1. NUR 113: SKILL 7-2: CARING FOR PATIENTS UNDER ISOLATION PRECAUTIONS

2. SKILL 7-2: Caring for Patients Under Isolation Precautions  When a patient has a known or suspected source of colonization or infection, health care workers follow specific infection prevention and control practices to reduce the risk of cross-contamination to other patients.  Certain procedures performed at a patient’s bedside require the application of personal protective equipment (PPE) such as a mask, cap, eyewear, gown or gloves.  Standard precautions require you to wear clean gloves before coming in contact with mucous membranes, non-intact skin, blood, body fluids, or other infectious material.

3. SKILL 7-2: Caring for Patients Under Isolation Precautions  Masks are worn when there is the risk of splash during a procedure or when certain sterile procedures such as changing a central line dressing are performed.  Protective eyewear and masks become important when there is a risk for splash or blood or other body fluids to the eyes or mouth.

4. CARING FOR PATIENTS UNDER ISOLATION PRECAUTIONS - INTRODUCTORY CATEGORYINFECTION / CONDITIION BARRIER PROTECTION Airborne precautions (droplet nuclei smaller than 5 microns) Measles, Chickenpox (varicella), disseminated varicella zoster, pulmonary or laryngeal tuberculosis Private room, negative- pressure airflow of at least 6 to 12 exchanges per hour via HEPA filtration ; mask or respiratory protection device, N 95 respirator required (depending on condition) Droplet precautions (droplets larger than 5 microns; being within 3 feet of the patient) Diphtheria (pharyngeal), rubella, streptococcal pharyngitis, pneumonia or scarlet fever in infants & young children, pertussis, mumps, Mycoplasma pneumonia, meningococcal pneumonia or sepsis, pneumonic plague Private room or cohort patients ; mask or respirator required (depending on condition (refer to agency policy)

5. CARING FOR PATIENTS UNDER ISOLATION PRECAUTIONS - INTRODUCTORY CATEGORY INFECTION / CONDITIION BARRIER PROTECTION Contact Precautions (direct patient or environmental contact) Colonization or infection with multi-drug resistant organisms such as VRE & MRSA, Clostridium difficile, Shigella, and other enteric pathogens; major wound infections; herpes simplex; scabies; varicella zoster (disseminated) Private Room or Cohort Patients (see agency policy), glove, gowns Protective Environment Allogeneic hematopoietic stem cell transplants Private room; positive airflow with 12 or more air exchanges per hour ; HEPA filtration for incoming air; mask to be worn by patient when out of room during times of construction in area

6. ASSESSMENT  1. Assess patient’s medical history for possible indications for isolation (e.g., risk factors for TB, major draining wound, or purulent productive cough).  2. Review laboratory test results (e.g., wound culture, acid-fast bacillus {AFB} smears, changes in WBC count).  3. Consider types of care measures that you will perform while in patient’s room (e.g., medication administration or dressing change).  4. Review nursing care plan notes or confer with colleagues regarding patient’s emotional state and reaction / adjustment to isolation. Also assess patient’s understanding of purpose of isolation.

7. PLANNING  1. Expected outcomes following completion of the procedure:  Patient asks for information about disease transmission – active interaction reveals patient’s willingness and / or ability to communicate and be taught and understand information.  Patient explains purpose of isolation – Instruction about precautions improve the patient’s ability to cooperate in care.

8. IMPLEMENTATION  1. Perform hand hygiene  2. Prepare all equipment needed in patient’s room.  3. Prepare for entrance into isolation room. Prior to applying PPE, step into patient’s room and stay by door. Introduce yourself and explain the care that you are providing.  A. Apply gown and secured – pull sleeves down to wrist. Tie securely at neck and waist.  B. Applied surgical mask or respirator around mouth and nose, had medical evaluation, and was fit-tested before using the respirator.

9. IMPLEMENTATION  C. If needed apply eyewear or goggles snugly around the face and the eyes. If you wear prescription glasses, side shields may be used.  D. Apply clean gloves. Bring glove cuffs over edge of gown sleeves.

10. IMPLEMENTATION – CONT’D  4. Enter patient’s room. Arrange supplies and equipment.  5. Explain purpose of isolation and precautions for patient and family to take. Offer opportunity to ask questions.  6. Obtain vital signs measurements.  A. Reusable equipment brought into the room must be thoroughly disinfected when removed from room.  B. If stethoscope is to be re-used, clean earpieces and diaphragm or bell with 70 % alcohol or agency- approved germicide. Set aside on clean surface.  C. Use individual or disposable thermometers and blood pressure cuffs when available.

11. IMPLEMENTATION – CONT’D  7. Administer medications  A. Give oral medication in wrapper or cup.  B. Dispose of wrapper or cup in plastic-lined receptacle.  C. Wear gloves when administering an injection.  D. Discard disposable syringe and uncapped or sheathed needle into designated sharps container.  E. Place reusable plastic syringe on clean towel for eventual removal and disinfection.  F. If you are not wearing gloves and hands contact a contaminated article or body fluids, perform hand hygiene as soon as possible.

12. IMPLEMENTATION – CONT’D  8. Administer hygiene, encouraging patient to ask any questions or express concerns about isolation. Provide informal teaching at this time.  A. Avoid allowing isolation gown to become wet; carry wash-basin outward away from gown; avoid leaning against wet tabletop.  B. Help patient remove own gown; discard in leak-proof linen bag.  C. Remove linen from bed; avoid contact with isolation gown. Place in leak-proof linen bag.  D. Provide clean bed linen and set of towels.  D. Change gloves and perform hand hygiene if gloves become excessively soiled and further care is necessary. Re-glove.

13. IMPLEMENTATION – CONT’D  9. Collect specimen  A. Place specimen containers on clean paper towel in patient’s bathroom.  B. Follow agency procedure for collecting specimen of body fluids.  C. Transfer specimen to container without soiling outside of container. Place container in plastic bag and place label on outside of bag or per agency policy. Label specimen in front of patient. Perform hand hygiene and re-glove if additional procedures are needed.  D. Check label on specimen for accuracy. Send to laboratory (warning labels are often used, depending on agency policy). Label containers of blood or body fluids with a biohazard sticker.

14. IMPLEMENTATION – CONT’D  10. Dispose of linen, trash, and disposable items.  A. Use single bags that are impervious to moisture and sturdy to contain soiled articles. Use double bag if necessary for heavily soiled linen or heavy wet trash.  B. Tie bags securely at top in knot  11. Remove all reusable pieces of equipment. Clean any contaminated surfaces with hospital approved disinfectant.

15. IMPLEMENTATION – CONT’D  12. Resupply room as needed. Have staff colleague hand new supplies to you.  13. Leave isolation room. Order of removal of PPE depend on what you wear in room. This sequence describes steps to take if all barriers are worn.  A. Remove gloves. Remove one glove by grasping cuff and pulling glove inside out over hand. Hold removed glove in gloved hand. Slide fingers of ungloved hand under remaining glove at the writs. Peel glove off over first glove. Discard gloves in the proper container.

16. IMPLEMENTATION – CONT’D  B. Remove eyewear, face shield, or goggles. Handle by headband or earpieces. Discard in proper container.  C. Untie neck strings and then untie back strings of the gown. Allow the gown to fall from the shoulders; touch inside of gown only. Remove hands from sleeves without touching outside of gown. Hold gown inside at shoulder seams and fold inside out into a bundle; discard in the laundry bag.  D. Remove mask. If the mask secures over the ears, remove elastic from the ears and pull the mask away from the face. For a tie-on mask, untie bottom mask string and then top strings, pull mask away from the face and drop it into the trash receptacle (do not touch outer surface of the mask).  E. Perform hand hygiene

17. IMPLEMENTATION – CONT’D  F. Retrieve wristwatch and stethoscope (unless items must remain in the room) and record vital sign values on note paper.  G. Explain to the patient when you plan to return to the room. Ask whether the patient requires any personal care items. Offer books, magazines, audiotapes.  H. Dispose of all contaminated supplies and equipment in manner that prevents the spread of microorganisms to other persons (see agency policy). Perform hand hygiene.  I. Leave room and close the door, if necessary. Close the door if the patient is on airborne precautions or in a negative airflow room. – This maintains negative airflow environment and reduces transmission of micro-organisms.

18. EVALUATION  1. While in the room, ask if the patient has had a sufficient chance to discuss health problems, course of treatment, or other topics important to them.  Measure patient’s perception of adequacy of discussions with caregivers.  2. Ask patient to describe the purpose of isolation and offer them a chance to ask questions.  Feedback demonstrates learning.

19. UNEXPECTED OUTCOMES  Patient avoids social and therapeutic discussions.  Confer with family and / or significant other and determine best approach to reduce patient’s sense of loneliness and depression.  Patient or health care worker may have an allergy to latex gloves.  Notify physician / employee health and treat sensitivity or allergic reaction appropriately.  Use latex-free gloves for future care activities.

20. RECORDING & REPORTING  1. Document procedures performed and patient’s response to social isolation. Also document any patient education performed and reinforced.  Document type of isolation in use and the microorganisms (if known).

21. END OF SKILL  This is the end of the skill  Your book has provided a video for you and the link is below:  http://booksite.Elsevier.com/Perry-Potter/clinicalSkills/video08.php http://booksite.Elsevier.com/Perry-Potter/clinicalSkills/video08.php  Elsevier: Perry-Potter: Clinical Nursing Skills and Techniques, 8e-7.2 Caring for patients under Isolation Precautions