MEDICAL – SURGICAL ASEPSIS

DEFINITION:

ASEPSIS: (Aseptic Technique)

The freedom from infection and disease- causing microorganisms (germs or pathogens) that causes infection. It is
also refers to the practices/ procedures that help reduce the risk of infection.

RATIONALE:
An infection results from the actions of pathogens within the body and involves a cyclical interaction of six
components, collectively called infection chain. Barriers to prevent and transmission of pathogens are the most
realistic means to prevent diseases caused by microorganisms being transferred from one person to another. To
decrease the possibility of transferring microorganisms from one place to another, aseptic technique is used.

Two Basic Types:

1. MEDICAL ASEPSIS: (Clean Technique)
It includes all practices intended to confine a specific microorganism to a specific area, limiting the number, growth,
and spread of microorganisms.

Note: In medical asepsis, an article becomes contaminated when it is touched by the client or comes in contact
with his supplies. Objects are often referred to as clean or dirty. Medical asepsis includes all practices intended to
confine a specific microorganism to a specific area, limiting the number, growth, and transmission of
microorganisms. In medical asepsis, objects are referred to as clean, which means the absence of almost all
microorganisms, or dirty (soiled, contaminated), which means likely to have microorganisms, some of which may be
capable of causing infection.

2. SURGICAL ASEPSIS: (Sterile Technique)

Refers to those practices that keep an area or objects free from all microorganisms; it includes practices that destroy all
microorganisms and spores. It prevents contamination of an open wound, serves to isolate an operative area from
the unsterile environment and maintains a sterile field for surgery.

Note: An article becomes contaminated when it is touched by an unsterile object. Surgical asepsis is used for all
procedures involving the sterile areas of the body.

HAND HYGIENE

DEFINITION:

The most effective basic technique in preventing and controlling the transmission of infection (Mathur, 2011; WHO
2009).

Note: Hand hygiene is important in every setting, including hospitals. It is considered one of the most effective
infection prevention measures. Any client may harbor microorganisms that are currently harmless to the client yet
potentially harmful to another person or to the same client if they find a portal of entry. Hand washing with soap
and water may be inadequate to sufficiently remove pathogens, particularly because health care personnel tend to
not wash thoroughly. After the initial soap and water hand washing, the CDC recommends the use of alcohol-based
antiseptic hand rubs (rinses, gels, or foams) before and after each direct client contact.

Hand Hygiene Products

 Alcohol-based (hand) rub. An alcohol-containing preparation (liquid, gel or foam) designed for application to the
hands to inactivate microorganisms and/or temporarily suppress their growth. Such preparations may contain one
or more types of alcohol, other active ingredients with excipients, and humectants.
 Antimicrobial (medicated) soap. Soap (detergent) containing an antiseptic agent at a concentration sufficient to
inactivate microorganisms and/or temporarily suppress their growth. The detergent activity of such soaps may also
dislodge transient microorganisms or other contaminants from the skin to facilitate their subsequent removal by
water.
  Antiseptic agent. An antimicrobial substance that inactivates microorganisms or inhibits their growth on living
tissues. Examples include alcohols, chlorhexidine gluconate (CHG), chlorine derivatives, iodine, chloroxylenol
(PCMX), quaternary ammonium compounds, and triclosan.
 Antiseptic hand wipe. A piece of fabric or paper pre-wetted with an antiseptic used for wiping hands to inactivate
and/or remove microbial contamination.
 Waterless antiseptic agent. An antiseptic agent (liquid, gel or foam) that does not require the use of exogenous
water. After application, the individual rubs the hands together until the skin feels dry.

Hand hygiene practices

 Antiseptic handwashing. Washing hands with soap and water, or other detergents containing an antiseptic agent.
 Antiseptic handrubbing (or handrubbing). Applying an antiseptic handrub to reduce or inhibit the growth of
microorganisms without the need for an exogenous source of water and requiring no rinsing or drying with towels
or other devices.
 Hand antisepsis/decontamination/degerming. Reducing or inhibiting the growth of microorganisms by the
application of an antiseptic handrub or by performing an antiseptic handwash.
 Handwashing. Washing hands with plain or antimicrobial soap and water.
 Hand cleansing. Action of performing hand hygiene for the purpose of physically or mechanically removing dirt,
organic material, and/or microorganisms.
 Hand disinfection is extensively used as a term in some parts of the world and can refer to antiseptic handwash,
antiseptic handrubbing, hand antisepsis/decontamination/degerming, handwashing with an antimicrobial soap and
water, hygienic hand antisepsis, or hygienic handrub
 Hygienic hand antisepsis. Treatment of hands with either an antiseptic handrub or antiseptic handwash to reduce
the transient microbial flora without necessarily affecting the resident skin flora.
 Hygienic handrub. Treatment of hands with an antiseptic handrub to reduce the transient flora without necessarily
affecting the resident skin flora. These preparations are broad spectrum and fast-acting, and persistent activity is
not necessary.
 Hygienic handwash. Treatment of hands with an antiseptic handwash and water to reduce the transient flora
without necessarily affecting the resident skin flora. It is broad spectrum, but is usually less efficacious and acts
more slowly than the hygienic handrub.
 Surgical hand antisepsis/surgical hand preparation/ presurgical hand preparation. Antiseptic handwash or antiseptic
handrub performed preoperatively by the surgical team to eliminate transient flora and reduce resident skin flora.
Such antiseptics often have persistent antimicrobial activity.
 Surgical handscrub(bing)/presurgical scrub refer to surgical hand preparation with antimicrobial soap and water.
Surgical handrub(bing) refers to surgical hand preparation with a waterless, alcohol-based handrub.
The “My 5 Moments for Hand Hygiene” approach defines the key moments when health-care workers should perform hand
hygiene. This approach recommends health-care workers to clean their hands:
1. before touching a patient,
2. before clean/aseptic procedures,
3. after body fluid exposure/risk,
4. after touching a patient, and
5. after touching patient surroundings

FIGURE1. “5 MOMENTS OF HAND HYGIENE”

Source: WHO Guidelines on Hand Hygiene in Health Care First Global Patient Safety Challenge Clean Care is Safer
Care (2009)
PURPOSES:
1. To reduce the number of microorganisms on the hands.
2. To reduce the risk of transmission of microorganisms to clients.
3. To reduce the risk of cross - contamination among clients.
4. To reduce the risk of infection among other health care workers,
5. To reduce the risk of transmission of infectious organisms to oneself.

MATERIALS NEEDED:
Antiseptic Hand-rub
1. Alcohol- based, waterless, antiseptic – containing emollient
Hand washing
1. Easy-to-reach sink with warm running water
2. Antimicrobial or non-antimicrobial soap
3. Paper Towels or air dryer (optional)
4. Disposal nail cleaner (optional)

PERTINENT INFORMATION OR PRECAUTIONS TO TAKE

1. For routine client care, vigorous hand washing under a stream of water for 15 to 20 SECONDS using granular
soap, soap-filled sheets, or liquid soap at the beginning of the nurse’s shift, when hands are visibly soiled, and
after using the toilet is recommended (WHO, 2009).

2. Transient bacteria, pathogenic as well nonpathogenic, can be removed with relative ease by washing hands
thoroughly and frequently,

3. FRICTION, RUNNING WATER and CLEANSING AGENT are necessary to emulsify, reduce surface tension, and
remove microorganisms and/or other materials that may be present on the hands.

4. Because handwashing procedure causes microorganisms to accumulate in the sink, it is important that the
nurse avoids touching the sink and splashing dirty water on his/her uniform as he/she washes. Filing the nail
short is necessary prior to handwashing.

5. The need for handwashing depends on the type, intensity and duration, and sequence of activity.

6. The CDC promotes the use of alcohol-based hand rubs (foam or gel) because:
• They kill bacteria more effectively and more quickly than hand washing with soap and water.
• They are less damaging to skin than soap and water, resulting in less dryness and irritation.
• They require less time than hand washing with soap and water.
• Bottles/dispensers can be placed at the point of care so they are more accessible.

EXPECTED RESPONSIBILITIES OF THE NURSES AND THE PATIENT

1. The skill of hand hygiene is performed by all care givers.

2. Instruct all caregivers to use proper hand hygiene
3. Evaluate the handwashing facilities in the home to determine the potential for contamination, how close the
facilities are to the patient, and available supplies in the area.
4. Evaluate the availability of warm running water and soap when conducting home visits and anticipate the need for
alternative handwashing products such as alcohol-based hand rubs and/or detergent-containing towels.
5. Instruct the patient and primary caregiver in proper techniques and situations for handwashing
PROCEDURE

SUGGESTED ACTION RATIONALE

PREPARATION

1. Collect all equipment. Allows working in an orderly and organized manner.

2. Assess the hands:

Although the research is controversial, microorganisms can
a. Removal of all jewelry is recommended. Push lodge in the settings of jewelry and under rings. Removal
wristwatch and long uniform sleeves above wrists. facilitates proper cleaning of the hands and arms. Provides
Avoid wearing rings. complete access to fingers, hands, and wrists. Some studies
show that skin underneath rings carry a higher bacterial
load. Gram-negative bacilli, enterobacteria, and
Staphylococcus aureus are more common under rings
(Boyce and Pittet, 2008; Fagernes and Lingaas, 2009).

Short, natural nails are less likely to harbor microorganisms,

scratch a client, or puncture gloves. Subungual areas of
hands harbor high concentrations of bacteria. Long nails and
b. Nails should be kept short. Inspect conditions of chipped or old polish increase the number of bacteria
nails. Natural tips should be 1/4 inch from fingertip residing on hands. Artificial applications increase microbial
and smooth. DO NOT WEAR artificial nails or load on hands (Boyce and Pittet, 2008; CDC, 2002)
extensions.

A nurse who has open sores may require a work assignment

with decreased risk for transmission of infectious organisms
due to the chance of acquiring or passing on an infection.
Open cuts or wounds can harbor high concentrations of
microorganisms. Health care facility or agency policy often
c. Inspect surface of the hands for breaks in the skin,prevents nurses from caring for high-risk patients if open
such as hangnails or cuts in skin or cuticles. Cover lesions are present on hands.
any skin lesions with a dressing before providing
care. If lesions are too large to cover, you may be
restricted from direct patient care (CDC, 2002).
Performance
3. If you are washing your hands where the client can observe
you, introduce yourself and explain to the client what you are
going to do and why it is necessary.
4A. SURGICAL HAND PREPARATION TECHNIQUE WITH AN ALCOHOL-BASED HANDRUB FORMULATION
Note: The hand rubbing technique for surgical hand preparation must be performed on perfectly clean, dry hands. On arrival
in the operating theater and after donned theater clothing (cap/hat/bonnet and mask) hands must be washed with soap and
water. After operation when removing gloves, hands muct be rubbed with an alcohol based formulation or washed with soap
and water if any residual talc or biological fluids are present (e.g. the glove is punctured).
a. Apply approximately 5ml(3 doses) of alcohol based Enough amount of antiseptic solution is needed to
hand rub in the palm of your left hand , using the thoroughly cover the hands.
elbow of your other arm to operate the dispenser
b. Dip the fingers of your right hand in the hand rub
to decontaminate under the nails (5 secs)

c. Smear the handrub on the right forearm up to the Covering all aspects of the hands kills transient bacteria;
elbow. Ensure that the whole skin area is covered by ensures complete antimicrobial action.
using circular movements around the forearm until
the handrub has fully evaporated (10-15 seconds)
d. Put approximately 5 ml (3 doses) of alcohol based
hand rub in the palm of your right hand , using the
elbow of your other arm to operate the dispenser.
Perform the same procedure vice versa (to the left
arm)
 E1. Cover the whole surface of the hands up to the
wrist with alcohol based hand rub, rubbing palm
against palm with a rotating movement.
E2. Rub the back of the left hand , including the wrist,
moving the right palm back and forth, and vice-versa
E3. Rub palm back and forth with fingers interlinked.
E4. Rub the back of the fingers by holding them in the
palm of the other hand with sideways back and forth
movement.
E5. Rub the thumb of the left hand by rotating it in the
clasped palm of the right hand and vice versa.
c. Rub hands together for several seconds until Provides enough time for antimicrobial solution to work.
alcohol is dry. Allow hands to dry before applying
sterile clothing and gloves.
4.B HANDWASHING USING ANTISEPTIC SOAP
5. Stand in front of sink, keeping hands and uniform away Inside of sink is a contaminated area. Reaching over sink
from sink surface. (If hands touch sink during hand washing, increases risk of touching edge, which is considered
repeat process.) contaminated.
6. Turn on water and adjust the flow. There are five common Knee pads within the operating room and treatment areas
types of faucet controls by moving these with the elbows are preferred to prevent hand contact with faucet. Faucet
instead of the hands: handles are likely to be contaminated with organic debris
a. Hand-operated handles; and microorganisms (AORN, 2007).
b. Knee levers;
c. Foot pedals;
d. Elbow controls.
e. Infrared control. Motion in front of the sensor
causes water to start and stop flowing automatically.
Turn faucet on or push knee pedals laterally or press pedals
with foot to regulate flow and temperature. Warm water removes less of the protective oils than hot
water.
7. Avoid splashing water against uniform. Microorganisms travel and grow in moisture.
8. Wet hands and wrists thoroughly under running water. Hands are the most contaminated parts to be washed.
Keep hands and forearms lower than elbows during washing Water flows from least to most contaminated area, rinsing
and apply soap to the hands; Hold the hands lower than the microorganisms into the sink; the hands are generally
elbows so that the water flows from the arms to the considered more contaminated than the lower arms. Note
fingertips. that this is a different technique than is used when
performing surgical hand washing.

9. Apply soap to the hands, if the soap is liquid, apply 3 to 5 Ensures that all surface areas of the hands and fingers are
mL (1 tsp) of antiseptic soap and rub hands together cleaned.
vigorously, lathering thoroughly. If it is bar soap, granules, or
sheets, rub them firmly between the hands.
11. Thoroughly wash and rinse the hands; Use firm, rubbing, The circular action creates friction that helps remove
and circular movements to wash the palm, back, and wrist of microorganisms mechanically. Interlacing the fingers and
each hand. Be sure to include the heel of the hand. Interlace thumbs cleans the interdigital spaces.
the fingers and thumbs, and move the hands back and forth.
a. Rub hands palm to palm
b. Right palm over left dorsum with interlaced fingers
and vice versa
c. Palm to palm with fingers interlaced
d. Backs of fingers to opposing palms with fingers
interlocked
e. Rotational rubbing of left thumb clasped in right
palm and vice versa.
f. Rotational rubbing, backwards and forwards with
clasped fingers of right hand in left palm and vice
versa.
Duration of the entire procedure :40-60 seconds
12. Rub the fingertips against the palm of the opposite hand. The nails and fingertips are commonly missed during hand
hygiene
Optional:*After washing, rinse the bar of soap well under Dirt and organisms can accumulate on the bar of soap and
running water and drop the soap into the soap dish without can be spread to the next user. The soap dish is considered
touching the dish. contaminated.
13. Rinse hands and wrists thoroughly under running water, Rinsing mechanically washes away dirt and microorganisms,
keeping hands down and elbows up. loosened with soap, water, and friction, into the sink.
14. Thoroughly pat dry the hands and arms with a paper Moist skin becomes chapped readily as does dry skin that is
towel without scrubbing. rubbed vigorously; chapping produces lesions
15. Discard the paper towel in the appropriate container. Prevents transfer of microorganisms.
16. Turn off the water; Use a new paper towel to grasp a This prevents the nurse from picking up microorganisms
hand-operated control. from the faucet handles. Wet towel and hands allow transfer
of pathogens by capillary action. Organisms can accumulate
on faucets and spread to others.
17. Repeat washing procedure as indicated. When hands are heavily contaminated, a second and even a
third washing are necessary to assure that all dirt and
organisms have been removed.
Hand Washing Before Performing Sterile Skills

Apply the soap and wash as described in step 11, but hold the In this way, the water runs from the area that
hands higher than the elbows during this hand wash. Wet the now has the fewest microorganisms to areas with a
hands and forearms under the running water, letting it run relatively greater number of pathogens.
from the fingertips to the elbows so that the hands become
cleaner than the elbows.

After washing and rinsing, use a towel to dry one hand A clean towel prevents the transfer of microorganisms from
thoroughly in a rotating motion from the fingers to the one elbow (least clean area) to the other hand (cleanest
elbow. Use a new towel to dry the other hand and arm. area).

EVALUATION

 There is no traditional evaluation of the effectiveness of the individual nurse’s hand washing practices. Institutional
quality control departments monitor the occurrence of client infections and investigate those situations in which
health care providers are implicated in the transmission of infectious organisms.
 Research has repeatedly shown the positive impact of careful hand hygiene on client health associated with
prevention of infection.).
 More researchers are focusing on the relationship between quality of hand hygiene products (gentle, nondrying,
aromatic) and adherence to recommended protocols.
FIGURE 2. SURGICAL HAND PREPRATION TECHNIQUE WITH AN ALCOHOL –BASED HAND
PREPARATION
Source: WHO Guidelines on Hand Hygiene in Health Care First Global Patient Safety Challenge Clean Care is Safer
Care (2009)
 FIGURE 3. HAND HYGIENE TECHNIQUE WITH SOAP AND WATER

Source: WHO Guidelines on Hand Hygiene in Health Care First Global Patient Safety Challenge Clean Care is Safer Care (2009)
 Rub hands thoroughly Apply waterless antiseptic to hands

Lather hands thoroughly

Turn on the water

Rinse Hands Turn off Faucet

Source: Potter, P.A, Perry, A.G, Stokert, P.A, Hall, A. (2013). Fundamentals of Nursing Eight Editiion: Elsevier Inc.

SURGICAL HANDWASHING / SCRUBBING

I.DEFINITION:
 Is the process of removing as many microorganisms as possible from the hands and arms by mechanical washing
and chemical antisepsis before participating in an operation ( Atkinson, 1992).

AIM:
To scrub hands and arms in a thorough manner in order to decrease the bacterial count, preparatory to
participating in procedures that require surgical technique (such as in operating rooms, delivery rooms, burn units
and special diagnostic areas).

II. PURPOSES:

1. To decrease the number of resident microorganisms on skin to an irreducible minimum.

2. Apply an antimicrobial residue on the skin and reduce the growth or microorganisms during the operative
procedure.
3. To remove soil, debris, natural skin oils, and hand lotions from the skin decreasing the ability of remaining
microorganisms to multiply.

III. MATERIALS NEEDED:

1. Deep sink with foot or knee controls for dispensing water and soap
(Faucets should be high enough for hands and forearms to fit comfortably)
2. Antimicrobial Solution
3. Surgical scrub sponge / brush (sterilized reusable) with plastic nail pick/ cleaners (optional)
4. Paper face mask, cap or hood, surgical shoe covers
5. Sterile towel for drying hands
6. Sterile pack containing sterile gown
7. Protective eyewear (glasses or goggles)

IV. EXPECTED RESPONSIBILITIES OF THE NURSES AND THE PATIENT

1. The skill of hand hygiene is performed by all care givers.

2. Instruct all caregivers to use proper hand hygiene
3. The skill of surgical hand asepsis can be delegated to properly trained surgical technicians (know the state Nurse
Practice Act).
4. Remove nail polish if chipped or worn longer than 4 days because it likely will harbor microorganisms (AORN,
2007).

Note: Patients undergoing operative procedures are at an increased risk for infection. Nurses working in operating rooms
perform surgical hand antisepsis to decrease and suppress the growth of skin microorganisms in case of glove tears. For
maximum elimination of bacteria, remove all jewelry and keep the nails clean and short.

V. PROPER DOCUMENTATION
• It is not necessary to record or report this procedure.
• Report any skin dermatitis to employee health or infection control per agency policy.

SUGGESTED ACTION RATIONALE

1. Preparation for surgical hand scrub.

a. begin with proper attire: To provide effective b a r r i e r s t h a t p r e v e n t s

t h e dissemination of microorganisms.
 A loose-fitting uniform can contaminate the hands if it
touches them.
i. newly laundered scrub suit or dress with short
sleeves (above elbows) which is well tucked in the
waist Hair is a gross contaminant and is also a source of
electrostatic spark.
ii. scrub cap or hood that completely covers all hair
and pierced-ear studs
Contains and filters droplets containing microorganisms
expelled from the mouth and nasopharynx during talking,
iii.fresh disposable mask that fit snugly and sneezing, and coughing. Mask prevents escape into air of
comfortably over nose and mouth microorganisms that can contaminate hands.

Reduces microbial transfer from the outside into the area

protects wearer from spills into or onto shoes during
procedures.
iv. shoes or slippers restricted to wear in the
department/OR suit. (shoe covers may be worn)
Worn to reduce risk of blood and body fluids from
splashing into eyes.
v. eyewear or face shield if necessary
b. Remove all jewelry that includes bracelets, rings, Jewelry may harbor or protect microorganisms from
and watches. removal. Allergic skin reactions may occur as a result of
scrub agent or glove powder accumulating under jewelry.

c. Inspect condition of cuticles, hands, and forearms These conditions increase likelihood of more microorganisms
for abrasions, cuts, or open lesions. residing on skin surfaces. Broken skin permits
microorganisms to enter layers of the skin, providing deeper
microbial breeding grounds (AORN, 2007).
d. Be sure that fingernails are short (not reaching Long nails and chipped or old polish increase number of
beyond the fingertip), clean, and healthy. Artificial bacteria residing on nails. Long fingernails can puncture
nails should be removed. Natural nails should be less gloves, causing contamination. Artificial nails are known to
than 1/4 inch long. harbor gram-negative microorganisms and fungus (AORN,
2007; CDC, 2002).

2. Use deep sink-’with foot pedals or knee controls for Minimizes risk of hands and lower arms touching dirty
dispensing soap and controlling water temperature and flow. surface. Warm water enhances action of soap and removes
Turn on the water and adjust water flow to lukewarm protective oils from skin. Excessively hot water open pores to
temperature (if possible) using knee or foot controls and bacteria; Knee or foot controls prevent contamination of
adjust to comfortable temperature. hands after scrub.

3. Prescrub wash/rinse: Holding hands above the level of the Water runs by gravity from fingertips to elbows. Hands
elbow, wet hands and forearms liberally so that the lukewarm become cleanest part of upper extremity. Keeping hands
water runs from the fingertips to the elbows. elevated allows water to flow from least to most
contaminated areas. Washing a wide area reduces risk of
contaminating overlying gown that the nurse later applies.

4. Dispense liberal amount of soap/antiseptic solution. (2-5 Antiseptics alter the physical and chemical properties of the
ml) into hands- Beginning at the fingertips, lather hands and cell membrane of microorganisms, thus destroying or
arms to 5 cm (2 in.) above elbows, using firm, rubbing, inhibiting cellular function. Washing wide area reduces risk
circular and interlaced-fingers technique. Move from of contaminating overlying gown that nurse later applies.
fingertips to the elbows of one hand and repeat for the Circular strokes clean most effectively and rubbing ensures a
second hand. Continue washing for 20-25 seconds. (Hands thorough and mechanical cleaning action.
need to be above elbows at all times.)
5. Rinse off lather on each hand and arms separately and Rinsing removes transient bacteria from fingers, hands, and
thoroughly, keeping the hands up and allowing water to drip forearms. Water should flow from area of least
from the elbows. contamination to area of most contamination
6. Under running water clean under nails of both hands with Removes dirt and organic material that harbor large
nail pick. Discard after use. numbers of microorganisms.

7. Obtain sterile brush from container. Rinse brush and

saturate with antiseptic agent, if not previously impregnated.

8.A. Surgical hand scrub (with brush)

(Brush stroke method)

a. Wet clean sponge and apply antimicrobial agent. Friction loosens resident bacteria that adhere to skin
Visualize each finger, hand, and arm as having four surfaces. Ensures coverage of all surfaces. Scrubbing is
sides. Wash all four sides effectively. Scrub the nails performed from cleanest area (hands) to marginal
of one hand with 15 strokes. Scrub the palm, each area (upper arms).
side of thumb and fingers, and posterior side of hand
with 10 strokes each.

b. Divide the arm mentally into thirds: scrub each Eliminates transient microorganisms and reduces resident
third 10 times (AORN, 2007). Some health care hand flora.
facility policies require scrub by time rather than 10
strokes. Rinse brush and repeat sequence for the
other arm. A two-brush method may be substituted.

c. After completing second arm, rinse brush and

discard brush or put it on the side of the sink without Hands remain the cleanest part of upper extremities.
touching any part of the sink. Flex arms and rinse
from fingertips to elbows in one continuous motion,
allowing water to run off at elbow.

d. Rinse hands and arms one at a time, from

fingertips to elbow. Hold arm upward leading water
drip to the elbows. Be careful not to contaminate rinsing removes resident and transient bacteria and
new surgically clean hands and arms. sediment.

e. Turn off water with foot or knee control, with

hands elevated in front of and away from body.
Enter operating room suite by backing into room.
Keeps hands free of microorganisms.
f. Approach sterile setup; grasp sterile towel, taking
care not to drip water onto sterile setup.

Water contaminates sterile setup.

g. Bending slightly at waist, keeping hands and arms
above waist and outstretched, grasp one end of
sterile towel and dry one hand, moving from fingers
to elbow in a rotating motion
Avoids sterile towel from contacting unsterile scrub attire
h. Repeat drying method for other hand by carefully and transferring contamination to hands. Dry skin from
reversing towel or using a new sterile towel. cleanest (hands) to least clean (elbows).

i. Drop towel into linen hamper or circulating nurse’s

hand.
Prevents accidental contamination.

Prevents accidental contamination.

8.B. Optional: Brushless Antiseptic Hand Rub
 a. After pre scrub wash, dry hands and forearms Promotes reduction in microorganisms on all surfaces of
thoroughly with paper towel. hands and arms.

b. Dispense 2 mL of antimicrobial agent hand

preparation into palm of one hand. Dip fingertips of
opposite hand into hand preparation and work it
under nails. Spread remaining hand preparation over
hand and up to just above elbow, covering all
surfaces.

c. Using another 2 mL of hand preparation, repeat Ensures complete antiseptic coverage of all hand surfaces.
with other hand.

d. Dispense another 2 mL of hand preparation into

either hand and reapply to all aspects of both hands
up to wrist. Allow to dry before donning gloves.

9. Proceed with sterile gowning.

Note :
1. Always hold the hands higher than the elbows and above waist at all times.

2. The length of the surgical scrub varies, as does the scrub procedure. Variations depend on frequency of scrubbing the
agent used. and the method.

3. Hands should be washed as soon as gloves are removed because resident microorganisms multiply rapidly in
warm, moist environment under gloves.

4. Everyone should scrub according to a standardized written procedure.

5. Surgical handwashing or scrubbing should take at least 5 minutes before the first procedure of the day (Garner
1985). The CDC does not recommend a duration for surgical scrubs between procedures. However, 2-5 min is
probably acceptable.

Clean under fingernails Scrub side of fingers

 Scrub Forearms Rinse Arms

Grasp sterile towel and Drying Sequence

Source: Potter, P.A, Perry, A.G, Stokert, P.A, Hall, A. (2013). Fundamentals of Nursing Eight Editiion: Elsevier Inc.

WIPING HANDS AND ARMS WITH STERILE TOWEL

1. Reach down to the opened sterile package and pick up the towel To avoid contamination.
directly as one, holding it away from you at all times. Be careful not
to drip water onto the pack or touch sterile field with your bare
hands. Be sure no one is within arm’s reach.

2. Step back and open towel full-length, holding one full-length,

holding one end away from non-sterile scrub attire. Bend slightly
forward to avoid towel touching attire.

3 . Dry both hands thoroughly but independently. To dry one arm, hold
the towel in opposite hand and, using an oscillating motion of the arm
(slow, circular rotating motion) from fingers up to the elbow. Never
return to an area you already dried.
Moist skin readily becomes chapped and subject to open
4. Carefully reverse the towel, still holding it away from the body. sores. Thorough drying also makes it easier to don sterile
Dry the opposite arm on the unused end of the towel. gloves. The nurse dries the hands from the cleanest least
clean area.
5. Discard the towel.

6. Keep the hand in front and above waist. -

this position maintains the cleanliness of the hands and

prevents accidental contamination.

GOWNING

I. DEFINITION : Is a protective barrier worn over scrub suit to prevent strike- through i.e. immigration of microorganisms from skin and
scrub suit of wearer to sterile field and client, and penetration of blood and body fluids from client scrub suit and skin
of the wearer,
 II. PURPOSES : 1. To protect client from organisms which may be carried by the nurse
2. To enable the nurse to work close to a sterile field.
3. To differentiate sterile (scrubbed) from unsterile (unscrubbed) team members.

III. MATERIALS NEEDED:

1. a sterile package containing sterile gown

2. Sterile pack containing sterile gown
3. Clean, flat, dry surface
4. Paper face masks, cap or hood, surgical shoe covers
5. Protective eyewear/face shield

IV.PROCEDURE

SUGGESTED ACTION RATIONALE

APPLYING STERILE GOWN

1. Reach down to sterile gown package and lift folded gown directly Provides wide margin of safety, avoiding contamination of gown
upward (The gown surface you are holding is the inside or unsterile
side).

2. Step back away from table into unobstructed area and extend the To prevent gown from touching an unsterile object and provide a
arms at shoulder level. wide safety while gowning.

3. Keeping arms extended and elbow slightly flexed locate the neck The gown will be unsterile if its outer surface touches
band and hold gown securely with both hands. any unsterile article.

4. Holding the inside front of the gown just below the neckband with
both hands; let the gown unfold by gently shaking it keeping the
inside of the gown toward the body. Do not touch the outside of
the gown with bare hands.

5. Holding hands at shoulder level slip both arms into arm- - Hands are not sterile and touching would contaminate the gown.
holes simultaneously, keeping arms extended. Work arms The sleeves should be considered sterile from 2 in. above the elbow
partway into the sleeves without touching the outside of the gown to the cuff, since arms of a scrubbed person must move across the
and making sure the sleeves do not touch an unsterile object. sterile field

6. If this is followed by donning sterile gown by using the- closed The gown acts as sterile ‘mitt’ which assists in movement into the
method, work the hands down the sleeves only to the proximal gown.
edge of cuffs. If donning sterile gloves by using the open method,
work the hands down the sleeves and through the cuffs.

7. The circulating nurse brings gown over the shoulders by reaching The inside of the gown is considered contaminated and thus
inside to shoulder and arm seams. The gown is pulled on, leaving may be touched by the unsterile person.
the sleeves extended over the hands (closed method). The back of
the gown is securely tied at the neck and waist, touching outside of
gown at the line of ties, in back only.

8. The gowned nurse bends forward to make the ties fall away - Care must be taken not to permit neckties to fall forward to the
from gown. These are then tied by the circulating nurse alter front of the gown as this would contaminate the gown. Waist ties
grasping the end of the ties being careful not to touch the front of are sterile until touched by the circulating nurse.
the gown.

9. If the top of the gown drops downward inadvertently, or if the Contact with any unsterile object makes the gown unsterile. When
gown is contaminated at any point, discard the gown as worn, sterile gowns should be considered sterile in front from the
contaminated and repeat the procedure. Never reverse a piece of chest to the level of the sterile field
sterile linen, if the wrong end is dropped toward the floor
 GLOVING
I. DEFINITION

 Sterile gloves complete the attire for scrubbed team members

 The sterile gloves put on immediately after gowning.
 Sterile gloves are packaged with a cuff of about 5 cm (2 in.) and with the palms facing upward when the package is
opened. The package usually indicates the size of the glove (e.g., size 6 or 7 1/2 or small, medium, large).

II. PURPOSES

1. OPEN METHOD
1 Toenablethenurse tohandleor touch sterileobjects freelywithoutcontaminatingthem
2.Topreventtransmissionofpotentiallyinfectiveorganismsfrom thenurse’shands toclientsathighriskfor infection

2.CLOSEDMETHOD:
1.Toenablethenursetoworkcloseto asterilefieldandhandlesterileobjectsfreely
2. To protectclientsfrombecoming contaminatedwithmicroorganismsonthenurse’shands, arms,andclothing

III. MATERIALS NEEDED:

1. Package of sterile gloves.

IV. PROPER DISPOSAL OF USED EQUIPMENT

1. Grasp outside of one cuff with other gloved hand; avoid touching wrist. Pull halfway down palm of hand. Take thumb of half-
ungloved hand and placeunder cuff of other glove.
2. Pull glove off, turning it inside out. Discard in receptacle. Rationale: Outside of glove does not touch skin surface.
3. Take fingers of bare hand and tuck inside remaining glove cuff. Peel glove off,
inside out. Discard in receptacle.

V. PERTINENT INFORMATION OR PRECAUTIONS TO TAKE

1. Review the client’s record and orders to determine exactly what procedure will be performed that requires sterile gloves.
2. Check the client record and ask about latex allergies.
3. Use nonlatex gloves whenever possible.

VII. EXPECTED RESPONSIBILITIES OF THE NURSES AND THE PATIENT

1. Sterile gloves are used by many health care providers.
2. All providers should be comfortable pointing out to each other when any break in sterile technique is
detected

VIII. PROPER DOCUMENTATION

Document that sterile technique was used in the performance of the procedures
TWO METHODS:

I. CLOSED TECHNIQUE

DEFINITION : It provide means of putting on a sterile gown and gloves without the outside of the gown or
gloves touching the skin.

PROCEDURE:
SUGGESTED ACTION

1. After scrubbing and drying the hands, perform gowning by working the hands down the sleeves only to the proximal edge of the
cuff.

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

3. 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, glove fingers are pointing toward you and the thumb of the
glove is to the right. The thumb side of the glove is down.

4. Grasp the back of the cuff in the left hand and turn/stretch glove over the end of the right sleeve, and hand. The cuff of glove is
now over the stockinet cuff of the gown, with hand still inside the sleeve.

5. Grasp the top right glove and underlying gown sleeve with covers left hand. Pull glove on over extended right fingers until it
completely covers the stockinet cuff. Pulling on is as though they are one unit.

6- Pick up left glove with right hand in the same manner reversing hands. Make sure that both gloves entirely cover the stockinet of
cuff portions of gown.
SUGGESTED ACTION RATIONALE
1. With hands covered by gown sleeves, open inner sterile glove Hands remain clean. Sterile gown cuff touches sterile glove surface.
package
2. Put the glove on the nondominant handshow a right-handed Sterile gown touches sterile glove.
person. With dominant hand inside gown cuff, pick up glove with
the thumb and index finger, handling it through the sleeve for
nondominant hand by grasping folded cuff.
3. Extend nondominant forearm with palm up and place palm of Positions glove for application over cuffed hand, keeping glove
glove against palm of nondominant hand. Glove fingers point sterile.
toward elbow.
4. Grasp back of glove cuff with covered dominant hand and turn Seal created by glove cuff over gown prevents exit of
glove cuff over end of nondominant hand and gown cuff. microorganisms over operative sterile field.
5. Grasp top of glove and underlying gown sleeve with covered
dominant hand. Carefully extend fingers into glove, being sure that
glove cuff covers gown cuff.
6. Glove dominant hand in same manner, reversing hands . Use Sterile touches sterile.
gloved nondominant hand to pull on glove. Keep hand inside
sleeve.
7. Be sure that fingers are fully extended into both gloves. Ensures that nurse has full dexterity while using gloved hand.
8. For wraparound sterile gowns: take gloved hand and release Front of gown is sterile
fastener or ties in front of gown.
9.Hand paper tab connected to sterile tie to circulating nurse, who Contact with team member could contaminate gown and gloves.
is nonsterile Circulating nurse stands still as you turn completely Gown must enclose undergarments.
around to left, allowing for margin of safety as gown wraps around
and covers your back. Take back sterile tie from circulating nurse
and secure tie to gown.
 Scrub nurse opens glove package

Glove is applied to left hand as right hand remains inside

cuff

Second glove is applied

Source: Potter, P.A, Perry, A.G, Stokert, P.A, Hall, A. (2013). Fundamentals of Nursing Eight Editiion: Elsevier Inc.
II. 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 the sterile gloves.
SUGGESTED ACTION RATIONALE
1.After scrubbing and drying hands, proceed to gowning by working
the hands down the sleeves and through the cuff without touching
the sterile exterior of the gown with bare hands.
2. Remove outer glove package wrapper by carefully separating and Prevents inner glove package from accidentally opening and
peeling apart sides. touching contaminated
objects.
3. Place the open package on a clean , dry surface just above the Any moisture on the surface could contaminate the gloves; Sterile
waist level, keeping gloves on wrappers inside surface object held below waist is contaminated. Inner surface of glove
package is sterile
4 Identify right and left glove. Each glove has cuff approximately 5 Proper identification of gloves prevents contamination by
cm (2 inches) wide. Glove dominant hand first. improper fit.
5. Glove dominant hand first. With the thumb and first two fingers, Gloving of dominant hand first improves dexterity. Inner edge of
grasp edge of cuff of the glove for dominant hand. Pick up the cuff lies against skin and thus is not sterile.
glove, holding away from the body, above waist, then step back
from the table. Touch only the inside of the cuff.
6. Carefully pull glove over dominant hand, leaving cuff turned well if glove’s outer surface touches hand or wrist, it is
down over hand and being sure it does not roll up wrist. Keep the contaminated. If the thumb is kept against the palm, it is less likely
thumb of the inserted hand against the palm of the hand during to contaminate the outside of the glove. If outer surface of glove
insertion. Be sure thumb and fingers are in proper spaces. touches hand or wrist, it is contaminated.
7. With gloved dominant hand, pick up the other glove by inserting Cuff protects gloved fingers. Sterile touching sterile prevents glove
the fingers underneath second glove’s cuff. Lift the glove away contamination.
from the body and step back.

8. Carefully pull second glove over nondominant hand. Do not allow Contact of gloved hand with exposed hand results in
fingers and thumb of gloved dominant hand to touch any part of contamination.
exposed nondominant hand. Keep thumb of dominant hand
abducted back.
9. After second glove is on, interlock fingers of gloved hands and contact of gloved hand with exposed hand results in
hold away from body above waist level until beginning procedure contamination.

III. GLOVING ANOTHER PERSON

1. Pick up the right glove, grasp it firmly, with fingers under the everted cuff. Hold the palm of glove towrd the surgeon.
2. Stretch the cuff sufficiently for the surgeon to insert the hand. Avoid touching the hand by holding your thumbs up.
3. Exert upward pressure as the surgeon plunges the hand into the gloves. Unfold the everted glove cuff of the sleeve.
4. Repeat for the left hand.

Note:
1. Place the sterile glove package on a clean, dry surface because any moisture in the surface may contaminate the gloves.
2. Always hold gloves above waist level.
3. First glove is put on with skin-to-skin technique, bare hand to inside cuff.
4. If gloves are not pre powdered, take packet of powder and apply lightly to hands so gloves will slip on easily.
Source: WHO Guidelines on Hand Hygiene in Health Care First Global Patient Safety Challenge Clean Care is Safer Care (2009)
Source: WHO Guidelines on Hand Hygiene in Health Care First Global Patient Safety Challenge Clean Care is Safer Care (2009)

Open Package
 Pull glove over dominant hand Slip fingers underneath cuff of second glove

Pull second glove over nondominant hand Hands are interlocked

ESTABLISHING AND MAINTAINING A STERILE FIELD

I.DEFINITION : A sterile field is a microorganisms - free area. Sterile objects may then be placed on the sterile field and still be
sterile.

II. PURPOSES
1. To ensurethat sterileitemsremainsterile.

III. MATERIALS NEEDED:

1. Sterile pack (commercial or institution wrapped) / Package containing a sterile drape

2. Sterile equipment as needed (e.g., wrapped sterile gauze, wrapped sterile bowl, antiseptic solution, sterile forceps)
3. Sterile drape to be used as a sterile field
4. Sterile gloves (optional, check agency policy)
5. Sterile solution and equipment specific to the procedure
6. Waist-high table or countertop surface
7. Appropriate PPE (see agency policy)

IV. PERTINENT INFORMATION OR PRECAUTIONS TO TAKE

1. Conduct any follow-up indicated during your care of the client.
 2. Ensure that adequate numbers and types of sterile supplies are available for the next health care provider.
3. When preparing a sterile field, the nurse may use gloved or ungloved hand.
4. The most important principle to follow in preparing a field is to AVOID CONTAMINATION by:
a) not reaching over a drape
b) not allowing the drape to touch the uniform.
c) not allowing the drape’s sterile surface to touch the client
5. Maintaining work area should be above waist level.
6. Sterile supplies should not be opened in a confined space-where a dirty object might fall on or strike them.

V. LEGAL IMPLICATIONS

VI. EXPECTED RESPONSIBILITIES OF THE NURSES AND THE PATIENT

1. Sterile fields and procedures may be within the scope of practice for many health care providers.
2. These providers may perform the procedure independently or with a nurse or other provider.
3. Although these providers may verbally communicate about the procedure to health care team members, the nurse must also
know where to locate their documentation in the client’s medical record
4. Conduct any follow-up indicated during your care of the client.
5. Ensure that adequate numbers and types of sterile supplies are available for the next health care provider.

SUGGESTED ACTION RATIONALE

IMPLEMENTATION

Preparation

a. Ensure that the package is clean and dry and select a clean, dry Moisture is noted on the inside of a plastic-wrapped package or the
work surface above waist level. outside of a cloth-wrapped package, it is considered contaminated
and must be discarded. A sterile object held below the waist is
contaminated.

Sterile supply or piece of equipment should never be used after the

expiration date. The item is discarded or returned to the supply
b. Check the sterilization expiration dates on the package, and look area for resterilization.
for any indications that it has been previously opened. Spots or
stains on cloth or paper-wrapped objects may indicate
contamination, and the objects should not be used.
Sterile field should be prepared as close as possible to time of use
c. Complete all priority care tasks before beginning procedure. (AORN, 2007).

d. Follow agency practice for disposal of possibly contaminated

packages.

1. Perform hand hygiene and observe other appropriate infection Reduces transmission of microorganisms.
prevention procedures

2. Open the package.

 *If the package is inside a plastic cover, remove the cover.

3.Open a Wrapped Package on a Surface

a. Place the package on a clean dry surface, in the center of the Wet surface under sterile field will contaminate it as solution is
work area so that the top flap of the wrapper opens away from you. absorbed. Pack can be opened without reaching over a sterile
Remove tape on pack. field. Touching only the outside of the wrapper maintains the
sterility of the inside of the wrapper. Pull the flap open, laying it
flat on the far surface.

b. Reaching around the package (not over it), pinch the first flap Touching only the outside of the wrapper maintains the sterility of
the outside of the wrapper between the thumb and index finger. the inside of the wrapper. Pull the flap open, laying it flat on the far
With some folded packages, it may be necessary to grasp the surface. Outer surface of package is considered unsterile. There is a
uppermost flap at each corner. Open the pack away from yourself, 2.5-cm (1-inch) border around any sterile drape or wrap that is
bringing your arm back around the outside of the open pack. considered unsterile.being able to watch each flap being opened
decreases the risk of contamination. Using both hands avoids
reaching over the sterile contents.

if the inner surface touches any unsterile article, it is

contaminated.
c. Open side flaps one at a time, opening the top one - first. Use
the right hand for the right flap and the left hand for the left flap.

d. Open flap nearest to you last by grasping the corner that is

turned, down. Make sure the flap does not touch your uniform.

Opening a Wrapped Package While Holding It

a. Hold the package in one hand with the top flap opening away Hands are considered contaminated and that at no time should they
from you. touch the contents of the package.

Sterility is maintained when sterile objects are placed within a

b.Using the other hand, open the package as described above, sterile field.
pulling the corners of the flaps well back. Tuck each of the corners
into the hand holding the package so that they do not flutter and
contaminate sterile objects. The hands are considered
contaminated, and at no time should they touch the contents of
the package.

(Inside the wrapper is considered sterile, except -for the 1-inch

border around the edges, and may be used as base for sterile field
or as a field to add additional items.)

Opening Commercially Prepared Packages

a. If the flap of the package has an unsealed corner, hold the Commercially prepared sterile packages and containers usually
package in one hand, and pull back on the flap with the other hand. have manufacturer’s directions for opening.

b.If the package has a partially sealed edge, grasp both sides of the
edge, one with each hand, and pull apart gently

3. Rewrap the sterile package as required by reversing the

order to unwrapping. Close the proximal flap first to prevent
reaching across sterrile field, the side flaps next, and the disatal
part last.
4. Establish a sterile field by using a drape.

a. Open the package containing the drape as described at STEP 3.

b. With one hand, pluck the corner of the drape that is folded back
on the top touching only one side of the drape.

c. Lift the drape out of the cover, and allow it to open freely
without touching any objects.
If the drape touches the outside of the package or any unsterile
surface, it is considered contaminated.
d. With the other hand, carefully pick up another corner of the
drape, holding it well away from you and, again, touching only the
same side of the drape as the first hand.

• Lay the drape on a clean and dry surface, placing the Bottom (i.e.,
the freely hanging side) farthest from you.
By placing the lowermost side farthest
away, you avoid leaning over the sterile field and
contaminating it.
5. Add necessary sterile supplies, being careful not to touch the
drape with the hands.

*To Add Wrapped Supplies to a Sterile Field

a. Open each wrapped package as described in the preceding steps. The sterile wrapper now covers the unsterile hand.

b. With the free hand, grasp the corners of the wrapper, and hold
them against the wrist of the other hand.

c. Place the sterile bowl, drape, or other supply on the sterile field
by approaching from an angle rather than holding the arm over the
field.

d. Discard the wrapper.

*Adding Commercially Packaged Supplies

to a Sterile Field

a. Open each package as previously described.

b. Hold the package 15 cm (6 in.) above the field, and allow the At a height of 15 cm (6 in.), the outside of the
contents to drop on the field. Keep in mind that 2.5 cm (1 in.) package is not likely to touch and contaminate the sterile field.
around the edge of the field is considered contaminated.

*Adding Solution to a Sterile Bowl

Liquids (e.g., normal saline) may need to be poured into containers

within a sterile field. Unwrapped bottles that contain sterile solution
are considered sterile on the inside and contaminated on the
outside because the bottle may have been handled. Bottles used in
an operating room may be sterilized on the outside as well as the
inside, however, and these are handled with sterile gloves.

a. Obtain the exact amount of solution, if possible. Once a sterile bottle has been opened, its sterility cannot be
ensured for future use. Follow agency policy for reuse of opened
sterile solution bottles.

b. Before pouring any liquid, read the label three times to make safety; prevent error by using wrong solution.
sure you have the correct solution and concentration (strength).
Wipe the outside of the bottle with a damp towel to remove any
large particles that could fall into the bowl or field.

c. Remove the lid or cap from the bottle and 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.

d. Hold the bottle so that the label is against the palm of the hand.
Any solution that flows down the outside of the bottle during
pouring will not damage or obliterate the label.

e. Hold the bottle of fluid at a height of 10 to 15 cm (4 to 6 in.) over

the bowl and to the side of the sterile field so that as little of the At this height, there is less likelihood of contaminating the sterile
bottle as possible is over the field. field by touching the field or by reaching an arm over it.

f. Pour the 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
g. Tilt the neck of the bottle back to vertical quickly when done
pouring so that none of the liquid flows down the outside of the Such drips would contaminate the sterile field
bottle. if the outside of the bottle is not sterile.

hIf the bottle will be used again, replace the lid securely and write
on the label the date and time of opening. Replacing the lid immediately maintains the sterility of the inner
aspect of the lid and the solution. Depending on agency policy, a
sterile container of solution that is opened may be used only
onceand is then discarded (such as in the operating room). In other
settings, policy may permit recapped bottles to be reused within 24
hrs.

6. Use sterile forceps to handle sterile supplies. Forceps are usually used to move a sterile article from one place to
another, for example, transferring sterile gauze from its package to
a sterile dressing tray. Forceps may be disposable or resterilized
after use. Commonly used forceps include hemostats and tissue
forceps.

Gravity prevents liquids on the tips of the

a.If forceps tips are wet, keep the tips lower than the Forceps from flowing to the unsterile handles and later back to the
wrist at all times, unless you are wearing sterile gloves. tips.

b. Hold sterile forceps above waist or table level,

whichever is higher. Items held below waist or table level are considered contaminated.

c. Hold sterile forceps within sight. While out of sight, forceps may, unknown to the user, become
unsterile. Any forceps that go out of sight should be considered
unsterile.

d. When using forceps to lift sterile supplies, be sure that The edges and outside of the sterile field are considered unsterile.
the forceps do not touch the edges or outside of the
wrapper.

The handles of these forceps harbor microorganisms from the bare

e. When placing forceps whose handles were in contact hand.
 with the bare hand, position the handles outside the
sterile area.

f. Deposit a sterile item on a sterile field without

permitting moist forceps to touch the sterile field when
the surface under the absorbent sterile field is unsterile
and a barrier drape is not used.

8. Document that sterile technique was used in the performance of

the procedure.
Note: Forceps are usually packaged and discarded or resterilized after use.
Handle sterile objects only with sterile forceps or sterile gloved hands.
EVALUATION
• Conduct any follow-up indicated during your care of the client. Ensure that adequate numbers and types of sterile supplies are
available for the next health care provider

APPLYING AND REMOVING PERSONAL PROTECTIVE EQUIPMENT

(GLOVES, GOWN, MASK, EYEWEAR)
Purpose: • To protect health care workers and clients from transmission of potentially infective material
SUGGESTED ACTION RATIONALE
1. Prior to performing the procedure, introduce self and verify the
client’s identity using agency protocol. Explain to the client what
you are going to do, why it is necessary, and how he or she can
participate.
2. Perform hand hygiene
3. Apply a clean gown.

a. Pick up a clean gown, and allow it to unfold in front of you

without allowing it to touch any area soiled with body
substances.

b. Slide the arms and the hands through the sleeves. Fasten
the ties at the neck to keep the gown in place.

c. 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, which can cause
inadvertent soiling of the uniform
4. Apply the face mask.
a. Locate the top edge of the mask. The mask usually has a
narrow metal strip along the edge.

b. Hold the mask by the top two strings or loops.

c. Place the upper edge of the mask over the bridge of the With the edge of the mask under the glasses, clouding of the
nose, and tie the upper ties at the back of the head or glasses is less likely to occur.
secure the loops around the ears. If glasses are worn, fit
the upper edge of the mask under the glasses. To be effective, a mask must cover both the nose and the mouth,
because air moves in and out of both.
d. Secure the lower edge of the mask under the chin, and tie
the lower ties at the nape of the neck.

e. If the mask has a metal strip, adjust this firmly over the A secure fit prevents both the escape and the inhalation of
bridge of the nose. microorganisms around the edges of the mask and the fogging of
eyeglasses.
 As masks are worn they become moist from the wearer’s breath
f. Avoid unnecessary talking and, if possible, sneezing or and can therefore which microorganisms through from the surface
coughing when caring for an at-risk client. Masks should be to the wearer.
changed as soon as moisture is detected on the surface.
A mask should be used only once because it becomes ineffective
when moist.

g. Wear the mask only once, and do not wear any mask
longer than the manufacturer recommends or once it
becomes wet.

h. Do not leave a used face mask hanging around the neck.

5. Apply protective eyewear if it is not combined with the face mask.
6. Apply clean gloves.
a. Take out a glove from its original box.

b. Touch only a restricted surface of the glove corresponding

to the wrist ( at the top edge of the cuff)

c. Don the first glove

d. Take the second glove with the bare hand and touch only
a restricted surface of glove corresponding to the wrist.

e. To avoid touching the skin of the forearm with the gloved

hand, turn the external surface of the glove to be donned
on the folded fingers of the gloved hand, thus permitting
to glove the second hand.

f. Once gloved. hands should not touch anything else that is

not defined by indicators and conditions for glove use.

g. If wearing a gown, pull the gloves up to cover the cuffs of

the gown. If not wearing a gown, pull the gloves up to
cover the wrists.
7. To remove soiled PPE, remove the gloves first since they are the
most soiled.
a. If wearing a gown that is tied at the waist in front, undo
the ties before removing gloves.

b. Remove the first glove by grasping it on its palmar surface, This keeps the soiled parts of the used gloves from touching the
taking care to touch only glove to glove. skin of the wrist or hand
.
c. Pull the first glove completely off by inverting or rolling
the glove inside out.

d. Continue to hold the inverted removed glove by the

fingers of the remaining gloved hand. Place the first two Touching the outside of the second soiled glove with the bare hand
fingers of the bare hand inside the cuff of the second is avoided.
glove

e. Pull the second glove off to 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
f. Using the bare hand, continue to remove the gloves, chance of transferring any microorganisms by direct contact.
which are now inside out, and dispose of them in the
refuse container.
8. Perform hand hygiene. Contact with microorganisms may occur while removing PPE.
9. Remove protective eyewear and dispose of properly or place in
the appropriate receptacle for cleaning
10. Remove the gown when preparing to leave the room.
a. 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 a respiratory infection.
b. Grasp the gown along the inside of the neck and pull
down over the shoulders. Do not shake the gown.
c. Roll up the gown with the soiled part inside, and discard it
in the appropriate container.
11. Remove the mask.
a. Remove the mask at the doorway to the client’s room. If This prevents the top part of the mask from falling onto the chest.
using a respirator mask, remove it after leaving the room
and closing the door.

b. If using a mask with strings, first untie the lower strings of

the mask.

The front of the mask through which the nurse has been breathing
c. Untie the top strings and, while holding the ties securely, is contaminated
remove the mask from the face. If side loops are present,
lift the side loops up and away from the ears and face. Do
not touch the front of the mask.

d. Discard a disposable mask in the waste container.

e. Perform proper hand hygiene again.

EVALUATION
• Conduct any follow-up indicated during your care of the client. If there has been any failure of the equipment and exposure to
potentially infective materials is suspected, follow the procedure in the Practice Guidelines: Steps to Follow After Exposure to
Bloodborne Pathogens.
• Ensure that an adequate supply of equipment is available for the next health care provider.
 USING A MASK

DEFINITION : Masks are made of washable cloth or disposable material intended to filter inspired air and expired air inorder to
trap organisms in its meshes.
 PURPOSES : 1. To prevent the inhalation of infective airborne microorganisms and droplet nuclei in which they are
carried.
2. To prevent the spread of airborne microorganisms from the nurse’s respiratory tract to client’s at risk or
to a sterile area.
3. To protect health care workers and clients from transmission of potentially infective materials

The Center for Disease Control (CDC) recommends that masks be worn:

1. Only those close to the client if the infection is transmitted by large-particle aerosols (generally travel short distances)
2. By all persons entering the room if the infection is transmitted by small particles aerosols (which remains suspended
in the air and thus travel greater in the rooms of clients
3. By all persons entering the rooms of clients who requires strict isolation, and those in close contact with clients who require
contact isolation.
PROCEDURE

SUGGESTED ACTION RATIONALE

Apply the face mask.

a. Locate the top edge of the mask. The mask usually has a narrow
metal strip along the edge.

b. Hold the mask by the top two strings or loops.

c. Place the upper edge of the mask over the bridge of the nose, With the edge of the mask under the glasses, clouding of the
and tie the upper ties at the back of the head or glasses is less likely to occur.
secure the loops around the ears. If glasses are worn, fit the upper
edge of the mask under the glasses.

d. Secure the lower edge of the mask under the chin, and tie the To be effective, a mask must cover both the nose and the mouth,
lower ties at the nape of the neck. because air moves in and out of both.

e.If the mask has a metal strip, adjust this firmly over the bridge of A secure fit prevents both
the nose. the escape and the inhalation of microorganisms around the edges
of the mask and the fogging of eyeglasses.

f. Avoid unnecessary talking and, if possible, sneezing or coughing

when caring for an at-risk client. Masks should be changed as soon as masks are worn they become moist from the wearer’s breath and
as moisture is detected on the surface. can therefore which microorganisms through from the surface
to the wearer.

g. Wear masks only once, and do not wear any mask longer than masks collect microorganisms outside surface, concentrating
the manufacturer recommends. Do not leave a used mask hanging them in that location. A mask should be used only once because it
around neck. becomes ineffective when moist.

h.Don gloves, if needed

Remove the mask.

a.Remove the mask at the doorway to the client’s room. If using a This prevents the top part of the mask from falling onto the chest.
respirator mask, remove it after leaving the room and closing the
door.

b. If using a mask with strings, first untie the lower strings of the
mask.
The front of the mask through which the nurse has been breathing
c. Untie the top strings and, while holding the ties securely, remove is contaminated.
the mask from the face. If side loops are present, lift the side loops
up and away from the ears and face. Do not touch the front of the
mask.

• Discard a disposable mask in the waste container.

• Perform proper hand hygiene again.

EVALUATION
• Conduct any follow-up indicated during your care of the client. If there has been any failure of the equipment and exposure to
potentially infective materials is suspected, follow the procedure in the Practice Guidelines: Steps to Follow After Exposure to Bloodborne
Pathogens later in this chapter.
• Ensure that an adequate supply of equipment is available for the next health care provider.

GOWNING FOR ISOLATION PRECAUTIONS

PURPOSES : 1. To prevent soiling of the care providers clothing from microorganisms that can be spread on clothing
2. To prevent transmission of microorganisms from the care provider to client at risk.

PROCEDURE

SUGGESTED ACTION b. Don face mask, if required.

1. Prepare to don the gown. 2. Don a clean gown.

a. Wash hands thoroughly to prevent a. Pick up a clean gown, and allow it to unfold in
the transmission of microorganisms to client. front of you without allowing it to touch any
area soiled with body.
 RATIONALE
b. Slide the arms and the hands through the sleeves. One arm at a
time.
infected clients may have lowered resistance to
microorganisms that do not usually cause infection.
c. Fasten ties at the neck to keep the gown in place, after
pulling gown over shoulders.

d. Wrap gown around waist, making sure the back is completely

covered. Fasten strings or waist ties or belts around waist.

3. Don disposable gloves, if required.

4. Remove the gown when preparing to leave the room.

a. If wearing gloves remove and dispose it in the
appro¬priate container.

b. Untie waist strings.

c. Untie neck strings, bringing them around shoulders so that

gown is partially off your shoulders.

d. Using your dominant hand and grasping clean part of

wristlet, pull sleeve wristlet over your non-dominant hand. Use overlapping securely covers uniform at the back. Waist ties
your non-dominant hand to pull sleeves wristlet over your keep the gown from falling away from the body and
dominant hand. prevents inadvertent soiling of the uniform.

the gloves are likely to be more soiled than the gown and
therefore removed first.
 e. Grasp outside of gown through sleeves at shoulders. Pull
gown over your arms.

f. Hold both shoulders in one hand. Carefully draw your other

hand out of the gown, turning arm of gown inside out. Repeat
this procedure in your other arm.

g. Hold gown away from your body. Roll gown with the soiled
part inside, and discard appropriate container. Avoid touching
soiled parts on the outside of the gown as much as possible.

h. If gown is reusable, hang it in appropriate place.

i. Remove and discard the mask, if one has been worn, in

appropriate container.

j. Washands. - to prevent cross infection of other client.

USING DISPOSABLE GLOVES

PURPOSES : 1. To reduce possibility of personnel coming in contact with infectious organisms that infect clients.
2. To reduce likelihood that personnel will transmit their own endogenous flora to clients.
3. To reduce possibility that personnel will become transiently colonized with microorganisms that can be
transmitted to other clients.
Specifically, gloves are recommended when:
1. the nurse has scratches or breaks in the skin
2. when performing venipuncture, finger, or heel sticks
3. when she/he expects to spill blood on the hands
4. when the nurse is inexperienced.

PROCEDURE

SUGGESTED ACTION RATIONALE

1. Prepare to don gloves.

a. Thoroughly wash and dry hands.
b. Don mask and a gown, if requires.

2. Don gloves.
a. Take clean gloves out of the box.
b. Slip fingers in openings and pull glove up to the wrist.
Repeat step with second glove.
c. If you are wearing a gown, place gloves so that they cover
gown wristlets. If you are not wearing a gown, place gloves so
that they cover your wrists.

3. Remove gloves.
a. Remove the first glove by grasping it on its palmar surface just
below the cuff, taking care to touch only glove to glove.

b. pull the first glove completely off by inverting or rolling the - this keeps the soiled parts of the used gloves from
glove inside out. touching the skin of the wrist or hand.
c. Continue to hold the inverted removed glove by the . fingers - touching the outside of the second soiled glove with the
of the remaining gloved hand. Place the first two lingers of the bare hand is avoided.
bare hand inside the cuff of the second glove.

d. Pull the second glove off to the fingers by turning it inside out.
This pulls the first glove inside second glove.
- the soiled part of the glove is folded to the inside to
e. Using a bare hand, continue to remove the gloves, which are reduce the chance of transferring any microorganisms by
now inside out, and dispose-of them in the refuse. direct contact.

f. Wash and dry your hands.