Gastroenteritis is known as one of the most prevalent conditions predominantly caused by norovirus worldwide (NSW Government, 2019). Although norovirus is usually a mild illness for people who are immunocompetent, it can be a serious infectious disease for frail older adults (Cardemil, Parashar, & Hall, 2017). This essay will define and explain the highly infectious norovirus as well as discuss the significance of the infection control precautions with accurate identification of the strategies. This essay will also discuss other required risk assessments and nursing care, including safety and cultural aspects relating to a specific case study of an elderly patient, Mr. Doug Sultan. For the purpose of the essay, norovirus itself will be defined and discussed along with infection control practices, professional patient-centred nursing care and patient safety inclusive of cultural safety.
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Norovirus is a virus that causes gastroenteritis, which is regarded as the most common disease in all age groups worldwide (NSW Government, 2018). Outbreaks can occur anytime and anywhere, but particularly prevalent in winter and crowded areas, such as schools, residential care facilities and hospitals with symptoms of severe vomiting and diarrhoea (NSW Government, 2018). Norovirus is highly contagious and is often transmitted from the vomit or stool of an infected person (NSW Government, 2018). It can be spread via multiple routes, including person-to-person contact, handling infectious objects or items, consumption of contaminated food or water and aerosolized particles in vomit (Chen, Hall, & Kirk, 2017). Even though there are various modes of transmission, direct person-to-person contact, such as shaking hands with someone who is infected with the virus is known as the most common mode of transmission which accounts for more than 90 per-cents of the outbreaks of norovirus in healthcare settings (Chen et al., 2017). Norovirus infection typically emerges as a fairly brief and mild illness for people who are immunocompetent, whereas it can cause considerable morbidity and mortality in frail elderly people (Cardemil et al., 2017). According to Cardemil et al. (2017) the elderly individuals have shown a longer period of experiencing diarrhoea and slower recovery from illness due to age-related immunosenescence. Additionally, norovirus infection in older people is likely to cause severe clinical complications which may eventually result in death (Cardemil et al., 2017). A global review in developed countries also found that the vast majority of norovirus-related deaths occurred in older adults and the direct causes of death included sepsis, aspiration pneumonia, and cardiac complications (Lindsay, Wolter, De Coster, Van Damme, & Verstraeten, 2015). Another reason that norovirus is risky for older people is that it can cause extreme dehydration due to excessive diarrhoea and vomiting (Chen et al., 2017). Chen et al., (2017) argue that this is the most prevalent complication requiring medical attention, which is of particular concern among older people with chronic diseases.
Despite intensive research for safe and effective norovirus antiviral drugs, no specific antiviral treatments have been approved (Chen et al., 2017). However, there are several precautions, including standard and transmission-based precautions, and strategies, that healthcare professionals and individuals can implement to prevent, manage and control the spread of norovirus. Standard precautions refer to what must be carried out every time, and what needs to always exist in all healthcare environments, to minimize the risk of infection (Curran, 2015). This includes fundamental strategies, such as hand hygiene, appropriate use of personal protective equipment (PPE), and safe use of sharps equipment (Curran, 2015). Among many strategies of standard precautions, proper hand hygiene with soap and water might be the single most important strategy to prevent norovirus transmission in healthcare settings (Rajagopalan, & Yoshikawa, 2016). Transmission-based precautions as well as continued implementation of standard precautions are used when patients are suspected or confirmed to have any infections (Curran, 2015). There are three different types of transmission-based precautions, including contact, droplet and airborne precautions, and particularly contact and droplet precautions should be maintained for interrupting norovirus transmission (Department of Health & Human Services, State Government of Victoria [DH & HS, SGV], 2020; NSW Government, 2019). Additional PPE with contact precautions, such as gloves, gown or apron is advised for those entering the patient care area, as norovirus can be spread through person-to-person contact and contact with contaminated surfaces (NSW Government, 2019). Enhanced cleaning and disinfecting of the patient care areas is another strategy to remove aerosolized particles of norovirus that can survive on surfaces for long periods (Chen et al., 2017). Minimising patient movement within a ward and restricting unnecessary visitors from affected areas should be maintained as the contact precautions, until at least 48 hours even after the symptoms are resolved (Cardemil et al., 2017). A strategy using PPE, such as a surgical mask and eye protection or a full-face protector can be considered with droplet precautions when there is a potential risk of vomit or faecal splashing (Cardemil et al., 2017; DH & HS, SGV, 2020).
As patients get older, they tend to become more vulnerable and need careful attention associated with other risk assessments. There are several risk assessments to be discussed for Mr. Doug Sultan which are not limited to norovirus, including fluid balance charts, nutritional status check and falls risk assessment. Firstly, fluid balance charts and nutritional status check are required for Mr. Sultan as he has a risk of dehydration due to the recent three times of diarrhea, and also has a risk of malnutrition since he appears to be underweight for his height (Cardemil et al., 2017; Mayo Foundation for Medical Education and Research [MFMER], 2019). Dehydration due to excessive diarrhea is considered as the most significant risk factors of elderly patients, as the symptoms can lead to the development of chronic disease and constant loss of body fluids and electrolytes (Chen et al., 2017). Malnutrition in older adults causes various health problems, including a weakened immune system, muscle and bone weakness which can lead to falls and fractures, and an increased risk of death (MFMER, 2019). Therefore, accurate documentation, regular monitoring of fluid balance chart and nutritional status, are essential for adequate amount of fluids and nutrients replenishment (Cardemil et al., 2017; MFMER, 2019). Falls risk assessment is also required for Mr. Sultan as he is unsteady when mobilising and uses a walking frame (Callis, 2016). An unsteady gait is one of many other risk factors associated with inpatient falls, and fall-related injuries lead to serious injuries, such as fractures and subdural hematomas that can contribute to co-morbidity and death in the healthcare environment (Callis, 2016). Nurses should, therefore, have a comprehensive fall risk assessment tool to initiate specific management plans for Mr. Sultan's safety (Callis, 2016). Furthermore, improvement in extrinsic factors of falls by educating and providing supportive and assistive equipment, such as lowering beds, safety buzzer and non-slip socks could be the prevention of falls for Mr. Sultan (DH & HS, SGV, 2020).
In addition to the monitoring potential risk factors, culturally safe healthcare services should be provided for patients who are originally from other cultural backgrounds like Mr. Doug Sultan. First of all, components of care plans such as cultural and spiritual beliefs, lifestyle, social history, likes and dislikes, and personal needs, are important to be understood when providing care to Aboriginal patients (Sivertsen, Harrington, & Hamiduzzaman, 2019). Sivertsen et al., (2019) argued that spirituality serves as a significant health determinant and influences the general care experiences of aboriginal residents. According to Sivertsen et al., (2019), there were cases wherein providing care, health carers found respecting and incorporating aspects of spiritual and cultural care for Aboriginal residents difficult due to lack of understanding of culture care plans. Additionally, health professionals should continue to educate themselves and provide information on quality standards of care to aboriginal residents like Mr. Sultan so that they can be provided culturally appropriate care (Sivertsen et al., 2019). Sivertsen et al., (2019) discovered a case where the lack of knowledge or understanding of the government standards prevented Aboriginal residents from seeking the culturally appropriate care that they are entitled to and thus resulted in fewer chances to voice their concerns around their cultural care needs.
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In conclusion, norovirus is the most common cause of gastroenteritis that frequently outbreaks throughout the year. The virus widely affects the community with symptoms of severe vomiting and diarrhoea. Persistent norovirus outbreaks can result in severe illness and are relatively risky for those who are immunocompromised, including older adults. Although there are no approved vaccines and antiviral treatments currently available for norovirus infection, it can prevent almost all risk factors of norovirus infection by proper hand hygiene. Several risk assessments are recommended for monitoring and controlling the risks especially in relation to Mr. Sultan's risk factors, such as dehydration, malnutrition and falls. Furthermore, culture care plans are necessary to be understood to improve care delivery and outcomes, and care standards should be educated for both carers and residents so that Aboriginal residents like Mr. Sultan can be provided with culturally appropriate nursing care.
- Curran, E. T. (2015). Standard precautions: What is meant and what is not. Journal of Hospital Infection, 90(1), 10-11. doi:10.1016/j.jhin.2014.12.020
- Callis, N. (2016). Falls prevention: Identification of predictive fall risk factors. Applied Nursing Research, 29, 53-58. doi:10.1016/j.apnr.2015.05.007
- Cardemil, Cristina V., MD, MPH, Parashar, Umesh D., MBBS, MPH, & Hall, Aron J., DVM, MSPH. (2017). Norovirus infection in older adults. Infectious Disease Clinics of North America, 31(4), 839-870. doi:10.1016/j.idc.2017.07.012
- Chen, Y., Hall, A. J., & Kirk, M. D. (2017). Norovirus disease in older adults living in long-term care facilities: Strategies for management. Current Geriatrics Reports, 6(1), 26-33. doi:10.1007/s13670-017-0195-z
- Department of Health & Human Services, State Government of Victoria. (2020). Falls prevention in hospital. Retrieved from https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/older-people/falls-mobility/falls/falls-preventing
- Lindsay, L., Wolter, J., De Coster, I., Van Damme, P., & Verstraeten, T. (2015). A decade of norovirus disease risk among older adults in upper-middle and high income countries: A systematic review. BMC Infectious Diseases, 15(1), 425. doi:10.1186/s12879-015-1168-5
- Mayo Foundation for Medical Education and Research. (2019). Senior health: How to prevent and detect malnutrition. Retrieved from https://www.mayoclinic.org/healthy-lifestyle/caregivers/in-depth/senior-health/art-20044699
- NSW Government. (2018). Norovirus fact sheet. Retrieved from https://www.health.nsw.gov.au/Infectious/factsheets/Pages/norovirus.aspx
- NSW Government. (2019). Viral gastroenteritis - infection control implications for hospitals and aged care facilities. Retrieved from https://www.health.nsw.gov.au/Infectious/factsheets/Pages/gastroenteritis-infection-control.aspx
- Rajagopalan, S., & Yoshikawa, T. T. (2016). Norovirus infections in Long‐Term care facilities. Journal of the American Geriatrics Society, 64(5), 1097-1103. doi:10.1111/jgs.14085
- Sivertsen, N., Harrington, A., & Hamiduzzaman, M. (2019). Exploring aboriginal aged care residents' cultural and spiritual needs in south australia. BMC Health Services Research, 19(1), 477-13. doi:10.1186/s12913-019-4322-8
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