Flashcards.

WHAT IS IT?

A colostomy is a stoma (opening on the abdomen) where stool exits into an appliance (bag). This card covers how to care for the stoma, the skin, and the appliance, plus diet teaching.

NURSING CONSIDERATIONS

• •Assess stoma appearance. Normal color is pink to red.
• •Report a stoma that is pale, dark, purple, or brown.
• •Cut the stoma appliance (bag) 1/16 to 1/8 inch larger than the stoma.
• •Cleanse the stomal area and keep it dry.
• •Apply skin barrier before applying the appliance.
• •Empty the appliance frequently to avoid complications, generally when 1/3 full.
• •A small needle-sized hole can be made in the pouch to let flatus (gas) escape. Seal it with a bandaid.

Diet teaching:

• •Foods that increase gas: beer, broccoli, brussel sprouts, cabbage, carbonated drinks, beans, dairy, spinach
• •Foods that thicken stool: applesauce, banana, bread, cheese, yogurt, rice, pasta

WHAT IS IT?

Hepatitis is inflammation of the liver, usually from a virus. Different types spread in different ways. As the liver is damaged, bilirubin and liver enzymes rise, which leads to jaundice and other symptoms.

Types and transmission:

• •Hepatitis A (HAV): health care workers are at risk; spreads by fecal-oral route, person-to-person, and poorly washed hands or utensils. Most contagious 10 to 14 days before symptoms start and is self-limiting (resolves on its own). Prevention: strict hand washing, standard precautions, hepatitis A vaccine.
• •Hepatitis B (HBV): spreads by blood or body fluids through IV drug use, sexual contact, or needle stick. Prevention: standard precautions, hand washing, blood screening, hepatitis B vaccine, needle precautions, safe sex practices.
• •Hepatitis C (HCV): blood-borne, IV drug users, needle stick. Prevention: standard precautions, needle safety, blood screening. NO vaccine available.
• •Hepatitis D (HDV): opportunistic infection associated with hepatitis B virus (HBV).
• •Hepatitis E (HEV): fecal-oral route, common in underdeveloped countries.

ASSESSMENT

Preicteric stage:

• •Flu-like symptoms, pain, low-grade fever

Icteric stage:

• •High bilirubin causes jaundiced (yellow) skin and eyes, dark urine, and pruritus (itching)
• •Clay-colored stool (from lack of bile secretion)
• •Elevated liver function tests (LFTs): AST, ALT, ALP, and ammonia

Posticteric stage:

• •Recovery phase, lab values return to normal, pain relief, increased energy

MANAGEMENT

Supportive therapy to address symptoms:

• •Lactulose for high ammonia levels
• •Antiemetics (anti-nausea medications)
• •Antihistamines (can help treat hepatitis C virus)
• •Antiviral therapy

WHAT IS IT?

Dialysis uses a semipermeable membrane to do many of the jobs the kidneys can no longer do. This includes clearing waste and toxins, removing urea, creatinine, and uric acid, and regulating electrolytes and acid-base balance.

TABLE

Hemodialysis:

• •Pulls blood from the patient through a machine that acts as the semipermeable membrane, then returns the blood to the patient
• •Requires vascular access
• •Risk for hypovolemic shock

Hemodialysis safety:

• •Protect vascular access (limb alert: no BP or sticks on that arm)
• •Pharmacologic considerations
• •Monitor vital signs closely

Peritoneal dialysis:

• •The peritoneum acts as the semipermeable membrane
• •Can be done at home
• •Risk for peritonitis

Peritoneal dialysis safety:

• •Prevent infection (hand hygiene and sterile technique)
• •Monitor for infection (peritonitis)

WHAT IS IT?

Leukemia is the overgrowth of abnormal, undeveloped WBCs (white blood cells). WBCs are needed for infection control and immunity. It is diagnosed by blood tests and a bone marrow biopsy.

TYPES (by WBC affected)

• •ALL (acute lymphocytic leukemia): 2 to 4 years of age
• •CLL (chronic lymphocytic leukemia): 50 to 70 years of age
• •AML (acute myelogenous leukemia): peaks at 60 years of age
• •CML (chronic myelogenous leukemia): incidence increases with age

ASSESSMENT

• •Weight loss
• •Fever
• •Infections
• •Pain in bones and joints
• •Night sweats
• •Aplastic anemia: pallor (pale skin), fatigue, easy bleeding and bruising
• •Increased WBC in CLL and CML
• •Decreased WBC in ALL and AML
• •Philadelphia chromosome in the majority of CML clients
• •Mouth sores from chemotherapy

MANAGEMENT

• •Chemotherapy and radiation
• •Bone marrow biopsy: apply pressure to the biopsy site
• •Initiate neutropenic precautions: strict handwashing, limit visitation, no fresh fruits or flowers
• •Plan activities to provide time for rest
• •Instruct the client on oral hygiene: rinse mouth with saline, avoid lemon or alcohol-based mouthwashes

WHAT IS IT?

Shingles is a viral infection caused by the herpes zoster virus. It is most common in elderly clients with a history of chickenpox or the chickenpox vaccine. It is highly contagious.

ASSESSMENT

• •Vesicular rash that follows the dermatome and is usually unilateral (on one side)
• •Painful and itchy
• •Fever, malaise, fatigue

MANAGEMENT

• •Contact isolation, or airborne isolation if the rash is disseminated (widespread)
• •Assess neurological status and signs of infection
• •Medications: antivirals, NSAIDs, and the shingles vaccine (for prevention)

WHAT IS IT?

A pressure ulcer is skin and tissue damage caused by pressure and/or shear (skin sliding against a surface), usually over a bony area. Nursing care focuses on prevention and treatment based on the stage.

NURSING CARE

• •Identify at-risk patients and start precautions and assessments
• •Keep skin dry and sheets wrinkle-free; turn and reposition frequently
• •Assess and document the status of the ulcer
• •Treatment may include creams, dressings, debridement (removing dead tissue), grafting, and vacuum-assisted suction

STAGING

• •Stage I: intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not show visible blanching.
• •Stage II: partial thickness loss of dermis, presenting as a shallow open ulcer with a red-pink wound. Presents as a shiny or dry shallow ulcer without slough or bruising.
• •Stage III: full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
• •Stage IV: full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
• •Unstageable: full thickness tissue loss where the actual depth is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and stage cannot be determined.
• •DTI (deep tissue injury): damage of underlying soft tissue from pressure and/or shear
• •[source fragment unclear, verify at source]

WHAT IS IT?

This card covers nursing care before, during, and after a seizure to keep the client safe.

MANAGEMENT

Before:

• •Give all medications on time
• •Use seizure precautions if at risk
• •Verify the order for PRN (as-needed) dosing and ensure medication is readily available

During (maintain airway):

• •Turn the client to the side in case of vomit
• •Have oxygen and suction equipment available
• •DO NOT force anything into the mouth during a seizure (including a bite block)

During (protect from injury):

• •Lower the bed to the lowest position
• •Use padded side rails
• •Loosen restrictive clothing
• •DO NOT try to restrain the client
• •Notify the MD of type, onset, and duration

After:

• •Keep the client safe while postictal (the recovery period after a seizure)

WHAT IS IT?

Influenza is a virus with multiple strains and increasing severity. It is spread through droplet contact.

ASSESSMENT

Symptoms:

• •Sudden onset
• •Lasts 6 to 7 days
• •Aches in the head, muscles, and body
• •Fatigue
• •Runny nose, sore throat, cough
• •Vomiting
• •High fever (102 to 104 degrees F)

MANAGEMENT

Vaccine, indicated annually for:

• •Healthcare workers
• •Elderly
• •Children over 6 months
• •Pregnant clients
• •Immunocompromised clients: do NOT give the nasal spray vaccine to immunocompromised clients

Vaccine contraindications:

• •Severe allergy to the flu vaccine, eggs, or latex
• •History of Guillain-Barre
• •Recent bone marrow or organ transplant (less than 6 months)

Anti-virals:

• •Oseltamivir (Tamiflu): within 48 hours of onset, best within 24 hours

WHAT IS IT?

Cognitive impairment disorders include autism-spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD), dementia, and Alzheimer's disease. Dementia is a broad category of brain diseases that are gradual and long-term and result in self-care deficits, largely affecting the client's ability to function. It causes judgment impairments and problems with problem solving and behavior. Alzheimer's disease is a TYPE of dementia and is an irreversible form caused by nerve cell deterioration, with a steady, progressive decline in functional capacity.

ASSESSMENT

• •Apraxia: difficulty performing motor tasks
• •Aphasia: difficulty progressing to inability to speak and understand what is being said
• •Agnosia: does not recognize familiar people or objects
• •Amnesia: memory loss

MANAGEMENT

Caregiver stress:

• •Role strain, for example a child caring for a parent
• •Sadness due to the loved one not recognizing them

Safety:

• •Wandering can be an issue; units should be locked/secured and clients supervised
• •Watch water temperature, as clients may burn themselves
• •Remove anything toxic or hazardous from easy access
• •Watch for agitation and remove things that increase it
• •Decrease stimuli and reassure the client
• •Never argue
• •Use a calm, reassuring voice with gentle touch when appropriate
• •Watch for sundowning (increased confusion at night)

Communicate:

• •Maintain eye contact
• •Stand in front of them; be calm, firm, and direct
• •Give simple one-step tasks/directions
• •Use short, simple words
• •Always identify them and yourself
• •Reorient as needed, which may be frequent

Promote their current abilities:

• •Keep familiar things around them
• •Continually reinforce what they know and can do at this point in time
• •Promote independence and supervise to ensure ADLs (activities of daily living) are taken care of

WHAT IS IT?

Hemophilia is an impaired ability to control blood clotting due to a deficiency in specific clotting proteins. It is an X-linked recessive disorder (hereditary). Carrier females pass it to a male child.

Quick Concept: Missing coagulation factors prevent fibrin formation, so the person bleeds for a long time because they cannot clot.

Types:

• •Hemophilia A (deficiency of factor VIII)
• •Hemophilia B (deficiency of factor IX)
• •Hemophilia C (deficiency of factor XI)

ASSESSMENT

• •Epistaxis (nose bleeds) and prolonged bleeding from trauma
• •Frequent bruising
• •Bleeding in the brain: visual changes, headaches, change in LOC (level of consciousness), slurred speech
• •GI (gastrointestinal) bleed: hematemesis (throwing up blood), melena (black stools = upper GI bleed)
• •Normal PT and thrombin time, prolonged PTT

MANAGEMENT

Goals:

• •Replace missing clotting factors
• •Prevent bleeding
• •Prevent long-term joint problems

Medications:

• •Replace the missing factor by slow IV push
• •DDAVP increases the body's production of clotting factor and is ONLY used in mild Hemophilia A

Access:

• •Many clients have a metaport for access
• •Maintain sterility when accessed
• •Only access when following policies or orders

TEST-TAKING TIPS

• •Deal with patients rather than with machines.
• •Avoid answers with: never, always, must, "why?", "I understand".
• •If two answers are opposites (for example hyper- vs. hypo-), one is usually correct.
• •Do not leave the patient alone.
• •Choose physical over psychological.
• •If you do not know the answer, pick the one with the most information.
• •Use ABC (Airway, Breathing, Circulation) except in emergencies, distress situations, and CPR.

PRIORITIZATION COMPARISONS

• •Assessment vs. Implementation
• •Acute vs. Chronic
• •Stable vs. Unstable
• •Expected vs. Unexpected
• •Real vs. Potential
• •Odd man out

DELEGATION

Do not delegate (PACET):

• •Planning
• •Assessment (initial)
• •Collaboration
• •Evaluation
• •Teaching

UAPs cannot be delegated:

• •"EAT" tasks, medication, and unstable patients

LPNs:

• •Cannot be delegated anything related to blood
• •Are assigned the most stable patients

CONVERSIONS

• •1 tsp = 5 mL
• •1 tbsp = 3 tsp (15 mL)
• •1 oz = 30 mL
• •1 cup = 8 oz
• •1 pint = 2 cups (16 oz)
• •1 quart = 2 pints (32 oz)
• •1 gr (grain) = 60 mg
• •1 kg = 2.2 lbs
• •1 g = 1 mL (diapers)
• •F = (C x 1.8) + 32

NORMAL VALUES

• •Temperature normal range: 98.6 F plus or minus 1 (37 C plus or minus 0.5)
• •MAP (mean arterial pressure): (systolic + 2 x diastolic) / 3; normal 70 to 105 mmHg (greater than 60 mmHg)
• •CVP (central venous pressure): 2 to 8 mmHg; CVP can indicate right ventricular failure or fluid volume overload

WHAT IS IT?

This card defines key ethics and legal terms in nursing.

TABLE

• •Veracity: truth, an essential part of a therapeutic relationship between a health care provider and patient
• •Beneficence: the duty to do good; an obligation to help the patient
• •Nonmaleficence: the duty to do no harm
• •Tort: litigation where one person asserts that an injury (physical, emotional, or financial) occurred because of another's actions or failure to act
• •Negligence: harm that results because a person did not act reasonably
• •Malpractice: professional negligence
• •Slander: character attacked and spoken in the presence of others
• •Assault: an act in which there is a threat or attempt to do bodily harm
• •Battery: unauthorized physical contact

WHAT IS IT?

This card covers the Parkland formula for fluid resuscitation in burns and a reference table of the cranial nerves.

PARKLAND FORMULA

• •Total fluid: 4 mL/kg/% body burned
• •1st 8 hours: 1/2 of total volume
• •2nd 8 hours: 1/4 of total volume
• •3rd 8 hours: 1/4 of total volume

CRANIAL NERVES (S = Sensory, M = Motor, B = Both)

• •I Olfactory: smell test
• •II Optic: visual acuity and visual fields
• •III Oculomotor: pupil constriction and extraocular movements
• •IV Trochlear: extraocular movements, inferior adduction
• •V Trigeminal: clench teeth and light touch
• •VI Abducens: extraocular movements, lateral abduction
• •VII Facial: facial movement, close eyes, smile
• •VIII Auditory: hearing and Romberg test
• •IX Glossopharyngeal: gag reflex
• •X Vagus: say "ah", uvular and palate movement
• •XI Accessory: turn head and lift shoulders to resistance
• •XII Hypoglossal: stick out tongue

WHAT IS IT?

This card is a memory aid for how hepatitis spreads and which infections are airborne.

HEPATITIS TRANSMISSION

• •Consonants (B, C, D): blood and body fluids
• •Vowels (A, E): fecal and oral

AIRBORNE (MTV)

• •Measles
• •TB (tuberculosis)
• •Varicella (chicken pox / herpes zoster, also called shingles)

WHAT IS IT?

This card covers Erikson's developmental stages plus several memory aids (cranial nerves, PPE order, and isolation precautions).

DEVELOPMENTAL STAGES (Erikson)

• •Infancy (0-18m): Trust vs. Mistrust. Development of trust based on caregivers.
• •Early childhood (18m-3yrs): Autonomy vs. Shame & Doubt. Development of a sense of personal control.
• •Preschool (3-5yrs): Initiative vs. Guilt. Development of a sense of purpose and direction.
• •School age (6-11yrs): Industry vs. Inferiority. Development of pride in accomplishments.
• •Adolescence (12-18yrs): Identity vs. Role Confusion. Exploration of independence and development of self.
• •Early adulthood (18-40yrs): Intimacy vs. Isolation. Development of personal relationships and love.
• •Adulthood (40-65yrs): Generativity vs. Stagnation. Fulfilling goals and building career and family.
• •Older adult (over 65yrs): Integrity vs. Despair. Looking back on life with acceptance.

CRANIAL NERVES (mnemonic)

• •Oh (Olfactory I), Oh (Optic II), Oh (Oculomotor III), To (Trochlear IV), Touch (Trigeminal V), And (Abducens VI), Feel (Facial VII), A (Auditory VIII), Girls (Glossopharyngeal IX), Vagina (Vagus X), And (Accessory XI), Hymen (Hypoglossal XII)
• •Function mnemonic: Some Say Marry Money But My Brother Says Big Bras Matter More

PPE (personal protective equipment) ORDER

• •Don PPE: 1. Hand hygiene 2. Gown 3. Mask 4. Goggles 5. Gloves
• •Remove PPE: 1. Gloves 2. Goggles 3. Gown 4. Mask 5. Hand hygiene

ISOLATION PRECAUTIONS

• •Droplet (SPIDERMAN): Sepsis, Scarlet fever, Streptococcal pharyngitis, Parvovirus B19, Pneumonia, Pertussis, Influenza, Diphtheria (pharyngeal), Epiglottitis, Rubella, Mumps, Meningitis, Mycoplasma or meningeal pneumonia, Adenovirus
• •Contact (MRS. WEE): Multidrug resistant organisms, Respiratory infection, Skin infections (VCHIPS), Wound infection, Enteric infection (C. difficile), Eye infection (conjunctivitis)

WHAT IS IT?

The APGAR score rates a newborn's condition right after birth. The five parts are Appearance, Pulse, Grimace, Activity, and Respiration.

SCORE INTERVENTIONS

• •8 to 10: no intervention required; support the newborn's spontaneous efforts
• •4 to 7: stimulate, rub the newborn's back, administer oxygen, rescore at specific intervals
• •0 to 3: requires full resuscitation, rescore at specific intervals

WHAT IS IT?

This card uses the memory aid CORBIN to list signs of a possible heart defect.

ASSESSMENT (CORBIN)

• •Color: bluish skin or extremities
• •O2: low pulse oximetry percentage
• •Rhythm: abnormal heart rate
• •Breathing: heavy or labored
• •Increase in sweat, especially on the forehead
• •Nursing: trouble feeding and breathing at the same time, or poor appetite

WHAT IS IT?

Each role on the care team has a legal limit to what it can do. The RN (registered nurse) does the work that needs judgment. The LPN/LVN (licensed practical nurse / licensed vocational nurse) does stable, routine care. The UAP (unlicensed assistive personnel) does basic tasks.

RN (registered nurse):

• •Does the nursing assessment (the first full look at the patient).
• •Makes the care plan and the nursing diagnosis.
• •Teaches the patient and family.
• •Gives IV (intravenous, into the vein) push medications and blood.
• •Cares for the unstable patient.

LPN/LVN (licensed practical/vocational nurse):

• •Gives most oral and intramuscular medications.
• •Does routine, stable tasks like dressing changes and tube feedings.
• •Reinforces teaching the RN already started.
• •Collects focused data, but does not do the first full assessment.

UAP (unlicensed assistive personnel):

• •Helps with bathing, feeding, walking, and toileting.
• •Takes routine vital signs on stable patients.
• •Measures intake and output (fluids in and out).

Quick Concept: RN = assess, teach, plan, judge. The RN keeps these and does not give them away.

WHAT IS IT?

Delegation is giving a task to another worker while the RN (registered nurse) keeps responsibility for the outcome. Some duties belong only to the RN and can never be handed off.

KEY POINTS

• •The RN cannot delegate the initial assessment (the first full evaluation of a patient).
• •The RN cannot delegate nursing judgment, planning, or evaluation of care.
• •The RN cannot delegate patient teaching.
• •The RN cannot delegate care of an unstable or unpredictable patient.
• •A helpful memory tool is the four words you never delegate: assess, teach, plan, evaluate.

NURSING CONSIDERATIONS

• •You may delegate a task, but you never delegate accountability for it.
• •When unsure, ask if the task needs nursing knowledge or judgment. If yes, the RN keeps it.
• •Delegate stable, routine, predictable tasks with clear outcomes.

WHAT IS IT?

Before the RN (registered nurse) hands a task to another worker, the RN checks five things. This framework comes from the NCSBN (National Council of State Boards of Nursing) and keeps delegation safe.

KEY POINTS

• •Right task: the job is appropriate to delegate (routine, stable, low risk).
• •Right circumstance: the patient and setting are stable and fit the task.
• •Right person: the worker is trained and allowed to do this task.
• •Right direction and communication: clear instructions, with the expected result and limits.
• •Right supervision and evaluation: the RN monitors, follows up, and checks the outcome.

NURSING CONSIDERATIONS

• •Skipping any one of the five rights makes the delegation unsafe.
• •The RN still answers for the result even after delegating.
• •Give specific instructions, such as what to report and when to report it.

WHAT IS IT?

When more than one patient needs help, treat the most life-threatening problem first. The ABCs put the airway, breathing, and circulation in order of urgency.

KEY POINTS

• •A = Airway: a blocked airway kills fastest, so it always comes first.
• •B = Breathing: after the airway is open, check that the patient can breathe and get oxygen.
• •C = Circulation: then check the pulse, blood pressure, and any bleeding.
• •Some sources add D = Disability (neurological status) and E = Exposure.

NURSING CONSIDERATIONS

• •A patient who cannot keep an open airway or breathe is the top priority.
• •Choking, no breath sounds, and severe bleeding all jump to the front of the line.
• •After the ABCs are stable, move on to other needs.

Quick Concept: Airway before breathing before circulation. Open the airway first, always.

WHAT IS IT?

Maslow's hierarchy of needs ranks human needs from most basic to highest. In nursing, meet the lower (physical) needs before the higher (emotional) ones when setting priorities.

KEY POINTS

• •Physiological needs come first: airway, breathing, food, water, sleep, elimination.
• •Safety and security come next: fall prevention, infection control, a safe environment.
• •Love and belonging: support, family, relationships.
• •Self-esteem: respect, dignity, confidence.
• •Self-actualization: reaching one's full potential, sits at the top.

NURSING CONSIDERATIONS

• •Always meet a physical need before a psychosocial (emotional or social) need.
• •The ABCs (airway, breathing, circulation) are the most urgent physiological needs.
• •Example: oxygen need comes before a patient's worry about going home.

Quick Concept: Physical before psychosocial. The body before the feelings.

WHAT IS IT?

To prioritize, compare how new and how stable each problem is. Acute means new or sudden. Chronic means long-lasting. Unstable means changing fast and at risk.

Acute vs chronic:

• •Acute problems are new, sudden, and often more urgent.
• •Chronic problems are long-standing and usually more predictable.
• •A sudden change in a chronic patient becomes acute and rises in priority.

Stable vs unstable:

• •Stable patients have steady vital signs and predictable needs.
• •Unstable patients have changing vital signs or new symptoms.
• •The unstable patient is the higher priority and needs the RN (registered nurse).

NURSING CONSIDERATIONS

• •See the acute, unstable patient before the chronic, stable one.
• •Expected findings for a known condition are lower priority than unexpected ones.
• •A new or worsening symptom always raises the priority.

Quick Concept: Acute and unstable beat chronic and stable.

WHAT IS IT?

Triage is sorting patients so the sickest are seen first. In the emergency department, a common system rates urgency as emergent, urgent, or non-urgent.

KEY POINTS

• •Emergent: life-threatening, must be seen now. Examples include chest pain, trouble breathing, active heavy bleeding.
• •Urgent: serious but not immediately life-threatening, should be seen soon. Examples include a simple fracture or moderate abdominal pain.
• •Non-urgent: not serious, can safely wait. Examples include a sprain, a rash, or a cold.

NURSING CONSIDERATIONS

• •Many emergency departments use a 5-level scale called the ESI (Emergency Severity Index), where level 1 is the most urgent and level 5 the least; verify the exact scale at your source.
• •The patient who waits the least is the one whose airway, breathing, or circulation is most at risk.
• •Triage is ongoing. Recheck waiting patients because their status can change.

WHAT IS IT?

START stands for Simple Triage And Rapid Treatment. It is used in a mass-casualty event (many victims at once). The goal shifts to doing the most good for the most people, so resources go where they will save lives.

Color categories:

• •Red (immediate): life-threatening but survivable with quick care. Treated first.
• •Yellow (delayed): serious injuries that can wait a short time without dying.
• •Green (minor): the walking wounded, minor injuries, can wait the longest.
• •Black (expectant): dead or injuries so severe that survival is unlikely. They receive comfort care, not the first resources.

NURSING CONSIDERATIONS

• •In a disaster, priority goes to those most likely to survive with treatment, not always the most injured.
• •This is different from daily triage, where the sickest patient is treated first.
• •A patient who is not breathing even after the airway is opened is tagged black in START.

Quick Concept: Red first, then yellow, then green. Black is last for resources.

WHAT IS IT?

Standard precautions are the basic infection-control steps used for every patient, every time. You assume any patient's blood and body fluids could carry infection, even if they look healthy.

KEY POINTS

• •Use them for all patients regardless of diagnosis.
• •Perform hand hygiene before and after every patient contact.
• •Wear gloves when you may touch blood, body fluids, mucous membranes, or broken skin.
• •Add a gown, mask, or eye protection when splashing is possible.
• •Handle sharps safely and never recap needles.

NURSING CONSIDERATIONS

• •Standard precautions are the foundation; transmission-based precautions are added on top when needed.
• •Body fluids include blood, urine, stool, saliva, wound drainage, and vomit.
• •Hand hygiene is the single most important way to prevent the spread of infection.

WHAT IS IT?

Contact precautions prevent the spread of germs passed by touch, either directly to the patient or to items in the room. They are added on top of standard precautions.

KEY POINTS

• •Wear a gown and gloves when entering the room.
• •Place the patient in a private room when possible.
• •Use dedicated equipment for that patient (own blood pressure cuff, thermometer).
• •Clean shared equipment between patients.

Example diseases:

• •MRSA (methicillin-resistant Staphylococcus aureus, a resistant skin bacterium).
• •VRE (vancomycin-resistant Enterococcus).
• •C. difficile (Clostridioides difficile, a gut infection causing diarrhea).
• •Scabies and other draining wound or skin infections.

NURSING CONSIDERATIONS

• •For C. difficile, wash hands with soap and water; alcohol gel does not kill its spores.
• •Remove the gown and gloves and wash hands before leaving the room.

Quick Concept: Contact means gown and gloves. The germ spreads by touch.

WHAT IS IT?

Droplet precautions stop germs that travel in large respiratory droplets when a person coughs, sneezes, or talks. These droplets fall quickly and travel only a short distance (about 3 to 6 feet).

KEY POINTS

• •Wear a surgical mask when within about 3 to 6 feet of the patient.
• •Place the patient in a private room when possible.
• •Put a surgical mask on the patient during transport.
• •A special air-handling room is not required.

Example diseases:

• •Influenza (the flu).
• •Pertussis (whooping cough).
• •Bacterial meningitis (Neisseria meningitidis).
• •Mumps and rubella.

NURSING CONSIDERATIONS

• •A regular surgical mask is enough; droplet does not need an N95 respirator.
• •Droplets do not stay in the air for long, so no special ventilation is needed.

Quick Concept: Droplet = surgical mask within a few feet.

WHAT IS IT?

Airborne precautions stop tiny germs that float in the air for long periods and travel long distances. These particles can be inhaled even after the patient leaves the area.

KEY POINTS

• •Place the patient in an AIIR (airborne infection isolation room), a negative-pressure room.
• •Keep the door closed at all times.
• •Wear a fitted N95 respirator (or higher), not just a surgical mask.
• •Put a surgical mask on the patient during any transport.

Example diseases:

• •Tuberculosis (TB).
• •Measles (rubeola).
• •Varicella (chickenpox), which also needs contact precautions.
• •Disseminated herpes zoster (widespread shingles).

NURSING CONSIDERATIONS

• •A memory tool for airborne diseases is My (measles), Chicken (varicella), Hez (herpes zoster), TB.
• •Negative pressure pulls room air out and filters it so germs do not escape to the hallway.

Quick Concept: Airborne = N95 plus a negative-pressure room with the door shut.

WHAT IS IT?

Donning means putting on PPE (personal protective equipment), the gear that protects you from infection. There is a set order so each piece covers the one before it.

STEPS

1. Perform hand hygiene first.

2. Put on the gown and tie it.

3. Put on the mask or respirator and fit it to the face.

4. Put on the goggles or face shield.

5. Put on the gloves last, pulling them over the gown cuffs.

NURSING CONSIDERATIONS

• •A memory tool for the order is Gown, Mask, Goggles, Gloves.
• •Gloves go on last so they seal over the gown sleeves.
• •For an N95 respirator, check the seal after putting it on.

Quick Concept: Don in this order: gown, mask, goggles, gloves.