الفهرس 
Introduction and Review of LiteratureOnly 14 pages are availabe for public view
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Abstract
Hospital-acquired infections, also known as Healthcare Associated Infections (HCAI). It can be defined as nosocomial acquired infections that are typically not present or might be incubating at the time of admission. These infections are usually acquired after hospitalization and manifest 48 hours after admission to the hospital. The infections are monitored closely by agencies such as the National Healthcare Safety Network (NHSN) of the Center for Disease Control and Prevention (CDC). Catheter-associated urinary tract infection (CAUTI) is the most common cause of health care-associated infection defined as a urinary tract infection that occurs in persons with an indwelling urinary catheter. A urinary tract infection (UTI) is an inflammatory response of the epithelium of the urinary tract to invasion and colonization by pathogen usually a bacterial species. CAUTI constitutes a major problem globally with social, personal effects, considerable morbidity, prolonged hospitalization, and greater health care expenditures as each incident of UTI increases intensive care unit stay by average of 5 to 6 days. General CAUTI risk factors advanced age, female sex, diabetic mellitus, long duration of catheterization, type of catheter and the technique used during catheter insertion as urinary catheter allows entry of microorganisms to the bladder. Also the critical illness and ICU hospitalization involves the interaction of several risk factors that can put the patient at high risk for the development of urinary tract infection. It is clear that a number of nursing strategies have been shown to be effective in reducing the incidence CAUTI. These strategies include insertion of a urinary catheter under aseptic technique, maintaining closed drainage system, hygienic, perineum and catheter care by using chrorhexidine gluconate solution must be done within daily routine care for all indwelling catheterized patients in intensive care units. The aim of the present study was to evaluate the efficacy of protocol of hygienic care by chlorhexidine gluconate on the occurrence of a catheter associated urinary tract infection among critical ill patients. Research design: A quasi- experimental design was utilized in this study. Setting: the present study was conducted at the Neurological Intensive Care Unit of both Tanta University Hospital and Neuro-psychiatry center at Tanta Main University Hospital. Subjects: A convenience sampling of (60) critical ill patients in the above previously mentioned settings. The sample size was calculated based on Epidemiological Information Program, based on the total patients per year according to review of Tanta Main University Hospital statistical Records. They will be divided into two equal groups; each group will be consisted of (30) patients as following: group (1): Study group, it consists of (30) patients and will be exposed to application of protocol of hygienic care by cholorohexidine gluconate 2% that will be implemented by the researcher. group (2): Control group, it consists of (30) patients and will be exposed to routine care in the intensive care units by nursing staff. The following criteria were used for selecting sample: - Inclusion criteria: -Patients aged between 21 and 55 years. -Both sexes. - Newly admitted patients. - Patients who fixed a urinary catheter during their hospital stay. Exclusion criteria: -Patients with a known allergy or hypersensitivity to CHG. -Patients with chronic, severe, generalized skin abnormalities. -Patients with a previous or current urinary tract infection. - Patients whose positive urine culture at the onset of catheterization. -patients with diabetes mellitus, cancer and recent surgery. Tools of data collection: - Three tools were used to evaluate the efficacy of protocol of hygienic care by chlorhexidine gluconate on the occurrence of a catheter associated urinary tract infection among critical ill patients, which includes the following: Tool (I): Structural Clinical Assessment Tool:- It was comprised of two parts:- Part (1): Socio-demographic characteristics of patients: which includes; patient’ code, age, sex, marital status, occupation, level of educational, Place of residency. Part (B): Patients’ clinical data:- It will be developed by the researcher based on literature review . to evaluate patients’ clinical data regarding; current diagnosis, weight, height, date of admission, previous admission to ICU, chief complaint and present history, past medical and surgical history, allergic history, duration of disease, types of treatment, reasons for catheter insertion, catheter size, medications that had been prescribed, laboratory investigation. Tool (II): Catheter Associated Urinary Tract Infection Assessment Profile (CAP):- Catheter associated urinary tract infection Assessment Profile was developed by Inouye etal.,(1990) to measure the presence or absence of the following clinical symptoms of CUTI through physical examination ; fever, suprapubic tenderness, flank tenderness, and delirium at pre, one week and two week post implementation of protocol of hygienic care by chrolohixidine gluconate. The catheter assessment profile tool contains definitions of each clinical sign and symptom as well as diagrams, to aid in their consistent assessment. Scoring system: it will be scored as the following; (0) indicate absence of clinical symptoms and (1) indicate presence of clinical symptom. Tool (III): Infection Assessment Sheet:- It comprises of two parts: Part (I): Catheter Urinary Tract Infection Assessment Sheet: Catheter urinary tract infection assessment sheet will be developed by the researcher based on literature review . It will be used for indicating the systemic and local signs of infection at pre, one week and two week post implementation of protocol of hygienic care by chrolohixidine gluconate as the following; -Systemic signs of infection which include; fever, chills, inflammation, swelling, allergy, urtcaria, pain, discomfort, acute change in mental status and increase WBCs in the blood. -Local signs of infection which includes; turbid urine, dysuria, hematuria, bad odour, purulent discharge from catheter site, nocturia, redness near the catheter site, pain near the catheter site and an increase of WBCs in urine. Scoring system: it will be scored as the following; (0) indicate absence of symptoms and (1) indicate presence of symptom. Part (II): Laboratory Investigations; the researcher will utilize specific laboratory investigations to assess presence of urinary catheter infection as, urine analysis to detect incidence of bacteria, white blood cells, R.B.Cs, nitrites, proteinuria, glycosuria, ketonuria, and renal calculi in urine sample, urine culture for isolation of different organisms and blood culture for bacteremia. Method: 1. Assessment phase:- Assessment of the critically ill patients will be done by using tool (I) part I and part II, Tool II and Tool III by the researcher for all patients in study and control groups to assess the patients who meet the inclusion criteria and will be included in the study. 2. Planning phase:- The protocol of hygienic care by chlorohexidine gluconate 2% will be planned based on the study subjects’ needs and literature review. - Setting the objectives of care: a- The general objective of the care is to reduce the occurrence of catheter associated urinary tract infection among critical ill patient. b - The specific objectives of the study are decrease signs and symptoms of catheter associated infection as fever, flank pain, suprapubic tenderness. Interpret the required care to be provided in case of appearance of any complications. -Preparing the content of the protocol of hygienic care; the content will be prepared by the researcher according to literature review (38-43) to meet the above mentioned specific objectives. An illustrative structured colored booklet will be prepared. -The hygienic care will be carried out in (2) basic phases individually for every patient as following: (Phase 1): will be carried out at the beginning of care to insert catheter and during any time will be determined to replace urinary catheter. (Phase 2): will be carried out every day through performing daily use of cholorohexidine gluconate 2% for the patients. The time of phases will be detected according to the condition of the patients. 3. Implementation phase:- - A protocol of hygienic care by daily chlorhexidine gluconate will be carried out by the researcher for the study subjects throughout the following phases:- -Phase (1):- Assessment of the patients and catheter insertion phase: It will be implemented by the researcher, this phase take about 30 minutes and include the following: - Assess the perineum area of patient on the admission to the hospital for detecting; skin irritation, skin breakdown, allergy, any abnormal signs and symptoms of infection as fever, inflammation, and swelling, leakage of urine, pain, bad odor and redness. - Choice of catheter size according to patients’ weight. -Application of infection control measures by using aseptic technique during insertion of catheter. -Clean of the perineum area of the patients before catheter insertion by chlorohexidine gluconate 2% then during insertion and maintenance to prevent catheter associated urinary tract infection -Insert urinary catheter for the patients according to specific procedure. -Aspirate 3 ml of urine from the sampling port of the catheter. -Take urine culture at the time of catheterization to be sure that patients are free from urinary catheter infection. -Phase (2); Application of Daily chrlohixidine Gluconate 2% for 14 days: it will include the following: a- Reassess the perineum area of patient daily. b- Application of infection control measures by using aseptic technique. c- If patient’ skin is extremely soiled, give a bath with soap and water first, Remedy skin cleanser by using a clean cloth for each skin area. Skin contamination with blood, secretions or faeces occurring will be removed using a 0.9% NaCl solution. d- Hygienic care with daily chlorhexidine gluconate 2% will be performed every morning shift at a detected time for 14 days for every patient. CHG 2% will prepare with diluted solution with equal amounts of warm tap water in clean basine with wash cloth. e- Hygienic care will carried out as the following; Assess and clean of perineum area, thigh, abdomen by CHG 2%, clean around/ below the catheter, clean sterile closed system, empty of the drainage bag and clean it, catheter change if needed, check catheter patency, ensure position of drainage tube & bag and frequent observation of urine character (color, odor and consistency). After completing the procedure, the skin will not rinsed, no liquids, moisturising lotion or other care cosmetics will not applied. - Daily review of the need to maintain the catheter, removal of it as soon as possible. - Control group will be received the routine nursing care provided to the patients by nurses in the Neuorological Intensive Care Unit of Tanta Main University Hospital which includes; clean perineum area with soap and water, clean area with betadine solution. 4. Evaluation phase:- - Every patient in both groups (study and control) will be assessed as the following:- 1-Tool I: before implementation of protocol of hygienic care by chlorhexidine gluconate to assess baseline data for patient. 2- Tool II: will be used pre, one week and two week post implementation of protocol of hygienic care by chlorhexidine gluconate. 3- Tool III: part I will be used pre, one week and two week post implementation of protocol of care, part II will be used immediately post catheter insertion, post 48 hours, then one week and two week post implementation of protocol of hygienic care by chlorhexidine gluconate. The main results of the present study: 1. The results revealed that more than one third of the patients in both control and study groups (43.33% and 33.33 % respectively) were between (40-<50) years old, with a mean age of 41.538.63in control group and 41.478.73in study group. 2. In relation to sex, more than half of the patients in control and study groups were male (63.33% and 53.33 % respectively), while 36.67% and 46.67% were female in control and study groups respectively 3. CAUTI is a common type of hospital acquired infection occurring in the context of indwelling urinary catheterization .The incidence rate of CAUTI among control group subjects was 93.33% while among study group subjects was 40.00%. 4. The most predominant microbiological agents that were identified from urine culture were: E-coli was the commonest pathogen in control group (30.00%) followed by Klebsiella (16.67%), Staphylococci (16.67%), Enterobacter (10.00%) and Pseudomonas (6.67%). On the other hand, Staphylococci was the commonest pathogen in study group (13.33%) followed by E-coli (3.33%), also Klebsiella (3.33%) and lastly Enterobacter (0.00%). 5. CAP level had statistically significant positive correlation with UTI manifestation (r= 0.379, p= 0.039) pre care in control group and in the study group CAP level had statistically significant urine correlation with UTI manifestation at the end of first week (r= 0.542, p= 0.002) and at the end of second week (r= 0.444, p= 0.014). CAP level had statistically significant positive correlation with systemic manifestation at the end of first week (r= 0.453, p= 0.012) and at the end of second week (r= 0.582, p= 0.001) in the control group 6. CAP level had statistically significant positive correlation with gender (r= 0.438, p= 0.016) and duration of previous admission (r= 0.395, p= 0.031) in control group. The current study revealed that most (59.3% and 80.0%) of the studied nurses in both groups did not attend training courses. 7. Systemic manifestations level had statistically significant positive correlation with duration of previous admission (r= 0.441, p= 0.015) after 2 weeks in the control group. On the other hand, systemic manifestations level had no statistically significant correlation with body mass index and prognosis in both control and study groups.. 8. It was observed that protocol of hygienic care which include using of sterile techniques by c Chlorhexidine Gluconate during catheter insertion and ongoing catheter care were effective in reducing incidence of CAUTI among study group patients than routine nursing hospital care among control group of critically-ill catheterized patients.. The recommendations of the present study are: 1. Recommendation for patients -Provide clear instruction to patients and care giver on proper hygienic care, urinary catheter care and drainage system by using Chlorhexidine Gluconate by using booklet conducted by the researcher. -Urine culture and sensitivity test should be done weekly and before catheter removal for all critically-ill catheterized patients . 2-Recommendation for clinical practice - Protocol of Hygienic Care by Chlorhexidine Gluconate on Occurrence of Catheter Associated Urinary Tract Infection which include using of aseptic techniques for catheterization and catheter care should be carried out as a routine care for critically catheterized patients. - Maintain CAUTI profile for Continuous assessment of signs and symptoms of CAUTI. - Daily evaluation of the need for continuing an indwelling catheter and removal of the catheter whenever possible and use of alternative method of bladder drainage. 3-Recommendations for education and training -Development of in-service training program for all health team workers especially nursing staff in intensive care units about care of indwelling catheterized patients and the preventive measures of catheter-associated urinary tract infections (CAUTIs). -Increase awareness of critical nurses about daily hygienic care by using Chlorhexidine Gluconate. 4. Recommendations for further research studies:- -Assessment of problems facing critical care nurse regarding hygienic and catheter care and their effect on nurses’ performance and satisfaction. -keeping Chlorhexidine.