Contact Precautions

7/17/2019 Contact Precautions

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Contact Precautions

Before entering: Wash hands THEN don gloves 1st and gown 2nd .Pt. gets private room.

Upon leaving: Remove gloves 1st and then gown. own wornd!ring transport.

E"amples: #R$%& R$' (also droplet)& *. +,--& $a//ies

Airborne Precautions

$ame order for don. Wear N0 mas& and removemas %-TER leaving the pt3s room.

4eep pt3s door losed at all time& private room with neg. airpress!re. #as worn d!ring transport.

E"amples: 'ariella (hien po")& #easles (R!/eola)& TB& Herpesdisseminated.

Droplet Precautions

Private room& and door ma5 /e open. 6nl5 need s!rgial mas

within 7 feet of patient.

E"ample: Pne!monia& #enioal #enigitis& ,nfl!en8a& R$'&$trept& $arlet -ever& Pert!ssis& R!/ella& #!mps& H. ,nfl!en8aet5pe B.

ELECTROLYES/THYROID/GLUCOSE

Hypocalceia: (*%T$) 9 *onv!lsions& %rrh5thmias& Tetan5&$pasms.

Hypercalceia: (#oans and roans) 9 -atig!eletharg5&*onstipation& stones& m!sle weaness



Hypo!aleia: %nore"ia& N'& Wea P!lses& inreased haneof DIG TO"ICITY#

Hyper!aleia: 'fi/& ardia arrest& m!sle twithing& e"tremit5n!m/ness

Hyponatreia: N'& H%& twithing& onf!sion

Hypernatreia: ,nreased temperat!re& weaness& thirst&h5potension& tah5ardia

Hyper$lyceia: ;Hot and +r5: $!gar High< inreased thirst&fatig!e& onf!sion& wt. loss& hot = dr5 sin.

Hypo$lyceia: *old and *lamm5: Need some and5. *old =*lamm5 sin& trem/ling& fatig!e& /l!rred vision& Na!sea&-ainting.

Hypert%yroi&is' Hot& thinning of sin& /rittle hair&restlessness& h5perative refle"es

Hypot%yroi&is' -atig!e& wt. gain& old& hair loss.

CO((O) PRO*LE(S

A&&ison+s D,' H5ponatremia& H5potension& dereased /loodvol!me& H>PERalemia& h5pogl5emia

Cus%in$+s' H5pernatremia& h5pertension& inreased /loodvol!me& H>P6alemia& h5pergl5emia.

Diabetic -etoaci&osis' Bod5 is !na/le to prod!e eno!ghins!lin& /reas down fats instead whih inreases etone /odies.$$: 4!ssma!l respirations& fr!it5 /reath& e"essive thirst&inreased voiding& N'& 4etones in !rine.

(yast%enia Gra.is' $igns$5mptoms start at the top. -aialdroop& ptosis& diplopia& and diffi!lt5 swallowing 9 ris foraspiration and hoing (B, +E%?). %void e"essive heat andalohol. #ore prone for infetion as well. ,mproves with rest.



(S' Will have n!m/ess and +iplopia. Use steroids& sleep onstomah to avoid ontrat!res& and avoid e"essive head. %t risfor in@!ries.

Guillain *arre' Bod53s imm!ne s5stem attas nervo!s s5stem(peripheral). ive high doses of imm!noglo/ins. $$: Resp.-ail!re& flaid paral5sis& !rinar5 retention.

Le$ionnaires D' $evere pne!monia a!sed /5 ?egionella. N6Tontagio!s (standard prea!tions). ,nhaled diretl5 from so!re&not /5 person.

(enieres Syn&roe' 'ertigo& avoid e"essive movement while

omm!niating with patient. +erease patient3s head movementin /ed.

Gastric Ulcers' Not relieved /5 food intae& pain mostnotiea/le 7ACA min!tes post meal.

Heroin 0it%&ra1al' R!nn5 nose& 5awning& m!sle@oint pain&diarrhea.

Plebitis' ,nflammation of vein. Remove atheter& appl5 warm

moist pas and hange ,' site.

Preeclapsia' Edema& protein!ria& HTN. ive #agnesi!m$!lfate for !terine rela"ation and slow down the preterm la/or.

Hip Replaceent' *an eep pillow /etween legs& want to avoid%++!tion (displaes). Tr5 to eep a/d!ted& /!t no more thanCA degrees.

Hypo2ia' Restlessness and an"io!sness most ommonl5 seen.%!s!ltate l!ngs. $een ver5 often with vented patients& andpne!moniaasthma patients.

I*S' #!sle ontrations of olon. *ramping& /loating& diarrhea&onstipation seen. Eliminate gl!ten& -6+#%P (-r!tose3s&?atose& et.). ive -,BER& antidiarheals& antiholinergis& andantidepressants if needed.



I*D'Ulerative *olitis (%ttas ?arge intestine). ?ining of olon/eomes inflamed& a!toimm!ne. This a!sesdisomfortempt5ing of stomah.

*hrons: %ttas an5 part of the intestine. $ame $$& and isa!toimm!ne. Both are onsidered as a part of ,B+.

+iet: ,nrease *alori intae as well as protein. Eat onl5 lowresid!e foods: no R%W fr!its or foods high in fi/er.

Pancreatitis' ,nflammation of panreas. Upper and #id , pain&N'& -ever& ,nreased HR. 4eep pt. NP6 to derease wor on

panreas. %B$6?UTE?> N6 ET6H& and ?,#,TE+ fats. #a5 /ea!sed /5 hroni !se& or from stones o/str!ting the pathwa5 of elimination.

Di.erticulosis' $mall po!hes in digestive s5stem lining. When,N-?%#E+ it is nown as diverti!litis. %nti/iotis for infetion.,nrease fi/er and fl!ids& no seeds& n!ts& or orn.

Heolytic Reaction' H5potension& lower /a pain& fever. #6$T+%NER6U$.

Aller$ic Reaction' Urtiaria (Hives)& ithing& respirator5 distress(Whee8ing)& epiglottal edema. ive Benadr5l.

Incenti.e Spiroeter' Have pt. /reathe ,N and hold for 7seonds /efore e"haling. Have patient sit !p (fowlershighfowlers) /efore proeding.

Autonoic Dysre3le2ia' #ost ommonl5 seen from a TC in@!r5and a/ove. E"essivel5 high BP& po!nding head ahe& prof!sesweating& nasal ongestion& Brad5ardia. +erease BP /5 raisingH6B& tae off loose lothes. TH,$ ,$ % HUE E#EREN*>(!s!all5 top priorit5 on N*?ED).

Diabetes Insipi&us' %+H is not ade!atel5 prod!ed. ,nreasedvoiding& and inreased thirst. Eletrol5te im/alane seen&H5pernatremia.



SIADH' %+H is ;inappropriatel5< !sed. This a!ses fl!id to /eretained. H5ponatremia is most ommonl5 seen.

)G Tube' #ae s!re to aspirate to mae s!re t!/e is in plae.pH sho!ld /e e!al to gastri ontents. ,rrigate onl5 afterpositioning is verified.

0et4to4Dry Dressin$' %void wetting dressing when taing it off so that optim!m de/ris is removed. %fter removed& plae newg!a8e in saline& s!ee8e !ntil not dripping& pa into wo!nd and

over dressing with dr5 pad& then tape.

5etal Heart Rate Patterns'

'*EH%6?P

' F varia/le deelsG * F ord ompression a!sedE F earl5 deelsG H F head ompression a!sed% F aelsG 6 F oa5& not a pro/lem? F late deels F plaental ins!ffiien5& anIt fill

Plae mother in trendelen/ergs for ord ompression to removepress!re off of ord& stop pitoin& and give o"5gen. -or ?%TEdeels& t!rn mother to side& give 62. %lwa5s man!all5 monitorfetal heart tones right after water /reas.

RH' #other is negative& /a/5 is positive. Rho%# is given forseond hild.

SCA)S

PET' Empt5 /ladder /efore test& warm traer d5e is in@eted



thro!gh ,'. This test allows organs to /e seen learl5. ,e. Brainaner& poor /lood flow.

(RI' Uses magneti and radio waves to reate pit!res. Noradiation !sed. ,nform ph5siian if patient has artifiial heartvalves& lips& paemaers& ear devies or an5thing with metal.

E(G' Eletrodes attahed to legs generall5 9 allows for m!slesto /e monitored.

CT' Uses Dra5s. $ome ma5 re!ire ontrast d5es. ,f d5es are!sed& no eating for JC ho!rs /efore test. ,nrease fl!id intae toremove d5e and derease wor on the idne5s.

I6P' Dra5 of idne5s& /ladder& !reters& and !rinar5 trat. Usedto identif5 stones& infetions& o/str!tions& and t!mors. *ontrastmaterial !sed: ,6+,NE. *he for iodine allerg5. *a!tion withdia/etes or idne5 pro/lems. ,nrease fl!id intae to remove d5eand derease wor on the idne5s.

POSITIO)I)G

Post A-A an& *-A' %void add!tion& plae in prone position

often d!ring the first 2J ho!rs.

*loo& pressures' H5pertension 9 p!t H6B !p (fowlers& highfowlers). H5potension 9 H6B goes down& la5 patient s!pine.,nreased ,*P 9 eep in low fowlers.

Post Lubar Puncture 7 (yelo$ra' Patient positioneds!pine to prevent leaage of *$-. N!rse sho!ld assess for leardrainage 9 re!ires ,##E+,%TE attention.

Dupin$ Syn&roe' Patient lies flat after meal for 7A min!tes.Eat in relining position.

Enea' $ide l5ing position or sims.

S%oc!' E"tremities elevated 2A degrees& modifiedTrendelen/ergs.



Air/Pulonary Ebolis' T!rn pt to left side and lower headof /ed. $$ inl!de s!dden onset of hest pain& diffi!lt5/reathing& sense of impending doom.

DELEGATIO)

N!rses are the ones that an assess and teah. -or priorit5!estions& an5 patient that is a new admission& /eing disharged&

@!st ret!rned from s!rger5& or needs something ta!ght is given tothe RN.

T,P$:

4now all la/ val!es& and the effets on the /od5 when the5 arenot in range. %irwa5 is alwa5s the priorit5. ,f the patient an3t ade!atel5tae in o"5gen& the rest of the /od5 is U$E?E$$. *ast are is e5 *he for /lanhing and olor hanges.$!dden pain ma5 /e ompartment s5ndrome. 'ER> $ER,6U$. Patients with a deteriorating mental stat!s (+erease in

lasgow) are alwa5s given to RN. +erease in ?6* is first signgenerall5. Bleeding is !s!all5 assessed for d!ring the first 2J ho!rs.,nfetion doesn3t !s!all5 o!r !ntil aro!nd JKL2 ho!rs. *ane !se: the ;good goes !p< and the ;/ad omes down<. oodfoot goes !p when waling !p stairs& /ad foot goes first whenwaling down. ive lidoaine for 'T%*H& and %tropine for an5thing Brad5. +raw !p Reg!lar ins!lin /efore N,ns!lin. Reg!lar is lear& N islo!d5. 2J hr. !rine olletion: disard first void of the morning& thenollet in a ontainer for the rest of the da5. Weight do!/les /5 C months and triples /5 1 5ear for infants.Ba/insi3s leaves /5 1 5ear. +o plent5 of !estions ($%T% and Priorit5) TB dr!gs are liver to"i and ma5 t!rn !rine orange. %ssess for

@a!ndie.



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Contact Precautions