CHAPTER I

PRINCIPLES OF STERILE TECHNIQUE

The PATIENT is the center of the sterile field, which includes the areas of the patient, the operating
table and furniture covered with sterile drapes and the personnel wearing OR attire. Strict adherence to sound
principles of sterile technique and recommended practices is mandatory for the safety of the patient. This
adherence reflects one’s surgical conscience. Principles remain the same; it is the degree of adherence to
them that varies. These principles are applied in the:
1. Preparation for operation by sterilization of necessary materials and supplies.
2. Preparation of the operating team to handle sterile supplies & intimately contact the surgical
site.
3. Creation and maintenance of the sterile field, including the preparation and draping of patient
to prevent contamination of the surgical wound.
4. Maintenance of sterility and asepsis throughout the operative procedure. Breaches in sterility
are to be corrected immediately.
5. Terminal sterilization and disinfection at the conclusion of the operation.

If the principles are understood, the need for their application becomes obvious. The sterile technique is the
basis of modern surgery.

Principles
Only Sterile Items Are Used Within the Sterile Field. Some items such as instruments, linens,
sponges, or basins may be obtained from stock supply of sterile packages. Others, such as instruments, may
be sterilized immediately preceding the operation and removed directly from the sterilizer to the sterile tables.
Every person who dispenses a sterile article must be sure of its sterility and of its remaining sterile until used.
Proper packaging, sterilizing and handling should provide such assurance. If you are in doubt of the sterility of
anything, consider it as not sterile. Known or potentially contaminated items must not be transferred to the sterile
field, for example:
• If sterilized package is found in a nonsterile workroom.
• If uncertain about actual timing or operation of the sterilizer. Items processed in a suspect load
are considered unsterile.
• If unsterile person comes into close contact with a sterile table and vice versa.
• If sterile table or unwrapped sterile items are not under constant observation.
• If sterile package falls to the floor, it must be discarded.
• Items dropped below waist level are considered unsterile and must be discarded.
• If the integrity of the packaging material is not intact.
• If sterile package wrapped in an absorbent material is damp or wet.

Sterile Persons Have Scrubbed and are Gowned and Gloved; Unsterile Persons Have Not.
• Self gowning and gloving should be done at a separate sterile surface.
• Stockinette cuffs of the gown are enclosed by the sterile gloves.
• Gowns are considered sterile only from the waist to shoulder level in front and the sleeves.
• Sterile persons keep hands in sight and at above waist level. (see Fig.1-1)
• Hands are kept away from the face. Elbows are kept close to sides. Hands are never folded
under arms because of perspiration in the axillary region.
• Changing table levels is avoided. If a sterile person must stand on a platform to reach the
operative field, the standing platform should be positioned first before the person steps up to
draped area.

Tables Are Sterile Only at Table Level.

• Only the top of the table with sterile drapes is considered sterile. Edges and sides of drape
extending below table level are considered unsterile.
• Anything falling or extending over table edge, such as a piece of suture, is unsterile.
Scrub nurse does not touch the part hanging below table level.
• In unfolding sterile drape, the part that drops below table surface is not brought back up to the
table level.
• Cords, tubing and other materials are secured on the sterile field.
 Sterile Persons Touch Only Sterile Items or Areas, Unsterile Persons Touch Only Unsterile
Items Or Areas.
• Sterile team members maintain contact with sterile field by means of gowns and gloves.
• Nonsterile circulating nurse does not directly come into contact with the sterile field.
• Supplies for sterile team members reach them by means of the circulating nurse who opens
wrapper on sterile packages.

Unsterile persons Avoid Reaching Over a Sterile Field; Sterile Persons Avoid Leaning Over
an Unsterile Area.
• Unsterile circulating nurse never reach over a sterile field to transfer sterile items.
• In pouring solution into a sterile basin, circulating nurse holds only the lip of the bottle over
basin to avoid reaching over a sterile area. (see Fig.1-2)
• Scrub nurse sets basins or glasses to be filled at the edge of the sterile table; circulating nurse
stands near this edge of the table to fill them.
• Circulating nurse stands at a distance from the sterile field to adjust light over it to avoid
microbial fallout over field.
• Surgeon turns away from the sterile field to have perspiration wiped from brow.
• Scrub nurse drapes a nonsterile table toward self first to protect gown (see Fig.1-3)
• Scrub nurse stands back from nonsterile table when draping it to avoid leaning over an unsterile
area (see Fig. 1-4, 1-5, 1-6)

Fig. 1-1 Fig.1-2

Sterile person keeps hands in sight at/or Circulating nurse pouring sterile solution into sterile basin.
above waist level or level of sterile field.

Fig.1-3 Fig 1-4

Sterile scrub nurse draping a small table. Draping a large nonsterile table.
Hands are protected by cuffing drape over them.

Fig. 1-5 Fig.1-6

Scrub nurse holds the sterile fan-folded drape and unfolds Nurse continuing to unfold sterile drape. Hands are inside sterile
drape first towards self. Note that hands are inside sterile cover for protection. Nurse may now move closer to the table, since
cover to protect them. the first part of unfolded drape now protects gown
 Edges Of Anything That Encloses Sterile Contents Are Considered Unsterile.
Boundaries between sterile and unsterile areas are not always rigidly defined. The following precautions
should be taken:
• In opening sterile packages, a margin of safety is always maintained. Ends of flaps are secured
in hand so they do not dangle loosely. The last flap is pulled toward the person opening the
package thereby exposing package contents away from non sterile hands.
• Sterile persons lift contents from packages by reaching down and lifting them straight up,
holding elbows high.
• Steam reaches only the area within the gasket of a sterilizer. Instrument trays should not touch
the edge of the sterilizer outside the gasket.
• Flaps on peel-open packages should be pulled back, not torn, to expose sterile contents.
Contents should be flipped or lifted upward and not permitted to slide over edges. Inner edge
of the heat seal is considered the line of demarcation between sterile and unsterile portion.
• If a sterile wrapper is used as a table cover, it should amply cover the entire table surface.
Only the interior surface level of the cover is considered sterile.
• Caps of solution bottles are unsterile, so after a sterile bottle is opened, contents must be used
or discarded. Cap cannot be replaced without contaminating pouring edges.

Sterile Field Is Created as Close as Possible to Time of Use. Degree of contamination is

proportionate to length of time sterile items are uncovered and exposed to the environment. Precautions
must be taken as follows:
• Sterile tables are set up just prior to the operation.
• It is difficult to uncover a table of sterile contents without contamination. Covering sterile tables
for later use is not recommended.

Sterile Areas Should Continuously Kept in View. Inadvertent contamination of sterile areas must
be readily visible. To ensure that this principle is carried out,
• Sterile persons face sterile areas.
• When sterile packs are opened in a room, or a sterile field is set up, someone must remain in the
room to maintain vigilance.
• Covered table is not under observation at all times and may pose questionable sterility issues.

Sterile Persons Keep Well within the Sterile Area. Allow a wide margin of safety when passing
unsterile areas and follow these rules:
• Sterile persons stand back at a safe distance from the operating table when drapping the patient.
• Sterile persons pass each other back to back (see Fig.1-7)
• Sterile person turns back to nonsterile person or area when passing.
• Sterile person faces sterile area when they pass through it.
• Sterile person asks nonsterile individual to step aside rather than risk contamination.
• Sterile person stay within and around a 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.

Fig. 1-7
Sequence of one sterile person going around another. They pass each other back to back, keeping well within the sterile area and
allowing a margin of safety between themselves
Sterile Persons Keep Contact with Sterile Areas to a Minimum. The following rules should be observed:
• Sterile persons do not lean on sterile tables and on draped patient.
• Sitting or leaning against a nonsterile surface is a break in technique. If the sterile team sits to
operate, they do so without proximity to nonsterile areas.

Unsterile Persons Avoid Sterile Areas. A wide margin of safety must be maintained when passing
sterile areas by following these rules:
• Unsterile persons maintain at least one foot (30cm.) distance from any area of the sterile field.
• Unsterile persons face & observe a sterile area when passing it to be sure they do not touch it.
• Unsterile persons never walk between two sterile areas, e.g. between sterile instrument tables.
• Circulating nurse restricts to a minimum all activities near the sterile field.

Destruction of Integrity of Microbial Barriers results in Contamination. Integrity of sterile

package or sterile drape is destroyed by perforation, puncture or strike-through. Ideal barrier materials are
abrasion resistant, impervious to permeation by fluids or dust that transport microorganisms. The integrity of
a sterile package, its expiration date, and appearance of process monitor must be checked for sterility just
prior to opening. To ensure sterility:
• Sterile packages are laid on dry surfaces.
• If sterile package becomes damp/wet, it is re-sterilized or discarded. A package is considered
nonsterile if any part of it comes in contact with moisture.
• Drapes are placed on a dry surface.
• If a solution soaks through the sterile drape to nonsterile area, the wet area is covered with
impervious sterile drape or towels.
• Packages wrapped in muslin or paper are permitted to cool after removal from the sterilizer to avoid
steam condensation and resultant contamination.
• Sterile items are stored in clean, dry areas.
• Sterile packages are handled with clean, dry hands.
• Undue pressure on sterile pack is avoided to prevent forcing sterile air out and pulling unsterile air
into the pack.

Microorganisms Must Be Kept to an Irreducible Minimum. Perfect asepsis in an operative field

is an ideal approach, it is not absolute. All microorganisms cannot be eliminated, but this does not obviate
necessity for strict sterile technique. It is generally agreed that:
• Skin cannot be sterilized. It is a potential source of contamination in every operation. Inherent
body defenses usually can overcome the relatively few organisms remaining after patient’s skin
preparation. All possible means are used to prevent entrance of microorganisms into the wound.
Preventive measures include:
a. Transient & resident flora are removed from skin around operative site of patient &
the hands & arms of sterile team members by mechanical washing & chemical antisepsis.
b. Gowning and gloving of operating team is accomplished without contamination of
sterile exterior of gowns and gloves.
c. Sterile gloved hands do not directly touch skin and the deeper tissues. Instruments used
in contact with skin are discarded and not reused.
d. If glove is pricked or punctured by needle or instrument, glove is changed
immediately. Needle or instrument is discarded from the sterile field.
e. Sterile dressing should be applied to the surgical site before the drapes are removed to
reduce the risk of touching the incision by contaminated hands / objects.

• Some areas cannot be scrubbed. When the operative field includes the mouth, nose, throat or
anus, the number of microorganisms present is great. Various parts of the body, such as the
gastrointestinal tract and vagina, usually are resistant to infection from florae that normally inhabit
these parts. However, the following steps may be taken to reduce the number of microorganisms
present in these areas and to prevent scattering them:
a. Surgeon makes an effort to use a sponge only once, then discards it.
b. Gastrointestinal tract is contaminated. Measures are used to
prevent spreading this contamination.
 c. Irrigation and suction may be done to remove gross debris.
d. Aseptic technique is generally used, but if it involves the vascular system, the items
used must be sterile.
• Infected areas are grossly contaminated. The team avoids spreading the contamination.
• Air is contaminated by dust and droplets. Environmental control measures are necessary.

Notes
 OPERATING ROOM ATTIRE
Operating Room Attire consists of the scrub dress, head cover, mask and shoes or shoe cover.
Sterile gown and gloves are added for scrubbed team.

Purpose: To provide effective barriers that prevents the dissemination of

microorganisms to the patient and to protect personnel from infected patients.
1. Scrub dress - worn only in the OR suite, allows the wearer to enter the sterile field
2. Head Cover - is used to cover hair completely.
3. Shoes - should be clean & conductive, washable and soft-soled covered by shoe covers.
4. Mask - is put on by all personnel before coming into the operating room & must be
worn over nose & mouth.
5. Sterile gown- are worn over scrub attire.
6. Sterile gloves- are worn to allow the wearer to handle sterile supplies & tissues of the surgical site.

Fig. 1-8
Operating room apparel Fig. 1-9 Shoe covers with conductive straps, pant leg not yet snapped or tied.

Fig. 1-10 A. Hood-type headgear with mask B. Headgear and mask.

POSITIONS FOR SURGERY

Fig. 1-11 Supine position Fig. 1-12 Modified Trendelenburg position

Supine position. The supine, or dorsal position is the usual position for induction of general anesthesia and
for entering the major body activities. The patient lies on his back with his arms in anatomical position and
the legs slightly apart. The palms of the hands should be facing the body to prevent undue muscle strain on
the arms.

Modified Trendelenburg position. The modified trendelenburg position is generally used for lower
abdominal surgery (allows gravity to assist in maintaining the intestines in the upper part of the abdominal
cavity) and some lower extremity surgery (assists in hemostasis). The patient is positioned as in the supine
position, and the entire operating table is slightly tilted so that the patient’s head is lower than his feet by 1 to
5 degrees.

Modified Reverse Trendelenburg Position. This position is generally used for upper abdominal surgery
and for neck and face surgery. This position permits improved operative exposure because gravity keeps the
intestines mostly in the lower part of the abdomen.

Fig. 1-13 Reverse modified Trendelenburg position

A. for upper abdominal surgery and B. for face and neck surgery

Lithotomy position. The lithotomy position is used in operation requiring a perineal approach.

Prone Position. Patients who are having surgery on the posterior part of the body are placed in the prone
position.

Lateral Position. The lateral position is generally used for operations on the kidneys, lungs or hips.

Modified Fowler’s Position. The modified Fowler position or the sitting position, is used mostly in
neurosurgery.

Fig. 1-14 Lithotomy position

A. with canvas strap stirrups B. with padded stirrups
 Fig. 1-15 A. Prone position B. Modified jackknife, usually for rectal surgery.

Fig. 1-16 Lateral Position Fig.1-17 Modified Fowler’s Position

PATIENTS’ SKIN PREP ON THE OPERATING TABLE

Area: Done after patient has been anesthetized and positioned on the operating table, skin of the
operative site and extensive area surrounding it, is mechanically cleansed again with an
antiseptic agent immediately prior to draping.

Responsibility:
The first assistant is the person who scrubs the patient after he has scrubbed his own hands and arms.

Basic Preparation Procedure for Clean Areas.

1. Don sterile gloves.
2. Scrub skin, starting at site of incision, with a circular motion or over widening circles to the
periphery. Use enough pressure & friction to remove dirt and microorganisms from skin & pores.
3. Discard sponge after reaching periphery. Never bring a soiled sponge back toward center of
the area.
4. Repeat scrub with a separate sponge for each round and apply antiseptic.
5. Paint area with solution from incision site to periphery with circular motions.

Contaminated Areas within the Operative Field

Umbilicus, stoma, draining sinuses, skin ulcers, vagina, anus, colostomy. (In all contaminated areas,
follow general rule of scrubbing the most contaminated area last or with a separate sponge)
Fig. 1-18 Lateral thoracoabdominal preparation. The area includes Fig.1-19 Chest and breast preparation. The area includes
shoulder axilla, chest & abdomen from neck to crest of the illium. Area ex- upper arm, down to elbow, axilla & chest wall to the table line&
tends beyond the midline, anteriorly & posteriorly. The patient is in lateral beyond sternum to opposite shoulder. Patient is in lateralposition.
position on the operating table.

Fig.1-20 Abdominal preparation. The area includes breast line to Fig 1-21 Knee and lower leg preparation. The area includes the
Upper third of thighs from table line, with patient in supine position. entire circumference of affected leg and extends from foot to
Shaded area shows anatomic area of hair removal. Arrows within area upper part of thigh.
Show direction of motion for skin preparation on operating table.

Fig. 1-22 Rectoperineal and vaginal preparation. The area includes Fig. 1-23 Hip preparation. The area includes the abdomen on
thepubis, vulva, labia, perineum, anus and adjacent areas, including affected side, thigh to the knees, buttocks to table line, groin and
inner aspects of upper third thighs. Pubis.
 SURGICAL SCRUB

Definition of Surgical Scrub

Surgical scrub is the removal of as many bacteria as possible from the hands and arms by
mechanical washing and chemical disinfection before participating in an operation. The surgical scrub is done
just prior to gowning and gloving for each operation.

Purpose:
To help prevent the possibility of contamination of the operative wound by bacteria on the hands and
arms.

Preparation Prior to Surgical Scrub

1. Skin and nails should be kept clean and in good condition and cuticles uncut.
2. Fingernails should not reach beyond the fingertip to avoid glove puncture.
3. There should be no fingernail polish.
4. Inspect hands for cuts and abrasions. Skin of hands and forearms should be intact, without
open lesions or cracked skin.
5. Remove all finger jewelries.
6. Be sure that hair is covered by headgear. Pierced ear studs must be contained by the head
cover.
7. Adjust disposable mask snugly and comfortably over nose and mouth.
8. Adjust eyeglasses comfortably in relation to mask.
9. Adjust water to a comfortable temperature.

Length of Scrubbing
The length of the surgical scrub varies from one institution to another, as does the scrub procedure.
Variations in length may depend on frequency of scrubbing and the agent used.

Surgical Scrub Procedure

A. Time method. Fingers, hands and arms are scrubbed by allotting a prescribed amount of time to each
anatomical area or each step of the procedure.

1. Complete scrub takes 5-7 minutes; this is done:

a. In the morning before the first gowning and gloving.
b. Following a clean case if gloves have been removed inadvertently before gowning.
c. Following a clean case, if gloves have had a hole between them.
d. Following a clean case if hands have been contaminated in any other way.
e. Before an emergency case at anytime.

2. Short scrub takes 3 minutes, this is done following a clean case, if the hands and arms have not
been contaminated. It is done to remove bacteria that have emerged from the pores and multiplied while the
gloves were on.

B. Counted brush-stroke method. A prescribed number of brush strokes applied lengthwise of the brush or
sponge, is used for each surface of the fingers, hands and arms. Scrub the nails of one hand 30 strokes; all
sides of each finger, 20 strokes; the back of hand, 20 strokes; the palm, 20 strokes; the arms, 20 strokes for
each third of the arm to 3 inches above the elbow.
A. B.

C. D.

E. Fig. 1-24 Proper scrub technique for the first 5 minutes

of a 10-minute scrub

A. Turn on water and get antiseptic solution.

B. Wash hands prior to scrubbing.
C. Clean fingernails under running water.
D. Scrub left hand.
E. Close-up of scrubbing left fingertips.
 F. G.

H. I.

J. K.

Fig. 1-25 Continuation of Proper Scrubbing Technique.

F. Scrub left arm
G. Scrub left elbow area.
H. Rinse brush and transfer to other hands.
I. Scrub right hand
J. Scrub right arm.
K. Scrub right elbow area
 L. M.

N. O.

P. Q.

Fig.1-26. Continuation of Proper scrubbing Technique

L. Rinse left hand and brush
M. Rinse left arm and elbow area
N. Rinse right hand.
O. Rinse right hand and elbow area. Complete scrub as indicated
with anatomical timed or stroke count scrub method.
P. Turn water faucet with brush if water faucet is hand controlled.
Q. Walk into operating room.
 DRYING HANDS AFTER SURGICAL SCRUB

When drying, stand away from objects and people. To eliminate unnecessary movement of the
towel, move the hand that is being dried rather than the towel. The drying procedure is done as follows:

1. When picking up the towel, do it with a swift, efficient motion.

2. Take the towel in the middle, being careful not to contaminate the sterile gown under it.
3. Bend at the waist to help prevent the sterile towel from touching the unsterile gown while
drying your hands and arms.
4. Dry hand to mid-lower arm, then transfer dry end of towel to other hand.
5. Do not return to dry same hand after drying the hand and arm.
6. After the second hand and mid-lower have been dried, fold towel in thirds and dry elbows.
7. Be sure hand is well covered. When transfer of towel is made from hand to hand, do not allow
hand to touch where elbow has touched.
8. Discard towel in linen hamper.

A. B. C.

D. E. F.

Fig. 1-27 Procedure for drying hands.

A. Pick up sterile towel from gown pack
B. Unfold towel.
C. Place a third of the towel over right hand, two thirds will be hanging toward left hand.
D. Dry left hand
E. Dry left arm.
F. Transfer dry end of towel ( a third) to left hand, two thirds toward right hand.
 G. H. I.

J. K. L.

Fig. 1-28 Continuation of Procedure for drying hands.

G. Dry right hand.
H. Dry right arm.
I. Fold towel into thirds.
J. Dry elbow area
K. Transfer towel, keeping hands on underside of towel.
L. Dry elbow area.

Notes
 GOWNING
Purposes of Gowning:
1. To exclude skin as possible contaminant & to create a barrier bet. sterile & unsterile areas.
2. To permit the wearer to come within the sterile field.
3. To carry out sterile techniques during an operative procedure.

General Considerations:
1. The scrub nurse gowns and gloves self, then gowns and gloves the surgeons and assistants.
2. Gown packages preferably are opened on a separate table from other packages to avoid any
chance of contamination from dripping water.
3. After scrubbing, hands and arms must be thoroughly dried before the sterile gown is donned to
prevent contamination of the gown by strike-through of organisms from skin and scrub attire.
4. The gown package for the scrub nurse contains one sterile gown, folded before sterilization,
with the inside out, so that the bare scrubbed hands will not contaminate the sterile outside of the
gown.
5. A towel for drying hands is placed on top of the gown during packaging. Scrub nurse holds the
towel away from the body, dries only well-scrubbed areas, hands first, and avoids contaminating
hands on the areas proximal to elbows.
6. Dry both hands, then one arm on one end of the towel, use the opposite end of the towel for t
he other arm.
7. To put on a sterile gown, the scrub nurse needs the assistance of the circulating nurse. The
scrub nurse receives the sterile gown from the circulating nurse if the gown is not individually
packed.

Gowning techniques:
1. Gowning for open glove technique
2. Gowning for closed glove technique
3. Gowning another person
4. Changing gown during operation
5. Removing gown

Gowning for Open Glove Technique

1. Reach down to the sterile package and lift the folded gown directly upward or scrub nurse
receives sterile gown from the circulating nurse.
2. Step back away from the table, into a clear area, to provide a wide margin of safety while
gowning.
3. Holding the folded gown, carefully locate the neckband or centerfold.
4. While holding the neckband with both hands or holding the centerfold with one hand, gently
shake the folds from the gown.
5. Slip both hands into the sleeves, holding the hands upward on level with the shoulder without
touching the outside part of the gown with bare hands.
6. Circulating nurse reaches inside the gown to the sleeve seams and pulls the sleeves over the
hands to the wrists.
7. Circulating nurse fastens back part, ties waist band, touching outside of gown at the line of ties
or fasteners in the back only.
* After this procedure, the scrub nurse gets ready to wear the sterile gloves.

Fig 1-29 Gowning for open glove technique

 Circulating nurse fastens back of scrub nurse’s gown. Note that hands extend through the stockinet cuffs.

Gowning for Closed Glove Technique

1. Reach down to the sterile package and lift the folded gown directly upward or scrub nurse
receives sterile gown from the circulating nurse.
2. Step back away from the table, into a clear area, to provide a wide margin of safety while
gowning.
3. Holding the folded gown, carefully locate the neckband or centerfold.
4. While holding the neckband with both hands or holding the centerfold with one hand, gently
shake the folds from the gown.
5. Slip both hands into the sleeves, holding the hands upward on level with the shoulder without
touching the outside part of the gown with bare hands.
6. Circulating nurse reaches inside the gown to the sleeve seams and pulls the gown on, leaving
the cuffs of the sleeves extended over the hands.
7. Circulating nurse fastens back part, ties waist band, touching outside of gown at the line of ties
or fasteners in the back only.

Gowning for Closed Glove Technique

Fig. 1-30

Scrub nurse, picking up gown below neck edge, lifts it directly Scrub nurse, putting on gown, gently shakes out the folds, then slips
upward and steps away to avoid touching an edge of the wrapper. Arms into the sleeves without touching the sterile outside of the
Note that the sterile inside of the wrapper covers the table. gown with bare hands.
Gown is folded inside out.

Circulating nurse, pulling the gown on for closed gloving tech- Circulating nurse, completes pulling on the nurse’s gown, ties the
nique, reaches inside the gown to the sleeve seams and pulls tapes on the inside of the back, and closes the fastener at the neck.
The gown on, leaving the cuffs of the sleeves extended over the
hands
Gowning Another Person
A team member in sterile gown and gloves may assist another team member in gowning by taking the
following steps.
1. Give the towel to the surgeon, being careful not to touch the hand.
2. Unfold the gown, holding it at the neckband.
3. Keep the hands on the outside part of the gown under the protective cuff and shoulder area.
Offer the inside of the gown to the surgeon. The surgeon slips into the sleeves.
4. Release the gown. The surgeon holds arms outstretched while the circulating nurse pulls the
gown onto the shoulders and adjusts the sleeves and cuffs.

A. B.

Fig. 1-31 Gowning another Person.

A. Scrub nurse hands folded sterile gown to surgeon.
B. Scrub nurse hands unfolded sterile gown to surgeon.

Changing Gown During Operation

1. Circulating nurse unfastens neck and waist. By grasping it at shoulders, the gown is pulled off
inside out. The gown is always removed first before the gloves. If only the sleeves are
contaminated, a sterile sleeve may be put on over a contaminated one.
2. Preferably a sterile team member may gown another. If this is not possible, step aside and put
on a sterile gown.

Removing Gown
1. The gown is always removed before the gloves. It is pulled downward from the shoulders,
turning the sleeves inside out as it is pulled off the arms.

A. B. C.

Fig. 1-32 Sequence of scrub nurse removing soiled gown at the end of operation. Clean arms and scrub dress are protected from contaminated
outside part of gown.
A. With gloves on, loosen cuffs of gown and shake them down over wrists. Then grasps right shoulder of gown (unbuttoned or
untied) with left hand.
B. In pulling the gown, off arms, turn arm of gown away from the body with flexed elbow.
C. Grasp the other shoulder with the other hand and remove gown entirely, pulling it off inside out; thus arms are kept clean.
 GLOVING

Gloves
Sterile gloves complete the attire for scrubbed team members.
The sterile gloves are put on immediately after gowning.

Purposes:
1. To exclude skin as a possible contaminant.
2. To create a barrier between sterile and unsterile areas.
3. To permit the wearer to handle sterile supplies or tissues of the operative wound.

Gloving techniques
Sterile gloves may be put on in two ways, by:
A. Closed Glove Technique. This is preferred except when changing a glove during an
operation or when donning gloves for procedures not requiring gowns. Properly executed, the
closed glove method affords assurance against contamination when gloving oneself, since no
bare skin is exposed in the process. If properly done, gloves can be put on safely either way. The
method of gloving determines how the gown is donned.
1. Using the left hand, and keeping it within the cuff of the left sleeve, pick up the glove, from
the inner wrap of the glove package, by grasping the folded cuff.
2. Extend the right forearm with palm upward. Place the palm of the glove against the palm of
the right hand, grasping in the right hand the top edge of the cuff, above the palm. In correct
position, gloved fingers are pointing toward you and the thumb of the glove is to the right. The
thumb side of the glove is down.
3. Grasp the back of the cuff in the left hand and turn it over the end of the right sleeve and hand.
The cuff of the glove is now the stockinet cuff of the gown, with hand still inside the sleeve.
4. Grasp the top right glove and underlying gown sleeve with covered left hand. Pull glove on
over extended right fingers until it completely covers the stockinet cuff.
5. Glove the left hand in the same manner, reversing hands. Use gloved right hand to pull on the
left glove.

Fig. 1-33 Closed glove method

A. B. C.

D. E. F.
B. Open Glove Technique. This method of gloving uses a skin-to-skin, glove-to-glove technique. The
hand, although scrubbed, is not sterile and must not contact the exterior of sterile gloves. The inverted cuff
on the gloves exposes the inner surfaces. The first glove is put on with skin-to-skin technique, bare hand to
inside cuff. The sterile fingers of that gloved hand then may touch the sterile exterior of the second glove,
i.e., glove-to-glove technique.
1. With left hand, grasp the cuff of the right glove on the fold. Pick up the glove and step back
from the table. Look behind you before moving.
2. Insert right hand into the glove and pull it on, leaving the cuff turned well down over hand.
3. Slip finger of the gloved right hand under the inverted cuff of the left glove. Pick up the glove
and step back.
4. Insert hand into the left glove and pull it on leaving the cuff turned down over the hand.
5. With fingers of the right hand, pull cuff of the left glove over cuff of the left sleeve. If the
stockinet is not right, fold a pleat, holding it within right thumb while pulling the glove over the
cuff. Avoid touching the bare wrists.
6. Repeat step 5 for the right cuff , using the left hand, & thus, completely gloving the right hand.

• Note: Open glove technique is used when only sterile gloves are worn, as for intravenous cutdown or administration of spinal
anesthesia or in the emergency department when donning sterile gloves for suturing lacerations. It is also used for changing a
glove during an operation.

• B. C.
A.

D. E. F.

Fig. 1-34 Open glove Method

GLOVING ANOTHER PERSON

1. Pick up the right glove, grasp it firmly with fingers under the everted cuff. Hold the palm of
the glove toward the surgeon.
2. Stretch the cuff sufficiently for the surgeon to insert the hand. Avoid touching the hand by
holding your thumbs out.
3. Exert upward pressure as the surgeon plunges his hand into the glove. Unfold the everted
glove cuff over the cuff of the sleeve.
4. Repeat for the left hand.
Fig. 1-35 Scrub nurse gloving surgeon or another person.

A. B. C.
 D E. F.

CHANGING GLOVE DURING OPERATION

If a glove becomes contaminated for any reason during an operative procedure, it must be changed
immediately. If you cannot step away at the moment, hold the contaminated hand away from the sterile area.
To change the glove:
1. Turn away from the sterile field.
2. Extend the contaminated hand to the circulating nurse who grasps the outside of the glove cuff
about 2 inches below the top of the glove and pulls the glove off, inside out.
3. Preferably, a sterile team member gloves another. If this is not possible, step aside and glove
the hand using the open glove technique.

Note: The closed glove technique cannot be used for glove change during an operation without
contamination of the new glove by the sleeve of the gown or without contamination of the hand
by the cuff of the gown. The cuff must not be pulled down over hand. If this method is used,
gloves and gown must be removed and another sterile gown donned before gloves.

Removing Gloves
Glove is removed after the gown. Gloves are turned inside out, using glove-to-glove then
skin-to-skin technique.

Fig 1-36 Sequence of scrub nurse in removing soiled gloves at the end of an operation.
A. Glove-to-glove, then, B. Skin-to-skin to protect clean hands from the contaminated outside of the gloves, which bear cells of the patient. Turn
gloves inside out when removing then, keeping hands “clean”.

A. B.
 DRAPING

Draping is the procedure of covering the patient and surrounding areas with a sterile barrier to create
and maintain an adequate sterile field during operation.

Techniques to Remember in Draping

1. Allow sufficient time to permit careful application.

2. Allow sufficient space to observe sterile technique.
3. Handle the drape as little as possible.
4. If a drape becomes contaminated, do not handle it further. Discard it without contaminating
gloves or other articles.
5. If in doubt as to its sterility, consider it contaminated.
6. If the end of the sheet falls below waist level, discard it.
7. Never reach across the operating table to drape the opposite side, go around the table.
8. Take the towels and towel clips to the side of the table from which the surgeon is going to
apply them before handing them to him.
9. Carry the folded drapes to the operating table; watch the front of the sterile gown; it may bulge
and touch the nonsterile table or blanket of the patient. Stand well back from the nonsterile table.
10. Hold drapes high enough to avoid touching them on the blanket but avoid touching the light.
11. Do not let your gloved hand touch the skin of the patient.
12. Hold the linen high until it is directly over the proper area then lay it down where it is to remain.
13. If a drape is incorrectly placed, the circulating nurse discards it from the table without
contaminating other drapes or site.
14. In unfolding the sheet on the operative site, toward the foot or the end of the table, protect the
gloved hands by enclosing it in the turned back cuff of the sheet provided for that purpose.
15. A towel clip that has been fastened through a drape has its points contaminated. Remove it
only if absolutely necessary then discard it.
16. Place the drapes on a dry area.

Fig. 1-36. Draping with a sterile laparotomy sheet. Fig. 1-37 Unfolding upper end of the laparotomy sheet
Scrub nurse carries folded sheet to table. Standing far over anesthesia screen. Note that hands approaching unsterile
back from the table, with one hand lay sheet on patient area are protected in a cuff of the drape and the sheet is stabilized
so opening in sheet is directly over prepared skin area. with other hand.