5.2 Standard Precautions & PPE Selection, Donning & Doffing
Key Takeaways
- Standard Precautions represent the foundational first tier of infection control applied to the care of all residents regardless of their confirmed diagnosis or perceived infection status.
- Under Standard Precautions and OSHA standards, all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes are treated as potentially infectious.
- Personal Protective Equipment (PPE) provides physical barriers against pathogen transmission; the CNA selects specific PPE items based on the anticipated degree of fluid contact and exposure risk.
- The CDC Donning sequence must be executed in precise anatomical order: Gown first, followed by Mask/Respirator, Goggles/Face Shield, and Gloves pulled over the gown cuffs.
- The CDC Doffing sequence prioritizes removing the most heavily contaminated items first: Gloves first, followed by Goggles/Face Shield, Gown, Mask/Respirator, and immediate Hand Hygiene.
Standard Precautions & PPE Selection, Donning & Doffing
In healthcare epidemiology, infection control relies on a two-tiered system developed by the Centers for Disease Control and Prevention (CDC) and enforced by the Occupational Safety and Health Administration (OSHA):
- Tier 1: Standard Precautions (universally applied to every resident in all healthcare settings).
- Tier 2: Transmission-Based Precautions (implemented for specific diagnosed or suspected contagious pathogens).
For Certified Nursing Assistants in Mississippi, mastering Standard Precautions and the correct use of Personal Protective Equipment (PPE) is essential. Because many residents carry asymptomatic, undiagnosed bloodborne or multidrug-resistant pathogens, healthcare workers cannot determine infectious risk by appearance alone. Adhering to Standard Precautions on every single shift protects both vulnerable residents and healthcare workers from cross-contamination.
1. Standard Precautions: The Universal First Tier
Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where healthcare is delivered.
+-----------------------------------------------------------------------------+
| STANDARD PRECAUTIONS UNIVERSAL RULE |
| |
| TREAT ALL: |
| - Blood and blood products |
| - All body fluids, secretions, and excretions (EXCEPT SWEAT) |
| * Urine, feces, emesis, sputum, semen, vaginal secretions, wound exudate|
| - Non-intact skin (cuts, abrasions, rashes, surgical wounds, ulcers) |
| - Mucous membranes (eyes, nose, mouth, genitalia, rectum) |
| |
| ... AS POTENTIALLY INFECTIOUS FOR TRANSMISSIBLE PATHOGENS! |
+-----------------------------------------------------------------------------+
Core Elements of Standard Precautions
- Hand Hygiene: Performed before and after touching residents, after contact with body fluids or contaminated items, and immediately after removing gloves.
- Personal Protective Equipment (PPE): Appropriate selection and utilization of gloves, gowns, masks, goggles, and face shields based on the anticipated level of exposure.
- Respiratory Hygiene / Cough Etiquette: Covering coughs and sneezes with tissues or inner elbow, prompt tissue disposal, and hand hygiene.
- Safe Sharps Management: Discarding all needles, lancets, and razors immediately in puncture-resistant biohazard sharps containers without recapping or bending.
- Environmental Cleaning & Linen Management: Routine cleaning of high-touch surfaces and proper containment of soiled linens without contaminating clothing or surroundings.
- Safe Injection Practices & Decontamination: Cleaning reusable equipment (vital sign cuffs, stethoscopes, commode pails) between resident uses.
[!NOTE] The Sweat Exception: Under CDC and OSHA definitions, sweat (perspiration) is the only bodily secretion that is not considered a potential vehicle for bloodborne or infectious pathogen transmission under Standard Precautions, unless it is visibly contaminated with blood.
2. Personal Protective Equipment (PPE) Components & Selection Matrix
Personal Protective Equipment (PPE) refers to specialized clothing or equipment worn by healthcare personnel to protect against exposure to infectious materials. The CNA selects PPE based on the specific clinical task and the likelihood of coming into contact with blood, bodily fluids, secretions, excretions, or mucous membranes.
+-----------------------------------------------------------------------------+
| PPE ARSENAL & CLINICAL INDICATIONS |
| |
| [GLOVES] ---> Protects hands from blood, body fluids, non-intact |
| skin, and mucous membranes. Disposable, single-use. |
| |
| [GOWNS] ---> Protects skin and clothing/scrubs from fluid splashes|
| sprays, or soiling. Fluid-resistant, full coverage. |
| |
| [MASKS] ---> Protects mouth and nasal mucous membranes from large |
| droplets, splashes, and sprays. Surgical mask. |
| |
| [RESPIRATORS] ---> N95 particulate respirator or PAPR. Filters ≥95% of |
| airborne particles (0.3 micron). Requires fit test. |
| |
| [GOGGLES / ---> Protects ocular conjunctiva and facial mucous |
| FACE SHIELDS] membranes from liquid splashes, sprays, and spatter. |
+-----------------------------------------------------------------------------+
Comprehensive PPE Selection Matrix by CNA Task
| Nursing Assistant Task / Procedure | Gloves Required? | Gown Required? | Mask / Eye Protection Required? | Clinical Rationale |
|---|---|---|---|---|
| Taking Routine Vital Signs (intact skin, non-isolation) | No | No | No | No contact with blood, body fluids, or mucous membranes. |
| Delivering Meal Tray / Feeding Alert Resident | No | No | No | Routine social interaction with intact skin; perform hand hygiene before and after. |
| Assisting with Oral Hygiene / Dentures | YES | No (unless splashing) | No (unless resident coughing/gagging) | Direct contact with oral mucous membranes and saliva. |
| Performing Perineal Care / Bedpan Emptying | YES | YES (if splashing likely) | No (unless heavy splashing anticipated) | Direct contact with urine, feces, and genital mucous membranes. |
| Giving a Complete Bed Bath | YES (for peri-care/axilla) | YES (if wet linen touches uniform) | No | Protects uniform from dampness; gloves mandatory for perineum and broken skin. |
| Emptying Urinary Catheter Drainage Bag | YES | No | No (goggles if splash risk) | Direct handling of concentrated bodily fluid excretions. |
| Changing Soiled, Feces-Contaminated Bed Linen | YES | YES | No | Prevents gross soiling of CNA uniform and bare hands. |
| Post-Mortem Care | YES | YES | YES (if body fluid release possible) | Potential exposure to expelling bodily fluids, feces, and blood. |
| Trimming Non-Diabetic Resident Fingernails | YES | No | No | Contact with subungual debris and potential non-intact cuticle skin. |
| Shaving a Resident with a Safety Razor | YES | No | No | Risk of micro-abrasions and potential blood exposure. |
Fundamental Rules of Glove Use
- Gloves do NOT replace hand hygiene! Hand hygiene must always be performed immediately before putting on gloves and immediately after removing gloves.
- Change gloves between tasks on the same resident: When moving from a contaminated body site (e.g., cleaning up a bowel movement during perineal care) to a clean body site (e.g., performing facial hygiene or back massage), gloves must be removed, hands sanitized, and clean gloves donned.
- Never wash, sanitize, or reuse disposable exam gloves: Alcohol hand rub degrades the latex, nitrile, or vinyl barrier, causing microscopic tears and pores.
- Change torn or punctured gloves immediately: Remove gloves, wash hands, and put on a fresh pair.
- Remove gloves before touching environmental clean surfaces: Never touch door handles, light switches, elevator buttons, or resident charts with contaminated gloved hands.
3. CDC Donning Sequence (Putting On PPE)
The order in which PPE is put on (donning) is engineered to ensure complete anatomical coverage and prevent gaps between protective layers. Donning occurs outside the resident's room or immediately before entering the patient care area.
+-----------------------------------------------------------------------------+
| CDC PPE DONNING SEQUENCE |
| |
| [STEP 1: GOWN] ---> Unfold fluid-resistant gown fully. Cover |
| torso from neck to knees, arms to wrists. |
| Tie securely at back of NECK and WAIST. |
| | |
| v |
| [STEP 2: MASK / ---> Secure ties or elastic loops over ears. |
| RESPIRATOR] Fit flexible nose wire snugly across bridge|
| of nose. Pull bottom completely under chin.|
| | |
| v |
| [STEP 3: GOGGLES / ---> Position goggles over eyes and adjust |
| FACE SHIELD] headband, or place face shield over face |
| and adjust brow band for full coverage. |
| | |
| v |
| [STEP 4: GLOVES] ---> Don disposable exam gloves last. Extend |
| glove cuffs to OVERLAP AND COVER WRISTS |
| of the isolation gown completely. |
+-----------------------------------------------------------------------------+
Step-by-Step Donning Checklist:
- Perform Hand Hygiene: Clean hands thoroughly with soap and water or ABHR before handling clean PPE.
- Step 1: Gown:
- Select the appropriate size fluid-resistant gown.
- Slip arms into sleeves, ensuring full torso coverage from neck to knees and arms to wrists.
- Tie the neck closure securely first.
- Wrap the back flaps of the gown around the back to cover clothing completely, and tie the waist strings securely. (Never leave waist ties undone or tied in the front where they can become contaminated).
- Step 2: Mask or Respirator:
- Place mask over nose and mouth.
- Secure elastic ear loops behind ears, or tie upper strings at crown of head and lower strings behind neck.
- Mold the flexible metal nose piece with fingertips over the bridge of the nose to achieve a custom seal.
- Pull the bottom of the mask fully under the chin.
- For N95 Respirator: Perform a user seal check (inhale and exhale sharply; verify no air leaks around facial perimeter).
- Step 3: Goggles or Face Shield:
- Place goggles over eyes and settle elastic strap around back of head.
- If using a full face shield, place brow foam across forehead and adjust elastic headband.
- Ensure unobstructed vision.
- Step 4: Gloves:
- Select proper size (latex, nitrile, or vinyl).
- Pull gloves onto hands, extending the glove cuffs over the knitted or elastic wrist cuffs of the gown to ensure no bare skin is exposed.
4. CDC Doffing Sequence (Taking Off PPE)
The sequence for removing PPE (doffing) is designed to prevent healthcare workers from contaminating their own bare skin, hair, scrubs, or mucous membranes with pathogens accumulated on the outer surfaces of PPE during care.
+-----------------------------------------------------------------------------+
| CLEAN VS. CONTAMINATED ANATOMICAL PPE ZONES |
| |
| [CONTAMINATED ZONES] [CLEAN / SAFE ZONES] |
| (Areas with direct fluid contact) (Areas not touched during care) |
| - Outside front of gloves - Inside of gloves |
| - Outside front and sleeves of gown- Inside/back of gown |
| - Outside front of goggles/shield - Gown neck and waist ties |
| - Outside front of mask/respirator - Ear loops / straps of mask & goggles |
+-----------------------------------------------------------------------------+
CDC Recommended Doffing Protocol (Standard Sequence)
Doffing occurs at the doorway of the resident room or in the anteroom (except the respirator/mask, which is removed outside the room for airborne isolation).
+-----------------------------------------------------------------------------+
| CDC PPE DOFFING SEQUENCE |
| |
| [STEP 1: GLOVES] ---> GLOVES ARE THE MOST CONTAMINATED ITEM! |
| Remove using glove-in-glove technique. |
| Discard in designated waste container. |
| | |
| v |
| [STEP 2: GOGGLES / ---> Touch ONLY the clean headband or ear pieces|
| FACE SHIELD] Lift up and away from face without touching|
| the contaminated front surface. Discard. |
| | |
| v |
| [STEP 3: GOWN] ---> Untie neck and waist ties. Peel gown away |
| from neck and shoulders, touching INSIDE |
| only. Turn gown INSIDE OUT into a ball. |
| | |
| v |
| [STEP 4: MASK / ---> Touch ONLY ear loops or bottom ties first, |
| RESPIRATOR] then top ties. Lift away without touching |
| contaminated front of mask. Discard. |
| | |
| v |
| [STEP 5: HAND HYGIENE] ---> IMMEDIATELY perform thorough hand hygiene |
| using soap and water or ABHR! |
+-----------------------------------------------------------------------------+
The Glove-in-Glove Removal Technique:
- Grasp the outside edge of one glove cuff with the opposite gloved hand, taking care not to touch bare wrist skin.
- Peel the glove down and away from the hand, turning the glove completely inside out as it comes off.
- Hold the removed inverted glove crumpled in the palm of the remaining gloved hand.
- Slide two bare fingers of the un-gloved hand under the inside wrist cuff of the remaining glove (touching only the clean interior surface).
- Peel the second glove down and off the hand, turning it inside out over the first glove, creating a self-contained bundle with all contaminated surfaces trapped inside.
- Discard the bundled gloves immediately into the trash.
Alternative Doffing Sequence: Combined Gown & Glove Removal
The CDC also recognizes an alternative doffing method where gown and gloves are removed simultaneously:
- Grasp the front of the gown at chest level with gloved hands and pull firmly away from the body to break the neck and waist ties.
- Roll the gown downward and away from the body, peeling off the gloves inside-out simultaneously as the sleeves are pulled down over the hands.
- Bundle the contaminated gown and gloves into a ball with the clean inside facing out, and discard into the receptacle.
- Proceed to remove eye protection, mask, and perform immediate hand hygiene.
[!WARNING] Critical Safety Rule: Never Touch the Front of PPE! The outside front of gloves, front of the gown, front of goggles, and front of the mask are heavily contaminated with pathogens. Touching the front of your mask with bare hands after care deposits millions of pathogens onto your fingertips, creating an immediate portal of entry when you subsequently touch your face.
5. Medical Waste Segregation: Regular Trash vs. Red Biohazard vs. Sharps
Proper disposal of medical waste protects healthcare personnel, environmental services staff, waste management workers, and the general public. Federal OSHA standards (29 CFR 1910.1030) strictly regulate how contaminated materials are segregated and contained.
+-----------------------------------------------------------------------------+
| HEALTHCARE WASTE CATEGORIES |
| |
| [REGULAR MUNICIPAL TRASH] ---> General solid waste; standard lined bin. |
| |
| [RED BIOHAZARD BAG] ---> Regulated medical waste (RMW); red bag |
| bearing universal biohazard symbol. |
| |
| [SHARPS DISPOSAL CONTAINER] ---> Rigid, puncture-resistant, leak-proof |
| container with locking lid. |
+-----------------------------------------------------------------------------+
Waste Classification & Segregation Criteria
| Waste Category | Color / Container Type | Defining Criteria / Examples | Non-Qualifying Items (Do Not Place Here) |
|---|---|---|---|
| Regular Trash | Standard black/clear trash can | Paper towels, disposable underpads with minor urine, lightly soiled incontinence briefs, empty IV bags, non-saturated exam gloves, food wrappers. | Dripping blood, liquid bodily fluids, needles, scalpels. |
| Regulated Biohazard Waste (RMW) | Red Plastic Bag with Universal Biohazard Symbol | Items saturated, soaked, caked, or dripping with liquid blood or body fluids; items that would release blood/fluids if compressed; bulk liquid blood; microbiological specimens. | Lightly soiled gloves, dry bandages with small blood spot, food trays, empty medication cups. |
| Biohazard Sharps | Rigid Red Puncture-Resistant Container | Hypodermic needles, syringe-needle units, lancets, IV stylets, safety razors, disposable scalpel blades, broken glass ampules. | Gauze, gloves, paper towels, non-sharp plastic tubing. |
[!IMPORTANT] The OSHA Blood Saturation Standard: Not everything touched by blood requires a red biohazard bag! A gauze pad or bandage with a small, dry, non-dripping spot of blood is classified as general solid waste and belongs in the regular trash. Red biohazard bags are reserved exclusively for items that are saturated, dripping, or caked with liquid blood/body fluids that could release infectious fluids under pressure. Overusing biohazard bags dramatically increases hazardous waste processing costs for facilities.
According to CDC guidelines, what is the correct sequence for putting on (donning) Personal Protective Equipment (PPE)?
A Certified Nursing Assistant has finished assisting a resident with perineal care and changing a heavily soiled incontinence brief. What is the correct order for removing (doffing) PPE under the standard CDC protocol?
Which item of used medical material MUST be discarded directly into a red biohazard bag labeled with the universal biohazard symbol?
While bathing a resident, a CNA notices a small tear on the index finger of their disposable nitrile glove. What should the CNA do immediately?
When removing an isolation gown during the doffing procedure, which part of the gown is considered clean and safe for the CNA's bare or newly sanitized hands to touch?