RNs Must Be Familiar With Transmission-Based Precautions

July 13th, 2012

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By , BSN, RN

Taking precautions is a standard of nursing and “Standard Precautions” are the base line for keeping you and your patients safer and healthier.

In 1996 the Hospital Infection Control Practices Advisory Committee (HICPAC) and the Centers for Disease Control and Prevention (CDC) released guidelines for isolation precautions in hospitals. They were broken into two tiers: Standard Precautions and Transmission-Based Precautions. Standard Precautions are just that, the standard; to be used at all times by all healthcare personnel when working with clients. The second tier is more diagnosis specific and different types of diseases require different actions

Tier two precautions are always used in conjunction with Standard Precautions for clients with known or suspected infections that are spread in one of three ways: airborne, droplet, and contact.

  1. Airborne Precautions – These precautions are put into play when patients are known or suspected of having serious illnesses transmitted by airborne droplet nuclei smaller than five microns. In English, that means people who have or are suspected of having rubella (measles), varicella (chicken pox) including disseminated zoster (shingles), and tuberculosis (TB).

    In admitting and caring for patients requiring airborne precautions you should:

    • Place the patient in a private room with negative air pressure controls. If no private room available place the client with another who is infected with the same microorganisms.
    • Wear a respiratory device (N95 respirator) when entering the room of a client who has or is suspected of having TB.
    • Susceptible people should not enter the room of a patient with rubella or varicella. If they absolutely must come in make sure they too have an N95 respirator.
    • Limit movement of the patient outside the room and make sure they wear a surgical mask when out and about.
  2. Droplet Precautions – Particle transmission greater than five microns are covered by these precautions and include such illnesses as:
    • Invasive Haemophilus influenza type b disease, including meningitis, pneumonia, epiglottitius, and sepsis.
    • Invasive Neisseria meningitides disease, including meningitis, pneumonia, and sepsis.
    • Other serious bacterial respiratory infections spread by droplet transmission, including:
      1. Diphtheria
      2. Mycoplasma pneumonia
      3. Pertussis (whooping cough)
      4. Pneumonic plague
      5. Streptococcal pharyngitis, pneumonia, or scarlet fever in infants and young children.
    • Serious viral infections spread by droplet transmission, including:
      1. Adenovirus
      2. Influenza
      3. Mumps
      4. Parvovirus B19
      5. Rubella

    When caring for patients who are under droplet precautions:

    • Place them in a private room or with someone else with the same infection.
    • Wear a mask if working within three feet of the patient.
    • Keep patient’s nose and mouth covered with a surgical mask when being transported outside their room.
  3. Contact Precautions – This level of precautionary measures are meant for those patients know or suspected to have serious illnesses easily transmitted by direct contact including contact with items in the patient’s environment. According to the CDC these illnesses include:
    • Gastrointestinal, respiratory, skin, or wound infections or colonization with multi-drug resistant bacteria.
    • Enteric infections with a low infectious dose or prolonged environmental survival including:
      1. Clostridium difficile (C-diff)
      2. For diapered or incontinent patients: enterohemorrhagic Escherichia coli (E-coli), Shigella, hepatitis A, or rotavirus.
    • Respiratory syncytial virus, parainfluenza virus, or enteroviral infections in infants and young children.
    • Skin infections that are highly contagious or that may occur on dry skin, including:
      1. Diphtheria (cutaneous)
      2. Herpes simplex virus
      3. Impetigo
      4. Major non-contained abscesses, cellulitis, or decubiti
      5. Pediculosis
      6. Scabies
      7. Zoster
      8. Viral hemorrhagic conjunctivitis and fevers (Lassa fever or Marburg virus)

    Keeping the patient in a private room or with someone else with the same diagnosis applies to contact isolation as well but the precaution regimen after that is a bit more involved. It includes:

    • Wear gloves as described in Standard Precautions but also make sure to remove gloves before leaving the patient’s room. Wash hands immediately after removing gloves using an antimicrobial hand wash and do not touch any possibly contaminated surfaces when exiting the room.
    • Wear a gown, if at all possible, when entering the room. Dispose of the gown before leaving the room and make sure your own clothing does not contact possible contaminated surfaces.
    • Limit the movement of the patient outside the room.
    • Dedicate the use of noncritical client care equipment to a single client or clients with same infecting microorganisms.

All of these forms of precautions fall under the heading of isolation precautions since in order to keep other patients, staff, and visitors to the hospital safe the patient is place in a room alone or only with another person with the same disease. Patients requiring isolation precautions are subject to a whole other series of possible problems because they are alone most of the time.

Because of their separation from others and the need for them to stay predominantly in a closed-door room nurses must be aware of the psychological toll isolation can take on the client. Two of the most common diagnoses are sensory deprivation and decreased self-esteem.

Sensory deprivation occurs when the environment lacks normal stimuli such as frequent communication with other people. Signs of boredom, inactivity, slowness of thought, daydreaming, increased sleeping, thought disorganization, anxiety, hallucinations, and panic are all symptoms of sensory deprivation.

A patient’s feelings of inferiority are often due to the perception of the infection itself and the required precautions. Being attended to by people who only wear masks and gloves and gowns in a country where such high value is placed on cleanliness can give patients the feeling they are at fault somehow and sometimes substandard.

As nurses, we need to provide care that prevents these or deals with them positively. We can initiate measures to help meet their needs including regular communication and as many diversions as possible. Every thing from books and newspapers to different foods or a new video game can help keep these feelings at bay.

Making sure the patient understands the what the infection is, how it is being treated and making sure the client’s family understands this too is also important.

Mostly, despite the Standard Precautions and all the other specialty precautions the most important care we can provide is warm, accepting behavior. We must take our own precautions to avoid sounding annoyed with the extra work they take or being bothered by the sight or smell of the infections. Nurses are the people in and out of the patient’s room the most frequently and we are their link to the regular world.

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