Contact, Droplet, and Airborne Precautions NCLEX: PPE by Infection Type (Student Guide)

Nurses practice STANDARD PRECAUTIONS with every patient every time — hand hygiene, gloves when touching body fluids, appropriate PPE for anticipated exposure, safe injection practices, and respiratory hygiene. These are the baseline. On top of standard precautions, TRANSMISSION-BASED PRECAUTIONS add specific requirements based on how the organism spreads. There are three categories, each with distinct PPE and room requirements: CONTACT PRECAUTIONS (organism spreads by touch): - PPE: gloves + gown upon entering the room - Room: private room preferred; cohort with same organism acceptable; door can remain open - Examples: MRSA, C. difficile, VRE, scabies, lice, RSV, wound infections with multidrug-resistant organisms DROPLET PRECAUTIONS (organism spreads in respiratory droplets that fall within 3 feet): - PPE: gloves + gown + SURGICAL mask within 3 feet of patient - Room: private room preferred; cohort with same organism acceptable; door can remain open - Examples: influenza, pertussis, meningococcal meningitis, mumps, rubella, pneumonic plague, diphtheria AIRBORNE PRECAUTIONS (organism spreads in tiny particles suspended in air): - PPE: gloves + gown + N95 RESPIRATOR (fit-tested) - Room: AIRBORNE INFECTION ISOLATION ROOM (AIIR) with negative pressure, 6-12 air changes/hour, door MUST remain closed - Examples: tuberculosis (active), measles, varicella (chickenpox/shingles), SARS, disseminated herpes zoster The mask distinction is heavily tested: surgical mask = droplet; N95 respirator = airborne. Mixing these up is one of the most common NCLEX errors. This content is for educational purposes only and supports nursing student learning. It does not constitute medical advice.

Contact precautions are required when the organism spreads through direct touch (skin-to-skin) or indirect touch (patient's environment → nurse's hands/gloves → another patient). Common organisms and conditions requiring contact precautions: MRSA (methicillin-resistant Staphylococcus aureus): skin, soft tissue, surgical wound, or bacteremia. Gloves and gown for all patient contact. VRE (vancomycin-resistant enterococcus): usually GI or urinary. Same PPE as MRSA. C. difficile: GI infection causing severe diarrhea. CRITICAL NOTE — alcohol-based hand sanitizer does NOT kill C. diff spores. You must use SOAP AND WATER for handwashing. Also use contact precautions with gloves and gown. (This is a favorite NCLEX question.) Multidrug-resistant gram-negatives (CRE, MDR-Pseudomonas, ESBL-producers): varies by organism but generally contact precautions. Scabies and lice: parasites transmitted by direct skin contact. Use contact precautions until 24 hours after effective treatment. RSV (respiratory syncytial virus) in children: pediatric respiratory infection. Despite being respiratory, primary transmission is via contaminated hands from nasal/oral secretions — contact precautions (plus droplet in some guidelines). Rotavirus: pediatric diarrheal illness. Contact precautions due to fecal-oral route. Wound infections with multidrug-resistant organisms: any open wound colonized or infected with MRSA, VRE, or similar. Impetigo (before 24 hours of antibiotic treatment): contagious skin infection. PPE for contact precautions: - Gloves: put on before entering the room, remove before leaving - Gown: put on before entering the room if there will be substantial contact with the patient or environment - Mask: not required for contact precautions alone (use standard precautions judgment for splashing) - Dedicated equipment: stethoscope, BP cuff, thermometer stay in the room Room setup: private room preferred. Cohort (two patients in same room) acceptable only if both have the same organism. Door can remain OPEN. Signs on the door. Patient transport: limit if possible. If transport necessary, cover any draining wound, and notify receiving department of precautions.

Droplet precautions apply when organisms are transmitted in respiratory droplets (> 5 microns) that fall within about 3 feet of the patient. Because droplets are relatively large and fall quickly, airborne transmission doesn't occur — they don't stay suspended. Common organisms and conditions requiring droplet precautions: Influenza (flu): respiratory droplet transmission. Surgical mask within 3 feet. Pertussis (whooping cough): highly contagious childhood disease, resurgent in under-vaccinated populations. Droplet precautions for 5 days after start of effective antibiotic treatment. Meningococcal meningitis (Neisseria meningitidis): bacterial meningitis that can cause rapidly fatal septicemia. Droplet precautions for 24 hours after start of effective antibiotic treatment. Close contacts need prophylactic antibiotics. Mumps, rubella (German measles): viral childhood illnesses with droplet transmission. Pneumonic plague (Yersinia pestis affecting lungs): rare but severe. Droplet precautions until 48 hours after effective antibiotic treatment. Diphtheria (respiratory form): droplet precautions until 2 negative cultures. Group A streptococcus (Streptococcus pyogenes) pneumonia or pharyngitis: droplet precautions for first 24 hours of treatment. Adenovirus (in certain settings): can be droplet (respiratory) or contact (GI) — varies by presentation. Covid-19 (depending on guidelines): has been variably classified as droplet + contact with airborne added during aerosol-generating procedures. Check current institutional guidelines for exam context. PPE for droplet precautions: - SURGICAL mask within 3 feet of patient (not N95 — this is a key distinction) - Gloves and gown as needed per standard precautions - Eye protection if splashing/spraying possible Room setup: private room preferred. Cohort acceptable if same organism. Spatial separation of at least 3 feet if private room not available. Door can remain OPEN. Patient transport: have the patient wear a surgical mask during transport. Notify receiving department of precautions. Common mistake: using N95 for droplet precautions. N95 is used for AIRBORNE, not droplet. Surgical mask is sufficient for droplet because the droplets fall quickly within 3 feet.

Airborne precautions are required when organisms travel in tiny particles (< 5 microns) that remain suspended in the air for extended periods, can travel long distances on air currents, and can be inhaled by anyone in the space — not just those within 3 feet. The classic airborne diseases (memorize these — MTV): - M: Measles - T: Tuberculosis (active pulmonary or laryngeal) - V: Varicella (chickenpox, disseminated shingles) Add: SARS, disseminated herpes zoster, and some emerging infections (Ebola in certain guidelines, monkeypox in some). Tuberculosis (active): the most-tested airborne disease. Patient needs AIIR with negative pressure. Staff must wear N95 respirators (fit-tested for each individual). Continue airborne precautions until patient has had 3 negative AFB sputum smears or is otherwise non-infectious by MD order. Measles (rubeola): highly contagious viral infection. Airborne for 4 days before and 4 days after rash appears. Unvaccinated staff members should not care for measles patients. Varicella (chickenpox): airborne until all lesions have crusted over. Disseminated zoster (shingles) in immunocompromised patients requires airborne precautions because it spreads like chickenpox. Herpes zoster (disseminated or in immunocompromised): airborne precautions due to potential viral aerosolization. Smallpox: airborne transmission. Rare in the modern era but tested as historical content. SARS and some emerging pathogens: check current guidelines — some airborne, some droplet + contact. PPE for airborne precautions: - N95 RESPIRATOR (fit-tested for each individual staff member) — NOT a surgical mask - Gown and gloves as needed - Eye protection for splash/spray risks Room setup: AIIR (Airborne Infection Isolation Room): - Negative pressure relative to surrounding areas - Minimum 6 air changes per hour (new construction: 12 ACH) - Air vented directly outside OR through HEPA filtration - Door MUST remain closed to maintain negative pressure - Anteroom preferred (chamber between room and hallway for PPE donning) Patient transport: patient wears a surgical mask (not N95 — patient's exhalations don't need filtering out, only respiratory droplets kept in). Notify receiving department. Minimize transport. Staff requirements: N95 must be fit-tested annually per OSHA. Different N95 models fit different faces — not interchangeable. Staff must know their specific fit-tested model. Most commonly missed concepts on NCLEX: - 'N95' vs 'surgical mask' distinction - 'Negative pressure' vs 'positive pressure' rooms (negative for airborne; positive for protective isolation of immunocompromised) - 'Door closed' requirement for airborne (contact and droplet allow door open)

Some diseases require precautions from multiple categories. NCLEX questions love testing these combinations. CONTACT + DROPLET: - Adenovirus in infants and children - Influenza in patients with respiratory illness requiring contact with secretions - Some resistant gram-negative respiratory infections CONTACT + AIRBORNE: - Varicella (chickenpox): touch the lesions (contact) OR inhale virus particles (airborne) - Disseminated herpes zoster: similar to varicella - Pulmonary TB with draining wound or massive secretions - SARS in active respiratory illness DROPLET + AIRBORNE DURING AEROSOL-GENERATING PROCEDURES: - Procedures like intubation, bronchoscopy, nebulizer treatments, or CPR can aerosolize droplets into airborne particles - Healthcare workers should use N95 + full PPE during these procedures for influenza, COVID-19, RSV in adults (in hospital), and similar IMMUNOCOMPROMISED PATIENT (PROTECTIVE ISOLATION): - Neutropenic patient (ANC < 500): protect FROM infection, not protect others from the patient - PPE: standard precautions (visitors wear masks if ill) - Room: POSITIVE pressure (opposite of airborne negative pressure) - HEPA filtration for bone marrow transplant patients - No fresh flowers or plants (fungal spores) - No raw fruits/vegetables (bacteria) - No sick visitors CONTRAST TABLE: | Precaution | PPE | Room Pressure | Door | |---|---|---|---| | Standard | Per exposure | Normal | Open | | Contact | Gloves, gown | Normal | Open | | Droplet | Gloves, gown, surgical mask | Normal | Open | | Airborne | Gloves, gown, N95 | NEGATIVE | CLOSED | | Protective (neutropenic) | Standard | POSITIVE | Closed | Key NCLEX trap: students often confuse 'negative pressure' (airborne — keep bugs IN) with 'positive pressure' (protective — keep bugs OUT). Negative pressure for active infection; positive pressure for immunosuppression.

Pattern 1 — 'Which patient should the nurse place in a private room first?' (Priority question) Approach: airborne > droplet > contact. Airborne patients need the AIIR most urgently. A patient with active TB goes in a private AIIR before a patient with MRSA. Pattern 2 — 'Which PPE is required for X patient?' Approach: identify the disease, match to category, recall the PPE. - MRSA → contact → gloves + gown - Influenza → droplet → gloves + gown + surgical mask - TB → airborne → gloves + gown + N95 Pattern 3 — 'The nurse enters a C. diff patient's room. Which action is correct?' Approach: contact precautions PLUS the special hand hygiene rule. Correct answer: wash hands with soap and water (NOT alcohol-based hand rub) because alcohol doesn't kill C. diff spores. Pattern 4 — 'The nurse is caring for a patient with measles. The door to the room is open. What should the nurse do?' Approach: measles = airborne = door MUST be closed for negative pressure to be maintained. Correct action: close the door and inform the team. Pattern 5 — 'A nurse caring for a TB patient has forgotten to be fit-tested for an N95. What should the nurse do?' Approach: fit-testing is mandatory for N95 use. The nurse should not enter the room without fit-tested N95 — either arrange for a different nurse or wait for fit-testing. Do NOT enter with only a surgical mask (insufficient for airborne). Pattern 6 — 'The nurse is preparing to transport a patient with active tuberculosis to radiology. What action is most appropriate?' Approach: patient wears a surgical mask during transport (filters patient's exhalations). Nurse wears their N95. Notify radiology of precautions before transport so they can have AIIR ready. Pattern 7 — 'A patient with C. difficile is admitted to a semi-private room. What should the nurse do?' Approach: private room preferred. If not available, the roommate should not be immunocompromised AND should ideally also have C. diff (cohort). Cohorting with a different disease is not appropriate. Advocate for transfer to private room. Pattern 8 — 'The nurse enters a neutropenic patient's room. Which finding requires immediate action?' Approach: reverse isolation — protect patient FROM infection. A visitor with a cold, fresh flowers in the room, raw fruit in the tray — these all pose infection risk to the patient and require action. Pattern 9 — 'Which patient has the highest priority for isolation?' Approach: ranking by urgency. Active tuberculosis is among the highest — uncontained aerosolized TB can infect many staff and patients. Then measles, then other airborne, then droplet, then contact.

Mistake 1: Using surgical mask for TB. Correction: TB is airborne — always N95 respirator. Surgical masks don't filter small airborne particles. Mistake 2: Using alcohol hand sanitizer after caring for C. diff patient. Correction: Wash with soap and water. Alcohol does not kill C. diff spores. This is heavily tested. Mistake 3: Cohorting MRSA with VRE. Correction: Cohorting is only appropriate if patients have the SAME organism. Don't combine different resistant organisms. Mistake 4: Leaving the door open for an airborne precaution room. Correction: Door must be closed for negative pressure to work. If door is open, the isolation is breached. Mistake 5: Putting a chickenpox patient on contact precautions only. Correction: Chickenpox (varicella) requires BOTH contact AND airborne precautions. It spreads by touching the lesions AND by inhaling viral particles. Mistake 6: Wearing the same N95 for multiple patients. Correction: N95s are disposable. Replace between patients. Extended use (same patient over time) is acceptable in some contexts but never cross-patient. Mistake 7: Assuming a surgical mask protects from TB if you're only briefly in the room. Correction: No amount of exposure time justifies a surgical mask for airborne pathogens. Any time in the room requires N95. Mistake 8: Using positive pressure for TB patient. Correction: TB requires NEGATIVE pressure (air flows INTO the room, not out). Positive pressure is for protective isolation of immunocompromised patients. Mistake 9: Not notifying transport/receiving department about isolation status. Correction: Always communicate isolation status so downstream staff can prepare (AIIR ready, proper PPE, transport route). Mistake 10: Stopping isolation when patient 'looks better' without confirming end-of-isolation criteria. Correction: Each disease has specific criteria. TB needs 3 negative AFB sputum smears. Varicella needs all lesions crusted. Pertussis needs 5 days of antibiotics. Don't stop early.