Fundamentals - Practice & Skills, part 3: Donning/Doffing PPE and Transmission Precautions

by Meris Shuwarger BSN, RN, CEN, TCRN July 22, 2021 Updated: June 16, 2022 10 min read

In this article, we'll cover the definition of PPE, and how you're supposed to take it on and off. We'll also explain the difference between standard, contact, droplet, airborne, and neutropenic precautions.

The Fundamentals of Nursing video series follows along with our Fundamentals of Nursing flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.

What is PPE?

PPE stands for personal protective equipment and it is the umbrella term for equipment used to reduce exposure to unsafe matter. Hardhats, earplugs and galoshes are examples of personal protective equipment for other industries.

As a nurse, your PPE will primarily include gloves, masks, and gowns; these protect you from contact with harmful or unsanitary substances when you enter a patient's room.

PPE was in the news during the COVID-19 pandemic because there was a shortage of it. During this time, healthcare workers, like many nurses, were forced to reuse PPE over and over because of the shortage. PPE like gloves and masks are meant to be disposed of after one use to keep nurses and patients safe.

Donning and Doffing PPE

There are specific ways you should don (put on) and doff (take off) PPE. If you need to remember the words donning and doffing, just remove the D! It may also help you to remember the lyric from the Christmas song Deck the Halls: "Don we now our gay apparel," where one dons (puts on) gay apparel—festive clothing!

Donning

Donning PPE should be done in this order:

  1. Hand hygiene
  2. Gown - tie to secure
  3. Mask - cover nose and chin
  4. Eye protection
  5. Gloves - cover cuff of gown

Cool Chicken Gown, Mask, Eyewear, Gloves = “Gee Meg, my patient is on isolation precautions!”

Doffing

Doffing PPE also has a specific order. In theory, doffing PPE in this order goes from dirtiest to cleanest:

  1. Gloves
  2. Eye protection
  3. Gown
  4. Mask
  5. Hand hygiene

It's important to remember not to touch the outside of your PPE at any point in time during removal. The outside is always considered contaminated even if it didn't make direct contact with anything. So you'll remove your gloves by turning them inside out, you'll remove your eyewear by inserting fingers under the straps, you'll remove your gown by holding it from the inside and taking it off inside out, and you'll remove your mask by inserting fingers under the straps.

Transmission precautions

Transmission precautions are the specific use of PPE and infection prevention practices used during patient care to decrease the spread of infectious agents. These include standard or universal precautions, contact, droplet, airborne, and protective isolation/neutropenic precautions.

Standard/Universal transmission precautions

Standard/universal transmission precautions are the transmission precautions used with every patient by default. During the COVID-19 pandemic most facilities require masks as part of standard/universal precautions.

These precautions include hand hygiene, clean gloves, safe injection practices, cough etiquette, and use of additional PPE (gown, mask, face shield) when splashing of bodily fluids is possible, like during a wound irrigation.

Contact precautions

Contact precautions are used for infections that could be spread by touching the patient or the patient's environment.

Contact infections

Infections that require contact precautions are c. difficile, multidrug resistant organisms like methicillin-resistant staphylococcus aureus (MRSA) or vancomycin-resistant enterococcus (VRE), respiratory syncytial virus (RSV), major wound infections, impetigo, lice, and scabies.

Contact precautions PPE

The PPE required for your protection in a contact precaution situation is a gown and gloves. In the case of a patient with C. difficile, wash hands with soap and water, not hand sanitizer.

Droplet precautions

Droplet precautions are used for infections that are spread via respiratory droplets.

Droplet infections

Infections that require droplet precautions include influenza, pertussis, group A strep, mumps, diphtheria, rubella, and bacterial meningitis.

Droplet precautions PPE

The PPE required for your protection in a droplet precaution situation is a gown, gloves, and surgical mask for any contact less than 3 feet away.

Airborne precautions

Airborne precautions are used for infections suspended in the air.

The difference between droplet and airborne infections is that droplets are larger than airborne particles, so they fall to the floor faster. They don't hang around in the air (suspended, aerosolized). Droplets fall faster.

Patients on airborne precautions should be provided a private room with negative-pressure airflow, which means that contaminants from inside their room are not able to escape their room and get into other rooms.

Airborne infections

Infections that require airborne precautions include varicella (chicken pox), measles, and tuberculosis.

PPE required for Airborne precautions

The PPE required for your protection in an airborne precaution situation is a gown, gloves, and N95 mask or respirator. Patients should wear a surgical mask any time they must leave the room.

What's the difference between an N95 mask and a surgical mask?

An N95 mask protects the wearer from others, while a surgical mask protects others from the wearer.

For example, if Meris has a patient with tuberculosis, she will wear an N95 mask when she is in their room. But if Meris's patient with tuberculosis needs to leave the room for a procedure, they should wear a surgical mask to protect others from their tuberculosis.

Protective isolation/neutropenic precautions

Protective isolation, also called neutropenic precautions, are precautions used to protect immunocompromised patients from infection ("reverse" isolation).

Nursing care

When caring for a patient who is in protective isolation, they will likely have a private room with positive-pressure airflow, which means that filtered air is being pumped into their room. Leave equipment in their room (e.g., stethoscope, blood pressure cuff) so that it is not traveling outside of and back into their room, bringing germs with it.

The PPE you'll wear during neutropenic precautions is a mask, gloves, and gown.

Don't allow flowers or live plants into their room as these natural items could contain pathogens or bacteria that are potentially dangerous to the patient.

Visitors may not be allowed, but if they are, all visitors must be screened for illness.

Patient teaching

There are some important teaching points to provide to patients who are under protective isolation.

They should perform frequent and thorough hand hygiene.

They should avoid crowds and contact with people who are sick.

They should NOT share personal items like a toothbrush, hairbrush, mascara wand, or utensils with others.

Patients on neutropenic precautions must avoid raw foods, including raw fruits and vegetables, and their meat should be cooked till well done. A rare hamburger with raw onions would not be ok, but a well-done hamburger with grilled onions would be permitted. Cooking kills the bacteria that could potentially live on raw fruits and vegetables that could be harmful to this patient.

They should avoid live plants and gardening because of the bacteria and fungi that are associated with plants. These materials pose more of a danger to this patient than they do to someone who is not immunocompromised.

Check out our Medical-Surgical Nursing Flashcards for more information on neutropenia.


Full Transcript

Hi, I'm Meris. And in this video, we're going to be talking about donning and doffing PPE, along with the different isolation and transmission precautions you may see your patients on. I'm going to be following along in our Fundamentals of Nursing flashcards. These are available on our website, levelupRN.com, if you want to get a set for yourself. If you already have a set and you're following along with me, I am starting on card number 49. So let's get started.

Okay. So to start us off, we're talking about how to don and doff personal protective equipment.

In layman's terms, that means how to put on and take off the stuff that's going to protect you when you go in your patient's room.

Now, we're going to call it PPE from here on out. So when I don PPE, I'm going to do it in a specific order. It's going to go gown, mask, eyewear, gloves.

And I have a Cool Chicken Hint. This is what I used in nursing school to get me through. It's GMEG, G-M-E-G, as in, "Gee, Meg, my patient's on isolation precautions."

So that's how I remember which order to put on my PPE, to don it.

Now, I'm all done taking care of my patient. I'm getting ready to leave their room. We're going to take it off, doff it, but in a slightly different order.

Theoretically, we are going from dirtiest to cleanest. So first, I'm going to remove my gloves, then my eye protection, then my gown. And lastly my mask. After I do all of that, then I will perform hand hygiene.

So also, I want to make sure that I don't touch the outside of my PPE at any point in time during removal because the outside is always considered to be contaminated even if it didn't make direct contact with anything.

Okay. Moving on to transmission precautions. The first one we have to talk about is standard or universal precautions. This means that is the standard that we universally apply to all patients.

So essentially, what this means is that we treat all patients as though they could have something that is contagious or harmful to us, so we are going to use the standard precautions, which is going to be hand hygiene and clean gloves.

So that just means gloves off the wall, not sterile gloves or anything, but we are washing our hands or using sanitizer and wearing gloves.

There's other things to keep in mind like safe injections practices and cough etiquette, but I'll let you read more about that on this card. Those are the big two: hand hygiene and wearing gloves.

Now, let's talk about contact precautions. Now, contact precautions are when we know that the patient has some sort of pathogen that is spread through the contact route of transmission. So some examples here would be C. diff, very important, MRSA, VRE, RSV, lice, scabies. All of these are going to be contact precautions pathogens.

Things to know, you need to wear a gown and gloves. So now we still have clean gloves.

We're adding a gown to protect our scrubs and our skin from making contact with that but very, very, very important key point down here at the bottom.

If you have a patient with C. diff, you must wash your hands with soap and water. Do not use alcohol-based sanitizer because C. diff is spread through endospores, and alcohol-based sanitizer does not get rid of endospores.

So very, very important to know about C. diff in particular.

Okay, moving on, let's talk about card number 51. We're going to start off with droplet precautions. So this if for any sort of condition that is spread through respiratory droplets.

Now, droplets are going to be larger than airborne precautions, so they fall to the floor faster. They don't hang around suspended aerosolized, so that's the difference between the two. So droplets fall faster.

So here, we just need to make sure we are wearing a gown, gloves, and a surgical mask if we are making contact within three feet of the patient. Remember, droplets that fall fast, they don't get very far. So within three feet, we need a surgical mask.

Who is on droplet precautions? Patients with influenza, patients with pertussis, group A strep, mumps, diphtheria, rubella, and bacterial meningitis. All of those are going to be droplets.

Now airborne is going to go a step further. These are conditions that are spread through aerosolized particles. So think about spraying an air freshener. It's going to spread out. It's going to stay suspended in the air for longer. So that's what's happening with these pathogens.

So these are really, really important to know which pathogens are they? The big one's going to be tuberculosis but we also have ones like varicella, which is chickenpox, and measles. Got to know that.

So we have to have a private room for these patients. But we need to make sure that the private room has a negative pressure airflow, meaning that air is being pumped out of the room, away, so that it's actually removing as many of those particles as possible.

And then - this is so important - when we go in the patient's room, we need to wear a gown, gloves, and an N95 respirator.

Okay? That's very important. A respirator or a mask that is called N95. An N95 protects me, the wearer, from you.

It does not keep the wearer from spreading their disease. So if the patient on airborne precautions ever had to leave the room for any reason, to go have surgery or imaging, then the patient needs to wear a surgical mask.

A surgical mask is what protects me from you when you are wearing it.

So N95 protects the wearer, surgical mask protects everyone else. Very important to understand the difference there.

Okay. And lastly, we're going to talk about a special type of isolation. This is called protective isolation. So all the other types were to protect me from the patient.

This one is to protect the patient from everybody else. So this might be someone who is immune-compromised.

Someone who has neutropenia, meaning that their white blood cell count is low.

Someone who just had some kind of radiation.

There's lots of reasons a patient might be on protective isolation.

So again, we want a private room. But in this case, we want positive pressure airflow meaning that we are pumping in fresh, clean air to the patient's room.

We also want to use dedicated equipment for this patient.

We want to wear appropriate PPE, mask, gown, and gloves, to protect the patient from us.

And then, we're not going to allow any sort of live plants or flowers in the patient's rooms.

They have pathogens and bacteria on them.

We may not allow visitors.

And if we do, they must be screened for illness.

And then, there's some other things that we need to teach these patients. If this is going to be an ongoing situation for them, they need to avoid crowded areas. They need to avoid contact with anyone who is known to be sick. They should not share personal items like hairbrush or toothbrush.

They should avoid raw foods. Baby carrots, not okay. Cooked carrots, okay. Because we want to kill off the pathogens so that my patient doesn't eat them, right.

And then we want to make sure that all of our meat is cooked thoroughly.

Again, medium-rare steak, not so good. Well-done, okay, we're good.

And then we also need to teach our patients to avoid live plants and gardening just because of all of the bacteria and fungi that are associated with plants.

Okay, so that is it for donning and doffing PPE and different types of isolation and transmission precautions. I hope that review was helpful. If it was, please go ahead and like the video.

Let me know in the comments, does GMEG help you or do you have a better way to remember how to put on your PPE?

My next video is going to be talking about everything you need to know about sterile fields, which is a lot. So be sure that you subscribe so that you are the first to know when it comes out. Thanks so much and happy studying.


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