Surgical Asepsis in the OR

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Surgical Asepsis in the OR

• Principles of Sterile Technique
• Becky Ellis, MN RN
• Nurse Educator N230

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Course Information

• You are about to begin learning about Surgical
  Asepsis. Part of this module is devoted to the
  theory of asepsis as it is used in the operating
  room. The second half of this module is devoted
  to teaching you the skills needed for your OR
  experience, particularly those of scrubbing,
  gowning, and gloving.

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Purpose

• The purpose of this module is to acquaint the
  nursing student with surgical asepsis, surgical
  scrubbing and the gowning and gloving techniques
  that will be used during their OR rotation. This
  module is meant to be on overview and a module to
  be studied at the students convenience.
• The student must successfully complete this
  module prior their OR check off in the skills lab
  and prior to their OR rotation at their health
  care facility.

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Learning Objectives

• After completing this self study course the
  student will be able to
• Describe the fundamental principles of safe
  conduct and the basic rules for aseptic technique
  in the operating room.
• Demonstrate the correct technique of the surgical
  scrub and the correct gowning and gloving
  technique.

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Pretest Instructions

• The next 5 questions compose a pretest to gauge
  your knowledge and ability prior to starting this
  module.
• Select the best answer, then double click with
  your mouse.
• Now here we go

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Pretest

• 1. The Definition of Asepsis is
• A. Soiled or infected with organisms
• B. Capable of producing disease
• C. Absence of microorganisms

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Wrong Answer Try Again
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Correct! The Absence of Microorganisms
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• 2. Cross-contamination is defined as
• A. Producing or capable of producing disease.
• B. Transmission of microorganisms from patient
  to patient and from inanimate objects to
  patients.
• C. Severe toxic state resulting from infection
  with pyogenic organisms.

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This is the Wrong answer Try Again
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• Correct!!
• Cross-contamination is the Transmission of
  microorganisms

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• 3. Which task or function during a surgical
  procedure is designed as being within the scope
  of the practice of the scrub nurse?
• A. Closing the surgical wound
• B. Setting up the sterile field
• C. Administering blood products

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Wrong Answer! Go back and try again
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• Right Again!!
• The Scrub nurse prepares the sterile field

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• 4. For which member of the surgical team is a
  surgical scrub unnecessary?
• A. Anesthetist/anesthesiologist
• B. Surgical technologist
• C. Scrub nurse

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Wrong Answer!! Return and try again
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• WOW!
• You are doing great. Another Right answer!
• Proceed onto the next question, please

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• 5. Which is the best technique for you to use
  when rinsing your hands and forearms after a
  surgical scrub?
• A. Rinsing is not performed after a surgical
  scrub because it will reduce the antimicrobial
  activity of the cleansing solution.
• B. Rinsing should start at the elbow with the
  water running down back down to the hand.
• C. Rinsing should start with the hand
  positioned such that water runs off the elbow
  rather than down to the hands.

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Wrong Again!!!! Try Again
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• Correct Answer!!
• You have completed your pretest so its time to
  continue on with the module.

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Answers to Pretest

• Correct answer is (a.) Absence of microorganisms.
• Correct answer is (b.) Transmission of
  microorganisms from patient to patient and from
  inanimate objects to patients.
• Correct answer is (b.) Setting up the sterile
  field.
• Correct answer is (a.) Anesthetist/anesthesiologis
  t.
• Correct answer is (c.) Rinsing should start with
  the hand positioned such that water runs off the
  elbow rather than down to the hands.

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Principles Of Aseptic Technique

• 1. Only sterile items are used within the
  sterile field
• 2. Sterile persons are gowned and gloved
• 3. Tables are sterile only at table level
• 4. Sterile persons touch only sterile items or
  areas
• 5. Unsterile persons avoid reaching over the
  sterile field
• 6. The edges of anything that encloses sterile
  contents are considered unsterile

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Principles of Aseptic Technique

• 7. The sterile field is created as close as
  possible to the time of use
• 8. Sterile areas are continuously kept in view
• 9. Sterile persons keep well within the sterile
  area
• 10. Sterile persons keep contact with sterile
  areas to a minimum
• 11. Unsterile persons avoid sterile areas
• 12. Destruction of the integrity of microbial
  barriers results in contamination

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1. Only Sterile Items Are Used Within A Sterile
Field

• Discard any contaminated items
• If a sterile package is found in a contaminated
  area.
• If uncertain about the actual timing or operation
  of the sterilizer.
• If an unsterile person comes into close contact
  with a sterile table.
• If a sterile table or unwrapped sterile items are
  not under constant supervision.

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Only Sterile Items Are Used Within the Sterile
Field (Continued)

• Discard any contaminated items
• If the integrity of the packaging material is not
  intact.
• If a sterile package wrapped in a material other
  than plastic or another moisture-resistant
  barrier becomes damp or wet.
• If a sterile package wrapped in a pervious woven
  material drops on the floor or other areas of
  questionable cleanliness.

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2. Sterile Persons are Gowned and Gloved

• Observed gowning practices.
• Self-gowning and gloving should be done from a
  separate sterile surface to avoid dripping water
  onto sterile supplies or a sterile table.
• The stockinette cuffs of the gown are enclosed
  beneath sterile gloves. The stockinette is
  absorbent and retains moisture, and doesnt
  provide a microbial border.
• Sterile persons keep their hands in sight at all
  times and at or above waist level or the level of
  the sterile field.

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Sterile Persons are Gowned and Gloved
(Continued)

• Observed gowning practices (cont).
• Hands are kept away from the face, and the elbows
  are kept close to the sides.
• The back of the gown is considered contaminated.
• The gown is considered sterile only to the
  highest level of the sterile tables.

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3. Tables Are Sterile Only At The Table Level

• Sterile table.
• Only the top of a sterile, draped table is
  considered sterile. The edges and sides of the
  drape extending below table level are considered
  unsterile.
• Anything falling or extending over the table
  edge, such as a piece of suture, is unsterile.
• When unfolding a sterile drape, the part that
  drops below the table surface is not brought back
  up to table level.

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4. Sterile Persons Tough Only Sterile Items or
Areas

• Sterile team members maintain contact with the
  sterile field by means of sterile gowns and
  gloves.
• The unsterile circulator does not directly
  contact the sterile field.
• Supplies are brought to sterile team members by
  the circulator, who opens the wrappers on sterile
  packages.

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5. Unsterile Persons Avoid Reaching Over the
Sterile Field

• The unsterile circulator never reaches over a
  sterile field to transfer sterile items.
• The circulator holds only the lip of the bottle
  over the basin when pouring solution into a
  sterile basin in order to avoid reaching over the
  sterile area.
• The scrub person sets basins or glasses to be
  filled at the edge of the sterile table.

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6. Edges of Anything That Encloses Sterile
Contents Are Considered Unsterile

• The inside of a wrapper is considered sterile to
  within 1 inch of the edges. The circulator opens
  top flap away from self. Then turns the sides
  under. The ends of the flaps are secured in the
  hand so they do not dangle loosely. The last
  flap is pulled toward the person opening the
  package, thereby exposing the package contents
  away from the unsterile hand.

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Edges of Anything That Encloses Sterile Contents
Are Considered Unsterile (Cont)

• Sterile persons lift contents from packages by
  reaching down and lifting them straight up,
  holding their elbows high.
• The flaps on peel-open packages should be pulled
  back, not torn, to expose the sterile contents.
  The contents should not be permitted to slide
  over the edges.

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Edges of Anything That Encloses Sterile Contents
Are Considered Unsterile (Cont)

• After a sterile bottle is opened, the contents
  are either used or discarded. The cap cannot be
  replaced without contaminating the pouring edges.

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7. The Sterile Field Is Created As Close As
Possible to the Time of Use

• Sterile tables are set up just prior to the
  surgical procedure.
• It is virtually impossible to uncover a table of
  sterile contents without contamination. Covering
  sterile tables for later use is not recommended.
• A covered table is not under observation at all
  times.

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8. Sterile Areas Are Continuously Kept in View

• Sterile persons face sterile areas.
• Someone must remain in the room to maintain
  vigilance when sterile packs are opened in a room
  or a sterile field is set up. Sterility cannot
  by ensured without direct observation. An
  unguarded sterile field should be considered
  contaminated.

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9. Sterile Persons Keep Well Within the Sterile
Area

• Sterile persons stand back at a safe distance
  from operating bed when draping the patient.
• Sterile persons pass each other back to back at a
  360-degree turn.
• Sterile persons turn their backs to an unsterile
  person or area when passing.
• Sterile persons face a sterile area to pass it.

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Sterile Persons Keep Well Within the Sterile
Area (Cont)

• Sterile persons ask an unsterile individual to
  step aside rather than risk contamination.
• Sterile persons stay within the sterile field.
  They do not walk around or go outside the room.
• Movement within and around a sterile area is kept
  to a minimum to avoid contamination of sterile
  items or persons.

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10. Sterile Persons Keep Contact With Sterile
Areas to a Minimum

• Sterile persons do not lean on sterile tables or
  on the draped patient.
• Sitting or leaning against an unsterile surface
  is a break in technique.

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11. Unsterile Persons Avoid Sterile Areas

• Unsterile persons maintain a distance of at least
  1 foot from any area of the sterile field.
• Unsterile persons face and observe a sterile area
  when passing to be sure they do not touch it.
• Unsterile persons never walk between two sterile
  areas.
• The circulator restricts to a minimum all
  activity near the sterile field.

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12. Destruction of the Integrity of Microbial
Barriers Results in Contamination

• Sterile packages are laid on dry surfaces only.
• If a sterile package wrapped in absorbent
  material becomes damp or wet, it is discarded.
  The package is considered unsterile if any part
  of it comes in contact with moisture.
• Drapes are placed on a dry field.

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Destruction of the Integrity of Microbial
Barriers Results in Contamination (Cont)

• If solutions soak through a sterile drape to an
  unsterile area, the wet area is covered with
  impervious sterile drapes or towels.
• Sterile items are stored in clean, dry areas.
• Sterile packages are handled with clean, dry
  hands.

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Setting Up An Unsterile Table As A Sterile Field

• The scrub person drapes an unsterile table toward
  self first to protect the gown. Gloved hands are
  protected by cuffing a drape over them.
• The scrub person stands back from the unsterile
  table when draping it in order avoid leaning over
  an unsterile are.

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There Is No Compromise with SterilityIts
Considered Sterile or Unsterile.
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The OR Scrub
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The Surgical Scrub

• Definition.
• The surgical scrub is the process of removing as
  many microorganisms as possible from the hands
  and arms by mechanical washing and chemical
  antisepsis before participating in a surgical
  procedure.
• Despite the mechanical action and the chemical
  antimicrobial component of the scrub process,
  skin is never sterile.

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The Methodology of the Scrub
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The Timed Method

• All surgical scrubs are 5 minutes in length.
• All are performed using a surgical scrub brush
  and an antimicrobial soap solution.

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Surgical Scrub Procedure

• Wet the hands and forearms
• Apply antiseptic agent from the dispenser to the
  hands.
• Wash the hands and arms thoroughly to 2 inches
  above the elbows, several times. Rinse
  thoroughly under running water with the hands
  upward, allowing water to drip from the flexed
  elbows.

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• Take a sterile brush or sponge (from a package or
  dispenser) and apply an antiseptic agent ( if it
  is not impregnated in the brush). Scrub each
  individual finger, including the nails, and the
  hands, a half minute for each hand.

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• Hold the brush in one hand and both hands under
  running water, and clean under the fingernails
  with a disposable plastic nail cleaner. Discard
  the cleaner after use.
• Again scrub each individual finger, including the
  nails and the hands with the brush, half a minute
  for each hand.

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The Final Rinse

• Be sure to keep both arms in the upright position
  (careful not to touch the faucet!) so that all
  water flows off the elbows and not back down to
  the freshly scrubbed hands. Bring arm through the
  water once, starting with the fingers, then pull
  the arm straight out. Do not let water run down
  to hands, must drip off elbows

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• Rinse the hands and brush, and discard the brush.
• Reapply the antimicrobial agent and wash the
  hands and arms, applying friction to the elbows,
  for 3 minutes. Interlace the fingers to clean
  between them.
• Rinse the hands and arms as described in the
  previous slide.

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Drying the Hands and Arms

• Reach down to the opened sterile package
  containing the gown, and pick up the towel. Be
  careful not to drip water onto the pack. Be sure
  no one is within arms reach.
• Open the towel full-length, holding one end away
  from the nonsterile scrub attire. Bend slightly
  forward.

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• Dry both hands thoroughly but independently. To
  dry one arm, hold the towel in the opposite hand
  and, using the oscillating motion of the arm,
  draw the towel up to the elbow.
• Carefully reverse the towel, still holding it
  away from the body. Dry the opposite arm on the
  unused end of the towel.

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Gowning and Gloving Techniques

• Reach down to the sterile package and lift the
  folded gown directly upward.
• Step back away from the table into an
  unobstructed area to provide a wide margin of
  safety while gowning.
• Holding the folded gown, carefully locate the
  neckline.

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• Holding the inside front of the gown just below
  the neckline with both hands, let the gown
  unfold, keeping the inside of the gown toward the
  body. Do not touch the outside of the gown with
  bare hands.
• Holding the hands at shoulder level, slip both
  arms into the armholes simultaneously.

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• The circulator brings the gown over the shoulders
  by reaching inside to the shoulder and arm seams.
  The gown is pulled on, leaving the cuffs of the
  sleeves extended over the hands. The back of the
  gown is securely tied or fastened at the neck and
  waist, touch the outside of the gown at the line
  of ties or fasteners in the back only.

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Gloving by the Closed Glove Technique

• Using the right hand and keeping it within the
  cuff of the sleeve, pick up the left glove from
  the inner wrap of the glove package by grasping
  the folded cuff.

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• Extend the left forearm with the palm upward.
  Place the palm of the glove against the palm of
  the left hand, grasping in the left hand the top
  edge of the cuff, above the palm. In correct
  position, glove fingers are pointing toward you
  and the thumb of the glove is down

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• Grasp the back of the cuff in the left hand and
  turn it over the end of the left sleeve and hand.
  The cuff of the glove is now over the
  stockinette cuff of the gown, with the hand still
  inside the sleeve.

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• Grasp the top of the left glove and underlying
  gown sleeve with the covered right hand. Pull
  the glove on over the extended right fingers
  until it completely covers the stockinette cuff.

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• Glove the right hand in the same manner,
  reversing hands. Use the gloved left hand to
  pull on the right glove.

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Gloving the Right Hand
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Scrubbing, Gowning, and Gloving Complete
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Group Discussion

• Now visit your Blackboard Course site and go the
  discussion board section. Discuss the following
  questions (on the next slide) with your other
  class members, be sure to share any previous
  experiences you may have had using Aseptic
  Technique along with any insights that you may
  have related to this topic.

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Questions for Discussion

• What would you do if, during your OR experience,
  you accidentally touched an unsterile object with
  your sterilely gloved hand?
• What would you do if, while scrubbing, you
  accidentally touched the faucet?
• Is it OK to prepare a sterile field an hour
  before the scheduled surgical case and leave the
  room to set up another OR room? Why or why not?
• What should you do if you notice a break in
  sterile technique by another member of the OR
  team that they may/or may not be aware of?

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• I would like to express thanks to Karen Steinke,
  RN, MN for graciously helping with the photos
  used in this presentation.