Nursing Procedure 1.4, 1.5
- Using Precaution (Isolation) Techniques: Infection Prevention (1.4)
- Disposing of Biohazardous Waste (1.5)
- Prevents spread of infection from client to others
- Decreases exposure of susceptible client to infection
Nursing Procedure 1.4, 1.5
Assessment should focus on the following:
Nursing diagnoses may include the following:
Outcome Identification and Planning
Sample desired outcomes include the following:
Special Considerations in Planning and Implementation
Refer to Display 1.3 for discussion of standard and expanded precautions. Hand hygiene is the single most important measure used to prevent the spread of infection. Perform hand hygiene before entering and upon leaving precaution (isolation) rooms, as well as between care procedures for different clients. Often handwashing is the required form of hand hygiene. Most hospital policies require a nurse to obtain a culture from a draining body area and to initiate precaution (isolation) procedures when positive cultures are reported. Consult the agency policy manual. A client may become withdrawn, depressed, and feel abandoned due to precaution (isolation). Plan frequent visits with the client and follow through as promised.
Provide family members with an information sheet with clear instructions.
| Action | Rationale | |
|---|---|---|
| Using Precaution (Isolation) Techniques | ||
| 1 | Clearly explain to client and family the precaution (isolation) type, reason initiated, how microorganisms are spread, staff and visitor restrictions related to dress and duration of contact (if applicable), and compliance needed; demonstrate procedure for applying sterile mask and gown. THE DOCTOR SHOULD INITIALLY INFORM THE CLIENT OF THE DIAGNOSED INFECTION. | Increases compliance of client, family, and visitors; decreases anxiety |
| 2 | Ensure that precaution (isolation) cart is complete and that sufficient trash cans and linen bags are in room. | Promotes organized, efficient, and proper disposal of contaminated materials |
| 3 | Keep sufficient linens and towels in room. | Avoids unnecessary trips into and out of room; decreases spread of microorganisms |
| 4 | Have housekeeping staff to check room daily for sufficient soap and paper towels. | Facilitates compliance with need for frequent handwashing |
| 5 | Perform hand hygiene and organize equipment. | Reduces microorganism transfer; promotes efficiency |
| 6 | Note doctor’s orders or refer to precaution (isolation) guidelines adopted by agency for precautions necessary to establish appropriate type of precaution (isolation) (see Appendix D). | Provides sufficient protection from microorganisms with minimum stress and restrictions on client, visitors, and staff |
| 7 | Obtain appropriate precaution (isolation) card and place on client’s door. (If card must be filled out, include instructions on hand hygiene; use of masks, gloves, and gowns; handling of linen and disposable items; and need for private room, if appropriate.) | Alerts visitors and staff to follow dress and hand hygiene restrictions |
| 8 | Review disinfectants needed to eliminate specific microorganisms. | Prepares nurse for environmental and client management |
| 9 | Inform any visitors of necessary precautions. | Allays fears to prevent withdrawal of friends and family from client; increases compliance |
| 10 | Maintain precaution (isolation) supplies and cart outside door of client’s room. | Facilitates maintenance of precaution (isolation) |
| 11 | Obtain supplies needed for wound care, if required, and keep sufficient supplies in client’s room. | Avoids unnecessary trips into and out of room; decreases spread of microorganisms |
| Disposing of Biohazardous Materials | ||
| 1 | Don gloves, maintain asepsis while handling waste. | Prevents contamination of hands; reduces risk of infection transmission |
| 2 | Keep disposal equipment readily available for use at all times (e.g., if using sharps, take sharps container into client area; replace sharps container when it is two-thirds full to avoid needlesticks when putting additional sharps in a nearly full container). | Allows for safe disposal of waste even if not anticipated before care |
| 3 | Dispose of used supplies taken into room or place them inside appropriate precaution (isolation) bag for removal. | Prevents spread of infection from objects used on or by client |
| 4 | When removing full sharps container, close securely (date and label, if agency policy). If transporting in car after a home visit, place in second rigid-walled container. Log in sharps container for disposal per agency policy. | Prevents contamination of supplies in car; adds extra barrier |
| 5 | Use plastic bags for trash and reusable equipment. Use biohazard bags to bag disposable drainage systems and soiled nonsharp biohazardous materials before delivering to agency’s disposal unit. If removing to car for disposal after a home visit, place bags in rigid container in car. | Prevents spread of infection from contaminated materials; keeps biohazardous waste separate from other supplies |
| 6 | Label reusable equipment. | Indicates date of use and possible replacement time |
| 7 | Place soiled linens in proper linen bags; doublebag linens if required by agency. Take linen bags to soiled utility room. (Instruct family to wash soiled linen and clothing separate from family wash if client is being cared for at home.) | Allows for washing without removing from bag |
| 8 | Clean room thoroughly with appropriate antimicrobial agent. If blood or body fluids spill in client’s home, use spill kit or spill cloth. | Kills virulent microorganisms; prevents exposure of other clients or family members to infection |
| 9 | Leave room unoccupied after client is discharged for appropriate time period. | Minimizes exchange of microorganisms between clients |
| 10 | Perform hand hygiene. | Reduces microorganism transfer |
Were desired outcomes achieved? Examples of evaluation include:
The following should be noted on the client's record:
