# During doffing of PPE after caring for a patient with suspected Ebola virus disease, which sequence should the nurse follow to minimize contamination risk? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541838 > language: ko > subject: Infectious Diseases ## 문제 During doffing of PPE after caring for a patient with suspected Ebola virus disease, which sequence should the nurse follow to minimize contamination risk? ## 보기 1. Remove gloves first, then gown, followed by face shield, and finally the respirator mask 2. Remove gown and gloves together as a unit, then face shield, followed by hand hygiene, and finally the respirator mask **✔ 정답** 3. Remove respirator mask first, then face shield, followed by gown, and finally the gloves 4. Remove face shield first, then gloves, followed by gown, and finally the respirator mask **정답: 2** ## 해설 The correct sequence is removing gown and gloves together first to minimize contamination, followed by face shield, hand hygiene, and finally the respirator mask, per CDC guidelines for Ebola. Other sequences increase self-contamination risk. ## 심화 해설 Correct Answer and Rationale The correct sequence is to remove the gown and gloves together as a unit, then the face shield, followed by hand hygiene, and finally the respirator mask. This method is grounded in the principle of removing the most contaminated items first while preserving respiratory protection until the end. Deep Dive into the Doffing Sequence The doffing process is the highest-risk moment for self-contamination during the use of personal protective equipment (PPE). The sequence is meticulously designed based on the assumption that the outer surfaces of all PPE are contaminated with the pathogen, in this case, the Ebola virus. The goal is to systematically peel away contaminated layers without touching clean skin, mucous membranes, or underlying clothing. Step-by-Step Breakdown of the Correct Sequence 1. Removal of Gown and Gloves as a Unit: The gown's front, sleeves, and the gloves' outer surfaces carry the heaviest pathogen load. By removing them together, you contain the contamination. The technique involves grasping the gown at the chest area with gloved hands and pulling it forward, breaking the fasteners. As the gown is pulled off, the gloves are peeled off simultaneously, turning them inside out over the gown. This bundles the most heavily contaminated items into a single package, with the clean inside of the gloves and gown facing outward. This method directly minimizes the risk of touching contaminated outer surfaces to the skin or clothing, a primary cause of occupational exposure [1,3]. 2. Removal of Face Shield: The face shield is removed next because it is also heavily contaminated from respiratory droplets and splashes. It is handled only by the headband or earpieces, which are considered relatively clean. Leaning forward slightly during removal allows gravity to pull the contaminated front surface away from the face, further reducing the risk of contact with the eyes or facial skin. 3. Hand Hygiene: Immediately after removing the gown, gloves, and face shield, hand hygiene with an alcohol-based hand rub or soap and water is performed. This critical step decontaminates the hands before they touch the respirator mask, which is the last line of defense. Any contamination transferred to the hands during the initial removal steps is neutralized here, preventing it from being carried to the face during respirator removal [1,3]. 4. Removal of the Respirator Mask: The respirator (e.g., N95) is removed last. The rationale is to maintain respiratory protection for as long as possible while other contaminated items are being handled. A respirator protects the wearer from inhaling airborne infectious particles. Removing it prematurely would expose the nurse's airway to any aerosolized virus generated during the doffing process. It is removed by grasping the straps at the back of the head and neck, pulling them forward and away from the face without touching the front of the mask, which is considered highly contaminated . Why the Other Options are Incorrect - Option 1 (Gloves first, then gown, face shield, respirator): Removing gloves first immediately contaminates the bare hands when they then touch the soiled gown to remove it. This breaks the barrier and creates a direct path for pathogen transmission to the skin. The gown and gloves should be removed as a single, contained unit to prevent this . - Option 3 (Respirator first): Removing the respirator mask first exposes the nurse's unprotected airway to any pathogens that may be aerosolized during the removal of the gown, gloves, or face shield. The respirator must remain in place until all other potentially contaminating items are removed and hand hygiene is performed. - Option 4 (Face shield first, then gloves, gown, respirator): While the face shield is contaminated, the gloves and gown carry a higher bioburden from direct patient contact. More critically, removing the face shield first does not address the core problem of bare-hand contamination when the gloves are subsequently removed separately from the gown. This sequence still leaves the nurse vulnerable to touching the soiled gown with unprotected hands. Clinical and Educational Context Errors in doffing are a significant and well-documented source of self-contamination among healthcare workers. Studies using fluorescent markers as pathogen surrogates have demonstrated that protocol deviations during doffing commonly lead to contamination of hands, wrists, and clothing . The complexity of the procedure requires deliberate practice and proficiency-based training. Simulation-based education, including one-on-one coaching and deliberate practice, has been shown to be an effective method for improving PPE competency and reducing these critical errors . The emergence of artificial intelligence (AI)-assisted training tools represents a novel approach to providing real-time feedback on donning and doffing sequences, potentially standardizing and scaling this essential instruction to ensure every healthcare worker can perform the procedure safely . ## 임상 시나리오 Clinical Practice Guide: PPE Doffing for High-Consequence Pathogens (e.g., Ebola) The doffing sequence is the highest-risk moment for self-contamination. The principle is to remove the most contaminated items first while preserving respiratory protection until the end. All steps must be performed slowly and deliberately, ideally under observation by a trained monitor. Correct Doffing Sequence - **Remove Gown and Gloves as a Unit:** Grasp the gown at the chest with gloved hands and pull forward, breaking fasteners. Simultaneously peel the gloves off inside-out, bundling them with the gown. The clean inside surfaces should face outward, containing the heaviest contamination. - **Remove Face Shield:** Handle only by the headband or earpieces at the back or sides. Do not touch the front surface, which is considered contaminated. - **Perform Hand Hygiene:** Immediately after removing the first bundle and face shield, perform thorough hand hygiene with an alcohol-based hand rub or soap and water to eliminate any potential contamination before touching the respirator. - **Remove Respirator Mask:** Grasp only the straps at the back of the head or sides. Do not touch the front of the respirator. Lean forward slightly and remove the straps, discarding the mask without touching the outer surface. - **Perform Final Hand Hygiene:** After all PPE is removed, perform hand hygiene again as the final step. Key Safety Points - Always use a trained observer to guide the doffing process and immediately identify any breaches. - Move slowly and deliberately; do not rush. This is not an emergency procedure. - If a breach occurs (e.g., touching contaminated surface to skin), stop immediately, perform hand hygiene on the affected area, and report per facility protocol. - The exact PPE ensemble may vary by facility, but the core principle of removing the most contaminated items first and the respirator last remains constant. ## 핵심 개념 - **Doffing** — The process of removing personal protective equipment (PPE), which is a high-risk moment for self-contamination and requires a strict, methodical sequence. - **Ebola virus disease** — A severe, often fatal hemorrhagic fever transmitted through direct contact with infected body fluids, requiring enhanced PPE and rigorous donning/doffing protocols under airborne and contact precautions. - **Self-contamination** — The inadvertent transfer of pathogens from contaminated PPE surfaces to the wearer's skin, mucous membranes, or underlying clothing, primarily occurring during incorrect doffing procedures. ## 같은 주제 문제 - [A nurse is caring for a patient with suspected Ebola virus disease in the isolation unit. …](https://mymerci.kr/pages/nclex_q.php?qn_id=541835) - [A nurse is caring for a patient with suspected Clostridium difficile infection in a medica…](https://mymerci.kr/pages/nclex_q.php?qn_id=541836) - [A nurse is caring for a patient with suspected Lassa fever in the isolation unit. 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