Exam 2 Concept Guide
NUR211 Exam 2 Study Guide
-Eye protection is utilized if irrigating a
Safety 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
respiratory secretions and contaminated
-Examples: Presence of stool incontinence objects/materials; note: use soap and water
(may include patients with norovirus, when hands are visibly soiled (e.g., blood,
rotavirus, or Clostridium difficile), draining body fluids)
wounds, uncontrolled secretions, pressure
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
close contact with other patients, and
-Perform hand hygiene before touching practice respiratory hygiene and cough
patient and prior to wearing gloves etiquette
-PPE use: *Airborne
-Wear gloves when touching the patient and -Examples Tuberculosis, Measles,
the patient’s immediate environment or Chickenpox (until lesions are crusted over),
belongings. *Wear a gown if substantial Localized (in immunocompromised patient)
contact with the patient or their environment or disseminated herpes zoster (until lesions
is anticipated, such as with active MRSA are crusted over)
patients
-Place the patient immediately in an airborne
-Perform hand hygiene after removal of infection isolation room (AIIR)
PPE; note: use soap and water when hands
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
door
*Droplet
-PPE use:
-Examples Respiratory viruses (influenza,
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
goggles or face shield should be worn
-Wear a facemask for close contact with the
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
respiratory secretions and/or body fluids and
-If extensive spraying of respiratory fluids is contaminated objects/materials; note: use
predicted, gloves and gown as well as soap and water when hands are visibly
goggles (or face shield in place of goggles) soiled (e.g., blood, body fluids)
should be worn
, 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
NUR211 Exam 2 Study Guide
-Eye protection is utilized if irrigating a
Safety 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
respiratory secretions and contaminated
-Examples: Presence of stool incontinence objects/materials; note: use soap and water
(may include patients with norovirus, when hands are visibly soiled (e.g., blood,
rotavirus, or Clostridium difficile), draining body fluids)
wounds, uncontrolled secretions, pressure
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
close contact with other patients, and
-Perform hand hygiene before touching practice respiratory hygiene and cough
patient and prior to wearing gloves etiquette
-PPE use: *Airborne
-Wear gloves when touching the patient and -Examples Tuberculosis, Measles,
the patient’s immediate environment or Chickenpox (until lesions are crusted over),
belongings. *Wear a gown if substantial Localized (in immunocompromised patient)
contact with the patient or their environment or disseminated herpes zoster (until lesions
is anticipated, such as with active MRSA are crusted over)
patients
-Place the patient immediately in an airborne
-Perform hand hygiene after removal of infection isolation room (AIIR)
PPE; note: use soap and water when hands
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
door
*Droplet
-PPE use:
-Examples Respiratory viruses (influenza,
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
goggles or face shield should be worn
-Wear a facemask for close contact with the
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
respiratory secretions and/or body fluids and
-If extensive spraying of respiratory fluids is contaminated objects/materials; note: use
predicted, gloves and gown as well as soap and water when hands are visibly
goggles (or face shield in place of goggles) soiled (e.g., blood, body fluids)
should be worn
, 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
