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Skills Assessment Report

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Skill Assessment - Don Personal Protective Equipment (PPE)

Step Pass Unsatisfactory
Preparation
Clinical Standards for Procedures and Interventions
Examines the patient's chart to determine the required isolation precautions and identifies the appropriate PPE needed.
Performs hand hygiene.
Gathers necessary equipment and dons equipment prior to entering the room.
N95 Respirator (if required)
Dons a respirator for airborne precautions.
Places the respirator on the face with clean hands, avoiding touching the inside of the mask.
Secures a snug fit and adjusts the mask to fit the bridge of the nose.
Performs a fit-check, verifying no leaks are present.
Isolation Gowning
Fully covers the torso from neck to knees, arms to the end of wrists, and secures the gown closed.
Applies hair and foot coverings if required.
Eye Protection (if required)
Places goggles or a face shield over the face and eyes and adjusts to fit, ensuring full eye coverage.
Gloving
Performs hand hygiene with hand sanitizer.
Aseptically applies gloves, extending the gloves to cover the wrist of the isolation gown.
Doffing
Removes gloves: The outside of the gloves are contaminated; grasps the outside of one glove with the opposite gloved hand and peels it off; holds the removed glove in the gloved hand; slides fingers of the ungloved hand under the remaining glove at the wrist and removes it.
Removes the gown: The front and sleeves of the gown are contaminated; unfastens the neck and waist ties; removes the gown using a peeling motion, turning it inside out; holds the removed gown away from the body, rolls it into a bundle, and discards it.
Performs hand hygiene: Cleans hands immediately after removing the gown and gloves.
Removes eye protection (if used): Handles by the headband or ear pieces; places in a designated receptacle for reprocessing or disposal.
Removes the mask or respirator: The front of the mask/respirator is contaminated; grasps only the bottom ties or elastics, then the top ties/elastics, and removes; discards in a waste container.
Post-Intervention Management Steps
Performs hand hygiene: Cleans hands immediately after removing all PPE.
Post-Intervention Management Steps

Summary Performance Evaluation

Evaluator

Student Signature

Evaluator Signature