Chapter 10: Sterile Technique

Question 1

Purpose

Answer 1

To keep area free from pathogenic organisms by isolating from the unsterile environment for surgery and invasive procedures

Minimize PT exposure to infection-causing agents= reduce in PT risk for infection

Question 2

Sterile technique PPE in the OR or diagnostic procedure areas

Answer 2

Apply mask, protective eyewear, a cap, perform surgical hand scrub, apply sterile gown, apply sterile gloves

Question 3

Medical asepsis procedure

Answer 3

Proper hand hygiene with appropriate cleaner or antiseptic is required before initiating any sterile procedure

Question 4

Surgical aseptic procedure

Answer 4

Used at the bedside with procedures requiring puncture of the skin or insertion of devices into the body that is normally sterile (e.g., sterile dressing change) or in a situation where skin integrity is compromised because of incision or burn

Perform hand hygiene, apply sterile gloves. Other PPE is required if there is a risk for splash.

Question 5

Principles of surgical asepsis

Answer 5

All items must be sterile; sterile barrier permeated by punctures, tears, or moisture must be considered contaminated; 1” edge of sterile field is considered contaminated; table draped as part of sterile field are considered sterile only at table level; unsterile by default if uncertain; sterile things only contact sterile things; unsterile things only contact unsterile things; movement cannot contaminated sterile field; sterile things out of view/ below waist is considered contaminated; complete ASAP- sterile object becomes contaminated by prolonged exposure to air.

Question 6

What to tell PT during procedure

Answer 6

Communicate about steps taken to prevent infection- include areas PT should avoid to maintain sterilization:

Avoid sudden body movements, refrain from touching sterile supplies, avoid coughing or talking over the sterile area

Question 7

Patient centered care

Answer 7

“Speak up”: intervene and stop a procedure when a break in sterile technique occurs

Individualized education reduces fear and misconceptions about sterile aseptic attire

Question 8

To reduce healthcare associated infections (HAIs)

Answer 8

Individualized education, insertions of devices only when necessary, use of sterile technique, removing devices when no longer needed, minimizing traffic, cleaning and disinfecting, changing skin preparation, administering antibiotics

Removing watches, jewelry, and artificial nails (the subungual-under nail- contain a high conc. of bacteria including coagulase-negative stafylococci, gram negative rods, and fungal growth)

Use of additional antiseptics (e.g., chlorhexidine) on PT skin to reduce bacteria

Question 9

When to apply sterile gloves

Answer 9

Depends on the type of procedure being performed

Question 10

When to apply a mask

Answer 10

Assess the risk for splash: does PT have a large, open wound? Are they immunosuppressed? Is there a splash risk from the wound?

Change mask wen it becomes moist or soiled (e.g., splattered with blood)

Wear eyewear if there is a risk of body fluids splashing in your eyes

Question 11

Assessment: applying and removing cap, mask, and protective eyewear

Answer 11

If HCP has S/S of resp. infection, avoid participation or wear a mask. A greater number of pathogenic microorganisms reside within the resp. tract when infection is present.

Some PTs are at greater risk for infection= use additional protective barriers

Question 12

NRSG Diagnoses: applying PPE

Answer 12

Ineffective protection

Risk for infection

Question 13

Planning: applying PPE

Answer 13

PT should not develop S/S of localized infection (e.g., redness, tenderness, edema, drainage) or systemic infection (e.g., fever, change in WBC count) 24 hrs following procedure

Prepare equipment and inspect packaging for integrity and exposure

Question 14

Implementation: applying PPE

Answer 14

Perform hand hygiene

W/ bedside procedures, apply gown (opening in back, covers garments, sleeves down to wrists, tied at neck and waist) if splatter/soil risk

Apply cap; Comb & secure hair behind ears (decrease exposure of hair); Use pins as needed

Apply mask (metal strip=top; hold by top two strings) tie top then tie bottom then pinch around bridge of nose

Apply protective eyewear (glasses, goggles, or face shield); ensure vision is clear.

Question 15

Sterile procedure

Answer 15

Perform all implementation steps

Apply sterile gown

Apply clean gloves for nonsterile procedures and sterile gloves for sterile procedures

Pull up gloves to cover each wrist (over the wrist of the gown)

Ensure a latex free environment if PT or HCP has latex allergy

Question 16

Removing protective barriers

Answer 16

Remove gloves first

Remove face shield next (if wearing)

Remove eyewear (avoid touching soiled lens)

Remove gown (unfasten neck ties, pull away from body, touch only inside, roll into bundle)

Remove mask (untie bottom then top, pull away from face while holding strings

Remove cap by lifting outer surface and pull away from hair

Question 17

Evaluation: applying PPE

Answer 17

Assess PT for S/S of systemic infection or local area of body treated for drainage, tenderness, edema, or redness

Question 19

Purpose of a sterile field

Answer 19

To provide a sterile surface for placement of sterile equipment. Sterile drapes establish a sterile field around a treatment site (e.g., surgical incision, venipuncture site, site for indwelling urinary catheter)

They provide a work surface to place supplies and manipulate items with sterile gloves

The inside cover of a sterile kit can be used as the sterile field

Once a sterile field is created, you are responsible for performing the procedure and ensuring the field doesn’t become contaminated

Question 20

Assessment: preparing a sterile field

Answer 20

Verify that procedure requires aseptic technique (medical or surgical?)

Teach not to touch; assess for latex allergy

Check package for punctures, tears, discoloration, moisture, or any other signs of contamination (check for sterilization indicator/marker that changes color when exposed to heat or steam)

Question 21

NRSG Diagnoses: preparing sterile field

Answer 21

Ineffective protection

Risk of infection

Question 22

Planning: preparing sterile field

Answer 22

Complete all other nursing interventions before procedure (e.g., med. admin., suctioning)

Ask visitors to briefly step out; limit movement to decrease contamination by air currents

Arrange equipment at bedside to prevent a break in sterile technique (Povidone-iodine and Chlorhexidine aren’t sterile sols. & require separate work stations

Position PT comfortably with area that needs procedure done exposed (NAP can assist). Teach PT to limit movement

Question 23

Unexpected outcomes

Answer 23

Notify HCP of change in condition of affected area; initiate treatments as ordered

Assess for redness, heat, edema, pain, or purulent drainage that develops at wound or treatment site; indicates possible infection

Question 24

Implementation: preparing sterile field

Answer 24

Apply necessary PPE

Select a clean, flat, dry work surface above the waist level (below is considered contaminated)

Perform hand hygiene (do not let water run down arms into clean hands-arms are considered contaminated)

Prepare sterile work surface

Question 25

Use of sterile commercial kit or pack containing sterile items

Answer 25

1. ) place sterile kit/pack on prepared work surface above waist level
2. ) open outside cover and remove package (inner kit remains sterile)
3. ) grasp outer surface of tip of outermost flap (outer 1” border is considered unsterile-can be touched with clean fingers)
4. ) open outermost flap away from body, keep arm outstretched and away from sterile field
5. ) open side flap pulling to side allowing it to lie flat on table surface (keep arm to side and not over sterile surface); repeat with other side
6. ) grasp outer border of last and innermost flap standing away from sterile package allowing flap to fall flat on table (NEVER reach over sterile field)

Question 26

Use of sterile linen-wrapped package

Answer 26

1. ) place package on clean, dry, flat work surface above waist level
2. ) remove sterile tape seal and unwrap both layers following same steps as for sterile kit; use opened package as sterile field (inner surface is considered sterile)

Linen-wrapped items have 2 layers. First is the dust cover, second must be opened to view chemical indicator

Question 27

Preparing a sterile drape

Answer 27

1. ) place pack on dry, flat surface and open same as the sterile kit
2. ) optional: apply sterile gloves (not needed if only touching outer 1” border)
3. ) lift at border using fingertips of one hand, throw out wrapper with other hand without touching no sterile objects
4. ) grasp adjacent corner of drape, hold straight up and away from body. Allow to unfold above waist
5. ) while holding, position bottom half of drape over intended work surface
6. ) allow top half to be placed over bottom half of work surface creating a flat, sterile work surface for placement of sterile supplies

Question 28

Adding sterile items to the sterile field

Answer 28

1. ) open sterile item while holding outside wrapper in nondominant hand; freeing dominant hand to unwrap outer wrapper
2. ) carefully peel wrapper over nondominant hand
3. ) ensure wrapper doesn’t fall onto sterile field; place item on sterile field at an angle (DO NOT hold arms over sterile field; DO NOT flip or toss objects onto sterile field)
4. ) dispose outer wrapper

Question 29

Pouring sterile solutions

Answer 29

1. ) verify contents and expiration date
2. ) place receptacle near table/surface edge (prevents reaching over field). Sterile kits have cups or molded secretions for fluids
3. ) remove sterile seal and cap from bottle in upward motion
4. ) hold solution ~1-2” above container, slowly pouring needed amount of solution to prevent splashing. Label should face palm of hand to prevent it from becoming wet and illegible

Question 30

Strike through

Answer 30

When liquids permeate sterile field or barrier

Results in contamination of sterile field

Question 31

Evaluation: preparing sterile field

Answer 31

Observe for breaks in sterile technique requiring you to set up a new sterile field

Question 32

If sterile field comes in contact with contaminated object or liquid splatters onto drape, causing strike through

Answer 32

Discontinue field preparation and start over with new equipment

Question 33

If a sterile item falls of the sterile field

Answer 33

Open another package containing a new sterile item and add it to the field unless the field becomes contaminated, in which a new sterile field is required

Question 34

What to record/ document after preparing a sterile field for a sterile procedure

Answer 34

No recording for prep of the sterile field.

Record sterile procedure performed and patient status on flow sheet

Question 35

Home care for sterile techniques

Answer 35

Most procedures in the home involve clean technique

If sterile technique is required, teach family/caregiver how to correctly use package wrapper as sterile drape/barrier when applying sterile dressing or the correct procedure for removing sterile items from the packaging

Question 36

Sterile gloving

Answer 36

Prevents transmission by direct/indirect contact in procedures such as inserting urinary catheters or applying sterile dressings

Assess for latex allergy. Repeated exposure can lead to allergy or worsen allergy.

Individuals at risk for this allergy include spina bifida, multiple surgeries/procedures, high exposure (HCP, housekeepers, food handlers, tire manufacturers, industrial workers who use gloves routinely), rubber industry workers, personal/family history of allergies. There is also a connection between allergy to avocados, bananas, chestnuts, kiwi, and passion fruit with latex allergy because these foods have some of the identical allergens found in latex.

Question 37

Irritant dermatitis reaction to latex

Answer 37

Skin reaction isolated to the area of contact

Acute reaction: red, dry, itchy and irritated

Chronic reaction: dry, thick skin, crusting and possibly cracking or peeling, results in open sores

Question 38

Type IV delayed hypersensitivity reaction to latex

Answer 38

Allergic reaction to chemicals used in latex

Acute reaction: dry, red, rash, itchy, hives, small blisters

Chronic reaction: dry, thickened skin, crusting, scabbing sores, vesicles, peeling (4-96 hours after exposure)

Question 39

Type I immediate hypersensitivity reaction to latex

Answer 39

Could be life-threatening, reactions start as soon as 2-3 minutes after exposure up to several hours

Acute reaction: hives, swelling, runny nose, nausea, abdominal cramps, dizziness, low blood pressure, bronchospasm, anaphylaxis (shock)

Question 40

Glove sizes

Answer 40

Gloves should not stretch so tightly over the fingers that they can tear easily, yet should be tight enough that objects can be easily picked up.

Sizes range (e.g., 6, 6 1/2, 7, etc.) can vary from “one size fits all”, small, medium, large

Question 41

Assessment: sterile gloving

Answer 41

Consider procedure- some ORs recommend double gloving to decrease risk for percutaneous injury

If PT has higher risk for infection= added precautions if necessary

Examine gloves- should be dry and intact with no water stains

Inspect hands for cuts, hangnails, open lesions, or abrasions. Can sometimes cover with impervious transparent dressing. Can sometimes prevent participation in a procedure

Question 42

Assess PT for risk factors or latex allergy before applying latex gloves

Answer 42

Previous reaction to adhesive tape, dental or face mask, golf club grip, ousting bag, rubber band, balloon, bandage, elastic underwear, IV tubing, rubber gloves, condom within hours of exposure

Personal history of asthma, contact dermatitis, eczema, urticaria, rhinitis

History of food allergies, especially avocado, banana, peach, chestnut, raw potato, kiwi, tomato, papaya

Previous history of adverse reactions during surgery or dental procedure

Previous reaction to latex product

Question 43

NRSG Diagnoses: sterile gloving

Answer 43

Ineffective protection

Risk for infection

Risk for injury

Question 44

Planning: sterile gloving

Answer 44

Patient should not develop S/S of infection after

It is expected that PT does not develop latex sensitivity/reaction

Synthetic nonlatex gloves (latex free/powder free) must be used when patients are at risk or if nurse has sensitivity/allergy to latex

Question 45

Implementation: applying sterile gloving

Answer 45

1. ) perform thorough hand hygiene
2. ) remove outer glove package wrapper by carefully separating and peeling apart sides
3. ) grasp inner package and lay on dry, clean, flat surface above waist. Open and keep gloves on inside surface of wrapper
4. ) I.D. Right and Left glove. Glove is ~2” wide; glove dominant hand first
5. ) use thumb and first 2 fingers of nondominant hand to pull glove over hand by the cuff (leave cuff-do not allow to roll up wrist)
6. ) slip fingers of dominant hand underneath cuff of second glove & carefully pull glove over hand
7. ) after second glove is on, interlock hands together and hold away from body above waist until beginning procedure to ensure smooth fit over fingers

DO NOT allow fingers and thumb of gloves dominant hand to touch any part of exposed nondominant hand. Keep thumb of dominant hand abducted back

Question 46

Implementation: removing sterile gloving

Answer 46

1. ) grasp outside of one cuff with other gloves hand (avoid touching wrist)
2. ) pull glove off, turn inside out, place in gloves hand
3. ) take fingers of bare hand and tuck inside remaining glove cuff. Peel off glove inside out over previously removed glove. Discard
4. ) perform thorough hand hygiene

Question 47

Evaluation: sterile gloving

Answer 47

Assess PT for S/S of infection, focusing on area treated

Assess PT for S/S of latex allergy

Question 48

If PT develops localized infection (e.g., urine becomes cloudy or odorous; wound becomes painful, edematous, or reddened with purulent drainage)

Answer 48

Contact HCP and implement treatments as ordered

Question 49

If PT develops systemic S/S of infection (e.g., fever, malaise, increased WBC count)

Answer 49

Contact HCP and implement treatments as ordered

Question 50

If PT. develops an allergic reaction to latex

Answer 50

Immediately remove source of latex

Bring emergency equipment to bedside. Have epinephrine injection ready for administration, and be prepared to initiate IV fluids and O2

Question 51

Recording/ documenting: sterile gloving

Answer 51

Not necessary to document application of gloves

Record procedure performed and PT response and status

In the event of a latex allergy reaction, record PT response on flow sheet. Note type of response and PT reaction to emergency treatment

Question 52

Teaching

Answer 52

Nurse or PT with known latex allergy should wear a medical bracelet/tag and carry a wallet card stating latex allergy

Should also carry a quick-acting oral antihistamine and an epinephrine autoinjector at all times