Labs 4 & 5 - QPA, SBAR, Isolation Precautions and PPE

QPA

Quick Priority Assessment.

When do you use the QPA as a tool?

At the START of a shift (and when first meeting a client) to quickly identify priorities and know the client's baseline

QPA vs focused assessment

• QPA = quick, done at the start of shift to know baseline.

• Focused assessment = based on the condition/diagnosis/past disease/medication the person has; specific to the person.

QPA: the 14 parts in order

1) Safety outside the room incl. PCRA

2) Safety in the room environment incl. PCRA

3) General appearance

4) Airway

5) Breathing

6) Circulation

7) Level of consciousness

8) Level of orientation

9) What's going in

10) What's coming out

11) Pain

12) Complete vital signs

13) Focused assessments related to the diagnosis

14) Safety: repeat safety check before leaving

Which QPA parts are done together in the Introduction?

• Airway

• LOC

• orientation to person

• general appearance

PCRA

Point-of-Care Risk Assessment.

QPA 1: Safety OUTSIDE the room (PCRA)

• Perform hand hygiene

• Check the doorway outside the room for isolation precautions, signs and/or symbols for risk of aggression, etc.

QPA 2: Safety in the room environment (PCRA)

• Check when you enter AND when you leave

• area clutter-free and free of hazards (wet floor)?

• Brakes on bed or wheelchair locked?

• Bed in the correct position?

• Side rails up appropriately?

• Call bell within reach?

• Client comfortable and in a safe position?

• Equipment available and in working order (O2, suction, airway)?

QPA safety: when do you check the room?

When you enter and when you leave.

QPA safety: equipment to check

• O2

• suction

• airway equipment available and in good working order.

QPA 3: General appearance

• Where and in what position did you find the client?

• Are they in acute distress?

• Are they moving?

• Are they responding?

• What do you see, hear, smell?

QPA 4: Airway

• Is it open?

• If the client is talking, the airway is open (identified in the introduction).

QPA 5: Breathing

• Look and listen.

• Assess respiratory ease or dyspnea.

• Assess respiratory rate, rhythm and depth

QPA 6: Circulation

• Observe skin colour (pale, dusky, grey, yellow, pink, red, flushed, mottled, blue).

• Assess the radial pulse (rate and rhythm).

• Quickly assess foot colour and note edema in the feet and ankles.

• Check skin temperature (back of your hand), skin dryness and capillary refill.

Which part of the hand checks skin temperature?

The back of your hand.

QPA 7: Level of consciousness (LOC)

• Alert, drowsy, stuporous (responds to pain only), coma.

• Identified with general appearance or during the introduction.

QPA 8: Level of orientation

• Person: 'Can you tell me your full name?' (can be done in the introduction).

• Place: 'Where are you? What is your address?'

• Time: 'What is today's date? What holiday just passed?' (be aware of cultural differences).

• Is the speech clear?

• Can they answer appropriately?

QPA 9: What's going in?

• Observe each line from SITE to SOURCE.

• At the site: IV site for phlebitis (warmth, redness, pain) or infiltration (swelling, coolness)

• is the dressing dry and intact?

• Follow tubing for kinks and excess tension.

• Check machine settings, drip rates (gtts/min), flow rates (L).

• Check identity, rate/level of O2, IV solution, feeding tubes.

Phlebitis (IV site)

Warmth, redness, pain at the IV site.

Infiltration (IV site)

Swelling, coolness at the IV site.

QPA 10: What's coming out?

• Follow each tube (incontinence pads, NG tubes, chest tubes, catheters, wound dressings) from the client to the bag/receptacle.

• Check the incontinence pad for wetness or feces

• dressings dry and intact

• no kinks or tension

• surgical drains working

• note colour and amount of drainage.

QPA 11: Pain

• Ask if they are in pain.

• Consider when the analgesic was last given and if non-pharmacological treatments are used.

• Use OPQRSTUV

QPA pain: R, S, Q, O, P, T, U, V details

• R Region/radiation (where, spreads?)

• S Severity (0 to 10, interferes with activities, tolerable level)

• Q Quality/quantity (sharp, dull, spasmodic, burning, throbbing, gnawing, deep, superficial, cramping, continuous, intermittent)

• O Onset (gradual or sudden) + other symptoms

• P Provocative/palliative

• T Timing

• U Understanding/impact

• V Values (comfort goal)

QPA 12: Complete vital signs

• Temperature

• pulse

• respiration

• blood pressure

• O2 saturation

QPA 13: Focused assessments related to the diagnosis

• Consider the client's medical diagnosis, medications

• info from shift report

QPA 14: Safety check before leaving

• Bed in lowest position

• rails up as appropriate

• call bell in place

• brakes engaged

• good body alignment

• client covered/dressed appropriately

• client has what they need; tell the client when you'll be back or when someone will replace you (going off shift); hand hygiene.

QPA 1-14 mnemonic idea: ABC

Airway (4), Breathing (5), Circulation (6) come right after safety and general appearance.

QPA tip

Sit or stand at the client's eye level during the introduction.

Why is it important to explain what you're doing (QPA/vitals)?

• Tell the patient what you're doing at each task (e.g., 'I'm going to push on your nails, this is not going to hurt') for consent, comfort and cooperation

• ALWAYS explain to the patient what you're doing).

Why get consent for vitals in the QPA?

'I'd like to check your vitals. Is that okay?'

= respects autonomy.

What does a stuporous client do?

Responds to pain only.

SBAR (from your notes)

Provides information concisely and clearly about a matter to another health care provider.

SBAR stands for

• Situation

• Background

• Assessment

• Recommendation

SBAR: Situation

What is happening right now: who you are, patient identity, the immediate problem/concern.

SBAR: Background

Relevant history: reason for admission, diagnosis, medications, allergies, recent vitals/changes

SBAR: Assessment

What you think the problem is: current assessment findings and vital signs.

SBAR: Recommendation

What you need or suggest: request, orders, timeframe/urgency.

Why isolation precautions exist

• Risk of spreading healthcare-associated infection (HAIs) or infectious disease between patients is high

• workers sometimes don't know a patient is infected

• most organisms causing nosocomial infections are in colonized body substances whether or not infection is confirmed

• feces, saliva, mucus and wound drainage always contain potentially infectious organisms.

Nosocomial

Illness picked up while getting medical care inside a hospital or other health care facility.

Two-tier approach (CDC 1996/2007; PHAC 2017)

• Tier one: Routine Practices

• Tier two: Additional Precautions (isolation precautions).

PHAC vs CDC guidelines

• PHAC covers acute, long-term, home and ambulatory care

• CDC guidelines were written for acute care only.

Tier One: Routine Practices

• For the care of ALL patients in any setting regardless of diagnosis or presumed infectiousness. Incorporate earlier universal precautions and body substance isolation.

• Apply with exposure to blood, all body fluids except sweat, non-intact skin, mucous membranes.

Why use routine practices for everyone?

Barrier protection is used for everyone because infection risk can be unknown.

Routine practices: hand hygiene

• Before and after direct patient contact

• before and after contact with the patient's environment

• after contact with blood, body fluids, secretions, excretions and contaminated equipment

• before gloves go on and immediately after gloves come off

Routine practices: gloves

• Worn when touching blood, body fluids, secretions, excretions, non-intact skin, mucous membranes or contaminated items

• Remove and perform hand hygiene between patients

• change gloves and clean hands between procedures on the same patient and after contact with highly contaminated material.

Routine practices: masks, eye protection, face shields

Worn if care or procedures may generate splashes or sprays of blood or body fluid, or by droplet transmission.

Routine practices: gowns

Used to protect uncovered skin and prevent soiling of clothing during procedures/care likely to generate a splash or spray of blood or body fluid.

Routine practices: equipment

Reusable patient care equipment is cleaned and reprocessed before use on another patient. Single-use items are discarded.

Routine practices: linen

• All soiled linen is handled the same way for all patients.

• If the bag soaks through, use an additional bag.

Routine practices: sharps

Discard used sharps and needles in a puncture-resistant container located where the item is used.

Routine practices: single room

• Generally unnecessary for routine care.

• Patients who visibly soil the environment or can't maintain hygiene go in a single room with dedicated toileting.

Tier Two: Additional Precautions (isolation precautions)

• Contain pathogens in one area (usually the patient's room).

• Only for patients infected or colonized with highly transmissible or epidemiologically significant pathogens.

• Used IN ADDITION to routine practices.

• Type depends on how the pathogen spreads.

Additional precautions: 3 categories

Airborne, droplet, contact.

Basic principles for all isolation categories

• Thorough hand hygiene before entering and leaving the room

• dispose of contaminated supplies/equipment based on mode of transmission

• apply knowledge of the disease and transmission mode when using barriers

• protect everyone exposed when transporting a patient outside the room.

Airborne precautions

• For known/suspected infections spread by airborne droplets (measles, chicken pox/varicella, disseminated zoster, tuberculosis).

• Private room with door CLOSED

• negative-pressure airflow, at least 6 air exchanges/hour

• N95 respirator for TB, or for varicella, disseminated zoster or measles if the worker is not immune.

Droplet precautions

• For infections spread by droplets from coughing, sneezing or talking (diphtheria (pharyngeal), rubella, influenza, pertussis, mumps, meningococcal pneumonia, coronavirus, sepsis).

• Private room or cohort patients

• door closed unless the bed is more than 2 m from the door

• mask when within 2 m of the patient.

Contact precautions

• For infections spread by direct or indirect contact (multidrug-resistant organisms, C. difficile, major wound infections, GI, respiratory or skin infections).

• Private room or cohort

• door can be OPEN

• gloves and gown on entry

• limit patient movement outside the room to necessary treatments

• clean and disinfect or discard items before removing from the room.

Which precaution needs a negative-pressure room?

Airborne (at least 6 air exchanges per hour; door closed).

Which precaution may have the door open?

Contact.

Which precaution requires a mask within 2 m?

Droplet.

Which precaution requires an N95?

Airborne.

Which precaution requires gloves and gown on entry?

Contact.

MRSA

Methicillin-resistant Staphylococcus aureus: a strain of staph bacteria that resists many common antibiotics, making infections harder to treat.

Isolation room setup

• Hand hygiene, bathing and toilet facilities in the room

• soap and water and alcohol hand rub available

• post a card outside the door listing precautions

• store PPE in an anteroom or near the point of use

• impervious linen bag, plastic-lined waste receptacle, rigid sharps container.

Negative vs positive pressure airflow

• Negative-pressure keeps infectious particles IN the room (airborne).

• Positive-pressure protects highly susceptible patients (e.g., organ transplant recipients).

PPE table: Contact

• PPE: gloves and gown.

• Common infections: norovirus and other GI infections, C. difficile, MRSA, scabies.

• Symptoms: diarrhea or vomiting, open wounds, patches of open skin.

PPE table: Droplet

• PPE: gloves, gown, surgical mask, eye protection.

• Common infections: influenza, common cold, whooping cough.

• Symptoms: coughing, sneezing.

PPE table: Airborne

• PPE: N95 respirator.

• Common infections: tuberculosis, measles, chicken pox, rubella.

• Symptoms: chronic cough, fever with unidentified rash.

Match: patient with diarrhea and C. diff

• Contact precautions (gloves and gown)

• soap and water for hand hygiene.

Match: patient with a cough and fever, influenza

Droplet precautions (gloves, gown, surgical mask, eye protection).

Match: patient with chronic cough and suspected TB

Airborne precautions (N95 respirator, negative-pressure room, door closed).

Match: fever with an unidentified rash

Consider airborne precautions (N95)

PPE risk assessment: routine practices questions (PICNet)

1) Is there a risk of splashing?

2) Is there a risk of droplets spraying into my face?

3) Will my clothing get soiled?

4) Is there a risk of contact with blood or bodily fluids? Always clean your hands before AND after glove use.

PICNet: examples that do NOT need gloves

Feeding a patient; pushing a wheelchair.

PICNet: examples that need gloves

Helping a patient use the bathroom; dressing a small wound.

PICNet: patient with fever and cough

Gloves, (consider) gown, mask, eye protection.

Contact precautions sign

• Yellow.

• Families/visitors: report to staff before entering

• clean hands before entering and when leaving.

• Staff: wear gown and gloves

• additional PPE based on point-of-care risk assessment.

Contact PLUS precautions sign

• Tan/gold.

• Same as contact (gown and gloves) PLUS 'Twice daily cleaning and disinfection with sporicidal agent' (used for C. difficile).

Droplet precautions sign

• Blue.

• Staff: medical mask and eye protection when within 2 metres of the patient

• additional PPE based on risk assessment.

• Draw curtains/barriers and keep 2 metres between patients.

Airborne precautions sign

• Green.

• Airborne infection isolation room (AIIR, negative pressure room)

• single-occupancy room with door closed, and if not available, consult Infection Prevention and Control.

• 'Keep door closed.'

• Staff: fit-tested respirator (N95 or equivalent).

• Consult IPAC before discontinuing airborne precautions.

Airborne and Contact precautions sign

• Pink.

• Gown and gloves

• fit-tested respirator (N95)

• additional PPE per risk assessment

• keep door closed

• AIIR

• consult IPAC before discontinuing.

Isolation signs: where do they go and how long do they stay?

• Outside the room door

• keep the sign posted until additional-precautions room cleaning and disinfection is completed.

Visitors on isolation

• Report to staff before entering

• clean hands before entering and when leaving the room.

Sign colours (memory)

• Contact = yellow

• Contact plus = tan/gold

• Droplet = blue

• Airborne = green

• Airborne and Contact = pink.

Psychological implications of isolation

• Loneliness (normal social relationships disrupted; especially harmful for children)

• altered body image

• feeling unclean, rejected, lonely or guilty

• practices intensify feelings of being different or undesirable

• private room limits sensory contact

• emotional state can interfere with recovery.

Nursing actions for isolated patients

• Before isolation teach patient/family about the disease, purpose and steps

• demonstrate and allow practice

• explain contaminated vs clean objects

• explain the risk of depression and loneliness to family

• teach visitors to avoid showing revulsion, fear or disgust

• keep the room clean and pleasant

• listen, don't hurry

• use mealtime for conversation

• comfort measures

• walking or sitting if appropriate

• recreational activities

• same standard of care and notes as for all other patients

• allow questions

• assess fir emotional issues caused by isolation

PPE basics

Gowns, masks, eyewear and gloves readily available.

PPE: gown

• Prevents contamination of clothes

• fluid-resistant; opens at the back

• covers all outer garments

• change if damaged or heavily contaminated.

PPE: surgical mask

• Protects against large-particle aerosols travelling 2 m

• never reuse

• discard if moist.

PPE: eye protection

• Protects against droplets to the eye

• Goggles, full face shield or visor attached to a mask.

• Prescription or fashion glasses do NOT offer sufficient protection.

PPE: N95 respirator

• Higher filtration than a surgical mask

• must fit snugly

• fit check, fit-tested.

PPE: gloves

• Prevent direct and indirect contact transmission

Glove tips

• Change between tasks on the same patient after contact with high concentrations of microorganisms

• remove promptly after use and before touching clean items or going to another patient

• if a glove tears, change gloves if care is not completed

• demonstrate glove use to visiting family and stress hand hygiene after removal.

DONNING order

1. Gown

2. hand hygiene

3. Mask

4. Eye protection

5. hand hygiene

6. Gloves

DONNING: gown

• Fully cover the torso from neck to knees, arms to wrists

• fasten ties at the back of the neck and at the waist.

DONNING: eye protection

• Goggles, face shield or visor; face shield should fit over the brow

• place over face and eyes and adjust to fit.

DONNING: gloves

• Extend over the cuffs of the gown

• keep gloved hands away from the face and limit touching surfaces

• change gloves and clean hands as needed (visibly soiled, between contaminated and clean tasks)

DOFFING order (lab slides)

1. Gloves (remove in room)

2. hand hygiene

3. Gown (remove in room)

4. hand hygiene

5. Eye protection (keep on until out of the room)

6. hand hygiene

7. Mask (keep on until out of the room)

PPE Cleanup order

1. hand hygiene

2. gloves

3. clean eye protection

4. handwash

After the last PPE item is off

• Hand hygiene again (all surfaces of hands and wrists), then tell the patient when you will return and ask if they need personal-care items, books or magazines

• leave and close the door if necessary (airborne = door closed).