Which step would the nurse take first when removing personal protective equipment in an isolation room?

Donning (applying) and doffing (removing) personal protective equipment NCLEX review for nursing students!

In this review, you will learn the sequences for putting on and taking off personal protective equipment (also called PPE), such as a gown, face mask and respirator, goggles, and gloves. This review will demonstrate one of the sequences you can use for donning and doffing PPE. However, it is important to always follow the sequences established by your facility, and remember sequences can change during pandemics, so always refer to the latest protocols in your area.

In addition, you must know what types of PPE you must wear for transmission-based precautions, and the different types of PPE. After reviewing these review notes, don’t forget to take the free review quiz on personal protective equipment.

Donning and Doffing PPE Demonstration

Donning and Doffing Personal Protective Equipment (PPE)

First, select the appropriate PPE you will need, along with the right size. The selection of PPE is determined by what type of potential infectious agent you will be encountering, as well as the type of procedure you will be performing.

Donning PPE

This is performed before entering the patient care area.

A sequence for donning PPE:

• Don the gown FIRST, followed by a mask or respirator (depending on what you need), then goggles or face shield, and lastly the gloves.

1. Perform hand hygiene.
2. Then put on the gown by sliding it up the arms, and insert the thumbs into the thumb inserts of the gown (if present). This particular gown has a loop that you can place over your head. Then, secure the gown by tying the ties in the back.
   
3. Next, don a face mask or respirator: If using a face mask with ear loops, place each loop over the ears, and then grasp the nose piece of the mask and bring it to cover the bridge of the nose. Mold the nose piece of the face mask with the fingertips of both hands by starting at the bridge of the nose and work outward toward the cheekbones, and then grasp the nose piece of the face mask and pull the bottom of the mask under chin.
   
4. If using an N95 respirator:
   1. Hold the respirator in one hand, with the front of the respirator touching the inside of your hand. The metal nose piece should rest near the fingertips. Be sure the top and bottom straps of the respirator are hanging down below your hand and are not tangled or twisted.
      
   2. Take the respirator and place it over your nose, mouth, and under the chin. Hold the respirator in place with one hand.
      
   3. Use your free hand to place the straps on your head. It’s very important the straps rest on the head and are NOT overlapping or tangled.
      
   4. First, take the top strap of the respirator and place it just past the top of your head, above the ears.
   5. Then take the bottom strap of the respirator and place it around the bottom of the head, just below the ears, and then make sure the straps aren’t overlapping or overly twisted.
      
   6. To ensure a proper seal of the respirator around the nose area, use the fingertips of both hands to bend the metal nose piece around the nose, starting in the center and working your way outward on each side.
      
   7. Now perform a Seal Test: Place both hands over the respirator.
      
   8. Take a sharp breath in and make sure that the respirator is sealing over the face during this inhalation.
   9. Keep both hands on the respirator and breathe out. While breathing out, feel for any air leaking around the nose piece and around the respirator’s perimeter.
   10. If air is leaking around the nose piece, try re-bending the nose piece with both hands and recheck the seal.
   11. If air is leaking around the respirator’s perimeter, try adjusting the straps and recheck again, making sure the respirator is not being affected by any piercings, facial hair, or glasses, which could prevent a proper seal.
   12. If the respirator still leaks after this, you may need a different size or type of respirator. Do NOT use the respirator if a proper seal has not been obtained.
5. Next, don a face shield or goggles: If using goggles, apply goggles over the eyes. Make sure any straps or bands of the goggles are secured around the head and the goggles fit snugly but comfortably.
   
6. Perform hand hygiene again.
7. Lastly, don gloves by pulling each glove over the hand and extending the cuff of the gloves over the sleeves of the gown.
   

Doffing PPE

Know areas that are “clean” vs “dirty”:

• Clean areas (you CAN touch while removing): the inside and back of the gown, gown’s ties, inside of the gloves, ear pieces/straps of mask/goggles/respirator/face shield
• Contaminated areas (you CAN’T touch while removing): outside the front of the gloves, front of gown (includes sleeves), and outside of the mask, face shield, goggles, respirator

This is performed before leaving the patient’s care area. If using a respirator, doff the respirator outside of the patient’s care area. NOTE: Update 2020, the CDC states the face shield or goggles can be remove outside the patient care area too. However, follow your facility recommendations for this step.

A sequence for doffing PPE:

• Doff the gloves FIRST, followed by the gown, then the face shield or goggles, and lastly, doff the mask or respirator.

1. First, remove the gloves. Do NOT touch the outside of the gloves because they are considered contaminated. To remove the gloves, start by taking your non-dominant gloved hand to grab the other glove around the cuff in the wrist area. Do this by using a pinching motion to grab it.Peel this glove off by turning it inside out, and wad it into a ball with your gloved hand. Keep it securely in your gloved hand. Then take the index finger of the ungloved hand and slide it carefully under the cuff of the gloved hand and peel the glove off the hand by pushing the index finger forward against the glove. This will turn the glove inside out. Dispose of the gloves.
   
2. Next, remove the gown. The front of the gown and sleeves are considered contaminated, whereas the ties and inside of the gown are considered clean. Therefore, avoid touching the front of the gown and sleeves. Carefully untie or break the ties of the gown. Peel off the gown by removing the thumbs from the inserts (if present), and then move the shoulders and arms up through the gown, which helps allow the gown to slide off the body. Then from the inside, with the assistance of the arms, roll the gown away from the body by turning it inside out. Form it into a ball and discard it.
   
3. Perform hand hygiene.
4. Next, remove the face shield or goggles. Do NOT touch the outside of the googles or face shield because they are considered contaminated. If goggles are used, remove the goggles by carefully grasping and lifting the back band of the goggles over the head. Dispose or clean the goggles per facility’s protocol.
   
5. Then remove the mask or respirator (again the respirator is removed OUTSIDE the patient’s care area). If a mask is worn, the front of the mask is considered contaminated. Therefore, grasp the ear loops of the mask with the fingertips and remove from face. Dispose of or clean and store the mask per facility’s protocol, and perform hand hygiene.
   
6. If a respirator is worn, the doffing procedure is performed outside the patient’s care area. The front of the respirator is considered contaminated. Therefore, remove by the straps.
   
   1. Grasp the BOTTOM strap of the mask and lift it over the head.
      
   2. Then grasp the TOP strap of the mask and lift it over the head.
      
   3. Dispose or reuse* the mask per facility’s protocol.
   4. Perform hand hygiene.

You may be interested in: Isolation Mnemonics

References:

Using Personal Protective Equipment (PPE). (2020). Retrieved 18 May 2020, from https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html