Resident With a New Cough and a Droplet Precaution Question
You are working a day shift on a medical-surgical unit. Mrs. Okafor, age 68, was admitted 3 days ago for a COPD exacerbation. At 09:00 she has a new productive cough, a temperature of 38.4 C (101.1 F), and chills. Her oxygen saturation is 90% on 2 L nasal cannula, down from 94% yesterday. She has an order for Droplet Precautions from a prior admission that expired. The physician is rounding on another floor and has not yet seen her. A roommate is in the next bed, separated only by a curtain. You have a linen cart in the hallway and a supply room two doors away.
1. What do you do before the physician arrives, and what is the reasoning behind each action?
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Treat this as a possible new respiratory infection and act on transmission risk immediately, within your scope.
- Put a mask on the resident if she can tolerate it, and put a mask on yourself before close contact. A new productive cough plus fever plus chills is a plausible droplet-spread illness (for example, influenza or another respiratory virus). Source control starts with the patient.
- Apply Droplet Precautions now per facility policy and standard precautions. Do not wait for the physician to write the order; nurses and CNAs routinely initiate transmission-based precautions and obtain the order afterward. Post the sign on the door.
- Address the roommate. Ask the charge nurse to move the roommate or move Mrs. Okafor to a single room if one exists. A curtain is not a barrier to droplets.
- Get the oxygen question to a licensed nurse. A saturation of 90% on 2 L, down 4 points, is a change in condition. Report it now - do not adjust the oxygen yourself, because that is outside CNA scope and the rate is ordered.
- Gather and report. Take a full set of vital signs, note the cough character and sputum, and give a clear SBAR report to the charge nurse or physician.
- Hand hygiene and PPE discipline. Keep a mask and gloves at the door, do not carry contaminated items to the linen cart, and clean your hands before and after every contact.
2. A coworker says, "She's probably just having a COPD flare, you're overreacting with the mask." How do you reason about whether to keep the precautions?
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Keep the precautions until a licensed provider rules out a transmissible infection. The reasoning is about the cost of being wrong.
- The findings overlap. A COPD exacerbation can cause cough and low oxygen, but a new fever of 38.4 C and chills point toward infection. You cannot distinguish the two from the bedside, and you do not need to.
- Asymmetric risk. If you are wrong about needing precautions, the cost is a mask and a posted sign. If your coworker is wrong, the cost is an outbreak among vulnerable patients, some of whom are on steroids or have chronic lung disease.
- Precautions are reversible; exposures are not. Droplet Precautions come down as soon as the provider documents the alternative. An exposure cannot be undone.
- Scope. Deciding the diagnosis is not the CNA's job; protecting the resident and neighbors is. Initiate, report, and let the provider discontinue.
Document the time precautions were started and the report you gave.