3.2 Hand Hygiene & Personal Protective Equipment (PPE)

Hand Hygiene & Personal Protective Equipment (PPE)

Healthcare workers' hands are the primary vector for pathogen transmission in hospitals and skilled nursing facilities. The Certified Nursing Assistant (CNA) provides intimate, direct physical care—including bathing, toileting, feeding, and dressing—multiple times per hour across numerous residents. Without rigorous hand hygiene and appropriate Personal Protective Equipment (PPE) usage, the CNA can rapidly spread multidrug-resistant organisms throughout an entire nursing facility unit.

Adhering to evidence-based protocols established by the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), and the North Dakota Department of Health and Human Services (ND HHS) is both a legal mandate and a professional ethical duty.

---

1. The CDC & WHO Hand Hygiene Framework

Hand hygiene is a general term referring to any action of hand cleaning, including washing hands with plain or antimicrobial soap and water, or applying an alcohol-based hand rub.

+-----------------------------------------------------------------------------+
|                    WHO "5 MOMENTS FOR HAND HYGIENE"                         |
|                                                                             |
|   [1. BEFORE TOUCHING A RESIDENT]                                           |
|       - Prior to shaking hands, helping up, taking vitals, bathing.         |
|                                                                             |
|   [2. BEFORE CLEAN / ASEPTIC PROCEDURES]                                    |
|       - Before oral care, eye drops, feeding, assisting with catheter.      |
|                                                                             |
|   [3. AFTER BODY FLUID EXPOSURE RISK]                                       |
|       - After emptying bedpans/urinals, peri-care, handling dirty linen.    |
|                                                                             |
|   [4. AFTER TOUCHING A RESIDENT]                                            |
|       - After finishing direct care, ambulation, taking pulse.              |
|                                                                             |
|   [5. AFTER TOUCHING RESIDENT SURROUNDINGS]                                 |
|       - After touching bed rails, overbed tables, call lights, TV remotes.  |
+-----------------------------------------------------------------------------+

The Two Modalities of Hand Hygiene:

1. Alcohol-Based Hand Rub (ABHR): Formulations containing 60% to 95% ethyl or isopropyl alcohol. This is the CDC-recommended preferred method for routine hand hygiene in healthcare settings because it is faster, more effective at reducing most bacterial counts, and less damaging to the skin than frequent soap and water washing.
2. Handwashing with Soap and Water: Mechanical scrubbing with liquid soap and running water to physically loosen, suspend, and rinse away transient microorganisms, dirt, and spores.

---

2. Soap & Water vs. Alcohol-Based Hand Sanitizer

Knowing when soap and water is clinically mandatory versus when alcohol hand sanitizer is acceptable is one of the most frequently tested topics on both the North Dakota CNA written examination and clinical skills evaluation.

+-----------------------------------------------------------------------------+
|                      HAND HYGIENE DECISION ALGORITHM                        |
|                                                                             |
|   Are hands visibly dirty, blood-stained, or soiled with body fluids?       |
|   [YES] =====================================> SOAP & WATER MANDATORY       |
|   [NO]                                                                      |
|     |                                                                       |
|     v                                                                       |
|   Did you care for a resident with C. diff or Norovirus?                    |
|   [YES] =====================================> SOAP & WATER MANDATORY       |
|   [NO]                                         (Alcohol fails on spores)    |
|     |                                                                       |
|     v                                                                       |
|   Are you about to eat / prepare food, or just used the restroom?           |
|   [YES] =====================================> SOAP & WATER MANDATORY       |
|   [NO]                                                                      |
|     |                                                                       |
|     v                                                                       |
|   Routine care between residents / after glove removal?                     |
|   [YES] =====================================> ALCOHOL-BASED HAND RUB (ABHR)|
+-----------------------------------------------------------------------------+

---

3. Step-by-Step Handwashing Procedure (North Dakota Skill Test Standard)

North Dakota's manual skill test treats hand hygiene in two distinct ways, and confusing them is one of the most common ways candidates lose steps:

So handwashing is not a stand-alone task on North Dakota's skill-task list, and soap-and-water washing is not required at the end of every task. It is guaranteed to appear on your test only because your first task is always one of the three mandatory tasks. Recontaminating clean hands — touching the faucet, the basin, or your uniform after washing — costs you the step regardless of which task you are performing.

+-----------------------------------------------------------------------------+
|             ND MANDATORY-TASK HANDWASHING: CRITICAL STEP ORDER              |
|                                                                             |
|   [1. SINK POSITION]   ---> Stand back; uniform NEVER touches sink basin.   |
|   [2. WATER TEMP]      ---> Turn on water; adjust to comfortably WARM.      |
|   [3. WET HANDS]       ---> Wet wrists/hands with FINGERTIPS POINTING DOWN. |
|   [4. APPLY SOAP]      ---> Apply liquid soap to create rich lather.        |
|   [5. 20-SEC FRICTION] ---> Scrub palms, dorsum, between fingers, knuckles, |
|                             wrists, and under nails for AT LEAST 20 SEC.    |
|   [6. RINSE DOWNWARD]  ---> Rinse from wrists to fingertips POINTING DOWN.  |
|   [7. DRY CLEANLY]     ---> Dry with paper towels from fingertips to wrists.|
|   [8. TURN OFF FAUCET] ---> Use a NEW, clean, dry paper towel on faucet!    |
+-----------------------------------------------------------------------------+

Step-by-Step Clinical Protocol:

1. Positioning at the Sink:
   • Stand near the sink without allowing your uniform or body to touch the sink basin or countertop. The sink is considered heavily contaminated with bacteria.
2. Water Flow & Temperature Adjustment:
   • Turn on the faucet. Adjust water flow to a moderate stream to avoid splashing water onto your scrubs (splashing spreads microorganisms). Adjust water to a comfortably warm temperature. (Hot water removes protective skin oils and increases dermatitis risk; cold water does not lather effectively).
3. Initial Wetting:
   • Wet hands and wrists thoroughly under running water, keeping hands and forearms lower than elbows and fingertips pointed downward. This ensures water flows from the least contaminated area (wrists) down to the most contaminated area (fingertips) and into the sink drain.
4. Soap Application:
   • Apply 3 to 5 mL (1–2 pumps) of liquid soap to hands.
5. Vigorous Friction (Minimum 20 Seconds):
   • Rub hands together vigorously to create a rich lather. Maintain active friction for at least 20 seconds (roughly the time it takes to sing "Happy Birthday" or "Twinkle, Twinkle Little Star" twice).
   • Friction Coverage Sequence:
     • Palms: Rub palm to palm with circular motions.
     • Backs of Hands (Dorsum): Place right palm over left dorsum with fingers interlaced, rub thoroughly, then switch.
     • Between Fingers: Interlace fingers and rub back and forth to clean webbing.
     • Knuckles & Thighs of Fingers: Interlock fingers into opposing palms and rub side-to-side.
     • Thumbs: Perform rotational rubbing of the left thumb clasped in the right palm, then switch.
     • Fingernails & Subungual Areas: Rub the fingertips and nails of the right hand in a circular motion against the left palm, then switch (or use a nail stick/brush if ordered).
     • Wrists: Wash 1 to 2 inches above the wrists using circular rotational motions.
6. Rinsing Technique:
   • Rinse hands and wrists thoroughly under running water. Keep fingertips pointed downward and hands below elbows so that water drains cleanly off the fingertips. Do not shake hands or touch the sink basin, faucet, or inner sink walls.
7. Drying Technique:
   • Keeping hands pointed down, take clean, dry paper towels.
   • Pat dry starting at the fingertips, moving upward to the palms, backs of hands, and ending at the wrists (cleanest to dirtiest progression).
   • Discard used paper towels into the waste receptacle without touching the trash can rim.
8. Turning Off the Water (Critical Safety Step):
   • Take a new, clean, dry paper towel and use it as a protective barrier to turn off the faucet handles.
   • Never touch the faucet handles with bare, clean hands or with a damp/wet paper towel (microorganisms wick through wet paper by capillary action).
   • Discard the barrier paper towel into the trash.
9. Exiting the Room:
   • If the door handle must be pulled to exit, use a clean paper towel or an elbow/sleeve to prevent recontaminating your hands.

[!TIP] Alcohol-Based Hand Rub (ABHR) Application Technique: Apply a palmful (about 3 mL / dime-to-quarter sized) of alcohol sanitizer into cupped hands. Rub all surfaces of hands, between fingers, thumbs, backs of hands, and wrists vigorously until completely dry. Do not wipe hands on scrubs or paper towels while wet, as this removes the alcohol before it can achieve full microbial kill.

---

4. Personal Protective Equipment (PPE) Components

Personal Protective Equipment encompasses specialized physical barriers designed to protect the healthcare worker's skin, mucous membranes, and clothing from contact with infectious agents.

+-----------------------------------------------------------------------------+
|                         PPE COMPONENT SPECTRUM                              |
|                                                                             |
|   [GLOVES]       ---> Protects hands from blood, body fluids, non-intact    |
|                       skin, and contaminated items. Clean vs. Sterile.      |
|   [GOWN]         ---> Protects skin and uniform from splashes, sprays, and   |
|                       contact with infected residents/linens. Fluid-proof.  |
|   [MASK]         ---> Protects nose and mouth from respiratory droplets.     |
|                       Surgical / procedure mask with malleable nose bridge. |
|   [RESPIRATOR]   ---> Protects against airborne droplet nuclei (<5 microns).|
|                       N95 or PAPR; requires fit testing and seal check.     |
|   [GOGGLES /     ---> Protects conjunctiva of eyes from blood/fluid splashes|
|    FACE SHIELD]       and aerosol sprays. Side shields mandatory.           |
+-----------------------------------------------------------------------------+

---

5. Donning & Doffing PPE Sequences (CDC & OSHA Standard)

The precise order of putting on (donning) and taking off (doffing) PPE is rigorously tested because improper removal is the leading cause of self-contamination among healthcare staff.

+-----------------------------------------------------------------------------+
|                        PPE DONNING (PUTTING ON) ORDER                       |
|                                                                             |
|   1. GOWN             ---> Cover torso, arms to wrists, tie neck & waist.   |
|          |                                                                  |
|          v                                                                  |
|   2. MASK / RESPIRATOR---> Fit over nose & chin, mold bridge wire securely. |
|          |                                                                  |
|          v                                                                  |
|   3. GOGGLES / SHIELD ---> Position over eyes/face, adjust strap.           |
|          |                                                                  |
|          v                                                                  |
|   4. GLOVES           ---> Extend cuffs OVER gown wrists (no exposed skin). |
+-----------------------------------------------------------------------------+

Memory Mnemonic for Donning:

Remember the acronym G-M-G-G: Gown -> Mask -> Goggles -> Gloves (think "from bottom to top on body, then gloves last").

+-----------------------------------------------------------------------------+
|                        PPE DOFFING (REMOVING) ORDER                         |
|                                                                             |
|   1. GLOVES           ---> Pinch outside to peel, slide finger under inside.|
|          |                 (MOST CONTAMINATED ITEM - REMOVE FIRST!)         |
|          v                                                                  |
|   2. GOGGLES / SHIELD ---> Grasp from back headband; lift away from face.   |
|          |                                                                  |
|          v                                                                  |
|   3. GOWN             ---> Untie waist & neck; pull from inside shoulders;  |
|          |                 roll dirty side INWARD into bundle.              |
|          v                                                                  |
|   4. MASK / RESPIRATOR---> Grasp bottom ties, then top ties; lift forward.  |
|          |                 (NEVER touch front of mask!)                     |
|          v                                                                  |
|   5. HAND HYGIENE     ---> PERFORM IMMEDIATELY AFTER DOFFING ALL PPE!       |
+-----------------------------------------------------------------------------+

Detailed Step-by-Step Doffing Protocol:

1. Glove Removal (Glove-to-Glove / Skin-to-Skin Technique):
   • Step A (Glove-to-Glove): Grasp the outside edge of one glove near the wrist with the other gloved hand. Peel the glove down and away from the hand, turning it completely inside-out. Hold the removed inside-out glove bunched in the remaining gloved hand.
   • Step B (Skin-to-Skin): Slide a bare, un-gloved finger underneath the wrist cuff of the remaining glove without touching the outside surface. Peel the glove off inside-out, enclosing the first glove inside.
   • Step C: Discard both gloves directly into the trash receptacle.
2. Goggles / Face Shield Removal:
   • The outside of goggles is contaminated. Handle only by the clean headband, ear loops, or side temples.
   • Lift upward and away from the face; discard or place in designated reprocessing container.
3. Isolation Gown Removal:
   • The gown front and sleeves are heavily contaminated.
   • Unfasten the waist ties, then the neck ties.
   • Reach up and slip fingers underneath the neckband or shoulders, pulling the gown down and away from the body.
   • As the gown peels down, turn the contaminated outside surface inward.
   • Roll the gown into a neat bundle with the clean inside facing out and discard into the linen hamper or waste container.
4. Mask / Respirator Removal:
   • The front of the mask is heavily contaminated—never touch the front of the mask!
   • Grasp the bottom ties or bottom elastic band first, then the top ties or top elastic band.
   • Lift the mask forward away from your face and discard into the trash container.
5. Immediate Hand Hygiene:
   • Wash hands thoroughly with soap and water or apply alcohol-based hand rub immediately after removing all PPE.

[!IMPORTANT] Alternative CDC Doffing Sequence (Combined Gown & Gloves): The CDC also approves an alternative doffing method where the gown and gloves are removed simultaneously: Grasp the gown at the chest, pull forward until ties break, roll the gown forward and inside-out while simultaneously peeling off the gloves into the rolled bundle. Next remove goggles, then mask, followed immediately by hand hygiene.

---

6. Critical Glove Safety Rules for CNAs

Gloves are the most frequently used item of PPE, but they are also the most frequently misused. A nursing assistant must understand the strict safety parameters governing medical glove use:

+-----------------------------------------------------------------------------+
|                       THE CARDINAL RULES OF GLOVE USE                       |
|                                                                             |
|   [RULE 1] Gloves are NOT a substitute for hand hygiene. Perform hand       |
|            hygiene BEFORE donning and IMMEDIATELY AFTER doffing gloves.     |
|                                                                             |
|   [RULE 2] CHANGE GLOVES between clean and dirty tasks on the SAME resident |
|            (e.g., after perineal care before oral care or back rub).        |
|                                                                             |
|   [RULE 3] NEVER wear the same pair of gloves from one resident to another. |
|                                                                             |
|   [RULE 4] NEVER wash, sanitize with alcohol, or reuse disposable gloves.   |
|                                                                             |
|   [RULE 5] Remove gloves immediately after completing a contaminated task   |
|            before touching clean environmental surfaces (door knobs, phones)|
+-----------------------------------------------------------------------------+

Why Hand Hygiene Is Required After Glove Removal:

1. Microscopic Perforations: Disposable examination gloves frequently develop microscopic tears and pinholes during manufacturing or clinical use, allowing pathogens to contact the skin.
2. Glove Removal Contamination: Pathogens on the outer glove surface can inadvertently touch the wrists or fingers during the removal process.
3. Bacterial Proliferation: The warm, dark, moist environment inside gloves promotes rapid multiplication of cutaneous microorganisms.