PROTECTION OF THE SUSCEPTIBLE HOST

The nurse intervenes to maintain the body’s normal healing processes (Box 29-12). Nurses also protect themselves and others from cross-infection through vigilant use of standard and transmission-based precautions. Decisions concerning the level of precaution required in specific circumstances are not always straightforward.

PROTECTIVE ENVIRONMENT

Private rooms used for isolation may have negative-pressure airflow to prevent infectious particles from flowing out of the room. Air leaving the room is filtered using high-efficiency particulate air (HEPA) filters to 99% clean it, ensuring air is free of microbes as it is released into the atmosphere (Siegel and others, 2007). Conversely, positive-pressure airflow is used in surgical operating rooms and for highly susceptible patients such as organ transplant recipients. Air in these rooms is HEPA filtered as it enters from the ceiling, and used air is extracted through vents located on the walls close to floor level. A notice listing the additional transmission-based precautions can be posted outside the room (Figure 29-6). This notice is a handy reference for healthcare personnel and visitors and alerts anyone who might enter the room that special precautions must be followed.

FIGURE 29-6 Example of transmission-based precautions poster for door of patient room.

From National Health and Medical Research Council (NHMRC) n.d. Canberra, NHMRC. Online. Available at http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/cd33_airborne_poster_111216.pdf

The private isolation room or an adjoining anteroom should contain soap and antiseptic solutions and toilet facilities. Personnel and visitors are required to wash their hands before approaching the patient’s bedside and again before leaving the room. If toilet facilities are unavailable, infection-control procedures for handling portable commodes, bed pans or urinals are implemented. Personal protective equipment should be stored in an anteroom between the room and hallway or in a convenient location close to the point of use.

An impervious bag for soiled or contaminated linen, as well as a rubbish container with plastic liners, should be readily available and never overfilled. Impervious receptacles prevent transmission of microorganisms by preventing seepage to and soiling of the outside surface. A disposable, rigid ‘sharps’ container should be available in the room to discard used needles, syringes and sharp objects.

Depending on the microorganism and the mode of transmission, the nurse must evaluate what articles or equipment may be taken into the patient’s room. For example, the NHMRC (2010) recommends the dedicated use of articles such as stethoscopes, sphygmomanometers and thermometers in the room of a patient infected or colonised with vancomycin-resistant enterococci (VRE). These devices should not be used on other patients unless they are first adequately cleaned and disinfected. If, after bringing any article into the room, the nurse exposes an article to infected material and then touches or removes the article, the risk of transmitting infection to other patients or personnel is increased. Box 29-13 describes the procedures commonly performed in a protective environment.

BOX 29-13 PROCEDURAL GUIDELINES FOR CARING FOR A PATIENT ON ISOLATION PRECAUTIONS

1. Assess isolation indications, e.g. current laboratory tests or patient’s history of exposure.

2. Review agency policies and precautions necessary for the specific isolation system, and consider care measures to be performed while in patient’s room.

3. Review nurses’ notes or confer with colleagues regarding patient’s emotional state and adjustment to isolation.

4. Wash hands and prepare all equipment to be taken into patient’s room.

5. Prepare for entrance into isolation room:

a. Place either surgical mask or respirator around mouth and nose. (Type will depend on type of isolation and facility policy.)

b. Wear protective eyewear.

c. Wear a freshly laundered gown and cover all outer garments. Pull sleeves down to the wrist. Tie securely at neck and waist (see illustration).

d. Put on disposable gloves. If gloves are worn with gown, bring glove cuffs over edge of gown sleeves. Note: If the patient is allergic to latex, nitrile, non-latex gloves should be worn.

Step 5c Tying gown at waist.

Step 5d Applying gloves over gown sleeves.

6. Enter patient’s room. Arrange supplies and equipment. If equipment being removed from the room requires reprocessing, place in a container with a well-fitting lid for transfer.

7. Explain the purpose of isolation and necessary precautions to the patient and family. Offer an opportunity to ask questions. Assess for evidence of emotional problems due to isolated state.

8. Assessing vital signs: wear personal protective attire including gown, gloves and eye protection.

a. If patient is infected or colonised with a resistant organism, e.g. vancomycin-resistant enterococcus (VRE) or methicillin-resistant Staphylococcus aureus (MRSA), assessment equipment must remain in the room. Assess vital signs routinely. Avoid contact of stethoscope or blood-pressure cuff with infected material.

b. Clean the diaphragm or bell of the stethoscope with an antimicrobial solution after each use to reduce contaminants. Set it aside on clean surface.

c. Individual or disposable thermometers should be used.

9. Administer medications (see Chapter 31):

a. Administer oral medications in wrapper or using a cup.

b. Dispose of the wrapper or cup in a plastic-lined receptacle.

c. Administer injections as ordered.

d. Do not remove the needle from the syringe. Discard the syringe and needle into a puncture-resistant container designated for sharp items.

e. Gloves must be worn at all times to avoid contact of hands with contaminated articles, blood, tissue or body fluids.

10. Administer hygiene, encouraging the patient to raise questions or concerns about their isolation. This time can often be effectively used for informal teaching.

a. Avoid allowing gown to become wet.

b. Remove linen from the patient’s bed; avoid contact with gown and place in an impervious linen bag.

c. Change gloves and wash hands or apply an antimicrobial, alcohol hand-rub until dry.

11. Collect specimens:

a. Place a specimen container on clean paper towel, labelled with the patient’s name, date of birth, date and time or specimen collection and the exact contents of the specimen to be collected.

b. Follow non-touch technique to collect the specimen.

c. Transfer the specimen to the container without soiling outside of container. Place the container in a plastic bag and register the specimen as per facility policy.

12. Dispose of linen and rubbish bags as they become full:

a. Use sturdy, moisture-resistant, single-use bags to contain soiled articles.

b. Tie bags securely at top in knot (see illustration).

13. Resupply the isolation room with equipment and consumables to ensure an adequate supply.

Step 12B Tie rubbish bag securely.

14. Leaving the isolation room:

a. Untie waist and neck strings of gown. Allow gown to fall from shoulders. Remove hands from sleeves without touching outside of gown. Hold gown inside at shoulder seams and fold inside out and dispose of.

b. Remove gloves. Remove one glove by grasping cuff and pulling glove inside out over hand. Discard glove. With ungloved hand, tuck finger inside cuff of remaining glove and pull it off, inside out (see illustration).

c. Untie the top mask string and then bottom strings, pull mask away from face and place in a rubbish receptacle. Do not handle outer surface of mask.

Step 14b Removing gloves.

Step 14c A, Untying top strings of mask. B, Dropping mask into rubbish bin.

d. Wash hands for minimum of 15 seconds.

e. Explain to the patient when you plan to return to room. Ask whether the patient requires any personal-care items, books or magazines.

f. Leave room and close the door.

g. All contaminated supplies and equipment should be disposed of in a manner that prevents spread of microorganisms to other persons (see agency policy).

h. Remove protective eyewear and wash hands for minimum of 15 seconds.

PERSONAL PROTECTIVE EQUIPMENT

Personal protective equipment (PPE) should be readily available for staff involved in patient care. A summary of PPE requirements for different clinical procedures according to the NHMRC (2010) guidelines is presented in Table 29-6. The main reason for wearing a gown is to prevent soiling of clothes during contact with the patient. Gowns protect healthcare personnel and visitors from coming into contact with infected material and blood or body fluids. Gowns may also be required for contact precautions, depending on the expected amount of exposure to infectious material. Gowns used for barrier protection are made of a fluid-resistant material and should be changed immediately if damaged or contaminated. Depending on agency policy, gowns can be disposable or reusable.

TABLE 29-6 SUMMARY OF PERSONAL PROTECTIVE EQUIPMENT REQUIREMENTS

Gowns usually open at the back and have ties or snaps at the neck and waist to keep the gown closed and secure and are long enough to cover all outer garments. Long sleeves with tight-fitting cuffs provide added protection and prevent cross-contamination from skin cells shed from the wearer to the patient. There is no special technique for donning clean gowns, provided they are fastened securely. The nurse must carefully remove and discard gowns to minimise contamination of the hands and uniform. The gown should be removed first and placed in a receptacle, followed by the gloves. The nurse’s hands must then be immediately washed.

Masks or masks with face shields should be worn when it is possible that blood or body fluids may be splashed or sprayed into the health worker’s face and when patient airborne or droplet precautions are implemented. A correctly applied mask fits snugly over the mouth and nose so that pathogens and body fluids cannot enter or escape through the sides (Box 29-14), thereby preventing contamination by droplet nuclei. A mask discourages the wearer from touching the eyes, nose or mouth. If a person wears glasses, the top edge of the mask fits below the glasses to prevent fogging of eyewear as the person exhales. A mask protects the nurse from inhaling microorganisms from a patient’s respiratory tract and prevents transmission of pathogens from the nurse’s respiratory tract to the patient. The surgical mask protects the wearer from inhaling large-particle aerosols that travel short distances (1 metre) and small-particle droplet nuclei that remain suspended in the air and travel longer distances. At times, a patient who is susceptible to infection may wear a mask to prevent inhalation of pathogens. Patients with droplet or airborne infections, transported outside their room, should wear a mask to protect other patients and personnel. Masks may prevent transmission of infection by direct contact with mucous membranes.

BOX 29-14 PROCEDURAL GUIDELINES FOR DONNING A SURGICAL-TYPE MASK

1. Find top edge of mask (usually has thin metal strip along edge). Pliable metal fits snugly against bridge of nose.

2. Hold mask by top two strings or loops. Tie two top ties at top of back of head (see illustration), with ties above ears. (Alternative: slip loops over each ear.)

3. Tie two lower ties snugly around neck with mask well under chin (see illustration).

4. Gently pinch upper metal band around bridge of nose.

Note: mask should be changed if wet, moist or contaminated.

Talking should be kept to a minimum while wearing a mask to reduce respiratory airflow. When a mask is worn, moisture increases around the mouth and nose, diminishing its effectiveness as a barrier to microorganisms. The mask should be discarded and never reused, as it is a contaminated filter. Staff must wash their hands immediately after discarding a mask. Patients and family members should be warned that a mask might cause a sensation of smothering. If family members are uncomfortable, they should leave the room, discard the mask and immediately wash their hands.

P2-rated respirators that meet the requirements of AS/NZS 1716 are required when caring for a patient with known or suspected tuberculosis (TB), avian influenza or severe acute respiratory syndrome (SARS). These masks have a suitable filtration rating and face-fit performance not achieved by a regular surgical mask and must be fit-tested to ensure an effective seal on the face of each wearer to control leakage around the edges of the mask. P2 masks are recommended for use against infections aerosols and mechanically and thermally generated particulates, so also provide protection from surgical plume generated intraoperatively by electrosurgery and lasers (Australian College of Operating Room Nurses, 2010). The nurse should be aware of agency policy regarding the type of respiratory protective devices required.

When full protective apparel is necessary, the nurse first washes and dries the hands, applies a mask and protective eyewear, applies a gown and then applies gloves. Gloves help to prevent the transmission of pathogens by direct and indirect contact. Clean, non-sterile gloves should be worn when handling body fluids and contaminated items. Clean gloves should be donned before touching mucous membranes and non-intact skin. Gloves should be changed between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Gloves should be removed promptly after use and disposed of appropriately. The wearer’s hands should be washed for 15 seconds using an antimicrobial solution or rubbed with an alcohol-based antimicrobial solution until it dries, before touching non-contaminated items and environmental surfaces and before nursing another patient. Washing hands immediately after glove removal helps prevent transfer of microorganisms.

Disposable gloves are easily applied and are designed to fit either hand. The glove can easily be torn. If a break or tear is detected in a glove while providing care, the nurse should change gloves. The nurse should explain the use of gloves to the patient’s family members and emphasise the importance of hand hygiene after the removal of gloves.

Nurses must wear protective attire, including eyewear and a mask or a face shield, when:

Protective eyewear, available as shields, plastic glasses or goggles, or reusable headbands with disposable shields (Figure 29-7) should fit snugly around the forehead and face to prevent fluids entering between the face and the eyewear.

FIGURE 29-7 Nurse wearing a P2-rated respirator and protective eyegear.

© 3M, reproduced with permission.

SPECIMEN COLLECTION

Laboratory studies are required when a patient is suspected of having an infectious disease. Body fluids and secretions suspected of containing infectious organisms are collected for culture and sensitivity tests (Box 29-15). The specimen is placed in a medium that promotes growth of organisms. A laboratory technologist then assesses the microorganisms growing in the culture. Sensitivity test results indicate antibiotics to which organisms are resistant or sensitive.

The nurse wears eye protection and uses disposable gloves and sterile equipment to obtain patient specimens. When collecting fresh material from the site of an infection, such as wound drainage, it is important to ensure the specimen is uncontaminated by neighbouring microbes. Specimen containers should be sealed tightly to prevent spillage and contamination of the outside of the container and be placed in a leakproof bag (NHMRC, 2010). Specimens must be clearly labelled on the body of the container (not the lid, as this can easily be discarded in the pathology department). The date and time of collection and exact title of the specimen, along with the correct patient details, should be documented on the label. Always confirm with the attending doctor whether the specimen is required to be sent fresh, in a specific medium or in a fixative solution such as formalin.

BAGGING RUBBISH OR LINEN

Nurses use special bagging procedures for removing contaminated items from a patient’s environment. Bagging prevents accidental exposure of personnel and prevents contamination of the surrounding environment.

The NHMRC (2010) recommends a single bag for discarding items if the bag is impervious and sturdy and if the article can be placed in the bag without contaminating the outside of the bag. Soiled or wet linen should be placed in an impervious laundry bag (to prevent seepage) in the patient’s room. This should be removed from the clinical environment as soon as possible. Double-bagging is only recommended if it is impossible to prevent contamination of the bag’s outer surface. All linen and rubbish bags must be securely tied and never overfilled.

TRANSPORTING PATIENTS

Before transferring a patient to a wheelchair or trolley, the nurse should ensure the patient is dressed in a clean gown to serve as a robe. Patients infected with organisms transmitted by the airborne route should leave their rooms only for essential purposes, such as diagnostic procedures or surgery. These patients must also wear masks, as previously discussed. Personnel transporting these patients should also wear barrier protection.

An extra layer of sheets should be used to cover the trolley or seat of the wheelchair as body fluids can leak onto transport equipment. The nurse must ensure that all transport equipment, including IV poles, is thoroughly disinfected immediately after use to prevent cross-infection to other patients.

Personnel in diagnostic or procedural areas or the operating room should be notified of a patient’s precautionary care and document this in the patient’s chart. The nurse explains ways the patient can help prevent transmission of their infection during transport; for example, a patient with a respiratory infection is provided with tissues and a bag to allow appropriate disposal of secretions.

The operating suite should be notified as soon as possible if an infectious patient requires surgery, as transmission-based precautions may be required and the order of the operating list may need to be altered to ensure the most infectious patient is operated on last. The operating room is then thoroughly cleaned and ‘rested’ to enable adequate HEPA filtered air changes to remove airborne microorganisms.

PSYCHOSOCIAL IMPLICATIONS OF ISOLATION

The use of contact precautions or isolation as strategies for infection prevention and control may have negative impacts on several aspects of patient care. Contact precautions and isolation can not only affect patient safety because of decreased time spent with healthcare workers (Abad and others, 2010), but can also increase patients’ risk for unintended psychological consequences such as loneliness, anxiety and depression (Abad and others, 2010; Morgan and others, 2009). When a patient needs to be cared for in a private room, a sense of loneliness may develop because usual social relationships are disrupted. As a result of the infectious process, a patient’s body image may be altered. They may feel unclean, rejected, lonely or guilty. Infection prevention and control practices further intensify these beliefs of difference or undesirability. Being alone in a private room limits sensory contact and can lead to sensory deprivation. This situation can be psychologically harmful, especially for children. Patient education prior to initiation of contact precautions as well as staff education regarding the potential shortcomings of care received by patients in isolation may decrease the risk for unintended negative consequences (Abad and others, 2010; Morgan and others, 2009). The nurse can act to minimise feelings of psychological and physical isolation to improve patients’ emotional state and recovery (see Research highlight).

Prior to implementing isolation procedures, the patient and family should clearly understand the nature of the disease or condition, how infectious organisms are transmitted, the difference between contaminated and clean objects and the purposes of isolation and specific precautions. If they can participate in maintaining infection prevention, the chances of reducing the spread of infection are increased. The patient and family should be taught when and how to wash their hands correctly and how to wear and discard barrier protection if appropriate. Each procedure should be demonstrated and the patient and family should be given an opportunity to practise. Participation of the patient and family in the treatment of the disease can provide a positive sense of purpose and empowerment.

The nurse also takes measures to improve the patient’s sensory stimulation while confined to a private room. The room environment should be clean and pleasant. Curtains or blinds should be open, and excess supplies and equipment removed. The nurse can effectively listen to the patient’s concerns or interests. If the nurse rushes through care or shows a lack of interest, the patient will feel rejected and even more isolated. Mealtime is a particularly good opportunity for conversation. Measures such as repositioning increase comfort. Recreational and diversional activities such as board games or cards may be an option to keep the patient mentally stimulated. Depending on the patient’s condition, the nurse should encourage the patient to sit out of bed and mobilise in order to minimise the chance of deep vein thrombosis formation. The nurse must explain to the family the patient’s risk of depression or loneliness. Visiting family members should be encouraged to avoid expressions or actions that convey revulsion or disgust. The nurse can explain ways to provide meaningful stimulation and a positive approach.

CLEANING

Reusable objects must first be cleaned after use, before further reprocessing occurs. Cleaning involves the removal of all foreign materials, such as soil and organic material, from objects. In larger healthcare facilities, central supply-department personnel manually remove gross debris and then, if recommended by the manufacturer, ultrasonically remove debris from crevices and joints in instruments and equipment. Generally, cleaning requires a mild detergent and water combined with the mechanical action of rubbing or scrubbing (NHMRC, 2010).

When cleaning and handling used items and equipment soiled by organic material, for example blood, faecal matter, sputum or pus, or by chemicals, the nurse must take care to minimise exposure to contaminated surfaces, which may include wearing a face shield, plastic apron and disposable gloves. These barriers help provide protection from infectious organisms.

The following general steps help ensure the cleanliness of an object:

It is recommended that a written description of the process and procedures for cleaning contaminated items should be available in all areas where this activity is likely to occur (Standards Australia, 2003).

DISINFECTION AND STERILISATION

After thorough cleaning, reusable objects are then, ideally, sterilised. If the item cannot withstand sterilisation, high-level disinfection may be used in accordance with manufacturer’s instructions.

Disinfection describes the process of eliminating microorganisms, with the exception of bacterial spores, by thermal of chemical means. Thermal disinfection is a simple, cost-effective method that uses heat and water at temperatures that would destroy pathogens (NHMRC, 2010). Chemical disinfection is generally accomplished by a chemical disinfectant, such as glutaraldehyde, that may or may not be used in conjunction with an automated washer-steriliser (NHMRC, 2010). Disinfectants such as alcohols, chlorines, glutaraldehydes and phenols can be caustic to equipment and toxic to tissues. Care must be taken to ensure all residual disinfectant is removed prior to use. The disinfected item must be thoroughly dried prior to storage.

Sterilisation involves the complete elimination or destruction of all microorganisms, including spores. Steam under pressure, ethylene oxide (ETO) gas, hydrogen peroxide plasma and chemicals such as periacetic acid are the most common sterilising agents. Once cleaned and disinfected or sterilised, reusable items are then appropriately repackaged, accurately labelled and diligently stored for next use.

It is important for the nurse to be aware of and recognise occupational risks associated while working with chemicals used in disinfection and sterilisation and take appropriate precautions, such as the use of a respirator mask to minimise exposure to toxic fumes when working with glutaraldehydes.

Whether an item is to be simply cleaned, cleaned and disinfected or cleaned and sterilised depends on the intended use of the item. There are three categories of classification: critical, semi-critical, and non-critical (Box 29-16). The approach of Australian/New Zealand Standard 4187 (Standards Australia, 2003) recommends that all items used within a body cavity be sterile and all items used within the aseptic field be documented, so they can be tracked should a product recall be necessary in the event of sterilisation failure.

Nurses should be familiar with the relevant standards, policies and procedures for cleaning, handling and reprocessing items and be competent in correct cleaning, disinfection and sterilisation techniques. Nurses may be required to perform these processes and must be competent to do so. The following factors influence the effectiveness of the disinfecting or sterilising method:

Selection of the appropriate method for disinfecting or sterilising an item depends on its intended use and the nature of the item; for example, delicate fibre-optic instruments such as endoscopes cannot tolerate steam and must be processed using gas, plasma or periacetic acid to achieve sterilisation (Table 29-7).

TABLE 29-7 EXAMPLES OF DISINFECTION AND STERILISATION PROCESSES

PRINCIPLES OF ASEPTIC NON-TOUCH TECHNIQUE

Aseptic non-touch technique (ANTT) is the framework for promoting and ensuring asepsis adopted in the current Australian infection control guidelines (NHMRC, 2010). In ANTT, asepsis is ensured by: identifying and then protecting key parts and key sites; effective hand hygiene; effective non-touch technique; appropriate glove choice; and use of aseptic fields (Rowley and others, 2010).

‘Key parts’—the aseptic key parts of procedure equipment—must be identified and protected at all times. Key parts must only come into direct contact with other aseptic key parts and/or key sites, such as wounds or insertion sites (Rowley and others, 2010). While effective hand hygiene is also an essential component of ANTT, it is known that hand hygiene is not always correctly performed; and that even when correctly performed, hand hygiene cannot always remove all pathogenic organisms. Therefore, a non-touch technique—identifying key parts and not touching them directly or indirectly—is a vital component of achieving asepsis. In other words, the optimal way of protecting key parts is never to touch them (Rowley and others, 2010). If it is necessary to touch key parts/sites directly, then sterile gloves should be used to minimise the risk of contamination. Otherwise, wear non-sterile gloves.

Even well-cleaned hospitals can be said to be ‘dirty’—busy and dynamic environments resident with unusual antibiotic-resistant organisms. Consequently, aseptic fields are important in providing a controlled aseptic working space to help promote or ensure the integrity of asepsis during clinical procedures. It is also important that aseptic fields are fit for purpose. In ANTT, aseptic fields are increased in size and sterilised drapes added on the basis of procedure complexity. For example, in IV therapy, ‘mobile’ aseptic fields such as plastic trays should be large enough and with sides high enough to provide an adequate working space to contain equipment, sharps and spillages. ANTT employs two types of aseptic fields—general and critical—that require different management depending on whether the primary purpose is to promote or ensure asepsis. General aseptic fields are used when key parts can be easily protected, and critical aseptic fields are used when key parts cannot be protected at all times due to their size or number (Rowley and others, 2010).

Ensuring and promoting asepsis using ANTT principles appropriately depends on the healthcare professional undertaking a risk assessment that takes into account: whether the procedure can be performed without touching key parts and key sites directly; the technical difficulty of the procedure and the competency of the healthcare professional; and risks posed by the immediate environment (Rowley and others, 2010). Although the principles of ANTT remain constant, the level of practice will change according to the risk assessment (NHMRC, 2010). The risk assessment will determine whether a ‘standard’ ANTT or a ‘surgical’ ANTT is required (Figure 29-8).

FIGURE 29-8 Use of standard and surgical aseptic non-touch technique. A, Standard aseptic non-touch technique (ANTT). B, Surgical ANTT.

From National Health and Medical Research Council (NHMRC) 2010 Australian guidelines for the prevention and control of infection in healthcare. Canberra, NHRMC. Online. Available at www.nhmrc.gov.au/guidelines/publications/cd33 29 Sep 2011.

PRINCIPLES OF SURGICAL ASEPSIS

The principles of surgical ANTT encompass situations where procedures are technically complex, involve large or numerous key parts, involve large open key sites and entail extended periods of time. One such example is surgery in the operating theatre (Rowley and others, 2010).

Surgical asepsis involves procedures which attempt to eliminate all microorganisms, including pathogens and spores, from an object or area by creating a critical aseptic field. In surgical asepsis an area or object is considered contaminated if touched by any object that is not sterile. For example, a torn surgical glove exposes the outside of the glove to the skin surface; it is therefore contaminated. Nurses working within a critical aseptic field or with sterile equipment must rectify the slightest break in asepsis, because contamination can place a patient at risk of infection

Surgical asepsis is commonly practised in the operating room and the perioperative nurse follows a series of steps to promote and ensure asepsis, including donning fresh scrub clothes, hair covering, mask and protective eyewear, and performing a thorough surgical hand and arm scrub. The perioperative nurse wears a sterile gown and gloves (see below).

PERFORMING ASEPTIC PROCEDURES

All equipment required, plus extra supplies in case of accidental contamination, should be assembled before a procedure. The nurse then avoids leaving the area unattended. If an object is contaminated during the procedure, it should be discarded immediately. Prior to commencement of the aseptic procedure, each step should be carefully explained to the patient to help gain their cooperation.

OPENING A STERILE ITEM ON A FLAT SURFACE

Sterile packaged items must be opened without contaminating the contents. Commercially packaged items are usually designed to allow the nurse to open or separate the paper or plastic cover, opening the wrapper away from the body (Figure 29-9). The following steps are used when opening items wrapped in polypropylene, paper or linen:

1. Ensure the surface of the trolley or table has been disinfected and dried.

2. Check the integrity of the packaging, the date, sterilisation indicator and contents.

3. Place the item flat in the centre of the work surface.

4. Remove the steriliser indicator label and affix to patient documentation. Then remove sterilisation tape or seal.

5. Grasp the outer surface of the tip of the outermost flap.

6. Open the outer flap away from the body, keeping the arm outstretched and away from the aseptic field (Figure 29-10A) and pull the packaging firmly.

7. Grasp the outside surface of the first side flap.

8. Open the side flap, allowing it to lie flat on the table surface. Keep the arm to the side and not over the sterile surface (Figure 29-10B). Do not allow the flaps to spring back over the sterile contents.

9. Grasp the outside surface of the second side flap and allow it to lie flat on the table surface (Figure 29-10C).

10. Grasp the outside surface of the last and innermost flap.

11. Stand away from the sterile package and pull the flap back, allowing it to fall flat on the surface (Figure 29-10D).

12. Use the inner surface of the package (except for the 2.5 cm border around the edges) as an aseptic field to add additional sterile items. The 2.5 cm border can be grasped to manoeuvre the field on the table surface.

FIGURE 29-9 When opening a commercially packaged sterile item, the nurse tears the wrapper away from the body.

From Potter PA, Perry AG 2013 Fundamentals of Nursing, ed 8. St Louis, Mosby.

FIGURE 29-10 Opening sterile packaged items on a flat surface. A, The nurse opens the top flap away from the body. B, The nurse’s arm is kept out away from the aseptic field while opening a side flap. C, The second side flap is opened. D, The back flap is opened.

From Potter PA, Perry AG 2013 Fundamentals of Nursing, ed 8. St Louis, Mosby.

PREPARING AN ASEPTIC FIELD

When performing aseptic procedures, the nurse requires an aseptic work area that provides room for handling and placing sterile items. An aseptic field is an area free of microorganisms and prepared to receive sterile items. The field may be prepared by using the inner surface of a sterile wrapper as the work surface or by using a sterile drape. Skill 29-2 describes preparation of an aseptic field. After the surface of the field is created, the nurse adds sterile items by placing them directly on the field or by transferring them with sterile forceps. When transferring sterile items, the nurse must carefully place objects onto the aseptic field. An object that comes in contact with the 2.5 cm border around the field must be discarded.

SKILL 29-2 Preparing an aseptic field

DELEGATION CONSIDERATIONS

Preparing an aseptic field requires specialised knowledge regarding surgical asepsis.

EQUIPMENT

• Sterile drapes

• Assorted sterile supplies

STEPS		RATIONALE
1. Prepare aseptic field just before planned procedure. Supplies are to be used immediately.		Prevents exposure of aseptic field and supplies to air and contamination.
2. Work surfaces should be above waist level. Clean the work surface with an antiseptic solution and dry thoroughly.		Sterile object held below waist is considered contaminated.
3. Check all necessary equipment is present and inspect the integrity of packaging.		Preparation of equipment in advance prevents break in technique.
4. Check chemical indicators on supplies that indicate sterility of equipment. Scan barcodes of items or attach labels to patient documentation to enable effective tracking of sterilised items.
5. Apply personal protective attire.
6. Wash and dry hands thoroughly.		Prevents transmission of infection.
7. Place pack containing sterile drape on work surface and open as shown in Figure 29-10.		Ensures sterility of packaged drape.
8. With fingertips of one hand, pick up folded top edge of sterile drape.		2.5 cm border around drape is unsterile and may be touched.
9. Gently lift drape up from its outer cover and let it unfold by itself without touching any object. Discard outer cover with your other hand.		If sterile object touches any other non-sterile object, it becomes contaminated.
10. With other hand, grasp adjacent corner of drape and hold it straight up and away from your body (see illustration).		Drape can now be properly placed while using two hands. Drape must be held away from unsterile surfaces.
11. Holding drape, first position and lay bottom half over intended work surface (see illustration).
12. Allow top half of drape to be placed over work surface last (see illustration).		Prevents nurse from reaching over aseptic field.
13. Grasp 2.5 cm border around edge to position as needed.		Creates aseptic work surface.
Step 10 Hold drape straight up and away from body	Step 11 Lay bottom half over work surface.	Step 12 Place top half of drape over work surface.
ADDING STERILE ITEMS
14. Open sterile item (following package directions) while holding outside wrapper in non-dominant hand.		Frees dominant hand for unwrapping outer wrapper.
15. Carefully peel wrapper onto non-dominant hand.		Item remains sterile. Inner surface of wrapper covers hand, making it sterile.
16. Being sure wrapper does not fall down on aseptic field, place item onto field at angle. Do not hold arm over aseptic field (see illustration).		Prevents reaching over field and contaminating its surface.
17. Dispose of outer wrapper.		Prevents accidental contamination of aseptic field.
18. Pouring sterile solutions:
	a. Verify contents and expiration date of solution.	Ensures correct solution and sterility of contents.
	b. Ensure receiving container for solution is on or near edge of aseptic field. Some aseptic field kits have cups or moulded plastic sections into which fluids can be poured.	Prevents reaching over aseptic field.
	c. Remove sterile seal and cap from bottle in an upward motion. Holding bottle away from aseptic field with label facing up and the bottle lip 3–4 cm over inside of receiving container, slowly pour contents into container (see Figure 29-11).	Prevents contamination of bottle lip and keeps inside of cap sterile. Edge and outside of bottle are considered contaminated. Slow pouring prevents splashing of liquids which causes fluid permeation of aseptic field and results in contamination.
19. Perform procedure using aseptic non-touch technique.		Prevents transmission of infection to patient.
Step 16 Placing sterile item on aseptic field.
RECORDING AND REPORTING
It is not necessary to record or report this procedure.

Sterile gloves may be worn while preparing items on the field. If this is done, the nurse can touch the entire drape, but sterile items must be handed over by an assistant. The nurse’s gloves cannot touch the wrappers of sterile items.

POURING STERILE SOLUTIONS

Often sterile solutions must be poured into sterile containers. The patient’s allergy status, the type, strength and expiry date of the solution should first be checked. A bottle containing a sterile solution is sterile on the inside and contaminated on the outside; the bottle’s neck is also contaminated, but the inside of the bottle cap is considered sterile. After a cap or lid is removed, it is held in the hand or placed sterile side (inside) up on a clean surface so the inside of the lid can be seen as it rests on the table surface. A bottle cap or lid should never rest on a sterile surface as the cap’s outer edge is unsterile and would contaminate the surface. Similarly, placing a sterile cap down on an unsterile surface increases contamination. A single-use solution is preferable; any remaining solution is discarded.

The bottle should be held with its label in the palm of the hand to prevent the possibility of the solution wetting and fading the label. The nurse pours the solution slowly to avoid splashing the underlying drape or field. The bottle should never be held so high above the container that even slow pouring will cause splashing. The bottle should be held outside the edge of the aseptic field (Figure 29-11).

FIGURE 29-11 Pouring a sterile solution into a receiving container on the aseptic field.

From Potter PA, Perry AG 2013 Fundamentals of Nursing, ed 8. St Louis, Mosby.

SURGICAL SCRUB

Patients undergoing operative procedures are at an increased risk of infection. Nurses working in operating rooms perform surgical hand and arm scrubs to decrease and suppress the growth of skin microorganisms in case of glove tears (Australian College of Operating Room Nurses, 2010).

All jewellery should be removed from the arms, wrists and hands, including rings, as these may harbour microorganisms. Fingernails must be kept clean, short and free of nail fillers, artificial nails and nail polish (Australian College of Operating Room Nurses, 2010). Nurses with active skin infections, open lesions or respiratory infections should be excluded from the surgical team. During surgical arm and handwashing (Skill 29-3), the nurse washes from fingertips to elbows with an antiseptic solution under tepid running water. The initial wash takes 5 minutes and includes the cleaning of fingernails with a disposable nail pick. A sterile scrub brush may be used for the initial scrub of the day; however, continued use can damage the outer layer of the skin. The recommended duration of subsequent surgical scrubs is 3 minutes, as the residual antimicrobial solution on the skin surface reduces the microbe population (Australian College of Operating Room Nurses, 2010; NHMRC, 2010). The light friction created by scrubbing effectively removes microorganisms; however, vigorous scrubbing may remove outer layers of the epidermis, exposing deeper layers to bacterial flora (Rothrock, 2007).

SKILL 29-3 Surgical handwashing (‘scrubbing’): preparing for gowning and gloving

DELEGATION CONSIDERATIONS

The role of the circulating and instrument nurse can be delegated to a surgical technologist or licensed practical nurse in some countries. In Australia, registered nurses perform these roles. Individual healthcare organisations will determine the level of competency required for the role of the circulating and instrument nurse.

EQUIPMENT

• Deep scrub sink with automatic, foot or knee controls for dispensing water and soap (taps should be high enough for hands and forearms to fit comfortably).

• Non-irritating, broad-spectrum, fast-acting antimicrobial scrub solutions, with an accumulative, residual effect, should be used. Note: the same antimicrobial solution used for the initial scrub of the day should be used for subsequent scrubs during the day, to maximise the residual cumulative antimicrobial effects. Staff using antimicrobial solutions should have direct access to the manufacturer’s material safety data sheet (MSDS) which outlines directions for use and first aid.

• Surgical scrub sponge with nail pick. Note: a scrub brush should only be used if hands are grossly contaminated, e.g. following gardening, painting, etc. Routine use damages the outer dermal layer of skin causing abrasions which breach the skin barrier enabling penetration of microbes into deeper tissue, increasing the risk of skin reactions.

• Other: personnel are required to remove jewellery and don protective attire: freshly laundered scrub attire, appropriate footwear, shoe covers as required, hair covering, appropriate surgical face mask and protective eyewear prior to scrubbing.

STEPS		RATIONALE
1. Scrub each side of each finger, between the fingers, and the back and front of the hand for 2 minutes. The first hand and arm wash (scrub) for the day should take 5 minutes; subsequent scrubs should take 3 minutes. (Department of Health and Ageing, 2004).		Allows sufficient time to ensure the effectiveness of the surgical scrub.
2. Ensure fingernails are short, clean, healthy and free of artificial nails, nail polish and nail fillers.		Long nails and chipped or old polish increase number of bacteria residing on the fingernails. Long fingernails can puncture gloves, causing contamination.
3. Inspect hands for presence of abrasions, cuts or open lesions. Consult infection-control professional as necessary.		Damaged tissue may have a greater number of microbes residing on skin surfaces.
4. Don surgical face mask and protective eyewear.		Protects from splashes of chemicals and patient blood and body fluids.
5. Turn on water using knee or foot controls and adjust to comfortable temperature.		Taps should be high enough to allow hands and forearms to fit comfortably underneath.
6. Start timing. Wet hands and arms under running lukewarm water and lather with an antimicrobial solution to 5 cm below the elbows. Keep hands higher than elbows at all times.		Water runs by gravity from fingertips to elbows. Hands become cleanest part of upper extremity. Keeping hands elevated allows water to flow from least to most contaminated areas.
7. Rinse hands and arms thoroughly under running warm water. Remember to keep hands above the elbows.		Rinsing removes transient microorganisms from fingers, hands and forearms.
8. Under running water, clean under nails of both hands with either a nail pick or the bristled side of a scrub brush (see illustration). Discard after use.		This removes debris that may harbour large numbers of microorganisms. Note: World Health Organization (WHO) guidelines recommend that a surgical handscrub with a medicated soap, such as chlorhexidine or povidone–iodine for 2 or 3 minutes, reduces bacterial counts to acceptable levels and the time required for surgical alcohol-based handrubbing depends on the compound used (WHO, 2009). WHO guidelines also state that for preoperative hand preparation, alcohol-based formulations have better antimicrobial effectiveness than all other currently available methods (WHO, 2009).
Step 8 Cleaning under fingernails.
9. Wash arms using a circular motion, from hands to elbows, without returning to hands (see illustration). Discard brush. This ‘pre-wash’ should take 2 minutes initially, then 1 minute for subsequent scrubs.		This step allows the antimicrobial solution time to work.
10. Re-apply the antimicrobial solution and wash all surfaces of hands including between fingers (see illustration) and around wrists. Wash arms using a circular motion from hands to elbows, without returning to hands. This process should take 3 minutes initially, then 2 minutes for subsequent scrubs.		Scrubbing in a circular motion loosens resident bacteria that adhere to skin and helps ensure full coverage of surfaces.
11. Ensure hands are elevated above the elbows. Carefully rinse hands and arms thoroughly under running water, without touching taps (see illustration).		Correct rinsing to remove antimicrobial solution helps prevent skin irritation.
Step 9 Washing arms.	Step 10 Scrubbing sides of fingers.	Step 11 Rinsing arms.
12. Turn off taps without touching them with the scrubbed parts of the hands and arms. Shake off excess water, clasp hands together and hold away from the body.		Keeping hands and arms elevated and away from clothing avoids contamination.
13. Walk carefully into the operating or set-up room to dry hands and arms in preparation for donning a sterile gown and gloves.		Floors around scrub sink can be slippery.
14. Obtain a sterile hand towel and stand back from the aseptic field. Lean forward, outstretch hands and allow the towel to unfold. Use one half of the towel to thoroughly pat dry, from the hand to the elbow using a circular motion, on one side of the towel, then use the other half of the towel to repeat the process for the other hand and arm (Australian College of Operating Room Nurses, 2010).		Leaning forward prevents accidental contact of arms with clothing. Drying hands thoroughly makes donning gloves easier.
15. Finally, drop the towel into the appropriate receptacle (Australian College of Operating Room Nurses, 2010) and proceed with gowning.
RECORDING AND REPORTING
• Scan barcodes of sterile items or apply tracking stickers to documentation. • Report any dermatitis to employee health services or infection control as per agency policy.

DONNING STERILE GLOVES

Sterile gloves are an additional barrier to bacterial transfer. Nurses who work on general nursing wards use open gloving (Skill 29-4) for aseptic procedures such as urinary catheter insertion. The closed gloving method (Skill 29-5) is performed after nurses put on sterile gowns and is practised in operating rooms and procedure rooms.

SKILL 29-4 Open gloving

DELEGATION CONSIDERATIONS

Requires knowledge of aseptic technique.

EQUIPMENT

• Sterile gloves of the correct size

• A clean surface on which to open the glove packet. Wipe over the surface with an antiseptic and allow it to dry thoroughly before use

STEPS		RATIONALE
OPEN GLOVING
1. Perform hand hygiene.		Removes bacteria from skin surfaces and reduces transmission of infection.
2. Open the glove packet by carefully separating and peeling apart the sides, on a recently cleaned surface.		Maintains the integrity of the sterile gloves.
3. Grasp the inner package, keeping the gloves on the sterile inside of the wrapper surface (see illustration).		Inner surface of glove package must remain sterile.
Step 3 Opening glove package.
4. Identify right and left glove. Each glove has cuff approximately 5 cm wide. Glove the dominant hand first.		Proper identification of gloves enables efficient, correct gloving. Gloving the dominant hand first improves dexterity
5. With thumb and first two fingers of the non-dominant hand, grasp edge of the cuff of the glove for dominant hand. Touch only glove’s inside surface		Inner edge of cuff will lie next to skin and is therefore not sterile.
6. Carefully pull glove over dominant hand, leaving cuff and being sure cuff does not roll up wrist. Be sure thumb and fingers are in proper spaces (see illustration).		If the outer surface of the glove touches the skin it is considered contaminated and must be replaced with a sterile glove.
Step 6 Pulling glove over dominant hand.
7. With gloved dominant hand, slip the fingers underneath second glove cuff (see illustration).		Cuff protects gloved fingers. Ensures sterile items only touch sterile surfaces, thus avoiding contamination.
8. Carefully pull second glove over non-dominant hand. Do not allow the fingers and thumb of the gloved, dominant hand to touch any part of exposed non-dominant hand. Keep the thumb of the dominant hand abducted back (see illustration).		Contact of gloved hand with exposed skin of ungloved hand causes contamination. Unsterile glove must then be removed and replaced with a sterile glove.
9. Once the second glove is applied, ensure a smooth fit over fingers and interlock the gloved hands, taking care not to touch the uniform (unless the nurse is wearing a sterile gown). The cuffs usually fall down after application. Be sure to touch only sterile sides (see illustration).		Ensures a smooth fit over fingers.
Step 7 Slipping fingers under cuff of second glove.	Step 8 Pulling second glove over non-dominant hand.	Step 9 Interlocking gloved hands.
GLOVE DISPOSAL
10. Grasp the outside of one cuff with the other gloved hand; avoid touching wrist.		Minimises contamination of underlying skin.
11. Pull the glove off, turning it inside out. Place the removed glove in the remaining gloved hand.		Outside of glove does not touch skin surface.
12. Use the fingers of the bare hand to pull the remaining glove from the cuff over the hand. This will remove the glove and tuck the other glove inside.		Contaminated gloves are contained.
13. Discard in an appropriate infectious waste receptacle.		Used gloves are contaminated with the microbes of the wearer and handled contaminants.
14. Ensure hands are washed hands thoroughly, or liberally apply an antimicrobial alcohol hand-rub immediately after the removal of gloves.		Microorganisms multiply in dark, moist, warm conditions such as on hands when gloves are worn. Gloves may contain microscopic perforations permitting the entry of microbes, which can proliferate on the wearer’s hands.
RECORDING AND REPORTING
It is not necessary to record or report this procedure.

SKILL 29-5 Donning a sterile gown and performing closed gloving

DELEGATION CONSIDERATIONS

The role of the circulating and instrument nurse can be delegated to a surgical technologist or licensed practical nurse in some countries. In Australia, registered nurses usually perform these roles. Individual healthcare organisations will determine the level of competency required for the role of the circulating and instrument nurse.

EQUIPMENT

• Freshly laundered scrub attire

• Appropriate, non-slip, clean shoes or shoes worn with shoe covers

• Hair covering: hat or balaclava (to contain facial hair)

• Two pairs of sterile gloves, the inner pair one size larger, the outer pair being the nurse’s correct size

• Surgical mask

• Appropriate eye protection: for infection control. Protective eyewear specific to various types of lasers may also be required

• Sterile gown that complies with national requirements.

STEPS	RATIONALE
DONNING A STERILE GOWN
1. Personnel are required to don protective attire: freshly laundered scrub attire, appropriate footwear, shoe covers as required, hair covering, appropriate surgical face mask and protective eyewear, prior to gowning and gloving.	Prevents hair and air droplet nuclei from contaminating the aseptic field. Eyewear protects staff from inadvertent splashes of chemicals, blood and body fluids.
2. Perform thorough surgical handwash (see Skill 29-3).	Removes transient and resident bacteria from fingers, hands and forearms.
3. The circulating nurse aseptically opens a sterile gown pack containing a sterile gown, which is folded inside out.	Outer surface of gown remains sterile.
4. The circulating nurse peels open glove package without contaminating the sterile inner contents. Inner glove package is then placed on sterile outer created by sterile outer wrapper.	Inner packaging and gloves remain sterile, allowing instrument nurse to handle aseptically.
5. Reach down to sterile gown package; lift folded gown directly up and step back away from table.	Provides sufficient space to don gown without contamination.
6. Hold the folded gown away from the scrub suit, locate neckband and allow the remainder of the gown to unfold without being touched.	Outside of gown remains sterile.
7. Use both hands to find the arm holes of the gown and push the hands and arms through simultaneously (see illustration), without allowing the hands to protrude out from the wrist cuffs. Once the gown is pulled on, the sleeves should cover hands.	Clean hands may touch the inside of the gown without contaminating the outer surface. Gown covers hands to prepare for closed gloving.
8. Circulating nurse may reach inside gown to arm seams to bring gown over shoulders. Ask the circulating nurse to securely tie up the back of the gown (see illustration).	Gown must completely enclose underlying garments. The front tie or tab of the gown is handed to another sterile person to ‘turn’ the gown. This allows a sterile flap to cover the back.
Step 7 Placing arms in sleeves with hands kept inside cuffs.	Step 8 Circulating nurse tying back of gown.
CLOSED GLOVING
1. With hands still covered by the gown sleeves, open the inner package of the larger sized gloves (see illustration). The right glove will be located on the right side of the package, and the left glove will be located on the left side of the package.	Outside of gown remains sterile. Double gloving is recommended to minimise cross-infection from sharp items.
2. With the dominant hand inside gown cuff, pick up the glove for the non-dominant hand by grasping the folded cuff.	Sterile gown touches sterile glove.
3. Extend non-dominant hand and forearm, with the palm facing upwards and place the palm of the glove against the palm of non-dominant hand. Glove fingers will point towards the elbow.	Positions glove for application over cuffed hand, maintaining glove sterility.
4. Grasp back of glove cuff with covered dominant hand. Turn glove cuff over end of non-dominant hand and gown cuff (see illustration).	Seal created by glove cuff over gown prevents exit of microorganisms over operative aseptic field.
5. Grasp the cuff of the glove and the underlying gown sleeve, with the gown cuff still covering dominant hand. Carefully extend fingers into the sterile glove.
Step 1 Opening glove package with covered hands.	Step 4 Applying glove to non-dominant hand as dominant hand remains inside gown cuff.
6. Glove the dominant hand in same manner, reversing hands (see illustration). Use gloved non-dominant hand to pull the other glove at the cuff of the gown and extend fingers into the glove. Keep the hand inside sleeve cuff at all times to ensure ‘closed gloving’. Ensure fingers are fully extended into both gloves.	When both hands are covered by sterile gloves, fingers can more easily be manipulated into the gloves. A seal is created by the glove cuff over the gown to prevent exit of microorganisms onto the operative aseptic field.
Step 6 Applying second glove.
7. The second outer pair of gloves can be applied by the instrument nurse; the sterile gloved hands touch the second sterile pair of gloves.
8. Undo the fastener or ties in front of the gown and hand to a gowned and gloved ‘sterile’ member of the surgical team. They will stand still while the instrument nurse turns around to cover their back, with extended gown flap. The instrument nurse retrieves their gown tie from sterile surgical team member and securely ties the gown (see illustration).	Contact with an unsterile team member can risk contamination of sterile gown or gloves. Gown must completely enclose underlying garments.
Step 8 Handing tie to ‘sterile’ team member.
9. The scrub team must ensure they either pass each other face to face or back to back, to avoid the unsterile back of the gown contaminating the aseptic field or personnel.	Scrubbed personnel are considered sterile from mid-chest to waist and elbows to glove tips only. The back of the gown, the area under the arms, the collar, the area below the waist and the sleeves above the elbows are considered unsterile, as the nurse cannot keep these areas in constant view to ensure their sterility.
RECORDING AND REPORTING
• It is not necessary to record or report this procedure.

The appropriate glove size should be selected; the glove should not stretch so tightly that it constricts hand movement or tears easily. Double gloving is recommended to maximise glove integrity and reduce the microbial load of contaminated needles perforating gloves. Gloves one size larger are applied first, with the nurse’s usual size of glove worn on top (Tanner and Parkinson, 2009).