Using Principles of Surgical Asepsis

Nursing Procedure 1.3

Using Principles of Surgical Asepsis

Avoids introducing microorganisms onto a designated sterile field.

Bactericidal or antimicrobial soap or surgical hand antiseptic cleanser
Sink with side or foot pedal
Surgical scrub sponge or a combination sponge-brush
Sterile gloves
Sterile gown
Mask
Hair covering and booties (optional)
Sterile materials (dressing, instruments)
Sterile sheets or towels (occasionally found in dressing tray)
Waste disposal materials: trash can, bags (precaution [isolation] bags optional)
Pen

Assessment should focus on the following:

Data from medical history and physical or diagnostic studies indicating susceptibility to or presence of infection (e.g., fever, cloudy urine, positive culture, decreased white blood cell count, history of immunosuppression or steroid intake)
Doctor's orders or agency policy regarding dressing changes and precaution (isolation) procedures
Client's or nurse's allergy to soap or bacteriostatic solutions
Client's room assignment (ward, double or single room)
Date of expiration and sterility indicator on sterile supplies and solutions
Client's knowledge of principles of asepsis
Client's ability to cooperate and not contaminate sterile field
Agency policy regarding surgical scrub procedure

Nursing diagnoses may include the following:

Risk for infection related to central line insertion and total parenteral nutrition (TPN) therapy
Deficient knowledge related to immunosuppression from renal transplant therapy

Outcome Identification and Planning

Desired Outcomes

Sample desired outcomes include the following:

Client shows no signs of infection or of additional infection.
Client verbalizes understanding of need for protective environment.

Special Considerations in Planning and Implementation

General

Variations in sterile technique (e.g., the omission of some protective coverings [hair cover, booties, mask]) may be used in performing some procedures. CONTINUE TO USE ASEPTIC PRINCIPLES TO GOVERN ACTIONS DURING A PROCEDURE. IF UNSURE OF STERILITY OF MATERIAL, GLOVE, OR FIELD, CONSIDER IT CONTAMINATED. Consult appropriate policies and procedures manuals.

Pediatric

If a child is restless or too young to understand the importance of maintaining a sterile field, restrain the child with linen or soft restraints during the procedure. Use a family member to assist in holding the child still and allaying fears, if possible; otherwise, seek assistance from other personnel. Consider that some parents may be conflicted about the use of physical assistance to perform procedure in maintaining a sterile area. Take the time to provide explanations to parents if parental or other assistance is necessary. If necessary, provide sedation or pain medication before the procedure to comfort and calm the child.

Geriatric

If a client is disoriented and restless, enlist assistance or use manual protective device(s) to hold client still during procedures that require maintenance of sterile materials (see Nursing Procedure 1.6).

Home Health

Bar pets from the room in which a sterile or clean procedure is being performed. Keep in mind that most procedures are performed with clean rather than sterile technique. Enlist and instruct a family member to serve as an assistant. Remove biohazardous waste from home each visit. See Display 1.2 for various considerations in teaching the client/family about infection control and disposal of biohazardous waste in the home. Disposal requirements for biohazardous waste vary by state and by agency.

[Outline]

Desired Outcomes
Special Considerations in Planning and Implementation

Action		Rationale
Determining Room Assignment
1	Use a private room (preferable) for performing a sterile procedure; transfer client to treatment room, if necessary.	Minimizes microorganisms in environment
Performing Surgical Hand Antisepsis (Surgical Scrub)
1	Don mask, hair cover, and booties, if required.	Prevents introduction of contaminants from mouth, hair, or shoes into environment
2	Perform surgical scrub using counted brush stroke method.	Reduces microorganisms on hands; counted brush stroke method places emphasis on specific areas and ensures that all skin surfaces are exposed to sufficient friction
	Remove rings (often must remove wedding band), chipped nail polish, and watch.	Removes sources that harbor and promote growth of microorganisms
	Stand in front of sink, being careful that uniform does not touch sink during washing procedure.	Sinks are considered contaminated; uniforms can carry microorganisms from place to place
	Wet hands and arms from elbows to fingertips under flowing water (use sink with side or foot pedal).	Aids in removal of microorganisms from least to most dirty
	Keep hands and forearms lower than elbows when washing.	Water flows from least to most contaminated area; hands are the most contaminated parts to be washed; permits cleaning of the dirtiest areas without risking contamination of other less dirty areas
	Place soap, preferably antimicrobial/bacteriostatic soap, on hands and rub vigorously for 15–30 s; use scrub brush gently—do not abrade skin.	Creates friction to remove microorganisms
	Using circular motion, scrub all skin areas, joints, fingernails, between fingers, and so forth (on all sides and 2 in. above elbows); slide ring, if present, up and down while rubbing fingers.	Works soap thoroughly over skin surface to increase removal of dirt and microorganisms; permits cleaning around and under ring
	Continue scrub for 5–10 min, or per agency policy.
	Rinse hands from fingers to elbows under flow of water.	Washes dirt and microorganisms from cleanest to least clean area
	Repeat soaping, rubbing, and rinsing until hands and arms are clean.
	Pat hands dry with sterile towel, moving from fingers to wrist to forearm.	Dries hands from cleanest to least clean area
	Turn off faucet with side or foot pedal.	Prevents recontamination of hands
Managing a Sterile Field
1	To create a sterile field:
	Arrange sterile supplies on overbed table or surgical stand. NEVER USE OPENED ITEMS OR ITEMS OF QUESTIONABLE STERILITY.	Organization reduces the risk of error and contamination
	Open packages to reveal supplies, using insides of packages to form sterile field; open package’s outer flap away from you, open side flaps next, and then pull inner flap toward you (Fig. 1.4); spread edges of package cover over table with fingertips.	Prevents reaching over exposed materials; reduces risk that edges, which are considered unsterile, will contaminate field
2	To add items to sterile field:
	Drop sterile items onto field, keeping packaging between items and hands (Fig. 1.5); use sterile forceps or tongs to remove items from package if unable to do so with sterile technique; if unable to remove item from package without contamination, wait until sterile garb is applied, then place items on sterile field.	Prevents contamination of supplies
	Use sterile gloves or sterile tongs to remove sterile towels from field, and cover field and supplies if not beginning procedure immediately. DO NOT REACH OVER OPEN STERILE FIELD, AS THIS EXPOSES FIELD TO CONTAMINATION.	Prevents loss of sterility if field is exposed to air for extended period of time
	Don sterile gown and sterile gloves (see Nursing Procedures 11.1 and 11.2).	Prevents exposure of sterile field to hands or clothing
	Begin procedure with hands held above waist.	Maintains area above the waist as sterile; area below waist is considered contaminated
3	To maintain a sterile field:
	Drape sterile sheets or towels over area surrounding site being treated.	Decreases chance of exposure to nonsterile sites
	Use sterile tongs or forceps to clean site thoroughly with bactericidal agent.	Maintains sterility of gloves; reduces microorganisms
	Discard tongs from sterile field.	Prevents field contamination
	Pour liquids into a sterile basin held by an assistant in sterile garb or by holding bottle over 1-in. outer parameter of field; avoid splashing on field. IF FIELD BECOMES WET, CONSIDER IT CONTAMINATED.	Prevents reaching over sterile field; allows water to conduct microorganisms from nonsterile area to sterile field
Maintaining Asepsis During Procedure
1	Remove soiled equipment from area or sterile field and drop trash in bag or receptacle; avoid touching nonsterile surfaces.	Prevents introduction of microorganisms onto sterile field
2	When procedure is complete and dressing is intact, label dressing with date, time, and your initials.	Indicates when next dressing change is due
Limiting Microorganisms in the Environment
1	Maintain a clean protective environment for immunosuppressed or burn clients:
	Place client in single room.	Decreases exposure to microorganisms
	Use a separate stethoscope, sphygmomanometer, and thermometer for client, if possible.	Prevents exposure to microorganisms
	Use only hospital gowns, linens, and materials; allow no items from home unless approved and sterilized by hospital.	Prevents introduction of possible source of contamination
	When client is severely immunosuppressed, remove papers, books, and other personal items from immediate area unless sterilization is possible.	Removes items that may be contaminated
	Use special food trays, disposable or presterilized.

Were desired outcomes achieved? Examples of evaluation include:

Desired outcome met: Client showed no signs of infection.
Desired outcome met: Client verbalized understanding of need for protective environment.

The following should be noted on the client's record:

Status of wound, dressing, and incision site, with indication of signs of infection, if any
Procedure performed
Protective garments used
Client teaching done regarding maintenance of dressing and sterile protective environment and verbalized understanding by client

section name header

Purpose ⬇

Equipment ⬆ ⬇

Assessment ⬆ ⬇

Nursing Diagnoses ⬆ ⬇

Outcome Id ⬆ ⬇

Implementation ⬆ ⬇

Evaluation ⬆ ⬇

Documentation ⬆