Skill 1-3

Using Personal Protective Equipment

Personal protective equipment (PPE) refers to specialized clothing or equipment worn by an employee for protection against infectious materials. PPE is used in health care settings to improve personnel safety in the health care environment (Centers for Disease Control and Prevention [CDC], 2007, updated 2019). This equipment includes clean (nonsterile) and sterile gloves, impervious gowns/aprons, surgical and high-efficiency particulate air (HEPA) masks, N95 disposable masks, face shields, and protective eyewear/goggles.

Understanding the potential contamination hazards related to the patient's diagnosis and condition and the institutional policies governing PPE is very important. The type of PPE used will vary based on the type of exposure anticipated and category of precautions: standard precautions and transmission-based precautions , including contact, droplet, and airborne precautions. It is the nurse's responsibility to enforce the proper wearing of PPE during patient care for members of the health care team and patients or visitors, as appropriate. Refer to Fundamentals Review 1-3 and 1-4 for a summary of CDC-recommended practices for standard and transmission-based precautions. Box 1-1 provides Guidelines for Effective Use of PPE.

Delegation Considerations

The application and use of PPE are appropriate for all health care providers.

Equipment

Gloves
Mask (surgical or particulate respirator)
Impervious gown
Goggles or face shield (protective eye wear; does not include eyeglasses)

Note: Equipment for PPE may vary depending on level of precautions required and facility policy.

Assessment

Assess the situation to determine the necessity for PPE.
Check the patient's medical record for information about a suspected or diagnosed infection or communicable disease.
Determine the possibility of exposure to blood and body fluids and identify the necessary equipment to prevent exposure; refer to the infection control manual provided by your facility.
Determine the need for Standard I or Transmission-based Precautions. Application is determined by the nature of the health care provider-patient interaction and the extent of anticipated exposure.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or needs may require the use of this skill as part of related interventions. An appropriate health problem or need may include:

Infection risk
Knowledge deficiency
Risk for Cross Infection

Outcome Identification and Planning

The expected outcome to achieve when using PPE is reduction in the risk of transmission of infectious agents among patients and health care personnel. Other outcomes that may be appropriate are that the patient and staff remain free from exposure to potentially infectious microorganisms and that the patient verbalizes information about the rationale for use of PPE.

Implementation

Action	Rationale
1. Check medical record and plan of care for type of precautions and review precautions in infection control manual.	Mode of transmission of organism determines type of precautions required.
2. Plan nursing activities before entering patient's room.	Organization facilitates performance of task and adherence to precautions.
3. Provide instruction about precautions and use of PPE to patient, family members, caregivers, and visitors.	Explanation encourages cooperation of patient, family, and caregivers and reduces apprehension about precaution procedures.
4. Perform hand hygiene.	Hand hygiene prevents the spread of microorganisms.
5. Put on gown, mask (surgical or particulate respirator), protective eyewear, and gloves based on the type of exposure anticipated and category of isolation precautions.	Use of PPE interrupts chain of infection and protects patient and nurse. Gown should protect all clothing and exposed skin on upper extremities. Gloves protect hands and wrists from microorganisms. Masks and particulate respirators protect wearer from direct contact with body fluids that may spray or splash; masks protect wearer from exposure to large-particle aerosols and particulate respirators protect wearer from inhalation of airborne droplet nuclei, and small-particle aerosols (Taylor et al., 2023). Eyewear protects mucous membranes in the eye from splashes.
a. Put on the gown, with the opening in the back. Tie gown securely at neck and waist (Figure 1).	The gown should fully cover the torso from the neck to knees, arms to the end of wrists, and wrap around the back.
b. Put on the mask or respirator over your nose, mouth, and chin (Figure 2). Secure ties or elastic bands at the middle of the head and neck. Fit mask snug to face and below chin. Fit flexible band to nose bridge. If respirator is used, perform a fit check. Inhale: The respirator should collapse. Exhale: Air should not leak out.	Masks protect the nurse or patient from droplet nuclei and large-particle aerosols. A mask must fit securely to provide protection.
c. Put on goggles (Figure 3). Place over the eyes and adjust to fit. Alternatively, a face shield could be used (Figure 4).	Eyewear protects mucous membranes in the eye from splashes; it must fit securely to provide protection.
d. Put on clean disposable gloves. Extend gloves to cover the wrist of the gown (Figure 5).	Gloves protect hands and wrists from microorganisms.
6. Identify the patient. Explain the procedure to the patient. Continue with patient care as appropriate.	Patient identification validates the correct patient and correct procedure. Discussion and explanation help allay anxiety and prepare the patient for what to expect.
Remove PPE
There are a variety of ways to remove PPE to achieve the goal of safe removal without contamination of clothes, skin, or mucous membranes (CDC, 2007; updated 2019). Two methods are outlined here, based on CDC recommendations.
Method A
7. Remove PPE: Except for respirator, if worn, remove PPE before exiting the patient room or in an anteroom. Remove the respirator after leaving the patient's room and closing the door.	Proper removal prevents contact with and the spread of microorganisms. Removing the respirator outside the patient's room prevents contact with airborne microorganisms.
a. The outsides of gloves are contaminated. If hands are contaminated during gown or glove removal, immediately perform hand hygiene.	Outside front of equipment is considered contaminated. Hand hygiene prevents transmission of microorganisms. The inside, outside back, and ties on head and back are considered clean, which are areas of PPE that are not likely to have been in contact with infectious organisms.
b. Grasp the palm area of one gloved hand with the opposite gloved hand and peel off first glove, turning the glove inside out as you pull it off (Figure 6). Hold the removed glove in the remaining gloved hand.	The outsides of gloves are contaminated. This process contains the contaminated areas.
c. Slide fingers of the ungloved hand under the remaining glove at the wrist, taking care not to touch the outer surface of the glove (Figure 7).	The ungloved hand is clean and should not touch contaminated areas.
d. Peel off the second glove over the first glove, containing the first glove inside the other (Figure 8). Discard in appropriate container.	This process contains the outside, contaminated areas of gloves. Proper disposal prevents transmission of microorganisms.
e. To remove the goggles or face shield: The outside of the goggles or face shield is contaminated—do not touch. If hands are contaminated during goggle or face shield removal, immediately perform hand hygiene. Handle by the headband or earpieces and remove from the back (Figure 9). Lift away from the face. Do not touch the front of the goggles or face shield. Place in the designated receptacle for reprocessing or in an appropriate waste container.	The outside of the goggles or face shield is contaminated; do not touch. Hand hygiene prevents transmission of microorganisms. Handling by the headband or earpieces and lifting away from the face prevents transmission of microorganisms. Proper disposal prevents transmission of microorganisms.
f. To remove the gown: The gown front and sleeves are contaminated. If hands are contaminated during gown removal, immediately perform hand hygiene. Unfasten ties, if at the neck and back, taking care that sleeves of gown do not contact the body. Allow the gown to fall away from shoulders. Touching only the inside of the gown, pull away from the neck and shoulders (Figure 10). Keeping hands on the inner surface of the gown, pull gown from arms (Figure 11). Turn gown inside out. Fold or roll into a bundle (Figure 12) and discard in an appropriate waste container.	The gown front and sleeves are contaminated. Hand hygiene prevents transmission of microorganisms. Touching only the inside of the gown and pulling it away from the torso prevents transmission of microorganisms. This process contains the outside, contaminated areas of gown. Proper disposal prevents transmission of microorganisms.
g. To remove the mask or respirator: The front of the mask/respirator is contaminated—do not touch. If hands are contaminated during mask/respirator removal, immediately perform hand hygiene. Grasp the bottom ties or elastic of the mask/respirator, then top ties or elastic and remove. Do not touch the front of mask or respirator (Figure 13). Discard in an appropriate waste container. If using a reusable respirator, save for future use in the designated area.	The front of the mask or respirator is contaminated; do not touch. Not touching the front of the mask and proper disposal of the mask prevent transmission of microorganisms.
8. Perform hand hygiene immediately after removing all PPE.	Hand hygiene prevents spread of microorganisms.
Remove PPE
There are a variety of ways to remove PPE to achieve the goal of safe removal without contamination of clothes, skin, or mucous membranes (CDC, 2007; updated 2019).
Method B
7. To remove the gown and gloves: Gown front and sleeves and the outsides of gloves are contaminated. If hands are contaminated during gown and glove removal, immediately perform hand hygiene. Touching outside of the gown only with gloved hands, grasp the gown in the front and pull away from the body, breaking the ties in the back (Figure 14). While removing the gown, fold or roll the gown inside-out into a bundle (Figure 15). As the gown is being removed, peel off gloves at the same time, only touching the inside of the gloves and gown with bare hands (Figure 16). Discard gown and gloves in an appropriate waste container.	The front of the gown and sleeves, including waist strings, are contaminated. Hand hygiene prevents transmission of microorganisms. The front of the gown and the outsides of gloves are contaminated. This process contains the outside, contaminated areas of the gown. Proper disposal prevents transmission of microorganisms.
8. To remove the goggles or face shield: The outside of the goggles or face shield is contaminated—do not touch. If hands are contaminated during goggle or face shield removal, immediately perform hand hygiene. Grasp the headband or earpieces and remove from the back (Figure 17). Lift away from the face. Do not touch the front of goggles or face shield. Place in designated receptacle for reprocessing or in an appropriate waste container.	The outside of the goggles or face shield is contaminated; do not touch. Hand hygiene prevents transmission of microorganisms. Handling by the headband or earpieces and lifting away from face prevents transmission of microorganisms. Proper disposal prevents transmission of microorganisms.
9. To remove mask or respirator: Front of mask/respirator is contaminated—do not touch. If hands are contaminated during mask/respirator removal, immediately perform hand hygiene. Grasp the bottom ties or elastic of the mask/respirator, then top ties or elastic, lift away from face, and remove (Figure 18). Do not touch the front of mask or respirator. Discard in an appropriate waste container. If using a reusable respirator, save for future use in the designated area.	The front of mask or respirator is contaminated; do not touch. Not touching the front of the mask and proper disposal of the mask prevent transmission of microorganisms. Hand hygiene prevents spread of microorganisms.
10. Perform hand hygiene immediately after removing all PPE.

Evaluation

The expected outcomes have been met when the transmission of infectious agents among patients and health care providers has been prevented, patients and staff are free from exposure to potentially infectious microorganisms, and the patient verbalizes an understanding about the rationale for use of PPE.

Documentation

It is not usually necessary to document the use of specific articles of PPE or each application of PPE. However, document the implementation and continuation of specific transmission-based precautions as part of the patient's care.

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

You did not realize the need for protective equipment at beginning of task: Stop task and obtain appropriate protective wear.
You are accidentally exposed to blood and body fluids: Stop task and immediately follow facility protocol for exposure, including reporting the exposure.

Special Considerations

Community-Based Care Considerations

Standard Precautions are used for all patient care, based on risk assessment, and make use of common-sense practices and PPE to protect health care providers from infection and prevent the spread of infection from person to person (CDC, 2016b).
Measures related to Respiratory Hygiene/Cough Etiquette should be implemented in community settings for any person with signs of illness including cough, congestion, rhinorrhea, or increased production of respiratory secretions (CDC, 2016b).

EVIDENCE FOR PRACTICE

PPE and Prevention of Transfer of Microorganisms

Prevention of health care-associated infections (HAIs) is a major challenge for health care providers. Infection-control guidelines recommend contact precautions for patients colonized or infected with specific multidrug-resistant organisms (MDROs) (CDC, 2007; updated 2019). These interventions include the use of nonsterile gloves during every interaction with patients to reduce the risk of transmission of microorganisms. Universal gloving has been suggested as an approach to reduce the transmission of MDROs (Chung et al., 2019). When universal gloving is implemented, health care providers wear gloves during every patient care activity for every patient. Does implementation of universal gloving prevent transmission of pathogens and decrease the incidence of HAIs?

Related Evidence

Chung, N. C. N., Kates, A. E., Ward, M. A., Kiscaden, E. J., Schacht Reisinger, H., Perencevich, E. N., Schweizer, M. L., & CDC Prevention Epicenters Program. (2019). Association between universal gloving and healthcare-associated infections: A systematic literature review and meta-analysis. Infection Control & Hospital Epidemiology, 40(7), 755-760. https://doi.org/10.1017/ice.2019.123

This systematic literature review and meta-analysis examined whether implementation of universal gloving is associated with decreased incidence of HAIs in clinical settings. A systematic literature search was conducted to identify relevant publications using search terms for universal gloving and HAIs. Pooled incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were calculated using random effects models. Heterogeneity was evaluated using the Woolf test and the I² test. Eight heterogeneous (I² = 59%) studies with varied results were included. Stratified analyses showed a nonsignificant association between universal gloving and incidence of methicillin-resistant Staphylococcus aureus (pooled IRR 0.94, 95% CI) and vancomycin-resistant enterococci (pooled IRR 0.94, 95% CI). Studies that implemented universal gloving alone showed a significant association with decreased incidence of HAIs (IRR 0.77, 95% CI), but studies implementing universal gloving as part of intervention bundles showed no significant association with incidence of HAIs (IRR 0.95, 95% CI). The researchers concluded universal gloving was associated with reduced incidence of HAIs and may be associated with a small protective effect against HAIs. The researchers suggested that, despite limited data, universal gloving may be considered in high-risk settings such as pediatric intensive care units and additional research is needed to determine the effects of universal gloving on a broader range of pathogens.

Relevance for Nursing Practice

Nurses should constantly strive to improve practice and be alert for interventions to help achieve better practice. As responsible practitioners, nurses and other health care personnel should continually review infection control standards and guidelines for best practice. It is important to examine and reflect on individual practice to ensure appropriate use of infection control measures, including use of PPE, to provide safe and responsible nursing care.

section name header

Skill 1-3

EVIDENCE FOR PRACTICE