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Surgical Asepsis
Chapter 20
• Assigned Reading
• Chapter 20, volumes one and two
• Principles of Surgical Asepsis
• Touching one sterile item with another sterile item
• Touching one sterile item with a non-sterile item
yields it contaminated
• Partially unwrapped sterile package is contaminated
• If a question arises about sterility it is contaminated
• A commercially packaged sterile item is not
considered sterile past its recommended expiration
date
• Once a sterile item is opened it is only a matter of
time before it becomes contaminated- set up
immediately before using
• A sterile wrapper, if it becomes wet, wicks
microorganisms from its supporting surface, causing
contamination
• Principles of Surgical Asepsis (cont.)
• Any opened sterile item or sterile area is
considered contaminated if it is left
unattended (in OR and Delivery, covered
with a sterile field)
• Coughing, sneezing, or excessive talking
over a sterile field causes contamination
• Reaching across an area that contains
sterile equipment has a high potential for
causing contamination and therefore is
avoided
• Sterile items that are located or lowered
below the waist are considered
contaminated
• Avoid use of one inch perimeter margin of
a sterile field
Sterilization
• Physical & chemical techniques that
destroy all microorganisms and
spores
Physical Sterilization
• Radiation- (generally combined with other
means). Effective for TB. Home means
includes sunlight
• Boiling (212F X 15 minutes)
• Free-flowing steam (212F heat vapors)
• Dry heat- Similar to baking in oven (330340F X 3 hours)
• Steam under pressure-most dependable.
Autoclave method. Temperature over 212F.
Pressure allows for hotter temperature
than boiling. Heat sensitive tapes may be
used.
Chemical Sterilization
• Peracetic Acid-quick and reliable for
sterilizing heat sensitive instruments.
30 minutes
• Ethylene Oxide Gas-destroys
microorganisms in 3 hours. Must air
following (5 days) to remove traces
of gas (could cause chemical burns)
Surgical Asepsis
Includes:
• Creation of a sterile environment
• Use of sterile
equipment/supplies/solutions
• Sterilization of reusable supplies
• Surgical hand scrub
• Surgical attire if in OR
• Sterile gloves
• Sterile field
• Use of sterile technique
Other Examples of Sterile Supplies
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Dressing supplies (gauze, kerlix)
Injection supplies (needles)
IV catheters
Sutures
Foley catheters
Surgical Asepsis
• Donning sterile gloves-Skill
• Donning sterile gown (during surgery
and delivery of infants). Apply mask
and hair cover first, then gown and
last gloves. Gown will be wrapped
from central supply with inside
facing towards you so you can grasp
and put on without contaminating
outside of gown which must remain
sterile.
Sterile Technique
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Used for . . .
Operating room
Dressings
Insertion of Foley catheters
Assisting physicians with
procedures
Gloves and Sterile Fields
Creating a Sterile Field
• A work area free of microorganisms
• Formed using the inner surface of a
cloth or paper wrapper that holds
sterile items
• The field enlarges the area where
sterile equipment or supplies are
placed
• Set the field up immediately before
planning to use
Creating a Sterile Field
Skill
• Inspect the work area to determine
the cleanliness and orderliness of
the surface on which you will work
• Obtain supplies
• Check the package to assure it is
sealed and that the date has not
expired
• Explain what you will do to the
patient
• Perform handwashing or hand antisepsis
• Open the barrier/field and lift one inch
from the edge straight up from the
wrapper, keeping the long edge from
touching the work station
• Keep above waist level
• Two ways to open the sterile field:
• Long way or short way are both
acceptable as long as contamination does
not occur
• Without shaking, lie the sterile field
onto the work station without
touching the sterile side of the field
(keep your hands on the underside of
the field)
Donning Sterile Gloves
• Select a package of sterile gloves of the
appropriate size
• Remove unnecessary items from the
overbed table
• Perform handwashing or alcohol-rub
antisepsis
• Open the outer wrapper of the gloves
• Carefully open the inner package and
expose the sterile glove with the cuff end
closest to you
• Pick up one glove at the folded edge of the
cuff using your thumb and fingers
• Insert your fingers while pulling and
stretching the glove over your hand,
taking care not to touch the outside of the
glove to anything that is nonsterile
• Unfold the cuff so the glove extends
above the wrist, but touch only the surface
that will be in direct contact with the skin
• Insert the gloved hand beneath the sterile
folded edge of the remaining glove
• Insert the fingers within the second glove
while pulling and stretching it over the
hand
• May use gloved hands to fix fingers
• Take care to avoid touching anything that
is not sterile
• Maintain your gloved hands at or above
waist level
Disposal of Contaminated Gloves
• Handout
• Grasp outside of one cuff with other
gloved hand; avoid touching wrist.
• Pull glove off, turning it inside out
and discard.
• See handout
Nursing Implications: Nursing Diagnoses
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Risk for infection
Risk for Infection Transmission
Ineffective Protection
Delayed Surgical Recovery
Deficient Knowledge
• Lab Practice for Sterile Gloves (pair)
• Lab Practice for Opening a Sterile
Field
Dressings and Wound Management
• Combination of Chapter 20 –
Principles of Surgical Asepsis and
Chapter 34 – Wound Care
• Assigned readings-chapter 20 and
chapter 34, volumes one and two
Goal of Wound Management
• To reapproximate the tissue to
restore its integrity
Wound Management
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Dressings
Drains
Sutures and Staples
Bandages and Binders
Irrigations
PURPOSES OF A DRESSING
• Keep the wound clean (use sterile
supplies and sterile technique)
• Absorbing drainage (various dressing
materials)
• Controlling bleeding (pressure dressings,
wraps)
• Protecting the wound from further injury
(i.e. duoderm)
• Holding medication in place
• Maintaining a moist environment
(hydrocolloid dressings, saline dressings,
Alldress system)
TYPES OF DRESSINGS
• Gauze dressings-highly absorbent to
cover fresh wounds that are likely to bleed
or exude drainage (woven cloth fibers).
Allows air flow to wound. Can debride new
granulation, may need to moisten with NS
if adhered to prevent debridement.
• Transparent dressings-Allows the nurse to
assess the wound; commonly used to
cover peripheral and central IV insertion
sites
• Hydrocolloid dressing-They keep wounds
moist because they heal more quickly in a
wet environment. Self adhesive. May stay
on 1 week.
Dressing Supplies for Typical Surgical Dressing
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2 X 2 gauze
4 X 4 gauze (come single packs and multipacks)
Fluffs
Drain sponges
ABD pad (Combine dressing)
Rolled gauze- Kerlix or Kling
Some agency have commercially packaged dressing
kits (expensive)
Solution to clean the wound (need to lip the containers
to remove contamination)
Sterile field (barrier)
Sterile gloves
Unsterile gloves to remove the old dressing
Bag/receptacle for disposal of old dressing
One Swipe per Gauze- BUNCH UP 4 X 4
TYPES OF DRAINS
• Purpose of drain is to remove blood and cellular
debris
• Open drains-flexible tubes that provide a pathway
for drainage toward the dressing. Called penrose
and often used for abdominal surgery or kidney
surgery.
• Drainage occurs by passive gravity & by capillary
action (movement of a liquid at the point of
contact with a solid, which would be the gauze)
• Closed drains-Hemovac and Jackson Pratt to pull
fluid by creating a vacuum or negative pressure.
Hemovac often used for orthopedic surgery.
• T-tube often used for gallbladder surgery or
biliary surgery.
Closed drains pull fluid by creating a vacuum or negative pressure. Open the vent on
the receptacle, squeeze the drainage collection chamber and then cap the vent.
Cleaning Around Drains
• Circular motion
• Start closest to the drain and go
outward
• Drains are often located beside a
surgical wound, rather than within the
wound line.
• After cleaning around the drain, a precut drain sponge is placed around the
drain.
• Expect more drainage from the exit
point of an open drain, more gauze
needed at this spot.
Types of Dressings
• Dry Sterile Dressing (DSD)-clean wound and
apply dry gauze, dressing material
• Newer recommendations may include clean
technique rather than sterile technique. Follow
agency protocols. For lab pass offs, will do sterile
technique with a penrose drain in place.
• Wet to dry dressing-cover wound only with wet
dressing then top with a dry gauze dressing; now
expect wet to moist dressings rather than wet to
dry
• Packing-follow medical orders for type, length,
width and if packing is medicated packing or
gauze packing (can be used for tunneling-use Qtips to pack or sterile forceps)
Dressing Change
• Follow medical orders for time,
frequency
• Often “initial” (original) dressing is
done by physician
Other Orders for Dressing Change
• Reinforce dressing- add to existing
dressing
Assessing Wound Drainage
• Amount and Color:
• Serous-clear, watery, thin, may be
straw colored
• Sanguineous-bright red, active
bleeding
• Serosanguineous-pale red, mixture
of clear & red fluid, more watery than
sanquinous
• Purulent-thick yellow, green, tan or
brown
Wound Complications
• Dehiscence-reopening of surgical
wound
• Evisceration-spilling of abdominal
contents-many factors; usually
follows dehiscence, abscess
formation (should evisceration occur,
cover with normal saline gauze to
keep moist)
• Infection/abscess-associated with
bowel/appendix-wound expect to see
open wound
Techniques to Keep a Dressing in Place
• Tape (different types of tape,
dependent on patient’s
tolerance/allergies
• Montgomery straps- often used if
need frequent dressing changes
• Netting (comes in several different
sizes)
To Remove Tape
• Remove tape by pulling it toward the
wound- prevents separation of
wound
Documentation of Dressing Change
• Describe the drainage on old
dressing
• Assess and describe the wound,
measure
• Clean the wound (and drain site if
applicable)
• Apply dressing material
• Document your assessment data,
actions and patient response (DAR)
NURSING IMPLICATIONS: NURSING
DIAGNOSES
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Acute Pain
Impaired Skin Integrity
Ineffective Tissue Perfusion
Impaired Tissue integrity
Risk for Infection
BANDAGES AND BINDERS
• Bandage-Strip or roll of cloth
wrapped around a body part
(example: Ace bandage)
• Binder-Type of bandage generally
applied to a particular body part
• Binders and bandages hold dressings
in place when tape cannot be used or
the dressing is large
• Supporting the area around a wound or
injury to reduce pain
• Limiting movement in the wound area to
promote healing
Ace Bandages
• Wrap from distal to proximal
direction
• Avoid gaps
• Equal tension
• Free of wrinkles
• Remove twice a day
• Check CSM-color, sensation,
movement
Irrigations
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Purpose:
Rinse out cellular debris
Remove purulent drainage
Bathe tissue with medications
Keep area moist
Types of Irrigations
•Clean technique:
•Eyes
•Ears
•Vagina
•Feeding tubes
•Nasogastric tubes
•Sterile technique:
•Wounds
•Bladder
Irrigations Kits
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Solution
Padding
Basin
Dressing Supplies
Date and time all containers
Sterile solutions expire 24 hours
after opening
• Irrigations done with smaller needle
rather than irrigation syringe in kit
Lab Practice
• Personal Dressing Kits- keep all supplies
• Lab demonstration by instructor
• Step by Step
• Set up disposal bag for old dressing
• Apply unsterile (clean) gloves and remove old dressing. (If dressing
sticks, apply saline and remove with clean glove). Assess wound and
drainage, discard dressing, remove and discard gloves.
• Perform hand hygiene
• Set up field
• Apply items to field (only add one sterile glove, other will be put on from
bedside)
• Lip solution (i.e. normal saline) to clean the wound
• Apply one sterile glove that was not on the field
• Clean incision first using one of the appropriate cleaning techniques
(hold cleaning container with non gloved hand). Bunch up the 4 x4 for
cleaning the incision.
• Clean incision before drain site
• With gloved hand go into field and apply second glove
• Apply dressing (gauze, drain sponge, gauze on top of drain sponge, abd.
pads)
• Secure dressing with tape (make a tab for easy removal)
DEBRIDEMENT – this is a review
• Sharp debridement-Removal of necrotic
tissue with a sterile scissors.
• Enzymatic debridement-Use of a topical
chemical substance that breakdown and
liquefy wound debris.
• Autolytic debridement-Painless, natural
physiologic process that allows the body’s
enzymes to soften, liquefy, and release
devitalized tissue
• Mechanical debridement-Use of wet-dry
dressing to remove debris
FACTORS WHICH AFFECT WOUND HEALING
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Type of wound injury
Expanse or depth of wound
Quality of circulation
Amount of wound debris
Presence of infection
Status of the client’s health
HEALING- review
• First Intention Healing-Primary intention
is a reparative process in which the
wound edges are directly next to each
other.
• Second Intention Healing-The wound
edges are widely separated, leading to a
more time-consuming and complex
reparative process.
• Third Intention Healing-The wound edges
are widely separated and are later
brought together with some type of
closure material.
Lab Practice
• Personal Dressing Kits- keep all supplies
• Lab demonstration by instructor
• Step by Step
• Set up disposal bag for old dressing
• Apply unsterile (clean) gloves and remove old dressing. (If dressing
sticks, apply saline and remove with clean glove). Assess wound and
drainage, discard dressing, remove and discard gloves.
• Perform hand hygiene
• Set up field
• Apply items to field (only add one sterile glove, other will be put on from
bedside)
• Lip solution (i.e. normal saline) to clean the wound
• Apply one sterile glove that was not on the field
• Clean incision first using one of the appropriate cleaning techniques
(hold cleaning container with non gloved hand). Bunch up the 4 x4 for
cleaning the incision.
• Clean incision before drain site
• With gloved hand go into field and apply second glove
• Apply dressing (gauze, drain sponge, gauze on top of drain sponge, abd.
pads)
• Secure dressing with tape (make a tab for easy removal)