Isolation Precaution Selection for Clinical Case
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For each client, click to specify which precaution (airborne, contact, droplet, or standard) the nurse should use when caring for that client. Each client may require more than one type of precaution, or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row. Note: Each category must have at least 1 response option selected. Client #1 History: Diagnosed with type 2 diabetes mellitus 20 years ago. Two years ago, client required a below-the-knee amputation of the left leg due to gangrene. Three months ago, developed an ulcer 2.5 cm x 2.5 cm (1 in x 1 in) on the dorsal aspect of the foot. Client was treated with antibiotics and hydrotherapy, but wound has continued to enlarge and deepen. Client is admitted due to a large 10 cm x 15 cm x 3.8 cm deep (4 in x 6 in x 1.5 in deep) wound on the dorsal aspect of the right foot. Copious amount of foul smelling yellow drainage continuously oozing from the wound. Client states they no longer wear socks because they become wet within one hour and need to be changed. Client ambulates using a wheelchair. They are no longer able to bear weight on their right leg. Vital Signs: Temperature $39.3^{\circ} \text{ C}$ ($102.7^{\circ} \text{ F}$), Heart rate 106/min, Respiratory rate 20/min, Blood pressure 138/90 mm Hg. Laboratory Results: Wound drainage is positive for vancomycin-resistant Enterococcus (VRE).
This question includes visual content: The image shows a web-based interface for a nursing assessment. On the left, it provides a patient history for Client #1, including a history of Type 2 diabetes, a past amputation, an infected foot ulcer, current vital signs (fever of 39.3 C), and lab results indicating vancomycin-resistant Enterococcus (VRE). On the right, there is a grid interface where the user must select the appropriate precautions (Airborne, Contact, Droplet, Standard) for five different clients (Client #1 through Client #5). For Client #1, the user must select from a set of checkboxes corresponding to each precaution type.
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In this problem, we need to determine the correct nursing precautions for Client number one based on their clinical presentation. This is a critical skill for prioritizing patient safety and preventing the spread of infection.
Determining Precautions for Client #1
Let's start by looking at the patient's history and current symptoms. The patient has a history of type two diabetes and a previous amputation. Currently, they have a large wound on their right foot with copious, foul smelling yellow drainage.
Clinical Observations
- Type 2 Diabetes
- Large foot wound
- Copious, foul-smelling yellow drainage
- Fever: 102.7° F (39.3° C)
Crucially, the laboratory results show that the wound drainage is positive for vancomycin resistant Enterococcus, or VRE.
Now, let's categorize the types of precautions. Standard precautions apply to all patients, regardless of their diagnosis. This includes hand hygiene and using personal protective equipment like gloves when there is potential contact with bodily fluids.
Types of Precautions
| Precaution | Purpose |
|---|---|
| Standard | Used for all patients to prevent contact with body fluids. |
| Contact | Used for pathogens spread by direct or indirect contact. |
| Droplet | Used for pathogens transmitted by large respiratory droplets. |
| Airborne | Used for pathogens transmitted by small aerosolized particles. |
Because the client has a large wound with continuous oozing and drainage, standard precautions are the baseline requirement.
Next, we consider transmission-based precautions. Since the client is positive for V-R-E, which is a multidrug-resistant organism, we must look at how it is spread.
Transmission-Based Precautions
Pathogen: VRE (Vancomycin-resistant Enterococcus)
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