5.2 Standard Precautions, Transmission-Based Precautions & PPE Sequence
Key Takeaways
- Standard Precautions represent the universal baseline standard of care, treating all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes as potentially infectious.
- Personal Protective Equipment (PPE) provides physical barrier protection and must be selected based on the specific anticipated mode of exposure and clinical precaution level.
- The standardized CDC Donning Sequence is: 1. Gown -> 2. Mask/Respirator -> 3. Goggles/Face Shield -> 4. Gloves (pulled over gown cuffs).
- The standardized CDC Doffing Sequence is: 1. Gloves -> 2. Goggles/Face Shield -> 3. Gown -> 4. Mask/Respirator (followed immediately by hand hygiene).
- Transmission-Based Precautions encompass Contact Precautions (gown and gloves for MRSA, VRE, C. diff), Droplet Precautions (surgical mask within 3–6 feet for Influenza, Pertussis, Meningitis), and Airborne Precautions (N95 respirator and negative-pressure AIIR for TB, Measles, Varicella).
5.2 Standard Precautions, Transmission-Based Precautions & PPE Sequence
Quick Answer: Standard Precautions apply universally to all residents at all times, treating all blood, body fluids (except sweat), non-intact skin, and mucous membranes as potentially infectious. Transmission-Based Precautions are added for specific known or suspected contagions: Contact Precautions (gown and gloves for MRSA, VRE, C. diff), Droplet Precautions (surgical mask within 3–6 feet for Influenza, Pertussis, Mumps), and Airborne Precautions (N95 respirator and negative-pressure AIIR room for Tuberculosis, Measles, Varicella). CDC Donning sequence: 1. Gown -> 2. Mask/Respirator -> 3. Goggles/Face Shield -> 4. Gloves. CDC Doffing sequence: 1. Gloves -> 2. Goggles/Face Shield -> 3. Gown -> 4. Mask/Respirator, completed with immediate hand hygiene.
Infection prevention and control in South Carolina healthcare facilities operates under a two-tiered system developed by the Centers for Disease Control and Prevention (CDC) and enforced by the Occupational Safety and Health Administration (OSHA). The first tier—Standard Precautions—is designed for the care of all residents regardless of their perceived infection status. The second tier—Transmission-Based Precautions—is applied to residents known or suspected to be infected with highly transmissible, epidemiologically significant pathogens.
Certified Nursing Assistants must master the precise selection, donning, and doffing sequences of Personal Protective Equipment (PPE). Incorrect PPE removal is one of the leading causes of self-contamination and pathogen dissemination among healthcare personnel.
1. Tier 1: Standard Precautions (Universal Practice)
Standard Precautions are the foundational infection control practices applied to all resident encounters in any healthcare setting, regardless of diagnosis or presumed infection status.
The Core Philosophy of Standard Precautions
The central premise of Standard Precautions is that all human blood, all body fluids, secretions, excretions (except sweat), non-intact skin, and mucous membranes must be treated as if they are infectious for HIV, HBV, HCV, and other transmissible pathogens.
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| STANDARD PRECAUTIONS MANDATE |
| |
| APPLIES TO ALL RESIDENTS AT ALL TIMES FOR CONTACT WITH: |
| - Blood and blood-derived products |
| - All body fluids, secretions, and excretions (urine, feces, sputum, |
| emesis, semen, vaginal secretions, pus, wound exudate) EXCEPT sweat |
| - Non-intact skin (cuts, burns, abrasions, pressure injuries, rashes) |
| - Mucous membranes (oral cavity, eyes, nostrils, vagina, rectum) |
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Essential Components of Standard Precautions
- Hand Hygiene: Performed before and after every resident contact, immediately after glove removal, and after touching body fluids or contaminated equipment.
- Appropriate PPE Selection:
- Gloves: Worn whenever touching blood, body fluids, mucous membranes, non-intact skin, or contaminated surfaces.
- Gown: Worn during procedures likely to generate splashes, sprays, or droplets of blood or body fluids (e.g., bed baths of incontinent residents, emptying drainage containers).
- Mask and Goggles / Face Shield: Worn during procedures likely to generate splashes or sprays of blood/fluids into the eyes, nose, or mouth.
- Respiratory Hygiene / Cough Etiquette: Covering mouth/nose with tissues when coughing, disposing of tissues promptly, wearing a mask when symptomatic with respiratory infection, and maintaining at least 3 feet of spatial separation.
- Safe Injection & Sharps Safety: Immediate disposal of sharps in puncture-resistant containers; never recapping needles.
- Environmental Cleaning & Linen Management: Disinfecting multi-use equipment between residents; rolling soiled linen with dirty surface inward; holding linen away from uniforms; never placing linen on floors.
2. Personal Protective Equipment (PPE) Components
PPE comprises specialized physical barrier equipment worn by healthcare workers to prevent exposure to infectious biological materials.
| PPE Item | Clinical Barrier Function | Specific Clinical Indications | Key Application Rules |
|---|---|---|---|
| Clean Examination Gloves | Protects hands from direct microbial contact and body fluids. | Incontinent care, perineal care, emptying urinary drainage bags, handling soiled linens, oral hygiene. | Change between tasks on same resident if moving from dirty to clean site; remove immediately after task; perform hand hygiene. |
| Isolation Gown | Protects uniform, arms, and exposed skin from fluids and contact. | Bathing residents with open wounds, managing profuse diarrhea, Contact Precautions rooms. | Must cover torso from neck to knees and wrap around back; fasten at neck and waist; discard before exiting room. |
| Surgical / Procedure Mask | Protects nasal and oral mucous membranes from large droplets. | Resident coughing forcefully, Droplet Precautions rooms, sterile tray assistance. | Pinch metallic strip over nasal bridge; ensure snug fit under chin; discard when moist or crushed. |
| Goggles / Face Shield | Protects conjunctiva of eyes and full facial area from splashes. | Irrigating wounds (by RN), suctioning airways, high-pressure equipment cleaning. | Personal eyeglasses are NOT approved eye protection; must provide top and side wrap-around coverage. |
| N95 / HEPA Respirator | Filters airborne particles >=0.3 microns with >=95% efficiency. | Caring for residents with active Tuberculosis, Measles, Chickenpox (Airborne Precautions). | Requires annual OSHA fit-testing and medical clearance; user seal check mandatory upon every donning. |
3. The CDC PPE Donning Sequence (Putting On)
Donning must occur in a precise, logical order before entering the resident's room or isolation area to ensure comprehensive barrier coverage.
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| CDC PPE DONNING SEQUENCE |
| |
| STEP 1: ISOLATION GOWN |
| - Fully cover torso from neck to knees, arms to end of wrists. |
| - Wrap around back and fasten securely at neck and waist. |
| |
| STEP 2: MASK OR N95 RESPIRATOR |
| - Secure ties or elastic bands at middle of head and neck. |
| - Fit flexible nosepiece over nasal bridge using both index fingers. |
| - Pull bottom of mask snugly under chin. Perform fit check for N95. |
| |
| STEP 3: GOGGLES OR FACE SHIELD |
| - Position over eyes and adjust headband for secure, comfortable fit. |
| |
| STEP 4: CLEAN EXAMINATION GLOVES |
| - Extend glove cuffs to OVERLAP and cover the wrists of the gown sleeves. |
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Critical Donning Technical Details
- Gown Fastening: Both the neck ties and waist ties must be tied. Leaving the back open exposes clothing to contaminated bed frames and chairs.
- Glove Cuffs Over Gown: Pulling glove cuffs up over the elastic or knitted cuffs of the isolation gown creates an uninterrupted seal, preventing body fluids from running down the wrist onto bare skin.
- N95 User Seal Check: After donning an N95 respirator, exhale sharply (positive pressure check) and inhale deeply (negative pressure check). If air leaks around the facial perimeter, readjust the nosepiece and headbands until an airtight seal is verified.
4. The CDC PPE Doffing Sequence (Taking Off)
The outside front and sleeves of PPE are heavily contaminated with pathogens. Doffing must follow a rigorous, non-contaminating sequence at the doorway or immediately outside the resident room (except respirators, which are always removed outside the room).
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| CDC PPE DOFFING SEQUENCE |
| |
| STEP 1: GLOVES (Most contaminated item - remove first) |
| - Grasp outside edge of opposite glove near wrist with gloved hand. |
| - Peel downward, turning glove inside-out into a ball in gloved hand. |
| - Slide clean bare fingers under wrist of remaining glove (skin-to-skin). |
| - Peel glove off inside-out over first glove, creating enclosed bundle. |
| - Discard immediately in biohazard/waste receptacle. |
| |
| STEP 2: GOGGLES OR FACE SHIELD |
| - Touch ONLY the clean headband or ear pieces from behind. |
| - Lift away from face without touching front surface; discard/sanitize. |
| |
| STEP 3: ISOLATION GOWN |
| - Unfasten neck and waist ties (or break ties gently without snapping). |
| - Pull gown away from neck and shoulders, touching inside of gown only. |
| - Turn gown inside out and roll into a compact bundle away from body. |
| - Discard in waste receptacle. |
| |
| STEP 4: MASK OR N95 RESPIRATOR |
| - Grasp bottom ties/elastic bands, then top ties from behind head. |
| - Pull away from face without touching front of mask. Discard. |
| |
| STEP 5: IMMEDIATE HAND HYGIENE |
| - Perform hand hygiene with soap/water or ABHR immediately after doffing. |
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Alternative Inside-Out Combined Gown and Glove Removal
In many South Carolina clinical facilities, the CDC-approved Combined Gown and Glove Removal method is utilized: Grasp the gown at the chest, pull forward to break ties, and roll the gown downward and inside out down the arms, peeling the gloves off simultaneously inside out with the gown sleeves, bundling all contaminated surfaces internally.
5. Tier 2: Transmission-Based Precautions
Transmission-Based Precautions are instituted in addition to Standard Precautions for residents colonized or infected with specific contagious pathogens transmitted via Contact, Droplet, or Airborne routes.
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| TRANSMISSION-BASED PRECAUTIONS CATEGORIES |
| |
| [CONTACT PRECAUTIONS] --> Direct/Indirect touch (MRSA, VRE, C. diff) |
| PPE: Gown & Gloves upon entry |
| |
| [DROPLET PRECAUTIONS] --> Heavy respiratory droplets (Flu, Pertussis) |
| PPE: Surgical mask within 3-6 feet |
| |
| [AIRBORNE PRECAUTIONS] --> Suspended microscopic nuclei (TB, Measles) |
| PPE: N95 Respirator + Negative Pressure Room |
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Comprehensive Transmission Precautions Comparison
| Precautions Category | Clinical Indications / Common Pathogens | Required PPE for CNA | Room Placement & Engineering Controls | Equipment & Resident Transport Rules |
|---|---|---|---|---|
| Contact Precautions | MRSA (wound/skin), VRE, C. diff, Scabies, Lice, Major draining abscesses, Rotavirus, ESBL infections. | Gown and Gloves donned prior to entering resident room; doffed before exiting. | Private room preferred; or cohort with resident having identical confirmed pathogen. | Dedicated multi-use equipment (stethoscope, BP cuff, thermometer stay in room); bleach wipes for C. diff; resident covered with clean sheet during transport. |
| Droplet Precautions | Influenza A/B, Pertussis (whooping cough), Mumps, Rubella, Neisseria meningitidis (meningitis), Group A Strep. | Surgical / Procedure Mask worn upon entry or within 3–6 feet; eye protection if splashing likely. | Private room preferred; door may remain open; 3 to 6 feet spatial separation between beds if cohorted. | Resident must wear a surgical mask during all transport outside room; transport limited to medically essential reasons only. |
| Airborne Precautions | Mycobacterium tuberculosis (active TB), Rubeola (Measles), Varicella-Zoster (Chickenpox), Disseminated Shingles. | N95 Respirator / PAPR donned before entering; doffed strictly OUTSIDE room. | Airborne Infection Isolation Room (AIIR) with negative air pressure, 6–12 air exchanges/hr, HEPA filtration, door closed at all times. | Resident wears surgical mask during transport; transport strictly minimized; non-immune staff prohibited from entering measles/varicella rooms. |
6. Psychosocial Impact of Isolation on Residents
While isolation precautions are vital to institutional safety, being confined to an isolation room can impose severe psychological distress on residents:
- Sensory Deprivation & Loneliness: Reduced social interaction, limited family visits, and seeing staff only in protective masks and gowns.
- Anxiety, Stigma, and Depression: Feeling "unclean," rejected, or burdensome to nursing staff.
CNA Supportive Interventions
- Do NOT Avoid the Resident: Answer call lights immediately. Never delay care or group tasks simply to avoid donning PPE.
- Therapeutic Presence: Spend dedicated time conversing with the resident; explain that isolation precautions exist to protect others, not to punish the resident.
- Cognitive & Recreational Engagement: Provide magazines, books, puzzles, crafts, television, and facilitate telephone or video calls with family members.
- Maintain Dignity: Always knock, greet the resident warmly by name, and display a welcoming facial expression and gentle eye contact over your mask.
When entering a room to provide care for a resident placed on Contact Precautions due to a Methicillin-Resistant Staphylococcus aureus (MRSA) wound infection, what is the correct PPE donning order?
A resident with active pulmonary tuberculosis (TB) is admitted to a skilled nursing facility. Which room placement and respiratory protection requirements must be strictly maintained?
Under the CDC Standard Precautions guidelines, which of the following body substances is EXCLUDED from requiring routine fluid barrier precautions unless it contains visible blood?
When removing Personal Protective Equipment (PPE) after assisting a resident on Droplet Precautions, which piece of equipment is considered the most contaminated and must be removed FIRST?