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Personal Protective Equipment Nursing CE Course

1.0 ANCC Contact Hour

About this course:

This learning activity aims to ensure that nurses working in various settings understand standard and transmission-based precautions and the proper use of personal protective equipment (PPE) according to the Centers for Disease Control and Prevention (CDC) guidelines to disrupt the chain of infection, including the different types of PPE and how to don and doff PPE equipment properly.

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Personal Protective Equipment

Disclosure Statement

This learning activity aims to ensure that nurses working in various settings understand standard and transmission-based precautions and the proper use of personal protective equipment (PPE) according to the Centers for Disease Control and Prevention (CDC) guidelines to disrupt the chain of infection, including the different types of PPE and how to don and doff PPE equipment properly.

Upon completion of this activity, learners should be able to:

  • discuss the elements of the chain of infection, and identify the modes and mechanisms of pathogen transmission in the healthcare environment
  • explain how to minimize a healthcare professional's (HCP's) risk of acquiring an infectious disease
  • identify and define standard and transmission-based precautions and associated HCP and patient implications
  • consider the latest CDC HCP guidelines for protection from infectious disease
  • identify the proper selection and use of PPE and barriers to prevent patient and HCP contact with potentially infectious material

Healthcare professionals (HCPs) risk contracting infectious diseases each time they enter their workplace. Proper infection control practices within the healthcare setting are a primary responsibility among all HCPs. In nursing, this responsibility affects all interactions with patients, coworkers, equipment, and the healthcare environment (Potter et al., 2023). It encompasses adherence to the following essential infection control practices:

  • scientifically accepted standards for handwashing
  • aseptic technique, including the use of gloves and other barriers for preventing bi-directional contact with blood and body fluids
  • a thorough cleaning followed by sterilization or disinfection of medical devices
  • disposal of non-reusable materials and equipment
  • cleaning of objects between patients that are visibly contaminated or subject to touch contamination with blood or body fluids
  • injury prevention techniques or engineering controls to reduce the opportunity for patient and employee exposures (Potter et al., 2023)

Compliance can be increased with frequent and high-quality training to understand how infection control strategies are effective and why they are necessary, such as the multimodal clean hands campaign developed by the World Health Organization's (WHO) Your 5 Moments for Hand Hygiene (See Figure 1). Consequences of poor compliance include increased health risks for HCPs, patients, and the public, such as increased infection rates and antimicrobial resistance (WHO, 2009, 2021).

Figure 1

Your 5 Moments for Hand Hygiene 

Minimizing Risk for Exposure

Handwashing is the most effective way to decrease disease transmission. HCPs have more risk of exposure to disease than through the hands alone; therefore, hand hygiene alone is insufficient protection. HCPs are exposed through direct contacts, such as touching; indirect contacts, such as equipment, eating utensils, or other vectors or vehicles of transmission; droplet transmission, such as coughing, sneezing, or spitting from the source to the eyes, nose, or mouth of others; or airborne transmission with the spread of microorganisms by dust particles or tiny droplets (less than 5 microns). Microorganisms enter the host through a portal of entry (usually the respiratory system). Portals of entry include skin, blood, and the respiratory, gastrointestinal, reproductive, and urinary tracts. Frequently, microorganisms enter the host's body by the same route they exited the source. HCPs use personal protective equipment (PPE) to decrease the risk of exposure by limiting the ability of microorganisms to enter their bodies. PPE includes gloves, respirators, facemasks, eyewear, and gowns to prevent the transmission of infectious materials found in blood, body fluids, secretions, and excretions (Centers for Disease Control and Prevention [CDC], 2016a; McCance & Huether, 2019; WHO, 2009). See Figure 2 for the chain of infection.


Figure 2

Chain of Infection

Standard and Transmission-Based Precautions

There are two primary tiers of CDC precautions to prevent the transmission of infectious agents: standard precautions and transmission-based precautions. Standard precautions are the basis of infection control practices and are of utmost importance to prevent the transmission of infectious agents and communicable diseases in healthcare settings. Standard precautions are applied to all patients in healthcare settings (regardless of the suspected or confirmed presence of an infectious agent). They are the first line of defense to break the chain of infection and protect HCPs and patients. Standard precautions are based on the concept that every patient's blood or body fluids are potentially contaminated with infectious agents. Standard precautions are used when contact with blood, blood products, body fluids, secretions, excretions (except sweat), non-intact skin, or mucous membranes is likely. Providing care using standard precautions includes hand hygiene; applying gloves, gown, facemask, or face shield; respiratory hygiene/cough etiquette; and safe injection practices. The selection of PPE depends upon anticipated blood, body fluid, or splash exposure (CDC, 2021; Siegel et al., 2022).

In 2013, the CDC recommended incorporating respiratory hygiene/cough etiquette into infection control as a component of standard precautions. These should be instituted in the healthcare setting at the first point of contact with a potentially infected person to prevent the transmission of all respiratory infections. The recommended practices have a strong evidence base. Respiratory hygiene/cough etiquette applies to anyone entering a healthcare setting (patients, visitors, and staff) with signs or symptoms of illness (cough, congestion, rhinorrhea, or increased production of respiratory secretions; CDC, 2021; Siegel et al., 2022). The components of respiratory hygiene/cough etiquette include the following:

  • covering the mouth and nose during coughing and sneezing
  • using disposable facial tissues to contain respiratory secretions, with prompt disposal into a hands-free receptacle
  • wearing a surgical mask when coughing to minimize contamination of the surrounding environment
  • turning the head when coughing and staying at least 3 feet away from others, especially in common waiting areas
  • washing hands with soap and water or alcohol-based hand rub after contact with respiratory secretions (CDC, 2021; Siegel et al., 2022)


Transmission-based precautions are the second tier of infection control and are intended for use alongside the standard precautions described above. Transmission-based precautions are reserved for patients suspected of being infected or colonized with specific infectious agents that require additional precautions to prevent transmission. Also referred to as isolation precautions, transmission-based precautions are based on the infectious organism's mode of transmission. Corresponding to the primary modes of transmission discussed ear

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lier, the major categories of transmission-based protection include contact, droplet, and airborne precautions. These are used for patients with highly transmissible pathogens when the route of transmission is not entirely interrupted by standard precautions (Siegel et al., 2022). Regardless of the specific type of transmission-based precautions required, the following principles should be routinely adhered to:

  • thoroughly perform hand hygiene before entering and leaving the room of a patient in isolation
  • properly dispose of contaminated supplies and equipment according to agency policy
  • apply knowledge of the mode of infection transmission when using PPE
  • protect all persons from exposure during the transport of an infected patient outside of the isolation room
  • single private rooms are preferred when available, but cohorting may be implemented during outbreaks of infections (i.e., the placement of patients infected with the same organism in the same room based on organizational needs; Siegel et al., 2022)

Contact precautions are used when a disease is transmitted via direct contact, contaminated body fluids, or indirectly through contaminated instruments, equipment, or the hands of HCPs. This precaution requires wearing gloves and a gown for all interactions involving contact with the patient or potentially contaminated areas in the patient's environment. These patients should also be in a private room with a private bathroom to prevent cross-contamination. Examples of infections in which contact precautions are instituted include vancomycin-resistant Enterococcus (VRE), methicillin-resistant Staphylococcus aureus (MRSA), Clostridium difficile (C. diff), respiratory syncytial virus (RSV), norovirus, rotavirus, and the herpes simplex virus. Contact precautions may also apply in the presence of excessive wound infection/drainage, fecal incontinence, or other discharges from the body that suggest an increased potential for extensive environmental contamination and risk of transmission (CDC, 2016b; Siegel et al., 2022).

Droplet precautions are used when a disease is transmitted by large droplets expelled into the air. They are larger than 5 microns and can travel 3 to 6 feet from the patient. This precaution requires the HCP to apply a surgical mask when within 6 feet of the patient (or before entering the patient's room) and use dedicated care equipment. Patients requiring droplet precautions include those with suspected or confirmed influenza, pertussis, meningococcal disease, COVID-19, or Mycoplasma pneumonia (CDC, 2016b; Siegel et al., 2022).

Airborne precautions are used when a disease is transmitted by smaller droplets (less than 5 microns). These droplets can remain airborne for extended periods. If possible, the patient should be placed in a private room with negative pressure airflow. This airflow filters air through a high-efficiency particulate air (HEPA) filter and then directs the air to the outside of the facility. This form of isolation requires an N95 respirator mask, gown, and gloves to be worn whenever the HCP enters the patient's room and should be applied before entering. Respirators must be appropriately fitted before use. Examples of diagnoses requiring airborne precautions are pulmonary tuberculosis, measles, varicella, and severe acute respiratory syndrome (SARS; CDC, 2016b; Siegel et al., 2022). With all of these types of transmission-based precautions, certain basic principles should be followed:

  • thoroughly perform hand hygiene before entering and leaving the room of a patient in isolation
  • properly dispose of contaminated supplies and equipment according to agency policy
  • apply knowledge of the mode of infection transmission when using PPE
  • protect all persons from exposure during the transport of an infected patient outside of the isolation room (Siegel et al., 2022)


Types of Personal Protective Equipment



Disposable gloves are made from various polymers such as latex, nitrile rubber, polyvinyl chloride (PVC, more commonly referred to as vinyl), and neoprene. They are available as unpowdered or powdered. Both nonsterile and sterile gloves are used by HCPs when delivering care to patients. Latex and nitrile gloves mold to the hand and offer superior protection against pathogens. Nitrile gloves are preferred over vinyl for tasks that require a high degree of dexterity. Vinyl gloves are acceptable when the risk of exposure to pathogens is low and a high degree of dexterity is unnecessary (Potter et al., 2023). Figure 3 demonstrates the differences between latex, nitrile, and vinyl gloves.


Figure 3

Comparison Chart of Latex, Nitrile, and Vinyl Gloves

The following are essential points to consider when using gloves. Wear clean, nonsterile gloves when touching blood, body fluids, secretions, excretions, and contaminated items. Apply gloves before touching mucous membranes and non-intact skin. Gloves should fit comfortably and never be reused. The use of gloves does not eliminate the need for hand hygiene. Likewise, completing hand hygiene does not eliminate the need for gloves. Change gloves between tasks and procedures on the same patient after contact with a material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another patient. Wash hands immediately to avoid transferring microorganisms to other patients or environments (Potter et al., 2023). The procedure for the proper application of nonsterile gloves is as follows (see Figure 4):

  • perform hand hygiene until the product disappears and the hands are dry
  • select the appropriate size glove
  • holding the glove at the opening, slip the fingers into the glove and pull tight
  • with the gloved hand, hold the second glove at the opening and slip the ungloved fingers into the glove and pull tight
  • pull gloves to the wrists of both hands (Potter et al., 2023)


Figure 4

Proper Application of Nonsterile Gloves                                                                         

The procedure for the proper removal of nonsterile gloves is as follows (see Figure 5):

  • remove the gloves by grasping the outside surface of the cuff of one hand using the other gloved hand
  • avoiding skin contact, roll the first glove inside out and place it in the palm of the gloved hand
  • grasp the second glove on the inside of the cuff and pull inside out
  • dispose of both gloves
  • perform hand hygiene (Potter et al., 2023)


Figure 5

Proper Removal of Nonsterile Gloves 

Latex and Latex-Free Equipment

The use of latex gloves increased in the late 1980s, and as a result, the rate of latex allergies also increased. In the 1990s, synthetic latex and powder-free glove options were introduced, resulting in fewer new latex allergy cases. Latex gloves are made from natural rubber, while nitrile and vinyl polymers are synthetic (see Figure 3 for a comparison of latex, nitrile, and vinyl gloves). Exposure to latex can lead to the development of hives, urticaria, flushing, swelling, shortness of breath, chest tightness, and anaphylaxis. Some individuals are sensitive to additional chemicals found on latex gloves resulting in contact dermatitis. Powdered latex gloves create an additional risk because the latex allergen adheres to the powder and can become airborne and inhaled into the lungs as the latex glove is used (American Academy of Allergy, Asthma & Immunology [AAAAI], 2020; Potter et al., 2023).

Since there is no treatment for latex allergies, HCPs and patients should avoid contact with latex-containing products. HCPs with latex allergies are protected under the Americans with Disabilities Act. Individuals with a sensitivity or allergy to kiwifruit, papayas, avocados, bananas, potatoes, European chestnuts, or tomatoes should be carefully screened as they are at higher risk of having a sensitivity or allergy to latex (AAAAI, 2020; Potter et al., 2023).



Facemasks provide barriers to infectious materials and are often used with other PPE, such as gowns and gloves. When worn correctly, facemasks and eye protection protect the mouth, nose, and eyes during procedures where there is a potential for droplets or blood or body fluids splashing. The use of facemasks during spinal/epidural access procedures is included in the definition of standard precautions. In addition to these standard precautions, transmission-based precautions are mandated by the CDC for highly transmissible diseases such as COVID-19, measles, varicella, tuberculosis, influenza, mumps, rubella, wound infections, scabies, and many other infectious diseases (Potter et al., 2023).

Procedure facemasks are flat, pleated, and affix to the head with ear loops. They are used for any nonsterile procedure. Surgical masks come in two basic types: one that is affixed to the head with two ties and may be flat/pleated or duck-billed in shape; the other type has two elastic loops, one for each ear. Both conform to the face with a flexible adjustment for the bridge of the nose that is adjusted by pinching at the bridge of the nose. All facemasks have some degree of fluid resistance, but those approved as surgical masks must meet specific standards to protect blood and body fluids from penetration. Surgical masks protect the HCP from sprays or splashes and prevent pathogens within the wearer's nose or mouth from potentially spreading to and infecting the patient (CDC, 2022; Potter et al., 2023). The steps for properly applying a surgical mask are as follows (see Figure 6):

  • place and hold the surgical mask over the nose, mouth, and chin while stretching the band over the ears or tying the ties behind the head and at the base of the neck
  • adjust the surgical mask so it is snug with no gaps; the surgical mask should not be touched or readjusted during use (Potter et al., 2023)


Figure 6 

Applying a Surgical Mask 

(Lara / Shutterstock)

The steps for properly removing a surgical mask are as follows (see Figure 7):

  • after properly removing and disposing of gloves, carefully remove the elastic from the ears or untie the surgical mask from the back of the head, bottom tie first, being sure to avoid touching the front of the facemask
  • dispose of the surgical mask
  • finally, perform hand hygiene (Potter et al., 2023)


Figure 7

Removing a Surgical Mask



Respirators, commonly referred to as N95 respirators or high-efficiency particulate air (HEPA) masks, cover the nose and mouth. These reduce the HCP's risk of inhaling hazardous airborne particles, gases, or vapors. Respirators are reserved for case-specific aerosolizing procedures where airborne particulates create a high risk of infection for the HCP. OSHA standards require that National Institute for Occupational Safety and Health (NIOSH)-approved N95 filtering facepiece respirators or higher are used when in contact with patients with suspected or confirmed airborne-transmitted diseases, such as TB or COVID-19. In addition, these masks must meet requirements to filter a minimum of 95% of 0.3 µm-size particles. Most N95 and HEPA respirators are single-use and disposable (see Figure 8), which tend to be lighter and less cumbersome for the wearer. Reusable options include elastomeric and powered air-purifying respirators (PAPR; see Figure 9). Some of these options have the advantage of also providing face and eye protection in one unit, as well as reducing the risk of self-contamination. Respirators are intended for protection against solids; they are highly durable devices and have a soft and comfortable inner surface, adjustable nosepiece, and secure head straps to provide a proper fit (CDC, 2021, 2022; Potter et al., 2023).


Figure 8

N95 Mask 


Figure 9

Types of Respiratory Protection 


There are fundamental differences between the major forms of respiratory protection used in healthcare settings: a surgical mask, an N95 respirator, and a half facepiece respirator/HEPA mask. While surgical masks are cleared by the US Food and Drug Administration (FDA), both respirators are evaluated, tested, and approved in the US by the NIOSH based on specific federal requirements. A surgical mask is disposable and loose-fitting but protects HCPs from splashes, sprays, and droplets because it is fluid resistant. It also protects the surgical patient from the HCP’s respiratory emissions. It does not require a fit test and does not provide reliable respiratory protection for the HCP from smaller airborne particles due to leakage around the edge of the mask when the HCP inhales. An N95 is tight-fitting and protects the HCP from exposure to large droplets and small particle non-oil aerosols (at least 95% of airborne particles). N95s were designed to be discarded after each patient encounter, after aerosol-generating procedures, when damaged/deformed, wet, visibly soiled, or contaminated with bodily fluids. A half-facepiece respirator is constructed of rubber or synthetic materials, making them reusable and tight-fitting. They should be cleaned and disinfected between each patient encounter. The associated filter blocks 95, 99, or 100% of small particles, vapors, or gases. Both types of respirators require fit testing to ensure a proper seal for the HCP and consequent respiratory protection (CDC, n.d.-a).


Face and Eye Protection

Protective goggles, face shields, and safety glasses provide a barrier to infectious substances. They are typically used with other PPE, such as gloves, gowns, respirators, and facemasks. The type of face and eye protection chosen depends on the specific work conditions and potential for exposure. Personal knowledge of potential exposure is essential for making an informed decision about the right face and eye protection. Eyeglasses prescribed for vision correction and contact lenses are not considered eye protection. Evaluating the combination of protection recommended for the specific work situation is essential for complete and proper protection. For example, some facemasks may not work with specific goggles or shields. Likewise, a full-face respirator may provide adequate protection without additional components of PPE (Potter et al., 2023; Siegel et al., 2022). 

Safety glasses are excellent for providing impact protection. However, they do not protect adequately from splashes, sprays, and respiratory droplets. Thus, they are not typically used for infection control. Goggles are available with direct or indirect venting. Direct-vented goggles have the potential to allow the penetration of splashes and are not as reliable as indirect-vented goggles. Goggles must fit snugly to provide adequate protection from splashes, sprays, and respiratory droplets (Potter et al., 2023; Siegel et al., 2022). The proper steps for applying safety goggles are as follows (see Figure 10):

  • grasp the temples (long arms) of the goggles, spread the temples open, and slowly place them over the ears
  • if needed, adjust the goggles for comfort (Potter et al., 2023) 


Figure 10                                                                


Applying and Adjusting Goggles



The proper steps for removing and disposing of goggles are as follows:

  • after removing and discarding gloves, grasp the earpieces and lift them away from the face, being sure to avoid touching the front of the goggles
  • discard disposable goggles in the appropriate receptacle; If the goggles are designed to be reused, clean and store them according to agency protocol (Potter et al., 2023)

Face shields are sometimes used as an alternative to goggles or safety glasses. Since the face shield has a larger surface area, it protects other facial areas in addition to the eyes. Face shields do not fit snugly against the face, making them vulnerable to splash and spray particles that can easily penetrate beneath the shield. Therefore, face shields are typically used with other forms of protection and should not be considered the best protection when used alone (Potter et al., 2023; Siegel et al., 2022).


A clean, nonsterile gown protects skin and prevents the soiling of clothing during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. Most patient interactions do not require a gown, but they are always needed when caring for patients on contact isolation precautions. Select a gown appropriate for the activity and the amount of fluid likely to be encountered; gowns are tested and determined to be either fluid-resistant or impervious. Remove a soiled gown as soon as possible and complete hand hygiene to avoid transferring microorganisms to other patients or equipment (Potter et al., 2023). The steps for donning a gown are as follows (see Figure 11):

  • select the appropriate type and size of gown
  • with the gown opening toward the back, put arms through the sleeves one at a time and pull the gown over the shoulders; secure the gown at the neck and waist utilizing the provided closure mechanism (Potter et al., 2023)


Figure 11


Donning a Gown 


To prevent clothing and equipment contamination, the gown must be properly removed. The steps for doffing a gown are as follows (see Figure 12):

  • if the gown is disposable, gloves may be rolled into the gown during the removal of the sleeves to prevent contamination; if using a washable gown, remove gloves first (following the removal steps in Figure 5)
  • untie the gown at the waist and neck and pull it away from the shoulders; roll it into a bundle while avoiding contact with the outside of the gown
  • if the gown is disposable, place it in the appropriate waste container after removal; if the gown is reusable, place it in the proper soiled laundry container after removal
  • regardless of the type of gown used, perform hand hygiene following removal (Potter et al., 2023)


Figure 12 

Doffing a Gown                                                 


Proper Donning and Doffing of Personal Protective Equipment


Adhering to the proper sequence of donning and doffing PPE is vital to reduce the spread of microorganisms. The graphic examples below demonstrate the CDC's recommendations for both tasks (see Figures 13 and 14). Proper doffing of PPE is essential to prevent contamination. Since more than one method may be acceptable, HCPs must consult the training and practices outlined by their institution's policies and procedures (CDC, 2021). 

Figure 13 

Applying Personal Protective Equipment 


Figure 14 

Removing Personal Protective Equipment 



Alternatively, if the HCP is wearing disposable gloves that extend on top of the cuff of the disposable gown, the HCP can pull forward on the front of the gown, causing the ties in the back to break. The HCP should ensure that they touch only the outside of the gown using their gloved hands during this maneuver. The HCP should then remove the gown, folding or rolling it inside-out or into a bundle. When removing the gown from the wrist, the HCP should peel off the gloves from the hands at the same time, touching only the inside of the gown/gloves with their bare hands. The HCP should then remove the goggles or face shield. After leaving the patient’s room, the mask or respirator can then be removed. Remember that the front and sleeves of the gown, the outside of the gloves, the outside/front of goggles or face shield, and the front of the mask/respirator are contaminated. If the HCP contaminates their hands during PPE removal at any point, they should stop and wash their hands or use an alcohol hand sanitizer before proceeding. Following any PPE removal, hand hygiene should be performed as described previously (CDC, 2021).


***For further information on infection control outside the use of PPE, please refer to NursingCE's module on Infection Control. 


American Academy of Allergy, Asthma & Immunology. (2020). Latex allergy. https://www.aaaai.org/tools-for-the-public/conditions-library/allergies/latex-allergy

AvaCare Medical. (n.d.). Disposable gloves: How to choose and use. Retrieved March 14, 2023, from https://avacaremedical.com/medical-gloves-guide

Centers for Disease Control and Prevention. (2016a). How infections spread. National Center for Emerging and Zoonotic Infectious Diseases. https://www.cdc.gov/infectioncontrol/spread/index.html

Centers for Disease Control and Prevention. (2016b). Transmission-based precautions. https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html

Centers for Disease Control and Prevention. (2021). Tools for protecting healthcare personnel. https://www.cdc.gov/HAI/prevent/ppe.html

Centers for Disease Control and Prevention. (2022). Hospital respiratory protection program toolkit: Resources for respiratory program administrators. https://www.cdc.gov/niosh/docs/2015-117/pdfs/2015-117revised042022.pdf?id=10.26616/NIOSHPUB2015117

McCance, K. L., & Heuther, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). Elsevier.

Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2023). Fundamentals of nursing (11th ed.). Elsevier.

Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & The Healthcare Infection Control Practices Advisory Committee. (2022). 2007 guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. https://www.cdc.gov/infectioncontrol/pdf/guidelines/isolation-guidelines-H.pdf

World Health Organization. (2009). Hand hygiene technical reference manual. https://www.who.int/publications/i/item/9789241598606

World Health Organization. (2021). Key facts and figures: World hand hygiene day 2021. https://www.who.int/campaigns/world-hand-hygiene-day/2021/key-facts-and-figures

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