NCLEX isolation precautions: contact, droplet and airborne

Which precaution for which disease

COVID-19 does not fit one row. CDC's current healthcare guidance is an N95 or higher respirator, gown, gloves and eye protection; a single-person room with the door closed when safe; an AIIR for aerosol-generating procedures when possible; and cohorting only with clients who have the same respiratory pathogen.

Two rules carry a lot of items. HIV and hepatitis B and C need only standard precautions: they spread through blood and needles, not the air. And localized shingles in a client with a normal immune system needs standard precautions with the lesions covered; only the disseminated or immunocompromised case goes to an AIIR. Contact, Droplet, Airborne: Pick the Right Door drills the sorting.

How long precautions last

Items also ask when precautions can stop. From CDC's isolation table and influenza guidance:

• Meningococcal disease: 24 hours after effective antibiotics start. Pertussis: 5 days after.
• Influenza: 7 days after onset, or until at least 24 hours after the fever resolves without fever-reducing medicine and respiratory symptoms are improving, whichever is longer.
• Tuberculosis: on effective therapy, improving, and 3 consecutive negative acid-fast sputum smears collected on separate days.
• Measles: 4 days after the rash appears (the whole illness if the client is immunocompromised). Chickenpox and zoster: until the lesions are dry and crusted.
• COVID-19: for most clients with mild to moderate illness who are not immunocompromised, at least 10 days after symptoms began, plus fever and symptom criteria.

PPE donning and doffing order (CDC)

CDC's sequence, from its PPE poster, starting with clean hands.

Donning:

1. Gown, neck to knees and arms to wrists, tied at the neck and waist.
2. Mask or respirator, nose band shaped to the face. Fit-check an N95 every time.
3. Goggles or face shield.
4. Gloves, pulled over the gown cuffs.

Doffing (CDC example 1):

1. Gloves, the most contaminated item.
2. Goggles or face shield, by the headband or ear pieces.
3. Gown, touching only the inside, rolled inside out.
4. Mask or respirator, bottom ties first, never touching the front.
5. Hand hygiene, immediately.

CDC's second example peels the gown and gloves off together, then eye protection, then the mask, then hand hygiene. In both, everything comes off before you leave the room except a respirator, which comes off after you leave and close the door. Clean your hands mid-sequence whenever they become contaminated. Short version: gloves on last and off first; mask on second and off last.

Room assignment and cohorting

• Each airborne client gets their own AIIR (only in an outbreak, at infection prevention's direction, are clients with the same airborne infection grouped). An AIIR means negative pressure, door closed, at least 6 air changes an hour (12 in new construction). Without an AIIR, a private room with the door closed reduces spread until transfer.
• Contact and droplet clients get a private room first. When rooms run out, cohort clients with the same pathogen: beds more than 3 feet apart, curtain drawn, fresh PPE and hand hygiene between the two.
• The last private room goes to the contact client with uncontained drainage or stool incontinence, or the droplet client with heavy coughing and sputum.
• Avoid rooming an infected client with someone immunocompromised or expected to stay a long time, or a contact client with someone who has an open wound.
• Transport only when necessary: droplet and airborne clients wear a surgical mask; a contact client's infected area is covered, as are chickenpox and draining TB lesions.

Neutropenic precautions: protecting the client

Neutropenic (protective) precautions run the other way: they keep organisms away from a client who cannot fight them, usually a chemotherapy client with an absolute neutrophil count below about 1,000 (policy sets the trigger; below 500 is severe).

• Private room; meticulous hand hygiene; staff and visitors with an infection stay out.
• No fresh or dried flowers and no potted plants.
• Meat and eggs cooked through, raw produce washed well; some units order a low-microbial diet.
• No rectal temperatures, suppositories or enemas.
• Fever is the emergency. CDC tells clients to call for 38 °C (100.4 °F) or higher for over an hour, or one reading of 38.3 °C (101 °F). On the exam, report any fever at once.

Clients after an allogeneic stem cell transplant go into CDC's Protective Environment: a positive-pressure room with HEPA-filtered air and at least 12 air changes an hour. It mirrors an AIIR: negative pressure keeps TB air in, positive pressure keeps hallway air out. Burns: The Parkland Formula and Neutropenic Fever covers neutropenic fever.

The traps the exam sets

• A surgical mask for TB or measles. Those need a fit-tested N95; the surgical mask goes on the client for transport.
• Hand sanitizer after a C. diff room. Soap and water. Gloves never replace hand hygiene.
• "The nurse is immune to measles, so no respirator." CDC says wear an N95 regardless. Immunity decides assignment: susceptible staff stay out of measles and chickenpox rooms when immune staff are available.
• A droplet mask "within 3 feet". CDC says put it on when you enter the room.
• Waiting for results. Precautions start on suspicion.
• Cohorting by precaution type instead of organism: clients with MRSA and with C. diff are both on contact precautions and still do not share.

A worked room-assignment item

The nurse has one airborne infection isolation room left and four admissions. Which client should be placed in it?

1. A client with influenza A, a temperature of 38.9 °C (102 °F) and a frequent cough. Droplet precautions: a private room and a surgical mask. Not the AIIR.
2. A client with meningococcal meningitis who started IV antibiotics 6 hours ago. Droplet until 24 hours of effective therapy. Not the AIIR.
3. A client with a 3-week productive cough, night sweats, weight loss and a cavity on the chest x-ray; sputum smears pending. Suspected pulmonary TB: airborne precautions now. The AIIR.
4. A client with a healthy immune system and shingles in one band across the chest, lesions covered. Localized zoster in a normal host: standard precautions. Not the AIIR.

Two facts decided it: the route (only TB is airborne here) and the word "pending", because precautions start on suspicion. Had the shingles client been on chemotherapy, that client would need an AIIR too. Isolation lists also come as select-all-that-apply items (how SATA is scored), and the infection control practice questions repeat these patterns.