Surgical Asepsis in the OR

Principles of Sterile Technique Becky Ellis, MN RN Nurse Educator N230

Course Information

You are about to begin learning about Surgical Asepsis. Part of this module is devoted to the theory of asepsis as it is used in the operating room. The second half of this module is devoted to teaching you the skills needed for your OR experience, particularly those of scrubbing, gowning, and gloving.

Purpose

The purpose of this module is to acquaint the nursing student with surgical asepsis, surgical scrubbing and the gowning and gloving techniques that will be used during their OR rotation. This module is meant to be on overview and a module to be studied at the students convenience. The student must successfully complete this module prior their OR check off in the skills lab and prior to their OR rotation at their health care facility.

Learning Objectives

After completing this self study course the student will be able to:

Describe the fundamental principles of safe conduct and the basic rules for aseptic technique in the operating room. Demonstrate the correct technique of the surgical scrub and the correct gowning and gloving technique.

Pretest Instructions
The next 5 questions compose a pretest to gauge your knowledge and ability prior to starting this module. Select the best answer, then double click with your mouse. Now here we go

Pretest
1. The Definition of Asepsis is: A. Soiled or infected with organisms B. Capable of producing disease C. Absence of microorganisms

2. Cross-contamination is defined as: A. Producing or capable of producing disease. B. Transmission of microorganisms from patient to patient and from inanimate objects to patients. C. Severe toxic state resulting from infection with pyogenic organisms.

Correct!!
Cross-contamination is the Transmission of microorganisms

3. Which task or function during a surgical procedure is designed as being within the scope of the practice of the scrub nurse? A. Closing the surgical wound B. Setting up the sterile field C. Administering blood products

Right Again!! The Scrub nurse prepares the sterile field

4. For which member of the surgical team is a surgical scrub unnecessary? A. Anesthetist/anesthesiologist B. Surgical technologist C. Scrub nurse

WOW! You are doing great. Another Right answer! Proceed onto the next question, please

5. Which is the best technique for you to use when rinsing your hands and forearms after a surgical scrub? A. Rinsing is not performed after a surgical scrub because it will reduce the antimicrobial activity of the cleansing solution. B. Rinsing should start at the elbow with the water running down back down to the hand. C. Rinsing should start with the hand positioned such that water runs off the elbow rather than down to the hands.

Correct Answer!! You have completed your pretest so its time to continue on with the module.

Answers to Pretest
1. 2.

3. 4. 5.

Correct answer is (a.) Absence of microorganisms. Correct answer is (b.) Transmission of microorganisms from patient to patient and from inanimate objects to patients. Correct answer is (b.) Setting up the sterile field. Correct answer is (a.) Anesthetist/anesthesiologist. Correct answer is (c.) Rinsing should start with the hand positioned such that water runs off the elbow rather than down to the hands.

1. Only sterile items are used within the sterile field 2. Sterile persons are gowned and gloved 3. Tables are sterile only at table level 4. Sterile persons touch only sterile items or areas 5. Unsterile persons avoid reaching over the sterile field 6. The edges of anything that encloses sterile contents are considered unsterile

7. The sterile field is created as close as possible to the time of use 8. Sterile areas are continuously kept in view 9. Sterile persons keep well within the sterile area 10. Sterile persons keep contact with sterile areas to a minimum 11. Unsterile persons avoid sterile areas 12. Destruction of the integrity of microbial barriers results in contamination

1. Only Sterile Items Are Used Within A Sterile Field

Discard any contaminated items: If a sterile package is found in a contaminated area. If uncertain about the actual timing or operation of the sterilizer. If an unsterile person comes into close contact with a sterile table. If a sterile table or unwrapped sterile items are not under constant supervision.

Only Sterile Items Are Used Within the Sterile Field (Continued)

Discard any contaminated items:

If the integrity of the packaging material is not intact. If a sterile package wrapped in a material other than plastic or another moistureresistant barrier becomes damp or wet. If a sterile package wrapped in a pervious woven material drops on the floor or other areas of questionable cleanliness.

2. Sterile Persons are Gowned and Gloved

Observed gowning practices.

Self-gowning and gloving should be done from a separate sterile surface to avoid dripping water onto sterile supplies or a sterile table. The stockinette cuffs of the gown are enclosed beneath sterile gloves. The stockinette is absorbent and retains moisture, and doesnt provide a microbial border. Sterile persons keep their hands in sight at all times and at or above waist level or the level of the sterile field.

Sterile Persons are Gowned and Gloved (Continued)

Observed gowning practices (cont).

Hands are kept away from the face, and the elbows are kept close to the sides. The back of the gown is considered contaminated. The gown is considered sterile only to the highest level of the sterile tables.

3. Tables Are Sterile Only At The Table Level

Sterile table.

Only the top of a sterile, draped table is considered sterile. The edges and sides of the drape extending below table level are considered unsterile. Anything falling or extending over the table edge, such as a piece of suture, is unsterile. When unfolding a sterile drape, the part that drops below the table surface is not brought back up to table level.

4. Sterile Persons Tough Only Sterile Items or Areas

Sterile team members maintain contact with the sterile field by means of sterile gowns and gloves. The unsterile circulator does not directly contact the sterile field. Supplies are brought to sterile team members by the circulator, who opens the wrappers on sterile packages.

5. Unsterile Persons Avoid Reaching Over the Sterile Field

The unsterile circulator never reaches over a sterile field to transfer sterile items. The circulator holds only the lip of the bottle over the basin when pouring solution into a sterile basin in order to avoid reaching over the sterile area. The scrub person sets basins or glasses to be filled at the edge of the sterile table.

6. Edges of Anything That Encloses Sterile Contents Are Considered Unsterile

The inside of a wrapper is considered sterile to within 1 inch of the edges. The circulator opens top flap away from self. Then turns the sides under. The ends of the flaps are secured in the hand so they do not dangle loosely. The last flap is pulled toward the person opening the package, thereby exposing the package contents away from the unsterile hand.

Edges of Anything That Encloses Sterile Contents Are Considered Unsterile (Cont)

Sterile persons lift contents from packages by reaching down and lifting them straight up, holding their elbows high. The flaps on peel-open packages should be pulled back, not torn, to expose the sterile contents. The contents should not be permitted to slide over the edges.

Edges of Anything That Encloses Sterile Contents Are Considered Unsterile (Cont)

After a sterile bottle is opened, the contents are either used or discarded. The cap cannot be replaced without contaminating the pouring edges.

7. The Sterile Field Is Created As Close As Possible to the Time of Use

Sterile tables are set up just prior to the surgical procedure. It is virtually impossible to uncover a table of sterile contents without contamination. Covering sterile tables for later use is not recommended. A covered table is not under observation at all times.

8. Sterile Areas Are Continuously Kept in View

Sterile persons face sterile areas. Someone must remain in the room to maintain vigilance when sterile packs are opened in a room or a sterile field is set up. Sterility cannot by ensured without direct observation. An unguarded sterile field should be considered contaminated.

9. Sterile Persons Keep Well Within the Sterile Area

Sterile persons stand back at a safe distance from operating bed when draping the patient. Sterile persons pass each other back to back at a 360-degree turn. Sterile persons turn their backs to an unsterile person or area when passing. Sterile persons face a sterile area to pass it.

Sterile Persons Keep Well Within the Sterile Area (Cont)

Sterile persons ask an unsterile individual to step aside rather than risk contamination. Sterile persons stay within the sterile field. They do not walk around or go outside the room. Movement within and around a sterile area is kept to a minimum to avoid contamination of sterile items or persons.

10. Sterile Persons Keep Contact With Sterile Areas to a Minimum

Sterile persons do not lean on sterile tables or on the draped patient. Sitting or leaning against an unsterile surface is a break in technique.

11. Unsterile Persons Avoid Sterile Areas

Unsterile persons maintain a distance of at least 1 foot from any area of the sterile field. Unsterile persons face and observe a sterile area when passing to be sure they do not touch it. Unsterile persons never walk between two sterile areas. The circulator restricts to a minimum all activity near the sterile field.

12. Destruction of the Integrity of Microbial Barriers Results in Contamination

Sterile packages are laid on dry surfaces only. If a sterile package wrapped in absorbent material becomes damp or wet, it is discarded. The package is considered unsterile if any part of it comes in contact with moisture. Drapes are placed on a dry field.

Destruction of the Integrity of Microbial Barriers Results in Contamination (Cont)

If solutions soak through a sterile drape to an unsterile area, the wet area is covered with impervious sterile drapes or towels. Sterile items are stored in clean, dry areas. Sterile packages are handled with clean, dry hands.

Setting Up An Unsterile Table As A Sterile Field

The scrub person drapes an unsterile table toward self first to protect the gown. Gloved hands are protected by cuffing a drape over them. The scrub person stands back from the unsterile table when draping it in order avoid leaning over an unsterile are.

There Is No Compromise with Sterility Its Considered Sterile or Unsterile.

The OR Scrub

The Surgical Scrub

Definition.

The surgical scrub is the process of removing as many microorganisms as possible from the hands and arms by mechanical washing and chemical antisepsis before participating in a surgical procedure.

Despite the mechanical action and the chemical antimicrobial component of the scrub process, skin is never sterile.

The Methodology of the Scrub

The Timed Method

All surgical scrubs are 5 minutes in length.

All are performed using a surgical scrub brush and an antimicrobial soap solution.

Surgical Scrub Procedure

1. 2.

3.

Wet the hands and forearms Apply antiseptic agent from the dispenser to the hands. Wash the hands and arms thoroughly to 2 inches above the elbows, several times. Rinse thoroughly under running water with the hands upward, allowing water to drip from the flexed elbows.

4.

Take a sterile brush or sponge (from a package or dispenser) and apply an antiseptic agent ( if it is not impregnated in the brush). Scrub each individual finger, including the nails, and the hands, a half minute for each hand.

5.

6.

Hold the brush in one hand and both hands under running water, and clean under the fingernails with a disposable plastic nail cleaner. Discard the cleaner after use. Again scrub each individual finger, including the nails and the hands with the brush, half a minute for each hand.

The Final Rinse

1.

Be sure to keep both arms in the upright position (careful not to touch the faucet!) so that all water flows off the elbows and not back down to the freshly scrubbed hands. Bring arm through the water once, starting with the fingers, then pull the arm straight out. Do not let water run down to hands, must drip off elbows

7. 8.

9.

Rinse the hands and brush, and discard the brush. Reapply the antimicrobial agent and wash the hands and arms, applying friction to the elbows, for 3 minutes. Interlace the fingers to clean between them. Rinse the hands and arms as described in the previous slide.

Drying the Hands and Arms

1.

2.

Reach down to the opened sterile package containing the gown, and pick up the towel. Be careful not to drip water onto the pack. Be sure no one is within arms reach. Open the towel fulllength, holding one end away from the nonsterile scrub attire. Bend slightly forward.

3.

4.

Dry both hands thoroughly but independently. To dry one arm, hold the towel in the opposite hand and, using the oscillating motion of the arm, draw the towel up to the elbow. Carefully reverse the towel, still holding it away from the body. Dry the opposite arm on the unused end of the towel.

Gowning and Gloving Techniques

1.

2.

3.

Reach down to the sterile package and lift the folded gown directly upward. Step back away from the table into an unobstructed area to provide a wide margin of safety while gowning. Holding the folded gown, carefully locate the neckline.

4.

5.

Holding the inside front of the gown just below the neckline with both hands, let the gown unfold, keeping the inside of the gown toward the body. Do not touch the outside of the gown with bare hands. Holding the hands at shoulder level, slip both arms into the armholes simultaneously.

6.

The circulator brings the gown over the shoulders by reaching inside to the shoulder and arm seams. The gown is pulled on, leaving the cuffs of the sleeves extended over the hands. The back of the gown is securely tied or fastened at the neck and waist, touch the outside of the gown at the line of ties or fasteners in the back only.

Gloving by the Closed Glove Technique

1.

Using the right hand and keeping it within the cuff of the sleeve, pick up the left glove from the inner wrap of the glove package by grasping the folded cuff.

2.

Extend the left forearm with the palm upward. Place the palm of the glove against the palm of the left hand, grasping in the left hand the top edge of the cuff, above the palm. In correct position, glove fingers are pointing toward you and the thumb of the glove is down

3.

Grasp the back of the cuff in the left hand and turn it over the end of the left sleeve and hand. The cuff of the glove is now over the stockinette cuff of the gown, with the hand still inside the sleeve.

4.

Grasp the top of the left glove and underlying gown sleeve with the covered right hand. Pull the glove on over the extended right fingers until it completely covers the stockinette cuff.

5.

Glove the right hand in the same manner, reversing hands. Use the gloved left hand to pull on the right glove.

Gloving the Right Hand

Scrubbing, Gowning, and Gloving Complete

Group Discussion

Now visit your Blackboard Course site and go the discussion board section. Discuss the following questions (on the next slide) with your other class members, be sure to share any previous experiences you may have had using Aseptic Technique along with any insights that you may have related to this topic.

Questions for Discussion

1.

2. 3.

4.

What would you do if, during your OR experience, you accidentally touched an unsterile object with your sterilely gloved hand? What would you do if, while scrubbing, you accidentally touched the faucet? Is it OK to prepare a sterile field an hour before the scheduled surgical case and leave the room to set up another OR room? Why or why not? What should you do if you notice a break in sterile technique by another member of the OR team that they may/or may not be aware of?

I would like to express thanks to Karen Steinke, RN, MN for graciously helping with the photos used in this presentation.