribed to avoid complications and recurrence of an AMI or lethal dysrhythmias.

Nursing Diagnoses & Outcomes

Prioritizing nursing diagnoses and care depends on which side of the heart is affected. With LV failure, respiratory complications are a primary consideration, whereas with RV failure, presentation of systemic signs and symptoms occur early on. Eventually as the patient’s condition deteriorates their body’s compensation mechanisms fail and cardiogenic shock worsens. Nursing interventions vary based on what stage of shock the person is in, their etiology and presentation, what procedures are planned or have been performed and when care is assumed.

The nursing diagnoses for Mrs. Rudd consist of (in priority):

Risk for decreased cardiac output related to altered cardiac rate and rhythm; reduced preload and increased systemic vascular resistance; infarcted muscle.

Ineffective tissue perfusion related to reduction or interruption of blood flow.

Risk for excess fluid volume related to decreased organ perfusion; increased sodium and water retention; sequestering of fluid in interstitial space and tissues.

Acute pain related to ischemic myocardial tissue.

Anxiety and fear related to change in health status.

Activity intolerance related to imbalance between myocardial oxygen supply and demand; presence of ischemia; cardiac depressant effects of certain drugs, such as beta blockers, antidysrhythmics.

Ineffective protection related to the risk of bleeding secondary to thrombolytic therapy.

Deficient knowledge regarding cause and treatment of condition, self-care, and discharge needs related to lack of information, misunderstanding of medical condition or therapy needs

Some expected outcomes for Mrs. Rudd include:

Maintain an adequate cardiac output during and following reperfusion therapy.

Demonstrate no signs of internal or external bleeding.

Rate chest pain as 2 or lower on a pain scale of 0 to 10.

Verbalize reduced anxiety and fear.

To recap, cardiogenic shock is a life-threatening complication of AMI. It is important to acknowledge that patient survival and recovery rely on early recognition of signs and symptoms of cardiogenic shock and rapid assessment and interventions by the nurse and treatment team.

Literature Review

Introduction

The purpose of this literature review is to analyze ten research articles that study the proper and improper use of personal protective equipment (PPE) and the effect that they have on infection rates. Many precautions to decrease the number of infections acquired from contamination, but even with all these interventions in place the number of related infections continues to be on the rise.  PPE consists of gloves, gowns, aprons, surgical face masks, protective eye wear, and face shield (Neo, Edward, & Mill, 2012).  PPE is a component of standard precautions and the implementation of these precautions is considered the most important strategy for preventing infections.  Best practice guidelines advocate risk appraisal for potential exposure by all health care workers and should provide appropriate equipment to manage the risk (Neo, Edward, & Mill, 2012).

Clinical Question

Does Proper PPE use among nurses compared to improper PPE use lead to a reduction in infection rates?

Background

The first article, “Review of personal protective equipment used in practice”, was a that examined the community nurse and the importance and use of PPE.  It also examined why there is a poor compliance with the use of standard precautions. In total there were thirty-three research articles, one audit report and two national guidelines.  The researchers found that using a gown along with gloves decreased the acquisition rate of Vancomycin resistant enterococci and created a reduction in the transmission of Methicillin resistant Staphylococcus aureus (Hinkin, Gammon, & Cutter, 2008). The researcher also found that the factors that influenced the noncompliance with PPE included workload and staffing levels, availability, perceived risk to healthcare workers, deficient knowledge and decreased dexterity due to PPE use (Hinkin, Gammon, & Cutter, 2008).   PPE must be worn appropriately because inappropriate use of PPE can actually increase the risk of infection.  Results from this study identified the efficacy in the role of PPE in infection control but also identified the shortfalls in compliance.

The second article, “Current evidence regarding non-compliance with personal protective-equipment-an integrative review to illuminate implications for nursing practice”, is an integrative review on current literature regarding the use of PPE in the operating room and the gaps and considerations from a nurses’ perspective.  While PPE provides a barrier between the user and microorganism and blood born viruses, the compliance rate is not where it should be.  There was an American study that observed 88 emergency department personnel and of the 304 procedures observed, 22% of staff did not have adequate protective eye wear and 32.3% did not have a mask (Neo, Edward, & Mill, 2012). Another study surveyed 192 RN’s in a hospital in Sydney, Australia and although 73% said that they used standard precautions for PPE at all times, only 50% wore gloves to take blood and only 77% wore gloves to clean up urine and feces (Neo, Edward, & Mill, 2012. The findings of this review showed that the compliance with standard precautions and PPE is suboptimal amongst healthcare workers.

The third article, “Contamination of Health Care Professionals During Removal of Personal Protective Equipment”, is a point-prevalence study and a quasi-experimental intervention that occurred from October 28, 2014 through March 31, 2015.  There was one test to see the frequency and sites of contamination on the skin and clothing of personnel after PPE removal at baseline vs. after an intervention put into place.  The second endpoint focused on the correlation between contamination of the skin with fluorescent light and bacteriophage MS2 which is a nonpathogenic, non-enveloped virus (Tomas et al., 2015). Of 435 glove and gown simulation removals contamination occurred with the fluorescent lotion in 200 which was 46% but after the intervention the rate of contamination decreased from 60% to 18.9% (Tomas et al., 2015). During the simulations the contamination rate with the fluorescent lotion was 58% vs the bacteriophage MS2 which was 52% (Tomas et al., 2015). Results from this study proves that contamination of health care workers occurs frequently (Tomas et al., 2015).

“Not just gloves”, is a literature review of the use of protective eyewear in the perioperative environment for nurses and other health care workers. The review included 85 related articles related specifically to the topic of interest. Standard precautions are the primary strategy for minimizing the transmission of health care associated infections for patients and occupationally acquired infections and diseases for staff (Mills, Moore, & Edward, 2011). This literature review found that following endoscopic procedures 31.8% of scrub nurses had invisible blood droplets present of their eye shields and mask (Mills, Moore, & Edward, 2011).  Information obtained from this review proves that PPE compliance among nurse and other health care workers is generally low.

The fifth article, “Prevention of Methicillin-Resistant Staphylococcus Aureus in Neonatal Intensive Care Units: A Systematic Review.”, that focused on decreasing the spread of MRSA in NICUs.  19 published works were used for this review that studied MRSA and how it might be spread in the NICU. In 7 out of 45 occurrences (16%) hand-hygiene compliance and PPE   were noted as a facilitator in the prevention of spreading MRSA (Mileski et al., 2018).  The results from this study concluded that adherence to strict hand hygiene, proper use of PPE, and patient and family education are proven most effective in reducing the spread of MRSA in the NICU. (Mileski et al., 2018).

“Importance of hand germ contamination in health-care workers as possible carriers of nosocomial infections,” is a randomized control where 100 nurses were divided evenly into 2 groups.  Group A was without handwashing prior to patient physical examination who showed a bacteria rate of 73.9% and group B who had handwashing prior to patient physical exam who showed 20.7% infection rate (Nogueras, Marinsalta, Roussell, & Notario, 2001).   Surprisingly 16 group B participants were contaminated after seeing a patient which is almost one-third of the group.  The study revealed that handwashing, as well as glove use is highly recommended.

The seventh article, “Knowledge, Attitudes and Practices related to standard precautions among nurses, “is a comparative study performed between February-April 2018.  The method used was a self-administered questionnaire given to 237 Chinese nurses and 120 Ethiopian nurses.  24.9% of Chinese nurses received infection prevention training compared to 38.3% of Ethiopian nurse (Zhu, Kahsay, & Gui, 2019). Most nurses agreed that wearing gloves, masks and goggles were important control measures against health care associated infections and that nurses of both countries showed a favorable attitude towards standard precautions.   The result of this study show that knowledge and attitude alone do not guarantee practice and that more education is needed for strategies to improve infection control (Zhu, Kahsay, & Gui, 2019).

“Cross-sectional survey of hand-hygiene compliance and attitudes of health care workers and visitors in the intensive care units at King Chulalongkorn Memorial Hospital, “ the researcher observed and examined hand-hygiene compliance of healthcare workers and visitors in the ICU over an 8 hour period.  Hand hygiene is considered to be the most crucial and least expensive measure to prevent cross-contamination of microorganisms.  After the 8-hour observation the hand-hygiene compliance rate with 378 episodes of patient contact there was less than 50% compliance (Patarakul et al., 2005).  The best compliance was observed was observed in the nursing students with 100% compliance, nurses 71.9% compliance and nursing assistants 63.9% compliance (Patarakul et al., 2005).  .  Bases on a total of 322 questionnaires returned most reasons noted for non-compliance were 51.2% not a priority, 35.7%, and 15.5 % hand irritation (Patarakul et al., 2005). The results of this study proved that knowledge, attitudes and beliefs regarding hand hygiene need to be improved.

The ninth article, “Infection control bundles in intensive care: an international cross-sectional survey in low- and middle-income countries,” the study aimed to determine the status of Infection Prevention and Control bundle practice and the most frequent interventional variables in low- and middle-income countries.  A questionnaire was emailed to Infectious Diseases International Research Initiative Group Members and dedicated IPC doctors working in LMICs to examine self-reported practices/policies regarding IPC bundles (Alp et al., 2019). This survey reports practices from one low-income country, 16 middle-income countries and eight high-income countries. Eighteen (95%) MICs had an IPC committee in their hospital and All HICs had at least one invasive device-related surveillance program (Alp et al., 2019).  The results of this study revealed that low- and middle-income countries need to develop their own bundles with low-cost and high-level-of-evidence variables adapted to the limited resources, with further validation in reducing infection rates (Alp et al., 2019)..

The last article, “Are you covered? Safe practices for the use of personal protective           equipment,” explores the use of PPE in droplet and airborne precautions in the emergency room.   Emergency nurse frequently encounter patients with a known or suspected illness.  Droplet precautions can travel between 3-10 feet and transmission of infection occurs through coughing, sneezing, talking and endotracheal intubation or suctioning.  To prevent the spread of infection, emergency nurses should follow appropriate infection control precautions and use PPE as recommended (Valdez, 2015).  The emergency nurse can reduce the risk of injury by adhering to infection control standards.

Conclusion

Each of the ten articles were primary sources that examines PPE use by nurse and whether it effectively decreases infection rates.  “Review of personal protective equipment used in practice” clearly found that using a gown along with gloves decreased the acquisition rate of Vancomycin resistant enterococci and created a reduction in the transmission of Methicillin resistant Staphylococcus aureus.  “Prevention of Methicillin-Resistant Staphylococcus Aureus in Neonatal Intensive Care Units: A Systematic Review” also proved that concluded that adherence to proper use of PPE would help to reduce the spread of MRSA in the NICU.  However, the other studies concluded that hand hygiene is considered to be the most crucial and least expensive measure to prevent cross-contamination of microorganisms.

References

• Alp. E., Cookson, B., Erdem, H., Rello, J., Akhvlediani. T., Akkoyunlu, Y, …Wongsurakıat, P., (2019). Infection control bundles in intensive care: An international cross-sectional survey in low- and middle-income countries.
  
  Journal of Hospital Infection, 101
  
  (3). Pages 48-256. Retrieved from
  
  https://doi.org/10.1016/j.jhin.2018.07.022
  
• Hinkin J, Gammon J, & Cutter J. (2008). Review of personal protection equipment used in practice.
  
  British Journal of Community Nursing
  
  ,
  
  13
  
  (1), 14–19. Retrieved from
  
  https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=105873857&site=eh
  
  ost-live&scope=site
• Mileski, M., Lee, K., Maung, S., Nelson, D., Palomares, O., & Paredes, N. (2018). Prevention of Methicillin-Resistant Staphylococcus Aureus in Neonatal Intensive Care Units: A Systematic Review.
  
  ABNF Journal
  
  ,
  
  29
  
  (2), 46–53. Retrieved from
  
  https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=129886044&site=eh
  
  ost-live&scope=site
• Mills, C., Moore, C., & Edward, K-L. (2011).   Not   just gloves.
  
  Acorn, 24
  
  (4), 14-18. Retrieved from
  
  https://search.proquest.com/docview/2068957941?accountid=160851
  
• Neo, F., Edward, K.-L., & Mills, C. (2012). Current evidence regarding non-compliance with personal protective equipment – an integrative review to illuminate implications for nursing practice.
  
  ACORN: The Journal of Perioperative Nursing in Australia, 25
  
  (4), 22 30. Retrieved fom
  
  https://search.ebscohost.com/login.aspxdirect=true&db=ccm&AN=10
  
  4412980&site=ehost-live&scope=site
• Nogueras, M., Marinsalta, N., Roussell, M., & Notario, R. (2001). Importance of hand germ contamination in health-care workers as possible carriers of nosocomial infections.
  
  Revista do Instituto De Medicina Tropical De São Paulo, 43
  
  (3), 149-52. Retrieved from
  
  https://search.proquest.com/docview/196529797?accountid=160851
  
• Patarakul, K., Khum, Auchana,  Kanha, Suthad,  Padungpean, Darunee & Jaichaiyapum, O. (2005). Cross-sectional survey of hand-hygiene compliance and attitudes of health care workers and visitors in the intensive care units at King Chulalongkorn Memorial Hospital.
  
  Journal of the Medical Association of Thailand = Chotmaihet thangphaet.
  
  88(4). S287-93.
• Tomas, M. E., Kundrapu, S., Thota, P., Sunkesula, V. C. K., Cadnum, J. L., Chittoor Mana, T. S., … Mana, T. S. C. (2015). Contamination of health care personnel during removal of personal protective equipment.
  
  JAMA Internal Medicine
  
  , 175(12), 1904–1910. Retrieved from
  
  https://doi.org/10.1001/jamainternmed.2015.4535
  
• Valdez, A. M. (2015). Are you covered? Safe practices for the use of personal protective equipment: JEN JEN.
  
  Journal of Emergency Nursing, 41
  
  (2), 154-157. Retrieved from doi:http://dx.doi.org/10.1016/j.jen.2014.11.011
• Zhu, S., Kahsay, K.M., & Gui, L. (2019). Knowledge, Attitudes and Practices related to standard precautions among nurses: A comparative study.
  
  Journal of Clinical Nursing. 28
  
  (19-20).  Pages 3538-3546. Retrieved from
  
  https://doi.org/10.1111/jocn.14945
  

This student written literature review is published as an example. See

How to Write a Literature Review

on our sister site UKDiss.com for a writing guide.