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Chapter 010
- 1. CHAPTER 10 SterileTechnique Copyright © 2018, Elsevier Inc. All rights reserved.
- 2. STERILETECHNIQUE Copyright © 2018, Elsevier Inc. All rights reserved. 2 • Purpose: to maintain an area free from pathogenic microorganisms • Minimizes patient exposure to infection- causing agents • Reduces infection risks of patients
- 3. STERILETECHNIQUE (CONT.) • Majority of sterile technique practice are used in the OR • Sterile technique includes: • Applying mask • Protective eyewear and cap • Performing surgical hand scrub • Applying sterile gown and gloves Copyright © 2018, Elsevier Inc. All rights reserved. 3
- 4. STERILETECHNIQUE (CONT.) Copyright © 2018, Elsevier Inc. All rights reserved. 4 • Proper hand hygiene is required • Used at bedside for procedures that require intentional puncture of skin, insertion of devices into a sterile part of the body, and when skin integrity is compromised • Standard precautions are the minimum standard for infection control
- 5. STERILETECHNIQUE (CONT.) Copyright © 2018, Elsevier Inc. All rights reserved. 5 • Must maintain sterile technique at all times throughout procedure • When completing sterile procedure at bedside: • Perform hand hygiene • Apply sterile gloves • Explain steps taken to prevent infection
- 6. QUICK QUIZ! For which of the following interventions will the nurse wear protective eye gear? A.During am care for a patient who is homeless. B.During insertion of an intravenous line (IV) in a pediatric patient. C.When suctioning a patient with tuberculosis (TB). D.When applying a cast to an elderly woman. Copyright © 2018, Elsevier Inc. All rights reserved. 6
- 7. PATIENT-CENTERED CARE • Invasive procedures cause infection risk • You are obligated to maintain surgical asepsis during those procedures and to intervene to stop it when a break in sterile technique occurs • Cultural considerations: Educate patients to reduce fears or misconceptions about attire worn during sterile asepsis Copyright © 2018, Elsevier Inc. All rights reserved. 7
- 8. EVIDENCE-BASED PRACTICE • Patient-centered education, inserting devices only when necessary, and removing unneeded devices decreases HAIs • Prevention of contamination is overall goal to reduce HAIs • Antiseptics reduce bacterial count on patient’s skin • Artificial nails/nail extenders encourage pathogens and fungus and should not be worn in a health care setting Copyright © 2017, Elsevier Inc. All rights reserved. 8
- 9. SAFETY GUIDELINES 1. Follow standard precautions with all patients. 2. Review agency policies and procedures before conducting a sterile procedure. 3. Assess a patient’s potential for infection before choosing the barrier to be used, such as masks or protective eyewear. Copyright © 2018, Elsevier Inc. All rights reserved. 9
- 10. SAFETY GUIDELINES (CONT.) 4. Use barrier techniques to decrease the transmission of microorganisms from health care personnel and the environment to a patient. 5. Remain organized while performing any sterile procedure. 6. Remember that hand hygiene is essential before initiating any sterile procedure. 7. Incorporate the principles of surgical asepsis when conducting any sterile procedure. Copyright © 2018, Elsevier Inc. All rights reserved. 10
- 11. APPLYING AND REMOVING CAP, MASK, AND PROTECTIVE EYEWEAR SKILL 10-1 Before applying a mask, assess patient’s potential for acquiring an infection If a mask is worn, change it when it becomes moist or soiled Wear cap/eyewear as needed Standard precautions require clean gloves before coming in contact with body fluids Copyright © 2018, Elsevier Inc. All rights reserved. 11
- 12. DELEGATION AND COLLABORATION The skill of applying and removing a cap, mask, and protective eyewear is required of all caregivers when working in sterile areas. All health care providers use clean gloves.The skill of applying PPE can be delegated to nursing assistive personnel (NAP) The nurse instructs NAP to: Be available to hand-off equipment or assist with patient positioning If procedure requires sterile technique, educate the NAP regarding the sterile field Hand hygiene performed before and after glove removal Copyright © 2018, Elsevier Inc. All rights reserved. 12
- 13. RECORDING AND REPORTING • No recording or reporting is required for this set of skills • Record specific procedure performed in nurses’ progress notes and describe patient’s status Copyright © 2018, Elsevier Inc. All rights reserved. 13
- 14. SPECIAL CONSIDERATIONS Home care Instruct family caregiver about specifics of when to apply a cap, a mask, and protective eyewear in the home Determine ability of family caregiver to safely implement sterile procedure Observe for signs and symptoms of infection Copyright © 2018, Elsevier Inc. All rights reserved. 14
- 15. PREPARING A STERILE FIELD SKILL 10-2 A sterile field provides a sterile surface for placement of sterile equipment A sterile drape establishes a sterile field around a treatment site After sterile kit is opened, inside surface can be considered a sterile field Copyright © 2018, Elsevier Inc. All rights reserved. 15
- 16. QUICK QUIZ! A sterile field consists of: A.The outer portion of a sterile tray. B.A table covered with a sterile drape. C.Contaminated dressings from the patient. D.Clean, latex-free catheters. Copyright © 2018, Elsevier Inc. All rights reserved. 16
- 17. DELEGATION AND COLLABORATION Surgical technicians may prepare a sterile field (see agency policy) however, nursing assistive personal (NAP) cannot The nurse directs NAP to: Assist with patient positioning and with obtaining any necessary supplies Copyright © 2018, Elsevier Inc. All rights reserved. 17
- 18. RECORDING AND REPORTING • No recording or reporting is required for this set of skills • Record sterile procedure performed and patient status in nurses’ notes in EHR or chart Copyright © 2018, Elsevier Inc. All rights reserved. 18
- 19. SPECIAL CONSIDERATIONS Home care Clean technique is often required Teach patient and family principles that apply to the sterile environment Assess patient and family understanding and ability to provide a sterile environment when needed to perform a specific procedure Copyright © 2018, Elsevier Inc. All rights reserved. 19
- 20. QUICK QUIZ! The task of preparing a sterile field cannot be delegated to the NAP.True or False? A.True. B.False. Copyright © 2018, Elsevier Inc. All rights reserved. 20
- 21. STERILE GLOVING SKILL 10-3 Sterile gloves help prevent the transmission of pathogens by direct and indirect contact Verify if patient or health care providers have latex allergy Select the proper glove size Select type of glove (latex or nonlatex) Copyright © 2018, Elsevier Inc. All rights reserved. 21
- 22. DELEGATION AND COLLABORATION Assisting with tasks that include the application and removal of sterile gloves may be delegated to NAP. Many procedures that require the use of sterile gloves cannot be delegated to NAP The nurse instructs NAP about: The reason for using sterile gloves for a specific procedure Copyright © 2018, Elsevier Inc. All rights reserved. 22
- 23. RECORDING AND REPORTING • It is not necessary to record application of gloves. Record specific procedure performed and patient response and status • In the event of a latex allergy reaction, record patient’s response in nurses’ notes and on vital sign flow sheet. Note type of response and patient’s reaction to emergency treatment Copyright © 2018, Elsevier Inc. All rights reserved. 23
- 24. SPECIAL CONSIDERATIONS Teaching Nurse or patient with a known latex allergy should wear a medical alert bracelet or tag and should carry a wallet card stating “latex allergy” Individuals with known latex allergies should carry at all times a quick-acting oral antihistamine and an epinephrine autoinjector Copyright © 2018, Elsevier Inc. All rights reserved. 24
Editor's Notes
- This chapter reviews three skills: applying and removing a cap, a mask, and protective eyewear; preparing a sterile field; and performing sterile gloving.
- In 2007, the Centers for Medicare & Medicaid Services (CMS) identified a list of conditions viewed to be reasonably preventable by applying evidence-based guidelines. Among these conditions are hospital-acquired vascular and urinary catheter–associated infections. Since October 1, 2008, hospitals receive no additional funds for treating these conditions. As of January 2012, CMS had identified 10 hospital-acquired conditions that are preventable based on evidence-based guidelines. In many instances, this has led institutions to encourage staff to speak up if they see a break in sterile technique by a co-worker. Regardless of the procedures followed or the setting, all individuals involved in surgical asepsis have a responsibility to provide and maintain a safe environment by following aseptic principles.
- As with medical asepsis, proper hand hygiene with an appropriate cleaner or antiseptic is required before initiating any sterile procedure. Surgical aseptic technique is also used at the beside during procedures that require intentional puncture of the patient skin or insertion of devices into an area of the body that is normally sterile (urinary catheter) or in a situation in which skin integrity is compromised because of incision or burn. [Review with students Box 10-1, Principles of Surgical Asepsis.]
- When sterile procedures are carried out in the OR or procedure area, health care providers must follow as series of steps to maintain sterile asepsis: applying a mask, protective eyewear, and cap; performing a surgical hand scrub; applying sterile gown and gloves. When sterile procedures, such as a sterile dressing change, are carried out at the bedside, the health care provider must perform hand hygiene and apply sterile gloves. When the risk of splash is present other personal protective equipment (PPE) is required. When completing a sterile procedure at the bedside, communicate with the patient what steps are being taken to prevent infection, including what actions the patient should avoid to keep the field sterile. These actions include avoiding sudden body movements, refraining from touching sterile supplies, and avoiding coughing or talking over sterile area.
- Correct answer: C Rationale: There is the potential for splattering of secretions from a patient who is contagious.
- [Ask students: what kinds of procedures are considered invasive? Discuss: starting an IV line or inserting a urinary catheter.] Whether performed in a hospital, ambulatory care setting, the patient’s home, or health care provider’s office, invasive procedures such as starting an IV line or inserting a urinary catheter pose a risk for infection. When a break in sterile technique occurs, The Joint Commission (TJC) encourages nurses to “speak up” in these instances. Take into consideration the patient’s cultural background or beliefs when sterile asepsis is required. Individualized patient-centered education for patients and families before any aseptic procedure reduces fears and misconceptions about any sterile asepsis attire. This also provides an opportunity for patients and families to ask questions and express their concerns regarding surgical attire.
- Recommendations such as patient-centered education, inserting devices only when necessary, using sterile technique, and removing devices that are no longer needed have decreased the number of health care–associated infections. Still more than 700,000 health care–associated infections occur annually and 75,000 deaths. Prevention of contamination is an overall goal to reduce health care–associated infections (HAIs). This can be done by minimizing traffic, comprehensive cleaning and disinfecting, as well as changing skin preparation, administration of antibiotics and removing watches, jewelry and artificial nails. Use of additional antiseptics, such as chlorhexidine, reduce bacterial count on the patient’s skin. Most health care agencies have policies against artificial nails, including extensions or tips, gels and acrylic overlays, and resin wraps. The subungual area (under a fingernail) of the hand and the “lifting” of the product from the nail bed contains a high concentrations of bacteria, more specifically coagulase-negative staphylococci, gram-negative rods, and fungal growth. These organisms are not effectively removed after hand hygiene.
- [Ask students: what are some cues to deciding the patient’s potential for infection?]
- [Discuss ways to stay organized while performing sterile procedures.]
- Although masks and caps are usually worn in surgical procedure areas (e.g., the OR), certain aseptic procedures performed at a patient’s bedside also might require these barriers. [Ask students: what are times when you might need to wear a mask, a cap, and protective eyewear outside of the OR? Discuss: it may be agency policy for a nurse to wear a mask during changing of a central line dressing or insertion of a peripherally inserted central catheter (PICC). Other policies might require that a nurse wear a mask and a cap to secure hair during dressing changes on a patient with extensive burns or a central line. Anytime there is risk of splattering blood or body fluid, there is also the need to apply protective eyewear. Some nurses choose to wear a surgical cap to secure loose hair that might contaminate at a sterile area.] Assess the patient’s potential for acquiring an infection before applying a mask. Does the patient have a large open wound? Do you have a respiratory infection? Is the patient immunosuppressed?
- The skill of applying and removing cap, mask, and protective eyewear is required of all caregivers when working in sterile areas. All health care providers use clean gloves. The skill of applying PPE can be delegated to nursing assistive personnel (NAP). The nurse instructs the NAP to: Be available to hand-off equipment or assist with patient positioning during a sterile procedure. If the procedure is to use sterile technique, educate the NAP regarding the sterile field. Performing hand hygiene before and after gloving.
- [Explain that no recording or reporting is needed because wearing PPE is a required (not optional!) step.]
- [Ask students: what factors would you assess in determining the family caregiver’s ability to safely implement sterile procedure?]
- [Ask students: what can be used as a sterile field? Discuss: a sterile field is an area considered free of microorganisms; it may consist of the inside of a sterile kit or tray, a work surface draped with a sterile towel or wrapper, or a table covered with a large sterile drape.] Sterile drapes establish a sterile field around a treatment site such as a surgical incision, a venipuncture site, or a site for introduction of an indwelling urinary catheter. Drapes also provide a work surface for placing sterile supplies and manipulating items with sterile gloves. Once you create a sterile field, you are responsible for performing the procedure without contaminating the field.
- Correct answer: B Rationale: The table covered with a sterile drape is considered sterile. The inner portion of the sterile tray is sterile; the outer portion is not. Although dressings are removed from the patient, they are contaminated and would therefore break the sterile field. Clean catheters are different from sterile catheters and therefore cannot be included in a sterile field.
- The task of preparing a sterile field cannot be delegated to NAP. Surgical technicians may prepare a sterile field (see agency policy) [Discuss your institution’s policy.]
- [Ask students: why is the patient’s status included when sterile procedure performance is recorded? Discuss.]
- Most care procedures in the home setting involve clean technique. In the event that a sterile environment is ordered, patient and family need to be aware of principles that apply to the sterile environment. For example, teach the family how to correctly use a package wrapper as a sterile drape/barrier when applying a sterile dressing, or teach the family the correct procedure for removing a sterile item from a package.
- Correct answer: A Rationale: Depending on agency policy, surgical technicians may prepare a sterile field. NAP may assist in positioning patients and obtaining extra supplies but cannot be responsible for setting up the sterile field.
- Nurses apply sterile gloves before performing sterile procedures such as inserting urinary catheters or applying sterile dressings. Sterile gloves are available in a wide range of sizes. Gloves should not stretch so tightly over the fingers that they can easily tear, yet they need to be tight enough that objects can be picked up easily. Remember that sterile gloves do not replace hand hygiene. Repeated exposure to latex can lead to a latex allergy in which latex-free gloves would need to be used. [Review with students Box 10-2, Individuals at Risk for Latex Allergy.] Latex proteins enter the body through skin or mucous membranes, intravascularly, or via inhalation. Reactions to latex range from mild to severe. [Review with students Box 10-3, Levels of Latex Reactions.] More health care agencies are implementing latex-safe environments for workers. If only sterile latex gloves are available, don a pair of synthetic gloves first because these provide a barrier between the skin and the latex gloves. To prevent glove contamination while waiting to handle sterile items, it is helpful to interlock the fingers and hold the hands together in front of the body and above waist level. Once gloved, keep your hands clasped about 30 cm (12 inches) in front of your body, above waist level and below the shoulders, until you are ready to perform the procedure.
- [Ask students: why is it important for the NAP to know the reason for using sterile gloves for a specific procedure? Discuss.]
- [Discuss various signs of latex allergy.]
- [Discuss other precautions for people with latex allergy, such as types of bandages.]