Caps, Masks, and Eye Protection (Home Health Care) - CE/NCPD

ALERT

Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.

Determine whether the patient has a known or suspected airborne transmissible disease. Wear respiratory protection, such as an N95 respirator or disposable particulate respirator, when caring for a patient with a known or suspected airborne transmissible disease.^{undefined#ref1">1}

OVERVIEW

Masks, caps (head covering), and eye protection are articles of PPE worn to prevent contact with infectious agents, vector agents (bedbugs, lice, fleas, ticks), or bodily fluids that may contain an infectious agent. PPE’s effectiveness is created by a barrier between health care team members, the patient or a visitor, and the infectious or vector agent.

The appropriate PPE is based on the type of exposure anticipated for patient care (e.g., touch, splashes, or sprays), type (if any) of isolation precautions, proper fit of the PPE, and compliance with the organization’s practice for use of PPE.

Although masks and caps are usually worn in operative or invasive procedure areas, there are sterile procedures performed in the patient’s home that also require these barriers. For example, a health care team member may be required to wear a mask while accessing an implanted venous access device or a peripherally inserted central catheter. The health care team member should use good judgment and follow the organization’s practice.

A mask is recommended when caring for immunosuppressed patients, patients with open wounds, or patients with a disease that is transmitted via the respiratory route. For diseases that are transmitted via the airborne route (e.g., tuberculosis, chicken pox), an N95 respirator mask is recommended. The organization’s practice should be followed to protect the patient, family, caregivers, visitors, and the health care team from the spread of disease. The immunosuppressed patient is at risk for acquiring an infection from the health care team member performing a central line dressing change if the team member does not wear a mask. A mask decreases the incidence of microorganisms escaping from the health care team member’s mouth and nose and contaminating the sterile field.

Eye protection provides barrier protection for the eyes. Goggles should fit snugly over and around the eyes or over personal prescription lenses. A face shield protects the membranes of the eyes, nose, and mouth when performing tasks that could generate splashes or sprays of bodily fluids.³ When skin protection is also needed, a face shield should be donned. A face shield should cover the forehead, extend below the chin, and wrap around the sides of the face.

PPE should be donned before initiating contact with the patient. When all immediate tasks are completed, the PPE is removed carefully to prevent self-contamination. If hands become contaminated while removing any article of PPE, they should be washed or decontaminated with an alcohol-based agent if washing with soap and water is not possible in the home setting. Handwashing should occur before removing the next article of PPE. All articles of PPE should be discarded in the appropriate receptacles per the organization’s practice. Gloves should be removed first (if worn), followed by eye protection (goggles or face shield), and then the mask and cap. Hand hygiene must be performed after removal of PPE.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Educate the patient and caregiver on when and how to don and doff a cap, mask, and eye protection, if needed.
• Explain to a patient with a known or suspected airborne transmissible disease that health care team members will wear respiratory protection, such as an N95 respirator or disposable particulate respirator during patient care.¹ Explain to a patient with influenza that health care team members will wear a mask during patient care because the disease is transmitted through the air.
• Encourage questions and answer them as they arise.

PROCEDURE

1. Perform hand hygiene.
2. Introduce yourself to the patient, family, and caregivers.
3. Verify the correct patient using two identifiers.
4. Explain the procedure to the patient, family, and caregivers and ensure that the patient agrees to treatment.
5. Prepare an area in a clean, convenient location, and assemble the necessary supplies.
6. Consider the type of procedure to be performed and follow the organization’s practice for use of a cap, mask, or eye protection.
7. Determine whether the patient has a known or suspected airborne transmissible disease. Wear respiratory protection, such as an N95 respirator or disposable particulate respirator, when caring for a patient with a known or suspected airborne transmissible disease.¹

   Rationale: Airborne precautions should be used when caring for a patient who is known or suspected to be infected with microorganisms that can be transmitted by an airborne route.¹

8. When choosing barriers for surgical asepsis, evaluate the patient’s actual or potential risk for infection (e.g., older adult, immunocompromised patient).

Donning Cap, Mask, and Eye Protection

1. Perform hand hygiene.
2. Don a cap (head covering).
   1. If hair is long, comb it back behind the ears and secure it. Comb hair in an area away from patient care. Secure hair in place with an appropriate device before donning a cap.
   2. Place the cap over the head, ensuring that all hair is tucked under the edges of the cap (Figure 1).
3. Don a mask. Ensure that the selected mask fully covers the nose and mouth and fits snugly.
   1. Mask with ties
      1. Find the top edge of the mask; most masks have a thin metal, thin foam, or adhesive strip along the top edge.

         Rationale: Pliable metal fits snugly against the bridge of nose, creating a seal.

      2. Hold the mask by the top two strings or loops, keeping the top edge of the mask above the bridge of the nose.

         Rationale: Handling the mask as described prevents hands from contacting the clean facial portion of the mask and ensures that the mask covers the entire nose.

      3. Tie the two top strings at the top of the back of the head, over the cap (if worn), with the strings above the ears (Figure 2).

         Rationale: Positioning the ties at the top of the back of the head provides a tight fit. Strings over the ears may cause irritation.

      4. Tie the two lower ties snugly around the neck with the mask well under the chin (Figure 3).

         Rationale: Tying the lower ties in this manner prevents microorganisms from escaping through the sides of the mask when talking and breathing.

      5. Gently pinch the upper metal band or adhesive strip around the bridge of the nose to create a seal.

         Rationale: The pliable metal or adhesive strip around the edges of the mask helps conform the mask to the face and prevents microorganisms from escaping around the nose.⁴

   2. Mask with elastic headbands
      1. Separate the two bands. Hold the mask in one hand and the bands in the other.
      2. Place and hold the mask over the nose, mouth, and chin.
      3. Stretch the bands over the head and secure them comfortably. Place one band on the upper back of the head and the other below the ears at the base of the neck.
4. Don eye protection (goggles or face shield).
   1. Don goggles, ensuring comfort, over the eyes and ensure that vision is clear.

      Do not use personal prescription lenses in place of goggles. Personal prescription lenses do not provide adequate eye protection.

   2. If a mask with a face shield is worn, adjust the face shield for adequate vision (Figure 4).
   3. Ensure that the eye protection fits snugly around the forehead and face.
5. Monitor the integrity of PPE during use.

   Change the mask immediately if splattered with bodily fluids.

6. Monitor situational changes and adjust PPE choices appropriately.

Donning an N95 Respirator²

1. Hold the N95 respirator in the palm of the hand with the straps facing the floor.
2. Place the respirator on the face, covering the nose and mouth.
3. Pull the bottom strap up and over the top of the head and position it behind the head, below the ears.
4. Take the upper strap and position it behind the head, toward the crown of the head.
5. Mold the nosepiece of the respirator over the bridge of the nose to obtain a tight seal.
6. Palpate the mask to ensure an adequate seal all around the face.
7. Follow the manufacturer’s instructions for wearing the N95 respirator.

Removing Cap, Mask, and Eye Protection

Remove articles of PPE carefully to prevent self-contamination. If hands become contaminated while removing the cap, mask, or eye protection, perform hand hygiene before removing the next article.

1. Remove eye protection without placing the hands over the lenses.
2. If wearing goggles and a mask, remove the goggles before removing the mask.
3. Discard a disposable face shield in the proper receptacle. Disinfect reusable eye protection after each use per the organization’s practice.¹

   The clear faceplate may become contaminated with droplets. Avoid touching the faceplate.¹

4. Remove the mask.

   Do not touch the front of the mask.

   1. If the mask has strings, untie the bottom strings.

      Rationale: Untying the bottom strings first prevents the top part of the mask from falling and contaminating the uniform.

   2. Untie the top strings of the mask and remove it from the face, holding the ties securely (Figure 5).

      Rationale: Untying the mask strings and holding them securely away from the mask prevents hand contact with the contaminated mask.

   3. If the mask has elastic straps, remove the elastic from around the ears and remove the mask from the face, holding the straps securely.
   4. Discard the mask in the proper trash receptacle.
5. Remove the cap.
   1. Stand away from the patient to prevent hair from falling onto the patient.
   2. Grasp the outer surface of the cap and lift it away from the hair.

      Rationale: Lifting the cap by the outer surface minimizes hand contact with hair.

   3. Discard the cap in the proper trash receptacle.
6. Perform hand hygiene.

Removing an N95 Respirator²

Remove and discard the N95 respirator without touching the front of the mask.

1. Tilt the head forward.
2. Using both hands, grab the bottom strap, pulling it to the sides and over the head.
3. Grab the upper strap with both hands and pull it to the sides and over the head. Keep tension on the upper strap during removal to let the mask fall forward.
4. Discard the N95 in the proper trash receptacle. Respirators are disposable, but the same individual may use them more than once. They should be stored between uses in a clean, breathable container (e.g., paper bag), in a dry place, and out of direct sunlight. Discard the respirator if it becomes wet or damaged.³
5. Perform hand hygiene.

EXPECTED OUTCOMES

• Appropriate PPE is chosen, worn, and discarded correctly.
• PPE is not contaminated during use.

UNEXPECTED OUTCOMES

• Appropriate PPE is not worn correctly.
• PPE is contaminated during use.

DOCUMENTATION

• Education
• Unexpected outcomes and related interventions

REFERENCES

1. Association of periOperative Registered Nurses (AORN). (2023). Transmission-based precautions. In Guidelines for perioperative practice (pp. 1185-1214). Denver: Author. (Level I)
2. Centers for Disease Control and Prevention (CDC). (n.d.). How to properly put on and take off a disposable respirator. Retrieved November 29, 2023, from https://www.cdc.gov/niosh/docs/2010-133/pdfs/2010-133.pdf (Level VII)
3. Centers for Disease Control and Prevention (CDC). (2023). Strategies for conserving the supply of N95^® filtering facepiece respirators. Retrieved November 29, 2023, from https://www.cdc.gov/niosh/topics/pandemic/strategies-n95.html (Level VII)
4. King, C.A. (2023). Chapter 4: Infection prevention and control. In J.C. Rothrock (Ed.), Alexander’s care of the patient in surgery (17th ed., pp. 53-102). St. Louis: Elsevier.

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports

Clinical Review: Susan M. Scully, MSN, RN, CNOR

Published: January 2024