Transmission-Based Precautions - Airborne, Droplet, Contact

TRANSMISSION-BASED PRECAUTIONS (TIER TWO) FOR USE WITH SPECIFIC TYPES OF PATIENTS Category Airborne Precautions (Droplets <5 μm) Droplet Precautions (Droplets >5 μm; being within 3 feet of the patient) Contact Precautions (Direct patient or environmental contact) Disease Measles, chickenpox (varicella), disseminated herpes zoster, Mycobacterium tuberculosis, rubeola Influenza, adenovirus, group A streptococcus, Neisseria meningitides, pertussis, rhinovirus, mycoplasma pneumoniae, pertussis, diphtheria, pneumonic plague, rubella, mumps, respiratory syncytial virus Colonization or infection with multidrug-resistant organisms, such as VRE and MRSA, Clostridium difficile, shigella and other enteric pathogens, major wound infections, herpes simplex, scabies, varicella zoster (disseminated), respiratory syncytial virus Barrier Protection Private room; negativepressure airflow of at least 6-12 exchanges per hour via HEPA filtration; mask or respiratory protection device, N95 respirator Private room or cohort patients; mask or respirator (refer to agency policy) Private room or cohort patients (see agency policy); gloves, gowns Protective environment Allogeneic hematopoietic stem cell transplants Private room; positive airflow with ≥12 air exchanges per hour; HEPA filtration for incoming air; mask, gloves, gowns TRICKS TO REMEMBER ABC S&D—look at what the question is asking for in this order—pick the best answer based on the ABC S&D Airway Breathing Circulation Safety Discomfort ADPIE—Remember this order and answer the question based on the template below Assess Diagnose Planning Implementation Evaluation REMEMBER, SAFETY OF THE PATIENT IS ALWAYS IMPORTANT LAB VALUES Potassium—(Banana) 3.5 – 5.0 Magnesium—(Mag Wheels) 1.3 – 2.1 Calcium—(Boone) 9.0 – 10.5 Chloride—(Pool temperature) 97 – 107 Phosphate—(Fossil) 3.0 – 4.5 Sodium—(Age decrease sodium intake) 135 – 145 Electrolyte Imbalances Hypercalcemia—bone pain, muscle weakness, excessive thirst, lethargy, nausea Hypercalcemia—numbness, tingling in digits, muscle cramps, wheezing, fatigue Hyperkalemia—heart arrythmias, numbness and tingling, breathing problems Hypokalemia—Muscle weakness, fatigue, heart arrythmias Hypermagnesemia—diminished deep tendon reflexes, flushing, headache, nausea, drowsiness. Hypomagnesemia—muscle weakness, twitches, tremors, irritability, insomnia, drowsiness Hyperchloremia—diarrhea, vomiting Hypochloremia—diarrhea, vomiting Hyperphosphatemia—Osteoporosis, cardiovascular disease Hypophosphatemia--changes in mental state, bone pain, fragility, fatigue, weight loss, weakness Hypernatremia—lethargy, myoclonic jerks, confusion, nystagmus, tachycardia Hyponatremia—nausea, vomiting, lethargy, seizure, neurological deficits 24 hour urine sample 1. Start the collection In the morning, after waking up and emptying your bladder for the first time, urinate into the toilet and note the exact time. This is the start time of your collection. 2. Collect all urine Collect every drop of urine in a special container for the next 24 hours. This includes urine passed with a bowel movement, but try not to include feces. 3. Finish the collection On the second day, urinate into the container within 10 minutes before or after the same time as the first morning void on the first day. 4. Store and label Store the container in the refrigerator or a cool place. Label the container with your name, the date, and the time of completion. 5. Return the sample Return the container to the lab as soon as possible. A 24-hour urine test measures the amount of protein or other substances in your urine to check how well your kidneys are working. Your healthcare provider may give you instructions on how and where to take the sample. You should check with your clinician before starting the collection if you have any questions or if you are taking any medications. When to use a facemask vs. respirator mask N95 Respirators An N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles. Note that the edges of the respirator are designed to form a seal around the nose and mouth. Surgical N95 Respirators are commonly used in healthcare settings and are a subset of N95 Filtering Facepiece Respirators (FFRs), often referred to as N95s. Face Masks A face mask is a product that covers the wearer's nose and mouth. Face masks are for use as source control by the general public and health care personnel (HCP) in accordance with CDC recommendations, and are not personal protective equipment. Face masks may or may not meet any fluid barrier or filtration efficiency levels; therefore, they are not a substitute for N95 respirators or other Filtering Facepiece Respirators (FFRs), which provide respiratory protection to the wearer, or for surgical masks, which provide fluid barrier protection to the wearer. Correct order of removing PPE The correct order for removing PPE after patient care Gloves Gown Goggles Mask Doff (off) the gloves FIRST, followed by the gown, then the face shield or goggles, and lastly, doff the mask or respirator. Types of Wound Drainage Serous: Clear, watery plasma wound drainage shows light colored circular spot. Purulent: Thick, yellow, green, tan, or brown wound drainage shows thick, yellow, green, tan, or brown stain. Serosanguineous: Pale, pink, watery; mixture of clear and red fluid wound drainage shows pale red and pink fluid completely staining the gauze. Sanguineous: Bright red; indicates active bleeding wound drainage shows bright red spot surrounded by light red stain. WOUND DRESSINGS Purposes of dressings. A dressing serves several purposes: • • • • • • Protects a wound from microorganism contamination Aids in hemostasis Promotes healing by maintaining wound moisture Promotes healing by absorbing drainage and debriding a wound Supports or splints a wound site Promotes thermal insulation of a wound surface DRESSINGS FOR WOUND CARE Pressure Pressure Injury Stage Injury Status. Dressing Adjuvants 1 Intact  None  Transparent dressing  Hydrocolloi d 2 Clean    Composite film Hydrocolloi d Hydrogel covered with foam or gauze dressing Comments. Allows visual assessment. Protects from shear. Do not use transparent dressing in presence of excessive moisture. Hydrocolloid does not allow visual assessment. Limits shear. Change when seal of dressing breaks; maximal wear time 7 days. Expected Change Resolves slowly without epidermal loss over 7–14 days Turning schedule. Support hydration. Nutritional support. Use pressureredistributio n bed or chair cushion. Heals through reepithelializatio n See previous stage. Manage incontinence . 3 Clean   4 Clean Hydrocolloi d Hydrogel covered with foam dressing  Calcium alginate  Gauze  Growth factors  Hydrogel covered with foam dressing Provides moist environment . Change when seal of dressing breaks; maximum wear time 7 days. Apply over wound to protect and absorb moisture. Use when there is significant exudate. Cover with secondary dressing Use with normal saline or other prescribed solution. Wring out excess solution; unfold to make contact with wound. Cover with dry dressing tape in place. Use with gauze per manufacture r instructions. See Stage 3: clean. Heals through granulation and reepithelializatio n See previous stages. Evaluate pressureredistributio n needs. Heals through granulation, scar tissue development, Surgical consultation may be necessary Unstageabl e Wound covere d with eschar  Calcium alginate Used with significant exudate; must cover with secondary dressing. and reepithelializatio n for closure. See Stages 1, 2, and 3.  Adherent film  Gauze plus ordered solution. Eschar lifts at edges as healing progresses  Enzymes Facilitates softening of eschar. Delivers solution and may soften the eschar. Breaks down eschar, providing debridemen t. If eschar is dry and intact and debridemen t is not part of the plan of care, no dressing is used, allowing eschar to act as physiologica l cover. See previous stages. Surgical consultation may be considered for debridement .  None Eschar loosens over time May be considered for slow debridement . BMI—Body Mass Index Overweight is defined as having a body mass index (BMI) of 25 to 29, and obesity is defined as a BMI of 30 or greater Hospice Care A hospice is a system of family-centered care that allows patients to live with comfort, independence, and dignity while easing the pain of terminal illness. A patient entering into hospice care is in the terminal phase of illness, and the patient, family, and health care provider agree that no further treatment will reverse the disease process. Hospice care is provided in a setting that best meets the needs of each patient and family, such as in a patient’s home or in nursing homes, assistedliving facilities, freestanding hospices, and hospitals. The focus of hospice care is supportive care, not curative treatment (see Chapter 36). Hospice benefits families and patients in the terminal phase of any disease, such as cardiomyopathy, multiple sclerosis, acquired immunodeficiency syndrome (AIDS), and cancer. Hospice team members are available 24 hours a day, 7 days a week to answer questions or visit anytime the need for support arises. Team members collaborate to provide care that ensures death with dignity. Services continue without interruption even if a patient’s care setting changes. A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? a. Assist the ambulating client back to the bed. b. Encourage the client to ambulate to resolve pneumonia. c. Obtain a prescription for portable oxygen while ambulating. d. Move the oximetry probe from the finger to the earlobe. Rationale An oxygen saturation below 90% indicates inadequate oxygenation. First, the client should be assisted to return to bed to minimize oxygen demands. Ambulation increases aeration of the lungs to prevent pooling of respiratory secretions, but the client's activity at this time is depleting oxygen saturation of the blood. Increased activity increases respiratory effort, and oxygen may be necessary to continue ambulation, but first the client should return to bed to rest. After completing an assessment and determining that a client has a problem, which action should the nurse perform next? a. Determine the etiology of the problem. b. Prioritize nursing care interventions. c. Plan appropriate interventions. d. Collaborate with the client to set goals. Rationale Before planning care, the nurse should determine the etiology, or cause, of the problem, because this will help determine goals, plan of care and priorities of interventions. A client receives a prescription for azithromycin (Zithromax) 500 mg PO x 3 days. Azithromycin is available as 250 mg scored tablets. How many tablets should the nurse administer per dose? (Enter the numerical value only.) Rationale Using the formula, D/H 500 mg/250 mg = 2 tablets Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? a. Reassure the client that he will become accustomed to the stoma appearance in time. b. Instruct the client that the stoma will become smaller when the initial swelling diminishes. c. Offer to contact a member of the local ostomy support group to help him with his concerns. d. Encourage the client to handle the stoma equipment to gain confidence with the procedure. Rationale Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished. This will help reduce the client's anxiety and promote acceptance of the colostomy. Which assessment data provides the most accurate determination of proper placement of a nasogastric tube? a. Aspirating gastric contents to assure a pH value of 4 or less. b. Hearing air pass in the stomach after injecting air into the tubing. c. Examining a chest x-ray obtained after the tubing was inserted. d. Checking the remaining length of tubing to ensure that the correct length was inserted. Rationale Assessing the pH of gastric contents and listening for air in the stomach are both methods used to determine proper placement of the nasogatric tube. However, the best indicator that the tube is properly placed is confirming with a chest x-ray. A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? a. Sexual activity patterns. b. Nutritional history. c. Leisure activities. d. Financial stressors. Rationale Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of anxiety, a nutritional history should be obtained first. The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? a. Avoid any types of sprays, powders, and perfumes. b. Wearing a mask while cleaning will not help to avoid allergens. c. Purchase any type of clothing, but be sure it is washed before wearing it. d. Pollen count is related to hay fever, not to allergens. Rationale The client with allergies should be instructed to reduce any exposure to pollen, dust, fumes, odors, sprays, powders, and perfumes. The client should be encouraged to wear a mask when working around dust or pollen. Clients with allergies should avoid any clothing that causes itching; washing clothes will not prevent an allergic reaction to some fabrics. Pollen count is related to allergens, and the client should be instructed to stay indoors when the pollen count is high. A client with multiple sclerosis is prescribed Dantrolene (Dantrium) 0.1 grams PO bid for spasticity. Dantrolene is available in 100 mg capsules. How many capsules should the nurse administer? (Enter numeric value only.) Rationale Using the conversion of 1 gram = 1000 mg: 0.1 gram = 100 mg 100 mg = 1 capsule During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? a. Adequate venous blood flow to the lower extremities. b. Estimated amount of body fat by an underarm skinfold. c. Degree of flexion and extension of the client's knee joint. d. Change in the circumference of the joint in centimeters. Rationale The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring device that is placed over a joint as the individual extends or flexes the joint to measure the degrees of flexion and extension on the protractor. On the other hand, a doppler is used to measure blood flow; calipers are used to measure body fat; and a tape measure is used to measure circumference of body parts. A client's daily PO prescription for aripiprazole (Abilify) is increased from 15 mg to 30 mg. The medication is available in 15 mg tablets, and the client already received one tablet today. How many additional tablets should the nurse administer so the client receives the total newly prescribed dose for the day? (Enter numeric value only.) Rationale 30 mg (total dose) - 15 mg (dose already administered) = 15 mg that still needs to be administered. Using the Desired/Have formula: 15 mg/15 mg = 1 tablet The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? a. Immediately after exhalation. b. During the inhalation. c. At the end of three inhalations. d. Immediately after inhalation. Rationale The client should be instructed to deliver medication through a metered inhaler during the last part of inhalation. After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and hold the breath for several seconds to allow for distribution of the medication. A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? a. Record the coughing incident. No further action is required at this time. b. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. c. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. d. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling Rationale Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action. The auscultating method has been found to be unreliable for small-bore feeding tubes. At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. Which is the best response to this client's silence? a. "It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel." b. "Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery." c. "It is OK if you don't want to talk about your surgery. I will be available when you are ready." d. "I will ask a woman who has had a mastectomy to come by and share her experiences with you." Rationale When a client is reluctant to look at a surgical wound or refuses to talk about the surgery, the nurse should reflect that these feelings are OK and that the nurse is available when the client is ready. Such a response displays sensitivity and understanding without judging the client. On the other hand, telling a client how she should feel is judgmental and insensitive. A client with pericardial effusion has phrenic nerve compression resulting in recurrent hiccups. The healthcare provider prescribes metoclopramide (Reglan) liquid 10 mg PO q 6 hours. Reglan is available as 5 mg/5 ml. A measuring device marked in teaspoons is being used. How many teaspoons should the nurse administer? Rationale First, using the formula, Desired dose/dose on Hand x Quantity of volume on hand (D/H x Q), 10 mg / 5 mg x 5ml = 10 ml Next using the known conversion of 5 ml = 1 tsp: 5 ml : 1 tsp :: 10 ml : X 5 / 10 : 1 / X 5X = 10 X=2 An older client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube (GT). What is the best position for the client for administration of the bolus tube feedings? a. Prone. b. Fowler's. c. Sims'. d. Supine. Rationale A gastrostomy tube (GT), known as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy procedure, is inserted directly into the stomach through an incision in the abdomen for long-term administration of nutrition and hydration in the debilitated client. The unresponsive client should be positioned in a semi-sitting (Fowler's) position during feeding through a gastrostomy tube to decrease the occurrence of aspiration. In prone or Sims' positions, the client is placed on the abdomen, an unsafe position for feeding. Placing the client in supine position increases the risk of aspiration. During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem? a. Restatement of responses. b. Open-ended questions. c. Closed-ended questions. d. Problem-seeking responses. Rationale Lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific information, the nurse should use closed-ended questions that focus on common signs and symptoms about a client’s health problem.Other question types are used when therapeutically interacting and should be used after specific information is obtained from the client. The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How many tablets should the nurse plan to administer? a. 1/2 tablet. b. 1 tablet. c. 1 1/2 tablets. d. 2 tablets. Rationale D/H X Q = 7.5/5 X 1 tablet = 1 1/2 tablets An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? a. Inquire about the source and type of pain. b. Examine the nose for congestion and discharge. c. Take vital signs for temperature elevation. d. Explore the abdominal area for distension. Rationale Different cultural groups often have their own terms for health conditions. African-American clients may refer to pain as "the miseries. " Based on understanding this term, the nurse should conduct a focused assessment on the source and type of pain. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? a. Loosen the right wrist restraint. b. Apply a pulse oximeter to the right hand. c. Compare hand color bilaterally. d. Palpate the right radial pulse. Rationale The nurse has observed that a client's fingers are blue distal to a wrist restraint. The priority nursing action is to restore circulation by loosening the restraint, because blue fingers (cyanosis) indicates decreased circulation. Assessing the depth of color change and the radial pulse are also important nursing interventions, but do not have the priority of removing the restraint. Pulse oximetry measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression (the restraints). The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? a. Observe the appearance of the skin under the ice pack. b. Instruct the client regarding the need for the covering. c. Reapply the covering after filling with fresh ice. d. Ask the client how long the ice was applied to the skin. Rationale The client has been using an ice pack without the protective covering. The first action the nurse should take is to assess the skin for any possible thermal injury. If no injury to the skin has occurred, the nurse can then explain the need for a cover and reapply the ice pack with the cover in place. An older client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? a. Massage any reddened areas for at least five minutes. b. Encourage active range of motion exercises on extremities. c. Position the client laterally, prone, and dorsally in sequence. d. Gently lift the client when moving into a desired position. Rationale To avoid shearing forces when repositioning, the client should be lifted gently across a surface. Reddened areas should not be massaged since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion may be limited on the affected leg. The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? a. Thalamus. b. Hypothalamus. c. Frontal lobe. d. Parietal lobe. Rationale The frontal lobe of the cerebrum controls higher mental activities, such as memory, intellect, language, emotions, and personality. On the other hand, the thalamus is an afferent relay center in the brain that directs impulses to the cerebral cortex. The hypothalamus regulates body temperature, appetite, maintains a wakeful state, and links higher centers with the autonomic nervous and endocrine systems, such as the pituitary. The parietal lobe is the location of sensory and motor functions. During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? a. additional coffee on the client's breakfast tray. b. Exchange the client's grape juice for cranberry juice. c. Bring the client additional fruit at mid-morning. d. Encourage additional oral intake of juices and water. Rationale Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract infection. The client needs to restore fluid volume more than solid foods (C).