Safety and Infection Control Study Guide for the NCLEX-RN Exam

Hazardous Materials

Nurses have a responsibility to practice safe and proper handling of patient care equipment, potentially infectious/biohazardous materials, as well as hazardous chemicals that are present in the workplace setting.

Identifying Hazardous Materials

Prior to handling or disposing of any material, the nurse must first determine if the material is hazardous. Common hazards include biohazardous, flammable, and infectious materials. Biohazardous material includes human body fluids, microbiological waste (lab waste contaminated with concentrated, infectious agents), animal waste, and pathological waste. Flammable items may include equipment, frayed electrical cords, specific medications, oxygen, and oxygen tubing. Infectious agents are often also biohazardous and may include human bodily fluids, materials in contact with ill patients, and cross-contamination of materials.

OSHA

The Occupational Safety and Health Administration (OSHA) is an organization that focuses on workplace safety and health. One of their jobs is to regulate written standards that discuss the proper standard precautions that should be taken to protect against blood-borne pathogen exposure. For example, OSHA has determined protocols for workplaces to follow in the event of patient infection, isolation precautions, standards of environmental infection control, nurse injury (i.e., needle stick), and latex allergy.

OSHA also has developed a system of Safety Data Sheets (SDS, previously Material Safety Data Sheets or MSDS) that describe the nature and potential hazards of all chemical agents present in an employment setting. These threats include chemical, environmental, or viral exposures that may increase the risk of specific health concerns or illnesses. The nurse should be aware of their existence and how to access them in the event of an exposure.

CDC and Standard Precautions

Part of OSHA’s written standards includes the Centers for Disease Control and Prevention (CDC) recommendations for the use of standard precautions. These are patient care standards that detail how to protect staff from bloodborne pathogens. The use of personal protective equipment (PPE), such as gloves as well as face and eye protection, should be utilized and followed in every patient encounter and especially in emergency/disaster response. OSHA also mandates that certain infectious diseases—such as sexually transmitted infections, vaccine-preventable illness, international outbreaks (Ebola, Zika, Yellow Fever, etc.), and others—be reported to the CDC to track concerns for outbreaks, incidence, and prevalence of infection in the population.

Needlestick Safety and Prevention Act

The Needlestick Safety and Prevention Act is an important piece of legislation that was enacted to protect workers in the healthcare setting. Safe disposal of all sharps materials should be practiced with the use of mandated, marked biohazardous sharps containers inpatient care areas and medication preparation stations. Never recap needles, and avoid bending or breaking them prior to disposal.

Internal Radiation Therapy

Internal radiation therapy may increase the risk of radiation exposure to those near to and caring for the patient. This type of therapy is most often used in oncology for the treatment of cancers of the prostate, rectum, or uterus. Internal radiation is a form of implantable therapy where activated pellets, seeds, ribbons, wires, needles, capsules, balloons, and/or tubes are used to slowly administer radiation to the area intended. It helps to provide closer management of cancerous lesions that are difficult to externally radiate.

After implantation of the radiated objects, the patient’s body may release low doses of radiation through the duration of therapy. Nurses should educate patients undergoing internal radiation therapy to limit visitors, stay a distance away from others, and avoid pregnant women and children until the implants are removed. The effects of radiation will slowly dissipate over a few weeks to months, and after the removal of the implants, the patient will no longer emit radiation.

Home Safety

Nurses play an important role in the identification, recommendation, and implementation of safety practices and equipment that are necessary for patient safety in the home environment. Patients and their families will often be involved in and work with the nurse in this process.

Nurses also implement home safety by teaching patients proper self-care and reviewing issues relating to the safe care of children. In the home, nurses should assess the need for walkway lighting, fire alarm maintenance, handrails, safe kitchen tools, and reduction of fall hazards (i.e., power cords, floor pillows, rugs, etc.). Preventive home safety measures can also include the patient’s use of protective equipment when using potentially dangerous devices at home such as using oven mitts to avoid burns, donning eye protection goggles when using power tools, and wearing helmets when riding bicycles or ATVs.

Reporting Incidents

Incident reporting is another responsibility of nursing staff. Skills of accurately and objectively reporting the events leading up to, during, and resulting from the incident are required to properly document it. Common incidents to report include near misses, medication error, substance abuse, improper care, staffing practices, and other treatment errors. The overall goal of incident reporting is to prevent further injury and repetition of the event in the future. Each facility will likely have its own procedures for this process. Copies of the incident report are never included in the medical record. However, the nurse should still document the simple facts of an incident in the patient’s chart.

Unsafe practice reporting— When a nurse witnesses unsafe practices of other healthcare personnel, he or she is responsible for reporting it to the appropriate overseeing agency, both at the nurse’s individual facility and to the state’s credentialing board.

Intervention during unsafe practices— To keep patients from harm, the nurse must identify and intervene appropriately when witnessing potentially unsafe actions of other healthcare team members. This may include confronting an individual and/or involving management nursing staff in the event.

Equipment Use

Nurses must ensure the safe and proper usage of all equipment involved in patient treatment and care. The nurse may be responsible for regular inspections as well as proper patient instruction if he or she needs to use the equipment at home. Monitor for fraying electrical cords, loose or missing parts on equipment, and broken equipment. If the equipment is found to be unsafe or malfunctions, the nurse must immediately stop using it, label it unsafe to use, and make sure it is placed in a location inaccessible to patient care. If possible, put it in a specially designated area for malfunctioning equipment and notify the proper personnel of the problem.

Security Plan

A nurse will be asked to perform the critical task of identifying patients in need of urgent care in the event of a natural disaster or emergency.

The Triage Exam

The purpose of the triage exam is to identify patients who need life-saving care and ensure they are the first patients to receive further evaluation and treatment. It will focus on the following areas in order of their importance:

Airway— Ensure the patient’s airway is clear and open if necessary.
Respiration— Assess for signs and symptoms of respiratory distress.
Quality of respiration— Assess the rate and effort of breathing and check for signs of adequate air exchange (capillary refill, color of skin, and lips). Auscultate for breath sounds.
Pulse— Identify a pulse and note its rate and strength.
External bleeding— Look for signs of significant wounds or injuries in areas with major blood vessels.
Blood pressure— Obtain a blood pressure.
Consciousness, pupillary response, and state of extremities— Assess the patient’s neurological status with his or her level of consciousness, pupillary response to light and signs of paralysis, or posturing of the extremities.

Specific Emergency Plans

Nurses will also have critical roles in the event of facility evacuations, newborn nursery security events/lockdowns, and violence threats or controlled access limitations. Routine drilling may be available at facilities to practice initiating the protocols in place in these events. Nurses must know how to lock down their units; use facility-based policies such as implementing “code-words” given to the patient to share with those people allowed to have access to his or her critical healthcare information; safely alert the appropriate hierarchy in the event of violence threats; and respecting visiting hour policies. Clinical decision making and critical thinking skills often play important parts in both the development and implementation of such plans.

Precautions

Many precautions are used in medicine to prevent the spread of infection. Standard precautions, the most frequent of the precautions, are used in every patient encounter. Transmission-based precautions help to prevent the spread of pathogenic microorganisms. Surgical asepsis, or sterile technique, is used in invasive and surgical procedures.

Standard Precautions

Standard precautions, or universal precautions, including the use of personal protective equipment or PPE (gloves, gowns, face shields, masks, and goggles), should be used in situations where there is potential exposure to blood or other bodily fluids, secretions, and/or excretions. Handwashing and the use of gloves are vital in the prevention of the transmission of infectious pathogens. When donning (putting on) PPE, always start with handwashing. Then, preferably outside the patient’s room, always don in the following order: gown, mask, eye protection, and, lastly, gloves. The reverse order should be used when doffing (taking off) PPE with handwashing as the final step.

Transmission-based Precautions

Pathogenic microorganisms are spread in various ways. The specific transmission-based precautions (also known as isolation precautions) are airborne, contact, and droplet.This will necessitate the nurse to become familiar with various infectious agents and their modes of transmission. Additionally, understand specific precautions needed when caring for those with drug-resistant infections. Below is a brief outline of the appropriate PPE and most common infectious agents in each precaution category.

Contact precautions— PPE required includes gown and gloves. Diseases requiring this level of isolation include C difficile, norovirus, open wounds (burns), respiratory syncytial virus (RSV), methicillin-resistant staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE)
Droplet precautions— PPE required includes gown, gloves, and mask. Respiratory illnesses such as rhinovirus/enterovirus or adenovirus, pneumonia, influenza, pertussis, mumps, and bacterial meningitis.
Airborne precautions— PPE required includes gown, gloves, and N95 respirator mask. Diseases requiring this level of isolation include measles, severe acute respiratory syndrome (SARS), varicella (chickenpox), and mycobacterium tuberculosis.

Immunocompromised patients may additionally require isolation precautions to protect the patient from externally transmitted infection. Due to their weakened immune system, these patients benefit from decreasing any additional exposure to infection. Another term for this type of isolation is reverse isolation. Generally, a minimum of contact precautions is recommended/required throughout the care of immunocompromised individuals.

Reporting Communicable Disease

Some diseases are so significant to public health that they must be reported to the Centers for Disease Control and Prevention (CDC). This reporting allows statistical analysis of the disease to determine how often it is occurring and any trends or outbreaks. The following are the most common diseases that require CDC reporting: chlamydia, gonorrhea, salmonellosis, rubeola (measles), pertussis, varicella, anthrax, botulism, diphtheria, giardiasis, hepatitis (A, B, C), leprosy, lyme disease, malaria, meningitis, mumps, poliomyelitis, Rocky Mountain spotted fever, rubella, smallpox, syphilis, tetanus, tuberculosis, typhoid fever, antibiotic resistant infections, and yellow fever.

Surgical Asepsis

These precautions are the practices necessary to keep areas and objects free from microorganisms. Sterile technique is the term that is often used in place of surgical asepsis. These techniques are used both in surgical procedures and other invasive therapies and treatments such as IV therapy, suturing, and the placement of urinary catheters.

These are the eight basic principles of sterile technique:

Every object used in a sterile field must be sterile.
If a sterile object touches an unsterile object, it is no longer sterile.
A sterile object that is out of view or below waist level is considered unsterile.
A sterile object can become unsterile through exposure to airborne pathogens.
Fluids flow in the direction of gravity.
Moisture or fluids passing through a sterile object can draw pathogens from unsterile surfaces above or below via capillary action.
The edges of a sterile field are unsterile.
The skin cannot be sterilized.

The nurse must always monitor for and evaluate the sterility of procedures and the equipment being used. When necessary “stop the line”, stopping all further activity due to a break in protocol/sterility. The break in sterility must be addressed prior to continuing on with the procedure. Nurses play a critical role in preventing patient harm by maintaining an honest, sterile environment during aseptic procedures and surgery.

Restraints and Safety Devices

Restraints and safety devices are tools that can be used to keep both patients and medical staff safe. A prescribing provider’s orders are required to initiate the use of restraints. This only varies in emergent situations where restraints may be placed initially and an order obtained shortly thereafter. There are chemical restraints (medications) as well as physical restraints (bedside rails, mits, extremity strap restraints, jackets, etc.). Be familiar with the use of all of these, when they are indicated, and the safest/most effective way to use each.

Nurses must frequently assess restrained patients and ensure their needs are met. Assessment and care measures include monitoring vital signs, signs of injury, nutrition, hydration, circulation, providing range of motion, hygiene, elimination, comfort, and safety. Patients are still entitled to maintain their dignity, safety, and patient rights while being restrained. Always use the least restrictive restraint possible for the least amount of time that ensures patient and staff safety. Each facility will have specific instructions, indications of use, and frequency of assessments clearly outlined. If restraints are inappropriately used, there are legal implications that will ensue.

Restraints are never to be used for convenience or patient punishment. Keep in mind that some medical conditions, such as seizures, will often include the use of restraints for the safety of the patient. Restraints for these patients follow the same guidelines as the rules listed previously.