NCLEX-PN Infection Control — Standard and Transmission-Based Precautions

INTERDISCIPLINARY TEAM COORDINATION and knowing when to involve each team member is a core NCLEX-PN coordinated care competency. SOCIAL WORKER ROLE in discharge planning: INSURANCE AND BENEFITS: expertise in Medicare, Medicaid, private insurance coverage for home health, skilled nursing facility, and rehabilitation services; COMMUNITY RESOURCES: knowledge of local agencies, support groups, meals programs (Meals on Wheels), transportation, housing assistance; HOME HEALTH COORDINATION: can arrange skilled nursing visits, physical therapy, occupational therapy, speech therapy, home health aide services; COMPLEX SOCIAL SITUATIONS: homelessness, domestic violence, elder abuse, substance use, mental health resources; FINANCIAL ASSISTANCE: medication assistance programs, patient assistance foundations; ADVANCE CARE PLANNING: assistance with advance directives, health care proxies, living wills. THE PN'S ROLE IN DISCHARGE: assess the client's understanding of discharge instructions; reinforce teaching; identify concerns or needs to report to the RN or social worker; document; the PN does NOT independently coordinate complex discharge arrangements — that is above PN scope. INTERDISCIPLINARY TEAM MEMBERS AND THEIR PRIMARY ROLES: RN — clinical coordination, complex discharge assessment, care coordination; LPN/LVN — implementing care plan, assessment under RN supervision, patient education (reinforcement), reporting; SOCIAL WORKER — psychosocial assessment, community resources, discharge planning; PHYSICAL THERAPIST — mobility, strength, balance, gait training; OCCUPATIONAL THERAPIST — ADLs, adaptive equipment, home safety; SPEECH-LANGUAGE PATHOLOGIST — swallowing, communication; DIETITIAN — nutritional assessment and counseling; CHAPLAIN — spiritual care; PHARMACIST — medication reconciliation and counseling; CASE MANAGER — insurance authorization, utilization review.

TRANSMISSION-BASED PRECAUTIONS are used in addition to standard precautions for clients with known or suspected specific infectious diseases. THREE TYPES based on route of transmission: (1) CONTACT PRECAUTIONS: for diseases spread by direct or indirect contact (touching the patient or contaminated surfaces); examples: MRSA, C. difficile, VRE, wound infections, scabies, head lice; PPE: GLOVES and GOWN on entry; (2) DROPLET PRECAUTIONS: for diseases spread by large droplets (>5 microns) produced by talking, coughing, sneezing — travel ≤3 feet; examples: influenza, pertussis, meningococcal disease, group A strep, mumps, rubella; PPE: SURGICAL MASK on entry; private room or cohorting; (3) AIRBORNE PRECAUTIONS: for diseases spread by SMALL particles (<5 microns) that remain suspended in air and travel longer distances; examples: TUBERCULOSIS (TB), VARICELLA (chickenpox), MEASLES (rubeola), SARS, MERS, COVID-19 (enhanced); PPE: N95 RESPIRATOR (or higher, like PAPR) — must be fit-tested; NEGATIVE PRESSURE ROOM (AIIR — airborne infection isolation room) — air flows INTO the room (door kept closed) and is exhausted outside or HEPA filtered; door must remain closed; patient must wear surgical mask if transported through hallways. PN NURSING RESPONSIBILITIES: apply and remove PPE correctly (donning: gown, mask/respirator, eye protection, gloves; doffing: gloves, eye protection, gown, mask last); perform hand hygiene before and after; maintain isolation room requirements; educate the client about isolation; reinforce respiratory hygiene. DISTINGUISH: N95 RESPIRATOR (airborne — filters 95% of airborne particles; requires fit-testing) vs. SURGICAL MASK (droplet — larger particles; no fit-test required).

DELEGATION PRINCIPLES for LPN/LVN: The LPN/LVN may delegate tasks to UAPs (nursing assistants, patient care technicians, aides) that are within the UAP's scope of training and the state practice act, AND that fall within the 'routine care' category. DELEGATION DECISION FRAMEWORK — consider: (1) TASK: is it a task that requires nursing judgment, assessment, or professional decision-making? (No = potentially delegatable); (2) STABILITY of the client: stable clients with predictable conditions are better candidates for delegation; (3) SETTING: some settings have more specific delegation rules; (4) COMPETENCY of the UAP: has the UAP been trained in this task? APPROPRIATE TASKS FOR UAP DELEGATION: vital signs measurement and recording (stable clients); bathing, grooming, hygiene care; ambulation assistance; feeding (for clients not at aspiration risk); intake/output measurement; specimen collection (urine, stool, sputum where non-invasive); bed making; transport (stable clients). NOT APPROPRIATE TO DELEGATE: (1) MEDICATION ADMINISTRATION — in most states, UAPs cannot administer medications; LPNs may delegate limited medication administration in specific settings with training (this varies by state); (2) CATHETER INSERTION — invasive procedure requiring nursing training; (3) PATIENT TEACHING — education requires professional nursing judgment; UAPs can reinforce teaching but cannot independently teach. CRITICAL NOTE: The LPN/LVN CANNOT independently delegate tasks that exceed the LPN's OWN SCOPE — if the LPN cannot do something (e.g., certain assessments or complex care), the LPN also cannot delegate it. Delegation is RETAINED responsibility — the LPN remains accountable for monitoring outcomes of delegated tasks and must report concerns to the RN.

The 10 RIGHTS OF MEDICATION ADMINISTRATION provide a framework for safe drug administration. Asking the client to state their name and date of birth verifies the RIGHT CLIENT (also called right patient). THE 10 RIGHTS: (1) RIGHT CLIENT: verify identity using TWO identifiers per Joint Commission standard (name + date of birth; name + medical record number; name + ID band); never rely on room number alone; ask the client to state their name (don't say 'Are you Mr. Smith?' — the client may say yes even if wrong); (2) RIGHT MEDICATION: verify the drug label matches the order three times (when taking from storage, when preparing, before administering); (3) RIGHT DOSE: verify the dose matches the order; calculate if converting; (4) RIGHT ROUTE: oral, IV, IM, SubQ, topical, etc.; verify order matches the available form; (5) RIGHT TIME: verify frequency and when last dose was given; (6) RIGHT DOCUMENTATION: document AFTER administration (not before); (7) RIGHT REASON: does this medication make sense for this client's diagnosis? (pharmaceutical knowledge); (8) RIGHT RESPONSE: assess effectiveness after administration (pain medication: did pain improve?); monitor for adverse effects; (9) RIGHT EDUCATION: client understands what the medication is for and its common side effects; (10) RIGHT TO REFUSE: client has the right to refuse medication; document refusal, notify provider. ADDITIONAL SAFETY CHECKS: HIGH ALERT MEDICATIONS (insulin, heparin, anticoagulants, concentrated electrolytes, opioids) require INDEPENDENT DOUBLE-CHECKS by two nurses before administration at most facilities; LOOK-ALIKE/SOUND-ALIKE (LASA) medications are a common source of errors; storage separation and labeling help prevent LASA errors. TWO-IDENTIFIER requirement is from The Joint Commission National Patient Safety Goals.

RECOGNIZING AND REPORTING SIGNIFICANT CHANGES is the most fundamental PN nursing responsibility. A blood pressure of 168/102 in a client whose baseline is 130/82 represents a clinically significant CHANGE FROM BASELINE that requires prompt assessment. WHY THIS IS A PRIORITY REPORT: (1) The CHANGE MATTERS as much as the absolute value — this client's normal is 130/82; a jump to 168/102 is unexpected and concerning regardless of whether 168/102 would be concerning in a client whose baseline was 165/100; (2) HYPERTENSIVE URGENCY (BP ≥180/120 without end-organ damage) and HYPERTENSIVE EMERGENCY (BP ≥180/120 with end-organ damage — headache, visual changes, chest pain, altered mental status, AKI, pulmonary edema) are serious conditions; this BP is approaching that range; (3) ASSOCIATED SYMPTOMS greatly change the urgency level; WHAT TO REPORT TO THE RN: BP reading with both numbers; the client's recent baseline; any associated symptoms (headache — assess quality and severity; visual disturbances; chest pain or pressure; confusion or altered mental status; shortness of breath; nausea); time of measurement; recent activity level. WHY NOT TO ACT INDEPENDENTLY: ADMINISTERING MEDICATION (Option C) is NOT within PN scope — the PN administers medications per the provider order; administering an extra dose without an order is a serious medication error; WAITING (Option A) or DOCUMENTING ONLY (Option D) delay necessary assessment of a potentially serious condition. SBAR COMMUNICATION: Situation: 'Mrs. Smith's BP is 168/102'; Background: 'Her recent baseline has been 130/82'; Assessment: 'She's also complaining of a mild headache'; Recommendation: 'I think she needs to be assessed by the provider.' NCLEX-PN PRINCIPLE: the PN's role in changing clinical situations is to RECOGNIZE and REPORT — assessment of complex clinical situations and medical management decisions are RN/provider scope.