Student Name: _______________________________________ ID No____________________
Date of Assessment___________________________________________
No.
2
Key
Completely
Done
1
Partially
Done
Not Done
0
Skill Title #3:
Performance Expectation
Acceptable performance. Consistent in logically following a taught set of rules
within a reasonable timeframe or using a reasonable alternative approach that would
probably give the same effect.
Perform with insignificant omission. Inconsistent in logically following a taught set
of rules and a reasonable timeframe
Perform with significant omission. Failure to logically follow a taught set of rules
and a reasonable timeframe. Or, the student has not performed the action at all.
Donning and Removing Personal Protective Equipment
Action
Pre‐performance
Assessment
1
Assess the patient for type of isolation precaution and consider which activities will
be done for the patient.
Preparation
2
Assembles equipment and supplies:
• Gown
• Mask
• Eyewear
• Clean gloves
• Appropriate waste container.
3
Removes or secure all loose items, such as nametags or jewelry.
4
Washes hands
Dons a Clean Gown.
5
Selects appropriate type and size: Opening is in the back.
6
Picks up the clean gown and allows it to unfold in front of you without allowing it to
touch any area soiled with body substances.
7
Slides the arms and the hands through the sleeves.
8
Secure at neck and ties, overlaps the gown at the back as much as possible, and
fastens the waist ties or belt.
9
* If gown is too small, use 2 gowns: Gown #1 ties in front Gown #2 ties in back
Dons the Face Mask.
10
Places over nose, mouth and chin
11
Fits flexible nose piece over nose bridge
12
Secures on head with ties or elastic
13
Adjusts to fit.
Dons a Particulate Respirator (N95)
14
Selects a fit tested respirator (N95 mask) that fits well
15
Hold the mask with a cupped hand and place firmly over nose, mouth and chin
16
Stretch and position top band high at the back head and bottom band under the
ears.
Performance
2
1
0
17
18
Fits flexible nose piece gently over nose bridge
Performs a fit check –
–Inhale – respirator should collapse
–Exhale – check for leakage around face
Dons Eye and Face Protection
19
Positions goggles over eyes and secure to the head using the ear pieces or headband
20
Positions face shield over face and secure on brow with headband
21
Adjusts to fit comfortably
Dons Clean Disposable Gloves.
22
Selects correct type and size
23
Inserts hands into gloves
24
Extends gloves over isolation gown cuffs
Removes Soiled Personal Protective Equipment
Removes Gloves
25
Removes the first glove by grasping it on its palmar surface just below the cuff,
taking care to touch only glove to glove.
26
Pulls the first glove completely off by inverting or rolling the glove inside out.
27
Continues to hold the inverted removed glove by the fingers of the remaining gloved
hand. Places the first two fingers of the bare hand inside the cuff of the second glove.
28
Pulls the second glove off to the fingers by turning it inside out. This pulls the first
glove inside the second glove.
29
Using the bare hand, continues to remove the gloves, which are now inside out, and
disposes of them in an appropriate container.
30
Hand hygiene.
Removes Goggles or Face Shield
Grasps ear or head pieces with ungloved hands
Lifts away from face
Places in designated receptacle for reprocessing or disposal
Removes Gown
Unfastens ties
Peels gown away from neck and shoulder
Turns contaminated outside toward the inside
Folds or rolls into a bundle
Discard
Hand hygiene.
Removes the mask:
Unties the bottom, then top tie
Removes from face
Discard
Hand washing
TOTAL SCORE
Assessor’s comment:
Assessor’s Name:
Assessor’s Signature:
/86