5.2 Standard Precautions and Personal Protective Equipment (PPE)

Fundamentals of Standard Precautions

Standard Precautions are a set of infection control practices used in the care of all residents, regardless of their diagnosis or presumed infection status. Formulated by the CDC, Standard Precautions are based on the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes may contain transmissible infectious pathogens.

By treating all body fluids as potentially infectious, nursing assistants create a continuous barrier against disease transmission in healthcare facilities.

The OSHA Bloodborne Pathogens Standard

The Occupational Safety and Health Administration (OSHA) mandates strict guidelines to protect healthcare workers from occupational exposure to bloodborne pathogens. Pathogens of highest clinical concern include:

• Hepatitis B Virus (HBV): A serious viral liver infection transmitted through blood and body fluids. HBV can survive on dry surfaces for at least seven days. Federal law requires healthcare employers to offer the Hepatitis B vaccine series free of charge to all employees at risk of blood exposure.
• Hepatitis C Virus (HCV): A bloodborne virus causing chronic liver disease and cirrhosis. There is currently no preventive vaccine for HCV.
• Human Immunodeficiency Virus (HIV): The virus that causes AIDS, weakening the immune system by destroying CD4 T-cells. Transmitted via infected blood, sexual fluids, and needle exposures.

Safe Handling of Linen, Sharps, and Body Fluid Spills

Components of Personal Protective Equipment (PPE)

Personal Protective Equipment (PPE) acts as a physical barrier between the healthcare worker and potential pathogens. The selection of PPE depends on the specific task being performed and the anticipated level of exposure to blood or body secretions.

Primary Types of PPE used by CNAs

• Gloves: Worn whenever there is anticipated contact with blood, body fluids, mucous membranes, non-intact skin, or contaminated items. Gloves must be changed between care activities on the same resident if moving from a contaminated to a clean site, and removed immediately after task completion. Gloves never replace hand hygiene.
• Isolation Gowns: Worn to protect skin and uniform during procedures likely to generate splashes, sprays, or splatters of blood, body fluids, secretions, or excretions (e.g., bathing a resident with exuding wounds, emptying urinary drainage bags).
• Masks and N95 Respirators: Surgical masks cover the nose and mouth to protect against splatters and large respiratory droplets. N95 respirators are specialized filtering devices worn for airborne pathogens like tuberculosis; they require individual fit-testing.
• Goggles and Face Shields: Provide eye and facial protection against fluid splashes. Regular prescription eyeglasses do not provide adequate protection and cannot replace safety goggles or full-face shields.

Sequence for Donning (Putting On) PPE

To ensure complete coverage and prevent contamination before entering a resident's room or starting a high-risk care procedure, PPE must be applied in a strict, standardized sequence.

Step-by-Step Donning Sequence

1. Gown: Select proper size. Unfold and hold gown in front of body. Insert arms into sleeves. Fully cover torso from neck to knees and arm wrists. Wrap gown around back and fasten securely at both the neck and waist.
2. Mask or Respirator: Position mask over nose, mouth, and chin. Secure ties or elastic bands at the middle of head and neck. Fit the flexible metal noseband snugly over the bridge of the nose. Ensure a tight seal around face edges.
3. Goggles or Face Shield: Place over face and eyes. Adjust headband or side arms so the shield fits comfortably and securely over the mask.
4. Gloves: Select correct glove size. Pull gloves on, extending the cuffs over the wrist cuffs of the isolation gown so that no skin is exposed.

Donning Memory Aid: Work from the body outward and upward, ending with gloves: Gown $\rightarrow$ Mask $\rightarrow$ Goggles $\rightarrow$ Gloves.

Sequence for Doffing (Removing) PPE

Removing PPE safely requires extreme caution because the outside surfaces of equipment are heavily contaminated with pathogens. PPE must be removed at the doorway or immediately outside the resident's room (except masks/respirators, which are removed after leaving an airborne isolation area).

Step-by-Step Doffing Sequence

1. Gloves: Remove gloves first because they are the most heavily contaminated item. Use the glove-in-glove technique:
   • Grasp the outside edge of one glove near the wrist with the opposite gloved hand.
   • Peel the glove down and away from the hand, turning it inside out. Hold the crumpled glove in the remaining gloved hand.
   • Slide ungloved fingers under the wrist cuff of the remaining glove without touching its outer surface.
   • Peel the glove off over the first glove, creating a enclosed pouch containing both inside-out gloves. Discard directly into biohazard trash.
2. Goggles or Face Shield: Handle only by the clean headband or earpieces from behind. Lift away from face and discard or place in designated decontamination container.
3. Gown: Unfasten neck ties, then waist ties. Touch only the clean inside of the gown. Pull gown down and away from neck and shoulders. Turn gown inside out as it is removed, roll into a bundle, and discard in trash.
4. Mask or Respirator: Grasp bottom ties or elastic straps first, then top ties or straps from behind head. Lift mask away from face without touching the contaminated front surface. Discard in trash.
5. Hand Hygiene: Perform hand hygiene immediately after removing all PPE.

Doffing Memory Aid: Remove in alphabetical order or by contamination level: Gloves $\rightarrow$ Goggles $\rightarrow$ Gown $\rightarrow$ Mask.