Module 2 Medical Asepsis, PPE, Infection Control, Documentation, SBAR

What is the most important purpose of patient records according to the American Nurses Association (ANA)?

Communicating within the health care team and providing information for accreditation, credentialing, legal, regulatory, reimbursement, research, and quality activities.

What does the saying 'If it wasn’t charted, it wasn’t done' emphasize in nursing documentation?

That nursing actions and interventions must be documented; otherwise they are considered not performed and may have legal implications.

Name the HIPAA rule areas discussed and their focus.

Privacy Rule (privacy of PHI), Security Rule (security of electronic PHI), and Breach Notification Rule (notifying breaches); confidentiality is also addressed by the Patient Safety Rule.

What rights do patients have under HIPAA regarding their health information?

See/copy their health record, update their health record, get a list of disclosures, request restrictions on disclosures, and choose how to receive health information.

Provide an example of a confidentiality breach in a clinical setting.

Discussing patient information in a public area.

Provide another confidentiality breach example.

Leaving patient information in a public area.

Provide another confidentiality breach example.

Leaving a computer unattended with patient information accessible.

What does the Joint Commission's 'Do Not Use' list advise regarding common abbreviations?

Avoid abbreviations like U for unit and IU for International Unit; spell out the terms as 'unit' and 'International Unit'.

What is the guidance on trailing zeros in medication doses?

Do not use trailing zeros after a decimal point; use X mg (e.g., 1 mg, not 1.0 mg); use a leading zero for values less than 1 (0.X mg).

What is Charting by Exception (CBE)?

A documentation method where only abnormal findings or deviations from predefined normals are recorded; normal findings are not charted.

What does PIE charting stand for and what is a key feature?

Problem, Intervention, Evaluation; the care plan is incorporated into the progress notes and problems are numbered.

What does SOAP format stand for in progress notes?

Subjective data, Objective data, Assessment, Plan.

What does Focus Charting use in its narrative, and what is the focus?

Data–Action–Response (DAR) format; focus is on the patient and patient concerns rather than solely on problems.

What is the Problem-Oriented Medical Record (POMR)?

A charting approach organized around the patient’s problems, with a master problem list and progress notes; typically uses SOAP or variants.

What is a Source-Oriented Record and its main advantage and disadvantage?

A paper record where data are organized by discipline on separate forms; advantage: easy to find data by discipline; disadvantage: data are fragmented and harder to track problems chronologically.

What is the difference between an EMR and an EHR?

EMR is an electronic record within a single organization; EHR is a shared, interoperable record that can be accessed by designated providers across organizations.

Name two benefits of Electronic Health Records (EHRs) as reported by AHRQ.

Reduction of medical errors and adverse events; improved documentation, coordination, and communication; enhanced lab/result management and CDS capabilities.

What is Health Information Exchange (HIE)?

An organization that enables secure electronic sharing of health-related information to improve quality, safety, and care coordination.

What is OASIS and in what setting is it used?

A data set used in home health care to assess and measure patient outcomes for Medicare home health services.

What are the four basic components of the Resident Assessment Instrument (RAI) used in long-term care?

Minimum Data Set (MDS), Triggers, Resident Assessment Protocols, Utilization Guidelines.

What should be included in a discharge summary?

Reason for treatment, significant findings, procedures performed and treatments rendered, patient’s condition on discharge/transfer, and specific instructions for the patient and family.

What are the key elements of bedside shift reporting and its benefits?

Oncoming and outgoing nurses assess the patient together at the bedside, review orders and goals, and involve the patient/family; benefits include improved safety, patient experience, and teamwork.

What does ISBARR stand for and how does it differ from SBAR?

Identity/Introduction, Situation, Background, Assessment, Recommendation, Read-back; ISBARR includes the introducer, while SBAR includes only Situation, Background, Assessment, Recommendation.

What are guidelines for Verbal Orders (VOs) and the read-back process?

VOs should be limited to urgent situations; read-back the order to verify accuracy; document as VO with date/time/name; the issuing clinician signs later.

Why is confidentiality especially important for minors like Jason Chandler, and what HIPAA consideration applies?

Minors’ PHI releases typically require parental consent; maintain confidentiality for the minor unless consent is given or required by policy.

What is an incident report and what is its purpose?

A variance report documenting unexpected events that may harm a patient or property; used for risk management and quality improvement and not for discipline.

What are the six components of the infection cycle?

Infectious agent, reservoir, portal of exit, means of transmission, portals of entry, and susceptible host.

How are bacteria categorized by Gram stain, and why does this matter for antibiotic therapy?

Bacteria are Gram-positive (thick cell wall, stained violet) or Gram-negative (thin wall, decolorized and not stained). This distinction helps determine which antibiotics are effective.

What is an airborne pathogen and which infections require airborne precautions?

An agent that can remain suspended in air; examples include tuberculosis, varicella (chickenpox), measles. Requires a private room with negative pressure and a fit-tested respirator (e.g., N95) for entry.

What are MDROs and give examples mentioned in the notes?

Multidrug-resistant organisms; examples include MRSA, VRE, CRE, and CRAB.

Differentiate colonization from infection.

Colonization: presence of organisms without disease signs; infection: organism causes clinical signs/symptoms of disease.

What are Standard Precautions?

Precautions used for all patients to protect workers and patients: hand hygiene, PPE as needed, respiratory hygiene, safe injection practices, and management of blood/body fluids.

What are the three types of Transmission-Based Precautions?

Airborne, Droplet, and Contact precautions, used in addition to Standard Precautions.

Explain the difference between droplet and airborne transmission.

Droplets are typically >5 μm and travel short distances; airborne particles are ≤5 μm and can remain suspended in air.

What are the WHO Five Moments for Hand Hygiene?

1) Before touching a patient 2) Before clean/aseptic procedures 3) After body fluid exposure or risk 4) After touching a patient 5) After touching patient surroundings.

What is the difference between transient and resident hand flora?

Transient flora are acquired during daily activities and are more easily removed; resident flora live in skin creases and are more persistent and harder to remove.

Why isn’t alcohol-based hand sanitizer always effective for C. difficile?

C. difficile forms spores that alcohol-based rubs do not kill; soap and water are preferred for CDI prevention.

When should soap and water be used instead of alcohol-based hand rub?

When hands are visibly dirty or contaminated with body fluids, or after CDI care; handwashing is required in these situations.

What are the primary body defenses against infection?

Skin and mucous membranes, normal flora, inflammatory response, and immune response (humoral and cell-mediated immunity).

Name the four stages of infection progression.

Incubation period, prodromal stage, full (acute) stage of illness, and convalescent period.

What are hallmark signs of the acute infection stage?

Redness, heat, swelling, pain, and loss of function at the infection site.

What are humoral and cell-mediated immunity?

Humoral immunity involves antigen–antibody (B-cell) responses; cell-mediated immunity involves lymphocytes that destroy infected cells (T-cells).

What is disinfection versus sterilization?

Disinfection destroys most pathogens except spores; sterilization destroys all microorganisms, including spores.

What are medical and surgical asepsis?

Medical asepsis (clean technique) reduces pathogens (hand hygiene, gloves); surgical asepsis (sterile technique) renders areas free of all microorganisms.

State one key rule about opening a sterile package to establish a sterile field.

The first edge of the wrapper should be directed away from you; the outer surface is considered unsterile and the border (about 1 inch) is contaminated.

What is the outer 1-inch border rule for sterile fields?

The outer 1-inch border of a sterile field is considered contaminated; items touching it are contaminated; keep field above waist level.

What PPE components protect mucous membranes during procedures?

Gown, mask or respirator, eye protection (goggles or face shield), and gloves; respirators (e.g., N95) for airborne procedures.

What are neutropenic precautions?

Enhanced precautions for immunocompromised patients: ensure health of caregivers, restrict sick visitors, avoid standing water and live plants, use PPE as indicated.

What is the role of an infection preventionist?

Epidemiology and surveillance; lead investigations; prevent transmission; coordinate risk assessment, education, and performance improvement; guide policy.

Why are HAIs economically and administratively significant?

HAIs cause deaths and billions in costs; CMS may not reimburse certain hospital-acquired conditions; emphasis on prevention and reporting.

What is endogenous versus exogenous infection?

Endogenous infection arises from the patient’s own flora; exogenous infection is acquired from others or the environment.

Define a fomite and a vector.

Fomite: inanimate object that transmits pathogens; Vector: living organism (usually an insect) that transmits pathogens.

How should you open a sterile package for a sterile field in practice?

Open away from the body, maintain sterile surface inside the wrapper, and handle only sterile surfaces to avoid contamination.

What is the purpose of using sterile gloves and how should they be removed safely?

Sterile gloves protect the sterile field; remove by rolling gloves inside out, touching only the sterile surfaces, and perform hand hygiene afterward.

What are typical examples of infections that require contact precautions?

Infections with MDROs such as MRSA, VRE, CRE, and others; emphasize hand hygiene and environmental cleaning.

What does SBAR stand for in standardized hand-off communication?

Situation, Background, Assessment, and Recommendations.

What does the I-SBAR-R modification add to SBAR?

Identity of the nurse and patient (I) plus Read-back (R) to confirm understanding.

What are the four levels of communication in nursing practice?

Intrapersonal, Interpersonal, Small-group, Organizational.

How would you describe the therapeutic nurse-patient relationship?

A caring, patient-centered, professional relationship that is dynamic, purposeful, time-limited, with clear boundaries.

What are the three phases of the therapeutic nurse–patient relationship?

Orientation phase, Working (identification/exploration) phase, Termination phase.

How does a therapeutic relationship differ from a friendship?

Therapeutic is professional and goal-oriented with unequal information sharing; friendship is informal and mutual.

What is rapport in nursing communication?

A sense of mutual trust and ease that facilitates open communication and collaboration.

Define nonverbal communication.

The transmission of information without words through touch, eye contact, facial expressions, posture, gestures, and other cues.

Name three common nonverbal cues used in nurse-patient interactions.

Eye contact, touch, facial expressions.

What is proxemics in communication?

The study of personal space and distance zones (intimate, personal, social, public) and their effects on interaction.

What should you do before entering a patient’s intimate or personal space?

Obtain the patient’s permission or consent to approach.

What are the three communication channels described in nursing?

Auditory, Visual, Kinesthetic.

What are the components of Berlo’s SMCR communication model?

Source/encoder, Message, Channel, Receiver/decoder.

What is 'noise' in the communication process?

Any distraction or interference that distorts the message.

What does CUS stand for in patient safety communication?

I’m Concerned, I’m Uncomfortable, This Is Unsafe.

What is the difference between empathy and sympathy?

Empathy is understanding another person’s feelings; sympathy is feeling sorrow for their situation.

Name one principle from the ANA’s social networking guidelines for nurses.

Do not transmit or place online individually identifiable patient information.

What is the purpose of the box Remembering 'Through the Eyes of a Patient' in communication?

To illustrate how patients perceive nurse communication and what constitutes respectful, patient-centered interaction.

What is the difference between privacy and confidentiality in nursing communication?

Privacy protects conversations from being overheard; confidentiality protects patient information and access to it.

What are key communication considerations for patients with special needs (Box 8-6)?

Acknowledge presence, orient to the environment, use simple language or interpreters, consider hearing/vision impairments, use assistive devices as needed.

What is an open-ended question in nursing interviews?

A question that allows broad, descriptive responses and prevents yes/no answers.

What is a closed question and when is it used?

A question that requires a brief yes/no or limited-answer response; used to obtain specific data quickly.

What is elderspeak and why is it discouraged?

Infantilizing, patronizing speech to older adults; considered ageist and disrespectful.

What is hand-off communication and why is SBAR recommended?

Transfer of patient care between providers; SBAR provides a clear, structured method to reduce errors during hand-offs.

What are incivility and bullying in the nursing workplace?

Disruptive behaviors that threaten safety and teamwork; require zero-tolerance policies and reporting.

What is the termination phase in the therapeutic nurse-patient relationship?

Concluding the relationship; review goals and progress; discuss feelings about termination and plan for continuing care.

What is therapeutic touch?

A nonverbal technique used to convey care and comfort; should be used considerately and with patient consent.

Why is listening and environment important in nurse-patient communication?

Active listening and a calm, private environment build trust, reduce distractions, and improve understanding.

What are the components listed on a medication order?

Patient’s name and date of birth; date and time order is written; name of drug; dosage; route; frequency; signature of the person writing the order.

What are the main types of medication orders?

Routine; Standing orders; PRN (as needed); One-time order; Stat order.

What are the Three Checks of Medication Administration?

Read the label when reaching for the container; after retrieval compare with the eMAR/MAR (or immediately before pouring from a multidose container); before giving the unit dose (or when replacing the multidose container in the drawer/shelf).

Name the classic five rights of medication administration.

Right medication; Right patient; Right dose; Right route; Right time.

What are some additional rights included with medication administration beyond the classic five?

Right reason; Right assessment data; Right documentation; Right response; Right to education; Right to refuse.

What information must be documented for controlled substances?

Name of patient; Amount used; Time given; Name of prescribing provider; Name of nurse administering; If unused portion, a second nurse witnesses waste.

What are two identifiers used to identify a patient (besides room number)?

Patient name; Date of birth or medical record number.

What forms do oral medications come in?

Solid forms: tablets, capsules, pills; Liquid forms: elixirs, spirits, suspensions, syrups.

What is the difference between syrup and suspension?

Syrup is a solution of sugar in purified water (may contain preservatives); Suspension is a liquid with undissolved drug particles that may separate.

What are common enteral medication routes/tubes?

Nasogastric (NG) tube; Nasointestinal tube; Percutaneous tube; PEG (percutaneous endoscopic gastrostomy); Jejunostomy.

What is recommended when diluting crushed medications for enteral administration?

Mix with 30 mL of purified water immediately prior to administration.

How much water should you flush before and after giving a med through an enteral tube?

Flush with at least 15 mL of purified water before administration and immediately after.

What should you do if an NGT is on suction during medication administration?

Disconnect suction and clamp the tube for 30 minutes.

How should medications be given through an enteral tube to ensure safety?

Give all medications individually and flush with water between meds.

What is the difference between buccal and sublingual administration?

Sublingual: placed under the tongue; Buccal: placed between the tongue and cheek; Do not swallow; both rely on local absorption.

List some topical routes for medication administration.

Skin or mucous membranes; Vaginal; Rectal; Inunction; Instillation; Irrigation; Transdermal patch; Pulmonary (inhalation).

What are key steps for administering eye drops?

Wear gloves; provide a tissue for patient; cleanse lids/lashes if drainage; tilt head back; do not touch the eye with the bottle tip; invert bottle; have patient look up; instill into lower conjunctival sac; release lid; have patient close eye; apply gentle pressure at inner canthus; do not rub; wipe excess.