Exam 2 Concept Guide
Safety -Eye protection is utilized if irrigating a
wound or if a specimen is needed with those
Infection control precautions guidelines
with a respiratory virus
and when to utilize
-Perform hand hygiene before and after
*Contact
touching the patient and after contact with
-Examples: Presence of stool incontinence respiratory secretions and contaminated
(may include patients with norovirus, objects/materials; note: use soap and water
rotavirus, or Clostridium difficile), draining when hands are visibly soiled (e.g., blood,
wounds, uncontrolled secretions, pressure body fluids)
ulcers, or presence of ostomy tubes and/or
-Instruct patient to wear a facemask when
bags draining body fluids
exiting the exam room, avoid coming into
-Perform hand hygiene before touching close contact with other patients, and
patient and prior to wearing gloves practice respiratory hygiene and cough
etiquette
-PPE use:
*Airborne
-Wear gloves when touching the patient and
the patient’s immediate environment or -Examples Tuberculosis, Measles,
belongings. *Wear a gown if substantial Chickenpox (until lesions are crusted over),
contact with the patient or their environment Localized (in immunocompromised patient)
is anticipated, such as with active MRSA or disseminated herpes zoster (until lesions
patients are crusted over)
-Perform hand hygiene after removal of -Place the patient immediately in an airborne
PPE; note: use soap and water when hands infection isolation room (AIIR)
are visibly soiled (e.g., blood, body fluids),
-If an AIIR is not available: Provide a
or after caring for patients with known or
facemask (e.g., procedure or surgical mask)
suspected infectious diarrhea
to the patient and place the patient
(e.g., Clostridium difficile, norovirus)
immediately in an exam room with a closed
*Droplet door
-Examples Respiratory viruses (influenza, -PPE use:
pertussis, parainfluenza virus, adenovirus,
-Wear a fit-tested N-95
respiratory syncytial virus)
-If substantial spraying of respiratory fluids
-PPE use:
is anticipated, gloves and gown as well as
-Wear a facemask for close contact with the goggles or face shield should be worn
patient; the facemask should be put on upon
-Perform hand hygiene before and after
entering the exam room
touching the patient and after contact with
-If extensive spraying of respiratory fluids is respiratory secretions and/or body fluids and
predicted, gloves and gown as well as contaminated objects/materials; note: use
goggles (or face shield in place of goggles) soap and water when hands are visibly
should be worn soiled (e.g., blood, body fluids)
, Exam 2 Concept Guide
*Special precautions Ways to avoid friction/shear
-Nurses need to use neutropenic Friction- occurs when two surfaces rub
precautions/protective for a patient whose against each other
immune system is compromised (e.g.,
Shear- results when one layer of tissue slides
recovering from transplantation surgery or
over another layer, shear separates the skin
receiving chemotherapy or heart transplant).
from underlying tissue
-Those who are immunosuppressed more
- Use of lift sheet to reduce shearing or USE
often than not become infected by organisms
A MECHANICAL LIFT….so… we need to
harbored in their own bodies, rather than by
evaluate self-mobility ability
pathogens present in the environment or
transmitted from other people. Use of Braden scale
-As with all patients, standard precautions Used for predicting pressure sore ulcer risk.
are required, but some additional measures
are helpful when a patient’s ability to Higher score = less risk
withstand any bacterial invasion is 19 – 23 No risk
compromised.
15 – 18 Mild
Recommendations in this situation include:
13 – 14 Moderate
-Ensure that caregiver is healthy.
10 – 12 High
-Restrict visits from friends and family
members who have colds or contagious Below 9 Very High
illnesses.
-Avoid collection of standing water in the
room (e.g., with flowers or in humidifiers) to
prevent bacteria typically found in this
water.
-The latest CDC isolation guidelines also
address environmental controls that foster a
“protective environment” to decrease the
risk of infection in the most severely
immunocompromised patients.
Skin breakdown risks
- Immobility Proper specimen teaching and collection
for sputum, urine,
- Poor Nutrition and Hydration
*Routine Urinalysis
- Decreased Moisture
-A sterile urine specimen is not required for
- Decreased Mental Status
a routine urinalysis.
- Increased Age
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