NR 224 Week 2 C. diff Contact Precautions Write-Up Example

Asepsis Write-Up: One Entry Into a Contact Precautions Room for C. difficile, Surface by Surface, From the Door Handle In to the Door Handle Out

Student Name

College of Nursing, Chamberlain University

NR 224: Fundamentals: Skills

Instructor Name

Month Day, Year

Asepsis Write-Up: One Entry Into a Contact Precautions Room for C. difficile, Surface by Surface, From the Door Handle In to the Door Handle Out

The Room and the Task

The write-up follows one entry into the room of Mrs. N., 79, who has diarrhea from Clostridioides difficile and is on contact precautions; details are composite. The task was to take her vital signs, empty and measure the contents of her bedside commode, help her back to bed and replace her water. The entry lasted about 12 minutes. It is written surface by surface, because asepsis in a room like this is less about knowing the rules than about what my hands touched, in what order, and what they carried out.

C. difficile matters for asepsis because it forms spores. Alcohol-based hand rub, which works well against most bacteria and viruses on the unit, does not reliably kill C. difficile spores. The joint IDSA and SHEA practice guideline for C. difficile recommends contact precautions, gowns and gloves, dedicated equipment and hand washing with soap and water in settings where spread is a concern (McDonald et al., 2018). Soap and water removes spores from the hands by friction and rinsing; it does not kill them.

Before going in, I also checked two things that change the plan. The first was whether anyone else needed to go in with me, since helping Mrs. N. off the commode alone would have meant a second nurse gowning up mid-task, which costs supplies and time. She was able to stand with one person, so I went in alone. The second was whether the room had its own supplies of gloves and a clean pitcher, so I would not have to leave and come back in the middle of the visit. Each extra entry is another chance to carry something out.

Where the Room Begins

The room begins at the doorway, not at the bed. The isolation cart outside the door holds gowns and gloves, and the sign on the door says contact precautions and soap and water. Before touching the door handle, I cleaned my hands with alcohol rub, because at that moment they carried the unit, not the room, and the next patient I would touch after this one needed protection from what I brought in. I put on a gown, tied at the neck and waist so it covered my scrubs from neck to knees, and then gloves, pulled over the gown's cuffs so no skin showed at the wrist.

I left my phone and pen in my pocket outside the gown, and I did not bring my own stethoscope. The room has a dedicated stethoscope and blood pressure cuff that stay in the room, because equipment carried between rooms carries spores with it.

Hands Change State More Than Once

Inside, my gloved hands moved from clean to contaminated and back more than once, and each change needed its own step. I took Mrs. N.'s blood pressure and temperature first, with the room's own equipment, while my gloves were still clean, because vital signs involve touching her skin and I wanted that done before touching anything soiled. Then I helped her from the commode to the bed, which meant touching her clothing, the commode arms and the bed rail. I emptied the commode into the toilet, measured the volume, noted its appearance and cleaned the commode pan.

At that point my gloves were grossly contaminated, and the next task, replacing her water pitcher and putting the call light in her hand, involved things she would touch and put in her mouth. So I removed the gloves, washed my hands with soap and water at the sink in the room, and put on a new pair before touching the pitcher. Sax et al. (2007) set out five moments when hands should be cleaned, grouped around contact with the patient, clean procedures, possible exposure to body fluids, and the patient's surroundings. In a 12-minute visit, I met four of the five, and each one was a different reason, not the same reason repeated.

Gloves Protect the Next Patient Too

Gloves in this room have two jobs. They protect my hands from the stool and the surfaces contaminated by it. And they protect the next patient, because the spores I would otherwise carry on my skin would go with me to the next room, where a patient on antibiotics might be vulnerable to infection. That second job is why gloves come off before touching clean things in the room, and why they come off before leaving it. A glove that touched the commode and then the water pitcher has failed at its second job without anyone seeing it.

Clean, Sterile and the Gap Between

Nothing in this visit was sterile. Contact precautions are about clean technique: keeping clean things clean and keeping contaminated things from spreading. The difference matters because sterile technique, which I will use for catheter insertion or dressing changes, has a field with edges and nothing unsterile may cross it. In this room there is no field. There is only an order of tasks and a set of barriers. Confusing the two would lead to one of two errors: treating the room as sterile and using far more supplies than needed, or treating a sterile procedure later in the week with the looser habits of this room.

Taking It All Off Again

Removal was done in the order that keeps the contaminated outside away from my skin. At the doorway, still inside the room, I removed my gloves first, peeling the second off inside the first, and then the gown, pulling it forward from the shoulders and rolling it inside out, touching only the inside. Both went into the bin inside the door. I washed my hands with soap and water at the room's sink for at least 20 seconds, rinsed and dried with a paper towel, and used the towel to open the door handle, because the handle is part of the room.

Outside, I did not touch the isolation cart or my face until I had cleaned my hands once more with alcohol rub, which is appropriate here because my hands were no longer soiled and had already been washed. The door handle I used on the way in was the last surface of the room, and the paper towel is how I left it behind.

References

McDonald, L. C., Gerding, D. N., Johnson, S., Bakken, J. S., Carroll, K. C., Coffin, S. E., Dubberke, E. R., Garey, K. W., Gould, C. V., Kelly, C., Loo, V., Shaklee Sammons, J., Sandora, T. J., & Wilcox, M. H. (2018). Clinical practice guidelines for Clostridium difficile infection in adults and children: 2017 update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases, 66(7), e1-e48. https://doi.org/10.1093/cid/cix1085

Sax, H., Allegranzi, B., Uçkay, I., Larson, E., Boyce, J., & Pittet, D. (2007). 'My five moments for hand hygiene': A user-centred design approach to understand, train, monitor and report hand hygiene. Journal of Hospital Infection, 67(1), 9-21. https://doi.org/10.1016/j.jhin.2007.06.004