Adding Sterile Items to a Sterile Field

Skill 1-6

Adding Sterile Items to a Sterile Field

A sterile field is created to provide a surgically aseptic workspace. It should be considered a restricted area. After establishing the sterile field, add other sterile items, including solutions, as needed. Items can be wrapped and sterilized within the facility, or they can be commercially prepared. Take care to ensure that nothing unsterile touches the field or other items in the field, including hands or clothes. Refer to Fundamentals Review 1-2 to review basic principles of surgical asepsis.

Delegation Considerations

Procedures requiring the use of a sterile field and other sterile items are not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, these procedures may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Sterile field
Sterile gauze, forceps, dressings, containers, solutions, or other sterile supplies, as needed
PPE, as indicated

Assessment

Assess the situation to determine the necessity for creating a sterile field. Assess the area in which the sterile field is to be prepared. Move any unnecessary equipment out of the immediate vicinity. Identify additional supplies needed for the procedure.

Assess that the sterile, packaged supplies are dry and unopened. Assess the package expiration date, making sure that the date is still valid.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or needs may require the use of this skill as part of related interventions. An appropriate health problem or need may include:

Infection risk
Risk for Cross Infection

Outcome Identification and Planning

The expected outcomes to achieve when adding items to a sterile field are that the sterile field is created without contamination, the sterile supplies are added to the sterile field and are not contaminated, and the patient remains free from exposure to pathogens.

Implementation

Action	Rationale
1. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
2. Identify the patient. Explain the procedure to the patient.	Patient identification validates the correct patient and correct procedure. Discussion and explanation help allay anxiety and prepare the patient for what to expect.
3. Check that the sterile, packaged drape and supplies are dry and unopened. Also note expiration date, making sure that the date is still valid.	Moisture contaminates a sterile package. An expiration date indicates period that package remains sterile.
4. Select a work area that is waist level or higher.	Work area is within sight. Bacteria tend to settle, so there is less contamination above the waist.
5. Prepare sterile field as described in Skill 1-4 or Skill 1-5.	Proper technique maintains sterility.
6. Add sterile item:
To Add a Facility-Wrapped and Sterilized Item
a. Hold facility-wrapped item in the dominant hand, with top flap opening away from the body. With other hand, reach around the package and unfold top flap and both sides.	Only sterile surface and item are exposed before dropping onto sterile field.
b. Keep a secure hold on the item through the wrapper with the dominant hand. Grasp the remaining flap of the wrapper closest to the body, taking care not to touch the inner surface of the wrapper or the item. Pull the flap back toward the wrist, so the wrapper covers the hand and wrist.	Only sterile surface and item are exposed before dropping onto sterile field.
c. Grasp all the corners of the wrapper together with the nondominant hand and pull back toward wrist, covering hand and wrist. Hold in place.	Only sterile surface and item are exposed before dropping onto sterile field.
d. Hold the item 6 inches above the surface of the sterile field and drop onto the field. Be careful to avoid touching the surface or other items or dropping any item onto the 1-inch border.	This prevents contamination of the field and inadvertent dropping of the sterile item too close to the edge or off the field. Any items landing on the 1-inch border are considered contaminated.
To Add a Commercially Wrapped and Sterilized Item
a. Depending on the type of package, hold package in one hand. Pull back top cover with other hand. Alternatively, carefully peel the edges apart using both hands (Figure 1).	This allows contents to remain uncontaminated by hands.
b. After top cover or edges are partially separated, hold the item 6 inches above the surface of the sterile field. Continue opening the package and drop the item onto the field (Figure 2). Be careful to avoid touching the surface or other items or dropping an item onto the 1-inch border.	This prevents contamination of the field and inadvertent dropping of the sterile item too close to the edge or off the field. Any items landing on the 1-inch border are considered contaminated.
c. Discard wrapper.	A neat work area promotes proper technique and avoids inadvertent contamination of the field.
To Add a Sterile Solution
a. Obtain appropriate solution and check expiration date.	Once opened, label any bottles with date and time. Solution may be kept for use for 24 hours once opened.
b. Open solution container according to directions and place cap on table away from the field with edges up (Figure 3).	Sterility of the inside of the cap is maintained.
c. Hold bottle outside the edge of the sterile field with the label side facing the palm of your hand and prepare to pour from a height of 4 to 6 inches (10 to 15 cm). Do not touch the tip of the bottle to the sterile container or field.	The label remains dry, and solution may be poured without reaching across sterile field. Minimal splashing occurs from that height. Accidentally touching the tip of the bottle to a container or dressing contaminates them both.
d. Pour required amount of solution steadily into sterile container previously added to the sterile field and positioned at side of sterile field or onto dressings (Figure 4). Avoid splashing any liquid.	A steady stream minimizes the risk of splashing; moisture contaminates sterile field.
e. Touch only the outside of the lid when recapping. Label solution with date and time of opening.	The solution remains uncontaminated and available for future use.
7. Continue with procedure as indicated.
8. When procedure is completed, remove PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the sterile field has been created without contamination, the sterile supplies have not been contaminated, and the patient has remained free of exposure to pathogens.

Documentation

It is not usually necessary to document the addition of sterile items to a sterile field. However, document the use of performing sterile technique for any procedure.

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

The item being added falls close to or on the edge of the field: Consider the outer 1-inch edge of a sterile field to be contaminated. Any item within the outer 1-inch is considered contaminated.
A part of the sterile field becomes contaminated: When any portion of the sterile field becomes contaminated, discard the sterile field and any items on the field and start over.
You realize a supply is missing after setting up the sterile field: Call for help. Do not leave the sterile field unattended. If you are unable to see the sterile field at all times, it is considered contaminated.
The patient touches the sterile field: If the patient touches the sterile field, discard the supplies and prepare a new sterile field. If the patient is confused, have someone assist by holding the patient's hands and/or reinforcing what is happening.

EVIDENCE FOR PRACTICE
AORN Guideline Quick View: Sterile Technique Association of periOperative Registered Nurses (AORN). (2018). AORN guideline quick view: Sterile technique. AORN Journal, 108(6), 705-710. https://doi.org/10.1002/aorn.12458 Refer to details in Skill 1-4, Evidence for Practice.

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Skill 1-6

EVIDENCE FOR PRACTICE