SURGICAL ASEPSIS for Nursing

SURGICAL ASEPSIS

SURGICAL ASEPSIS

OBJECTIVES
–     1.  Define surgical asepsis.
–     2.  Describe the principles of surgical
–          asepsis
–     3.  Give rationale for proper labeling of
–          sterile items
–     4.  Demonstrate aseptic practices: face mask;
–          gown; gloves
–     5.  Practice setting up a sterile field and adding dry
–          and liquid sterile items to a sterile field.Maintaining Surgical Asepsis
–     Sterile – free from microorganism
–     Surgical asepsis:
–    Practiced in OR & special diagnostic areas
–    Employed in many procedures in general care areas (administering injections, changing wound dressings, performing urinary catheterizations,& administering IV therapy

Principles and Practices of Surgical Asepsis
     1. All objects used in a sterile field must be  sterile
–    All articles are sterilized appropriately by dry or moist heat, chemicals or radiation before use.
–    Sterile articles can be stored only for a prescribed time; after that, they are considered unsterile
–    Always check a package containing a sterile object for intactness, dryness, and expiration date
–    Check sterilization dates & periods on the labels
–    Check chemical indicators of sterilization before using a package

2. Sterile objects become unsterile when  touched by unsterile objects
–    Handle sterile objects (touch open wounds or enter body cavities ) only with sterile forceps or sterile gloved hands
–    Discard /resterilize objects that come into contact with unsterile objects
–    Whenever sterility of an object is questionable, assume the article is unsterile

3. Sterile items out of vision or below waist level are considered unsterile
–     Once left unattended, sterile field is considered unsterile.
–     Sterile objects are always kept in view. Nurses do not turn their backs on sterile field.
–     Only the front part of sterile gown & 2 inches above elbows to cuff of sleeves are considered sterile.
–     Always keep sterile gloved hands in sight & above waist level.
–     Sterile draped tables are considered sterile only at surface level.
–     Once sterile field becomes unsterile, it must be set up again.

4. Sterile objects can become unsterile by prolonged exposure to airborne microorganisms
–     Keep doors closed & traffic to  minimum in areas where sterile procedure is being performed.
–     Keep areas in which sterile procedures are carried out as clean as possible by frequent damp cleaning with detergent germicides to minimize contamination in area.
–     Keep hair clean & short or enclose in net to prevent hair from falling in sterile field.
–     Wear surgical caps in OR, delivery rooms, & burn units
–     Refrain from coughing/sneezing over sterile field. Droplets containing microorganisms can travel 1 m (3 ft).
–     Nurses with mild URTI  refrain from carrying out sterile procedure or wear masks

5.  Fluids flow to the direction of gravity
–     Unless gloves are worn, hold wet forceps with tips below handles.
–     During surgical handwash, hold hands higher than elbows
6. Moisture that passes trough sterile object draws microorganisms from unsterile surfaces above or below to the sterile surface by capillary action.
–     Sterile moistureproof barriers are used  beneath sterile objects .If liquid is spilled onto sterile field, barrier keeps liquid from seeping beneath it.
–     Keep sterile covers on sterile equipment dry. Damp surfaces can attract microorganisms in the air.
–     Replace sterile drapes that do not have sterile barrier underneath when they become moist.

7. The edges of a sterile field are considered unsterile.
–     2.5 cm (1-in) margin at edge of opened drape is considered unsterile because edges are in contact with unsterile surfaces.
8. The skin cannot be sterilized and is unsterile.
–     Use sterile gloves or sterile forceps to handle sterile items.
–     Prior to surgical aseptic procedure, wash hands to reduce number of microorganisms on them.

9. Conscientiousness, alertness, and honesty are essential qualities in maintaining surgical asepsis.
–     When sterile object becomes unsterile, it does not necessarily change in appearance.
–     The person who sees a sterile object become contaminated must correct or report the situation.
–     Do not set up a sterile field ahead of time for future use.
Sterile Field
–     Is a microorganism free-area
–     Often established by using:
–     innermost side of sterile wrapper or
–     sterile drape

Maintaining Surgical Asepsis
–     ASSESSMENT
–    Review client’s  record
–    Discuss with client exactly what procedure will be performed that will require sterile field
–    Presence or excessive risk for infection
–    Ability to cooperate

Establishing and Maintaining a Sterile Field
–     Equipment
–    Package containing sterile drape
–    Sterile equipment as needed (e.g., wrapped sterile gauze, wrapped sterile bowl, antiseptic solution, sterile forceps)
Preparation
–     1. Confirm sterility of package
–     Ensure package is clean & dry
–     Check sterilization expiration dates
–     Follow agency practice about disposal of possible contaminated packages
–     Inspect to make sure that it is intact ( not torn).

Performance
–     1. Explain to client what you are going to do,
why , & how he/she can cooperate.
–     2.  Observe other appropriate infection
control procedures.
–     3.  Provide for client privacy.
–     4.  Open package. If inside plastic cover,
remove cover.

Opening a Wrapped Package on a Surface
–     Place package in center of work area so top flap of wrapper opens away from you. This position prevents you from subsequently reaching directly over exposed sterile contents, which could contaminate them.
–     Reaching around package (not over it), pinch first flap on the outside of wrapper between thumb & index finger. Touching only the outside of wrapper maintains sterility of the inside of wrapper. Pull flap open, laying it flat on the far surface.
–     Repeat for side flaps, opening the top one first. Use right hand for right flap, & left hand for left flap. By using both hands, you avoid reaching over sterile contents.
–     Pull fourth flap toward you by grasping the corner that is turned down. Make sure that the flap does not touch any object. If the inner surface touches any unsterile article, it is contaminated.
Variation: Opening a Wrapped Package while Holding It
–     Hold package in one hand with top flap opening away from you.
–     Using other hand, open package as described above pulling corners of flaps well back. Hands are contaminated, & should not touch contents of package.
Variation: Opening Commercially Prepared Packages
–     If flap of package has an unsealed corner, hold container in one hand, & pull back on the flap with other hand
–     If package has partially sealed edge, grasp both sides of the edge, one with each hand & pull apart gently.
–     5.  Establish a sterile field by using a drape
–     Open package containing the drape as described.
–     With one hand, pluck the corner of the drape that is folded back on the top.
–     Lift drape out of the cover, & allow it to open freely without touching any articles. If the drape touches the outside of the package or any unsterile surface, it is considered contaminated.
–      Discard the cover.
–      With the other hand, carefully  pick up another bottom (i.e., corner of the drape, holding it well away from you.
–     Lay the drape on a clean & dry surface, placing the freely hanging side) farthest from you. By placing the lowermost side farthest away, you avoid leaning over the sterile field & contaminating it.
–     6.  Add necessary sterile supplies.
–     Adding Wrapped Supplies to a Sterile Field
–     Open each wrapped package as earlier described.
–     With free hand, grasp corners of wrappers, & hold them against the wrist of the other hand. The sterile wrapper now covers the unsterile hand.
–     Place sterile bowl, drape, or other supply on sterile field by approaching from an angle rather than holding the arm over the field.
–     Discard the wrapper.
Variation: Adding Commercially Packaged Supplies to a Sterile Field
–     Open each package as previously described.
–     Hold the package 15 cm (6 in) above the field & allow contents to drop on the field. At this height, the outside of the package is not likely to touch & contaminate the sterile field.

Adding Solution to a Sterile Bowl
–     Before pouring any liquid, read label 3Xs to make sure you have correct solution & strength.
–     Obtain exact amount of solution, if possible. Once a sterile container has been opened, its sterility cannot be ensured for future use. Follow agency policy for reuse of open sterile solutions.
–     Remove the lid or cap from the bottle & invert the lid before placing it on a surface that is not sterile. Inverting the lid maintains the sterility of the inside surface because it is not allowed to touch an unsterile surface.
–     Hold the bottle at a slight angle so that the label is uppermost. Any solution that flows down the outside of the bottle during pouring will not damage the label.
–     Hold the bottle of fluid at a height of 10 to 15 cm (4 to 6 in) over the bowl  & to the side of the sterile field so that as little of the bottle as possible is over the field. At this height, there is less likelihood of contaminating the sterile field by touching the field or by reaching an arm over it.
–     Pour solution gently to avoid splashing the liquid. If a barrier drape (one that has a water-resistant layer) is not used and the drape is on an unsterile surface, moisture will contaminate the field by wicking microorganisms through the drape.
–     or If the bottle will be used again, replace the lid securely & write on the label the date & time of opening. Replacing the lid immediately maintains the sterility of the inner aspect of the lid & the solution. Depending on agency policy, a sterile container of solution that is opened may be used only once & then discarded kept up to 24 hrs.

–     7.  Use sterile forceps to handle sterile supplies.
–    Forceps are usually  used to move sterile article.
–     Commonly used forceps:
–     Hemostats
–     Tissue forceps
–    Keep the tips of wet forces lower than the wrist at all times. Gravity prevents liquids on the tips of the forceps from flowing to the unsterile handles and later back to the tips.
–    Hold sterile forceps above waist level.
–    Hold sterile forceps within sight.

Use of forceps
supplies, be sure forceps do not touch the edges or outside of wrappers.
–    When placing forceps whose handles were in contact with bare hand, position the handles.
STERILE GLOVES
–     Gloves may be donned by:
–    Open method: most frequently used outside OR
–    Closed method: requires the nurse to wear a sterile gown

Donning and Removing Sterile Gloves (Open Method)
–     Equipment
–    Package of sterile glove
–     Performance
–    1. Explain to client what you are going to do, why and
how he/she can cooperate.
–    2. Observe proper infection control procedures.
–    3. Provide for client privacy.
–    4. Open the package of sterile gloves.
–     Place the package of gloves on a clean dry surface. Any moisture on the surface could contaminate the gloves.
–     Some gloves are packed in an inner as well as an outer package. Open the outer package without contaminating the gloves or the inner package,
–     Remove the inner package from the outer package.
–     Open the inner package. The inner surfaces which are next to the sterile gloves, will remain sterile.
–    5. Put the first glove on the dominant hand
–     If the gloves are packaged so that they lie side by side, grasp the glove for the dominant hand by its folded cuff edge (on the palmar side) with the thumb and first finger of the nondominant hand. Touch only the inside of the cuff. The hands are not sterile. By touching only the inside of the glove, the nurse avoids contaminating the outside.
–     Or
–     If the gloves are packaged one on top of the other, grasp cuff of the top glove as above, using the opposite hand.
–    Insert the dominant hand  into the glove and pull the glove on. Keep the thumb of the inserted hand against the palm of the hand during insertion. If the thumb is kept against the palm, it is less likely to  contaminate the outside of the glove.
–     6. Put the second glove on the nondominant hand.
–    Pick up the other glove with the sterile gloved hand, inserting the gloved fingers under the cuff and holding the gloved thumb close to the gloved palm. This helps prevent accidental contamination of the glove by the bare hand.
–    Pull on the second glove carefully. Hold the thumb  of the gloved first hand as far as possible from the palm. In this position, the thumb is less likely to touch the arm and become contaminated.
–    Adjust each glove so that it fits smoothly and carefully pull the cuffs up by sliding the fingers under the cuff.
Donning and Removing Personal Protective Equipment (Gloves, Gown, Mask, Eyewear)
–     Performance
  1. Explain to the client what you are going to do,
       why, and how she/he can cooperate.
    2. Wash your hands.
    3. Don a clean gown
             Pick up a clean gown and allow it to unfold
in front of you without allowing it to touch
any surfaces that are soiled with body
substances.

–    Slide the arms and the hands through the sleeves.
–    Fasten the ties at the neck to keep the gown in place.
–     Overlap the gown at the back as much as possible and fasten the waist ties or belt. Overlapping securely covers the uniform at the back. Waist ties keep the gown from falling away from the body and prevent inadvertent soiling of the uniform.

–     4.  Don the face mask.
–      Locate the top edge of the mask. The mask
usually has a narrow metal strip along the
edge.
–      Hold the mask by the top two strings or loops.
–      Place the upper edge of the mask over the bridge of the nose, and
tie the upper ties at the back of the head or secure the loops
around the ears. If glasses are worn, fit the upper edge of the
mask under the glasses. With the edge of the mask under the
glasses, clouding of the glasses is less likely to occur.
–      Secure the lower edge of the mask under the chin, and tie the
lower ties at the nape of the neck. To be effective, a mask must
cover both the nose and mouth since air moves in and out of both.

–    If the mask has a metal strip, adjust firmly over the bridge of the nose. A secured fit prevents both the escape and the inhalation of microorganisms around the edges of he mask, and the fogging of eyeglasses.
–    Wear the mask only once, and do not wear any mask longer than the manufacturer recommends or once it becomes wet. A mask should be used only once because it becomes ineffective when moist.
–    Do not leave a used face mask hanging around the neck.
–     5. Don clean disposable gloves.
–    If wearing a gown, pull gloves up to cover the cuffs of the gown. If not wearing a gown, pull gloves up to cover wrists.
–     6. To remove soiled personal protective equipment, remove the gloves first because they are the most soiled.
–    If wearing a gown that is tied at the waist in front, undo the ties at the waist in front, undo the ties before removing gloves.
–    Remove the first glove by grasping it on its palmar surface just below the cuff, taking care to touch only glove to glove. This keeps the soiled parts of the used gloves from touching the skin of the wrist or hand.
–    Pull the first glove completely off by inverting or rolling the gloves inside out
–    Continue to hold the inverted removed glove by the fingers of the remaining gloved hand. Place the first two fingers of the bare hand inside the cuff of the second glove. Touching the outside of the second soiled glove with the bare hand is avoided.
Removing gloves contd.
–    Pull the second glove off the fingers by turning it inside out. This pulls the first glove inside the second glove. The soiled part of the glove is folded to the inside to reduce the chance of transferring any microorganisms by direct contact.
–    Using the bare hand, continue to remove the gloves, which are now inside out, and dispose of them in the waste container.
–    7. Wash your hands
8. Remove the mask.
–     If using a mask with strings, first untie the lower strings of the mask. This prevents the top part of the mask from falling onto the chest.
–     Untie the top strings,and while holding the ties securely, remove the mask from the face. This prevents hand contact with the moistened contaminated portion of the mask.
–     Or
–     If side loops are present, lift the side loops up and away from the ears and face.
Removing the mask contd.
–     Discard a disposable mask in the waste container.
–     Wash the hands again if they have become contaminated by accidentally touching the soiled part of the mask.

–     9. Remove the gown when preparing to leave the room.
–     Unless a  gown is grossly soiled with body substances, no special precautions
are needed to remove it. If a gown is grossly soiled:
–    Avoid touching soiled parts on the outside of the gown, if possible. The top part of the gown may be soiled, for example, if you have been holding an infant with respiratory infection.
–    Grasp gown along the inside of the neck and pull down over the shoulders.
–    Roll up the gown with the soiled part inside and discard it in the appropriate container.
–     10.  Remove protective eyewear and dispose of properly
           or place in the appropriate receptacle for cleaning.

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