Standard Precaution

Nursing Process

Assessment
• Assess for skin integrity
• Assess for presence of drainage from lesions or body cavity.
• Assess for ability to deal with oral secretions.
• Assess for compliance to hygiene measure (i.e., covering mouth when coughing, ability to control body fluid).
• Assess ability to carry out activities of daily living (ADL).
• Assess extent of barrier techniques needed (i.e., gloves, gown, mask, protective eye wear).
• Assess need for special equipment (i.e., hazardous west bags, plastic bags for specimens).

Planning
• To prevent clients (especially compromised clients) from acquiring nosolomial infections.
• To prevent the spread of micro organism to health professionals.
• To reduce potential for transmission of micro organisms.
• To protect hospital personnel and others from contamination.
• To provide appropriate equipment and techniques for preventives measures.

Implementation/Procedures
Donning protective gear utilizing standard precautions.
Exiting a client’s room utilizing standard precautions.

Evaluation/Expected outcomes
- Clients remain infection free.
- Transmission of micro organism is controlled.
- Health care workers protected from micro organism.
- Appropriate nursing interventions are carried out for the client.