Exam 2 Concept Guide
Safety -Eye protection is utilized if irrigating a
Infection control precautions wound or if a specimen is needed with those
guidelines and when to utilize with a respiratory virus
*Contact -Perform hand hygiene before and after
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
bags draining body fluids -Instruct patient to wear a facemask when
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
-PPE use: etiquette
-Wear gloves when touching the patient and *Airborne
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),
or after caring for patients with known or -If an AIIR is not available: Provide a
suspected infectious diarrhea facemask (e.g., procedure or surgical mask)
(e.g., Clostridium difficile, norovirus) to the patient and place the patient
immediately in an exam room with a closed
*Droplet door
-Examples Respiratory viruses (influenza, -PPE use:
pertussis, parainfluenza virus, adenovirus,
respiratory syncytial virus) -Wear a fit-tested N-95
-PPE use: -If substantial spraying of respiratory fluids
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
entering the exam room -Perform hand hygiene before and after
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.,
recovering from transplantation surgery or Shear- results when one layer of tissue slides
receiving chemotherapy or heart transplant). over another layer, shear separates the skin
from underlying tissue
-Those who are immunosuppressed more
often than not become infected by organisms - Use of lift sheet to reduce shearing or USE
harbored in their own bodies, rather than by A MECHANICAL LIFT….so… we need to
pathogens present in the environment or evaluate self-mobility ability
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
illnesses.
High
-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
- Poor Nutrition and Hydration
Proper specimen teaching and
- Decreased Moisture collection for sputum, urine,
- Decreased Mental Status *Routine Urinalysis
- Increased Age -A sterile urine specimen is not required
for a routine urinalysis.
Safety -Eye protection is utilized if irrigating a
Infection control precautions wound or if a specimen is needed with those
guidelines and when to utilize with a respiratory virus
*Contact -Perform hand hygiene before and after
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
bags draining body fluids -Instruct patient to wear a facemask when
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
-PPE use: etiquette
-Wear gloves when touching the patient and *Airborne
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),
or after caring for patients with known or -If an AIIR is not available: Provide a
suspected infectious diarrhea facemask (e.g., procedure or surgical mask)
(e.g., Clostridium difficile, norovirus) to the patient and place the patient
immediately in an exam room with a closed
*Droplet door
-Examples Respiratory viruses (influenza, -PPE use:
pertussis, parainfluenza virus, adenovirus,
respiratory syncytial virus) -Wear a fit-tested N-95
-PPE use: -If substantial spraying of respiratory fluids
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
entering the exam room -Perform hand hygiene before and after
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.,
recovering from transplantation surgery or Shear- results when one layer of tissue slides
receiving chemotherapy or heart transplant). over another layer, shear separates the skin
from underlying tissue
-Those who are immunosuppressed more
often than not become infected by organisms - Use of lift sheet to reduce shearing or USE
harbored in their own bodies, rather than by A MECHANICAL LIFT….so… we need to
pathogens present in the environment or evaluate self-mobility ability
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
illnesses.
High
-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
- Poor Nutrition and Hydration
Proper specimen teaching and
- Decreased Moisture collection for sputum, urine,
- Decreased Mental Status *Routine Urinalysis
- Increased Age -A sterile urine specimen is not required
for a routine urinalysis.
