Transmission-Based Precautions, PPE & Isolation Care

Transmission-Based Precautions, PPE & Isolation Care

Standard Precautions are applied to every resident, every time, on the assumption that any blood or body fluid may be infectious. Transmission-Based Precautions are the second tier: extra measures added when a resident has, or is suspected of having, an organism spread by a specific route. They are always added to Standard Precautions, never substituted for them.

Personal Protective Equipment (PPE) Protocols

Personal Protective Equipment (PPE) acts as a physical barrier between the healthcare worker and infectious pathogens. CNAs must select appropriate PPE based on the type of care task and the anticipated level of exposure to body fluids.

PPE Selection Criteria

• Gloves: Worn when touching blood, body fluids, secretions, excretions, mucous membranes, or non-intact skin, and when handling contaminated equipment.
• Isolation Gown: Worn to protect clothing and exposed skin during procedures likely to generate splashes or sprays of blood, body fluids, or excretions.
• Mask / Respirator: Worn to protect mucous membranes of the nose and mouth during splash-prone procedures or when caring for residents with respiratory infections.
• Goggles / Face Shield: Worn to protect eyes and face whenever splashes, sprays, or droplets of body fluids are anticipated.

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Donning and Doffing PPE Sequences

The specific order for donning (putting on) and doffing (taking off) PPE is tested extensively on CNA certification exams. Following the correct sequence prevents self-contamination and environmental cross-contamination.

Donning Order (Putting On PPE)

Location: Donned outside the resident's room prior to entry.

1. Gown: Select proper size. Cover torso completely from neck to knees and arms to end of wrists. Fasten securely at the back of the neck and waist.
2. Mask or Respirator: Secure ties or elastic bands at middle of head and neck. Fit flexible noseband snugly over nose bridge. Fit mask snugly below chin and pull lower edge under chin. (Perform user seal check for N95 respirators).
3. Goggles or Face Shield: Place over face and eyes and adjust strap to fit comfortably around head.
4. Gloves: Select correct size. Pull glove cuffs over the wrists of the isolation gown to ensure full skin coverage.

Doffing Order (Taking Off PPE)

Location: Doffed at the doorway or immediately inside the resident's room before exiting (EXCEPT masks/respirators, which are removed outside the room if caring for airborne infections).

1. Gloves: Gloves are considered the most contaminated PPE item.
   • Grasp outer edge of one glove cuff with opposite gloved hand and peel off, turning glove inside out into a ball held in the remaining gloved hand.
   • Slide bare fingers of un-gloved hand under the remaining glove cuff at the wrist and peel off inside out over the first glove, creating a contained pouch. Discard into waste receptacle.
2. Goggles or Face Shield: Outside of goggles/shield is contaminated. Touch only the clean headband or ear pieces to lift up and away from face. Discard or place in designated decontamination bin.
3. Gown: Unfasten gown neck and waist ties. Touch only inside of gown. Pull gown down and away from neck and shoulders. Turn gown inside out as it is rolled into a bundle and discard into biohazard or linen container.
4. Mask or Respirator: Front of mask is contaminated. Do NOT touch front of mask. Grasp bottom ties/elastics, then top ties/elastics, and pull mask forward away from face. Discard in trash.
5. Hand Hygiene: Perform hand hygiene immediately after removing all PPE.

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Transmission-Based Precautions

When Standard Precautions alone are insufficient to interrupt pathogen transmission, Transmission-Based Precautions are ordered by the physician or infection control team. These precautions are categorized by the pathogen's primary mode of transmission.

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Medical Asepsis vs. Surgical Asepsis

In nursing care, maintaining cleanliness involves two distinct levels of asepsis:

• Medical Asepsis ("Clean Technique"): Practices designed to reduce the number, growth, and spread of pathogenic microorganisms. Includes hand hygiene, wearing clean gloves, cleaning environment with disinfectants, and keeping clean linens off floor.
• Surgical Asepsis ("Sterile Technique"): Practices that render and keep objects and areas completely free of all microorganisms and spores. Used in operating rooms, sterile dressing changes, and urinary catheter insertions. (CNAs do not perform sterile procedures but assist licensed nurses and must maintain sterile field integrity by not touching sterile items).

Handling Masks and Respirators Correctly

• Handle a mask by the ties or ear loops only. The front is contaminated from the moment you begin wearing it.
• Change a mask when it becomes moist or soiled. A wet mask no longer filters and actually wicks organisms through.
• Never let a mask hang around your neck, rest on your forehead, or sit in a pocket between residents. A mask that has been off the face is contaminated on both sides.
• An N95 respirator requires fit testing before use and a user seal check every time you put it on: cover the respirator with both hands, exhale sharply to feel for leaks around the edges, then inhale sharply to confirm it collapses slightly against the face. Facial hair breaks the seal.
• One mask per resident on precautions; do not wear the same mask from room to room.

Dedicated Equipment and Room Setup

Residents on Contact Precautions get dedicated equipment — their own blood pressure cuff, stethoscope, thermometer, and gait belt kept in the room. When a piece of equipment genuinely must be shared, it is cleaned and disinfected between residents with the facility's approved product. Keep an adequate supply of gowns, gloves, and a waste container immediately inside the door so no one is tempted to skip PPE because the supply cart is down the hall.

Caring for the Isolated Resident

Isolation is a medical necessity and a psychological injury at the same time. Residents in isolation experience loneliness, boredom, sensory deprivation, and shame. Families visit less. Staff, usually without realizing it, enter less often and stay less long. Depression, poor intake, and functional decline follow within days.

In Rhode Island, "care of patients on precautions" is an explicitly listed nursing assistant duty under 216-RICR-40-05-22.12.1(A)(2). Countering the psychological cost of isolation is part of that duty, not an optional kindness.

💡 A resident on precautions still has every right every other resident has — dignity, privacy, choice, activities, and social contact. Precautions restrict how care is delivered. They never restrict whether it is delivered.