You are a nursing student in your first semester of nursing school. Your assigned patient has been discharged before your arrival. Your instructor provides you with the name of another patient to care for, based on the recommendation of the staff. Before you can review the information about the patient with your instructor, she is called to consult with another student and a physician about an emergent patient situation. You read the clinical pathway for John Willis and find that he has methicillin-resistant Staphylococcus aureus (MRSA) in his sputum and suspected pulmonary tuberculosis (TB). You remember reviewing these topics in class and in the learning resource center. Because your instructor is still occupied with the patient emergency, you decide to begin caring for your new patient, instead of wasting time waiting to review the information with her. When you go to your patient's room, you see the isolation cart containing the transmission-based precaution supplies outside the room, with the hospital's policy and procedure posted for precautions to use for TB and MRSA. You see there are individual masks in plastic bags with different people's names on them, as well as masks with protective eye shields. You recall something from class about wearing a specially fitted mask when implementing these precautions, but realize you do not remember as much as you thought you did. You are unsure of exactly what you need to do. You find the staff nurse assigned to the patient in another patient's room, interrupt his conversation, and say, “I don't have a mask to care for my patient.” The nurse sharply responds, “Just go get started. I'm in the middle of something.” You consider just going in and introducing yourself and checking on the patient's status. Should you “borrow” a mask from one of the bags? You think it is your duty to care for this patient, but think you may need more information to be safe.
Prescribed Interventions
- Airborne precautions
- Contact precautions
- Sputum specimen for culture and sensitivity and acid-fast bacillus (AFB)
- Vital signs every shift
Developing Clinical Reasoning and Clinical Judgment
- Compare the mode of transmission for TB and MRSA.
- What may have led to the nurse's abrupt and sharp response?
- Identify the appropriate protective equipment needed to care for a patient with TB and a patient with MRSA.
- Describe another way in which you could have approached this situation.
- What are the potential consequences of a lack of use of appropriate transmission-based precautions?
Suggested Responses for Integrated Nursing Care
- Pulmonary TB transmission occurs through the air from one person to another. MRSA transmission can occur through direct contact with contaminated blood or body fluids. MRSA can be spread by direct or indirect contact. In this case, MRSA could be transmitted indirectly by coming into contact with items used to care for the patient, such as blood pressure cuffs or linen, or contact with contaminated surfaces in the room.
- Facilities require the use of appropriate personal protective equipment (PPE), including gowns, gloves, and masks, when caring for patients with TB and MRSA. Unique to the Airborne Precautions needed for TB is the use of specially fitted masks, either a high-efficiency particulate air (HEPA) filter respirator or N95 respirator mask certified by NIOSH to prevent the inspiration of airborne microorganisms (refer to Chapter 1). N95 respirators require fit-testing to ensure the mask is on correctly and adjusted to fit properly. If a fit-tested mask is required by your facility, you would either need to be fit-tested for a mask (often done by Employee Health) or reassigned to another patient. In addition, to protect yourself whenever there is the potential for contamination to your eyes, such as coughing, you should wear goggles or a mask with a face shield. Institutions vary greatly in their supplies. If you do not take the appropriate transmission-based precautions, you put yourself at risk for exposure to disease; in this case, TB and MRSA. In addition, entering other patients' rooms results in the potential for transmission of microorganisms and infection (refer to Chapter 1). It is always your responsibility, even as a student, to follow the policies and procedures of the facility where you are placed for clinical experiences.
- Hospitals are stressful places. Understanding when and how to communicate with others is an invaluable set of skills. Waiting for the nurse to complete a conversation and task before asking for guidance would have been the ideal situation. Nurses have to prioritize the care they provide. Asking, “Do you have a moment to review something with me?” is a good way to ensure getting the time and attention you need. Because there was no emergency to obtain the vital signs and sputum specimen, they can wait until you are sure you can provide safe care.
- You were right to question the appropriateness of caring for this patient and in thinking you may need more information to be safe. In this situation, waiting to review the patient information with your instructor is the ideal solution. Your instructor did not have all the information about the patient before being called away to an emergency. She would not have assigned this patient to you after reviewing his diagnosis, realizing that you would need a specially fitted mask to care for the patient. While waiting for your instructor, you should obtain as much information as possible. Background research and knowledge are powerful tools. Examples of resources you can access include the hospital policies and procedure files, the infection control manual, the infection control nurse, and experienced staff members, provided they are able to take time out from their patient care responsibilities. Then, when your instructor is available, you can share this information with them to plan your care for that day.