Principles Underlying Medical and Surgical Asepsis The patient is a source of pathogenic microorganisms.

ganisms. The patients microorganisms leave trough specific routes. There are always microorganisms in the environment, which in some individuals and under certain circumstances can cause illness. Microorganisms harmful to man can be transmitted by direct and indirect contact. Spread of infection from source to others can be prevented by various methods to stop the spread as close to the source as possible. The effectiveness of medical/surgical asepsis is dependent on the conscientiousness of those carrying them out. In observing medical asepsis, areas are considered contaminated if bear or are suspected of having pathogens. In observing surgical asepsis, areas are considered contaminated if touched by any object is not sterile. Breaking the chain of infection: Asepsis Practices

Handwashing Cleaning, Disinfection, Sterilization Use of Barriers Isolation system Surgical Asepsis

1. Handwashing. Handwashing is the single most important infection control practice. All caregivers, clients and family member learn handwashing techniques. Microorganisms are transient flora until the hands are washed. Soap and water and alcohol based handrubs are effective preparations for removing transient microorganisms. Wash hands before and after every client contact. Effectiveness of hand washing is greatly influence by adequate friction and thoroughness of surface cleansed. Handwashing for medical asepsis is done by, holding lower than the elbows. Hands are more contaminated than lower arms. Wash hands using running water, soap and friction for 15 to 30 seconds on each hand. This is to mechanically loosen remove dirt and microorganisms on all hand surfaces. Clean under fingernails. Ideally, turn faucet with clean pare towel. Keep fingernails short and avoid nail polish prevent harboring microorganisms. Always wear gloves during client care when the skin is abraded.

2. Cleaning, Disinfecting, and sterile Cleaning - The physics removal of visible and debris by washing, dusting or mopping surfaces that are contaminated. Soap is used for mechanical cleaning. Disinfecting - The chemical or physical processes used to reduce the number of potential pathogens on an objects surface. But spores of the pathogens are not necessarily destroyed. Sterilization - The complete destruction of all microorganisms, including spores, leaving no viable of organisms. Factors to be considered in the selection in the sterilization or Disinfection methods: 1. Nature of organisms present. Some may be destroyed easily, others more difficult. 2. Number of organisms present. More organisms required longer time to destroy. Organisms protected by coagulated protein require longer time to destroy. Cleaned articles before disinfections or sterilization are rendered clean/sterile more quickly. 3. Types of equipment. Equipment with small lumen, ir points difficult to clean and requires special care. 4. Intended use of equipment. For medical asepsis: clean technique For surgical asepsis: clean technique 5. Available means of sterilization and disinfections. Methods of sterilization 1. Steam sterilization autoclaving is sterilization using supersaturated steam under pressure. This method is non toxic, inexpensive, sporicidal, and able to penetrate fabrics rapidly. It used to sterilize surgical dressings, Color indicator strips change color, indicating that sterilization has occurred Check packaging for integrity and always check the expiration date to ensure sterility of the object. 2. Gas sterilization ethylene oxide is a colorless gas that can penetrate plastic, rubber, cotton and other substances. This is used to sterilize oxygen or suction gauges, BP apparatus, stethoscope, and catheters. Articles must be left to release the gas thorough aeration before they are used. This type of sterilization is expensive and requires 2 to 5 hours to be accomplished. Ethylene oxide is toxic to humans. 3. Radiation Ionizing radiation penetrates deeply into objects.

This is used in sterilizing drugs, foods and other heat sensitive items.

4. Chemicals These are effective disinfectants. They are all types of microorganisms, act rapidly, work with water, are inexpensive, are stable in light and heat, are not harmful to body tissues, do not destroy articles. These are used for instruments and equipment such as glass thermometer. Chorine is used for disinfecting water. 5. Boiling water This is lest expensive for use in home. Items like glass baby bottles should be boiled for at least 15 minutes. Types of Disinfection Concurrent Disinfection Ongoing practice that are observed in the care of the client, supplies immediate environment, to limit/control the spread of microorganisms. Terminal Disinfection Practices to remove pathogens from the clients belongings and his immediate environment after his illness is no longer communicable. Medical Aseptic practice to be implemented during client care Wash hands frequently, especially: 1. Before handling foods 2. Before and after using the toilet 3. Before and after performing nursing procedures 4. Before and after each patient contact Keep soiled items/equipment from touching the clothings. E.g. soiled linens. Instruct client to cover mouth and nose when coughing and sneezing. Avoid rising dust; do not shake linens. Clean least contaminated areas first then move to more contaminated areas. Practice segregation of wastes Sterilize objects suspected of contaminating pathogens. Use practices of good personal hygiene to help prevent spread of microorganisms 3. Use of Barriers Techniques that prevent the transfer of pathogens from one person to another are referred to as barriers. The most commonly used barriers are as follows: Mask Caps and shoe covings Gloves Private rooms Waterproof disposable bags for linen and trash Labeling and bagging of contaminated equipment and specimens

Control of airflow into the sterile areas and out of contaminated areas Goggles of face shields Mask Mask should fit tightly to the face, covering the nose and the mouth Mask loses their effectiveness if they are wet, worn for long periods, and when are not changed after caring for each client. Disposable particulate respirators look like mask but fit the face more tightly and are able to filter out particles or organisms as small as 1 micro millimeter. These are indicated whenever a caregiver is working with a client who has, or is suspected of having contagious diseases such as tuberculosis. Gowns Gowns should be worn when caregivers clothings is likely to be soiled by infected material Used gowns only once and discard them Change gown when it becomes wet. Gloves Gloves protect the hands for acquiring infective organisms. These reduce likelihood of transmission of microbial flora from personnel to clients or from client to other clients. Gloves should be changed and discarded between clients or when they are become torn or grossly soiled. Hands are washed and dried before and after removing gloves. Gloves should not be washed and reused. Private rooms Separation of clients into private rooms decreases the chance of transmission of infection by all routes. If this is impossible, a client with an infection may be placed in the same room as another client who is infected with the same microorganisms, as they are not infected with other potentially transmissible microorganisms and likelihood of reinfection with the same microorganism is minimal. If transport to another department in necessary, clients gowns and dressings should be change before leaving the room and the client should wear necessary barriers such as mask or gown. Equipment and refuse handling Articles and linens soiled by any body fluid should be placed in impervious (water proof) bags before they are removed from the clients bedside. Waste segregation and disposal should ensure prevention of transfer of microorganisms.

 Categories of institutional wastes are as follows: A. Infection Waste - Blood and blood products - Pathology laboratory specimen - Laboratory cultures - Body parts from surgery - Contaminated equipment (suction catheters, nasogastric tubes) - Food - Unrinsed infant and adult diapers B. Injurious Waste - Needles - Scalpel blades - Lancet - Broken glass - Pipettes C. Hazardous Waste - Radioactive materials - Chemotherapy solutions and their containers and other caustic chemicals 4. Isolation system Isolation refers to techniques used to prevent or to limit the spread of infection Isolation precaution are classified as standard precautions, transmissions based precautions and protective isolation. Standard Precaution Synthesize the major features of universal precautions and body substance isolation. These precautions are intended to prevent transmission of bloodborne and moist body substance pathogens. A. Wear clean gloves when touching 1. Blood, body fluids, secretions and excretions, and items containing these body substances. 2. Mucous membrane 3. Non intact skin B. Perform handwashing immediately 1. When there is direct with blood, body fluids, secretions and excretions, or contaminated items. 2. After removing gloves. 3. Between patient contacts.

catheters,

urinary

C. Wear a mask, eye protection and face shield during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions. D. Wear a mask, eye protection and face shield during procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions or excretion, or cause soiling of clothings. E. Removed soiled protective items promptly when the potential for contact with reservoirs of pathogens is no longer present. F. Clean and reprocess all equipment before reuse by another patient. G. Discard all single use items promptly in appropriate container that prevent contact with blood, body fluids, secretions and excretions, contamination of clothing, or transfer to other patients and the environment. Never Recap Needles use your needle disposal container. Transmission Based precautions 1. Airborne Precautions. These are used fr microorganisms transmitted by small particle droplets that can remain suspended and become widely dispersed by air currents E.g. TB, varicella, measles. 2. Droplet Precautions. These are used for microorganisms transmitted by larger particle droplets. 3. Contact Precautions. These are used with organisms that can be transmitted by hand or skin to skin contact, such as during client care activities or when touching the clients environmental surfaces or care items. E.g. clostridium difficile, shigella, impetigo. Protective Isolation Implemented to prevent infection for people whose resistance to infection/ body defenses are lowered or compromised. E.g. clients with low wbc count (leukopenia) on immunosuppressive medications like cancer chemotherapy; with extensive burns The client should be placed in a private room. Restrict visitors. Only cooked or canned fruits are allowed 5. Surgical Asepsis The purpose of sterile technique is to prevent the introduction of microorganisms. Surgical asepsis is required in the following situations: - Surgical procedures. - All procedures that cause a break in skin or mucous membranes (e.g. intramascular injections). - Complex dressing changes and wound care. - Care for high risk groups (e.g. transplant recipients, burn clients, clients with cancer. Principles of surgical asepsis

1. Moisture causes contamination. Prevent splashing of liquids in the sterile fields Place wet objects on sterile, water impermeable surfaces, such as sterile basin. Rationale: microorganisms travel more easily through moist environment, when sterile surface becomes moist, microorganisms from the unsterile may be transmitted into the sterile surface. 2. Never assume that an object is sterile Ensure that it is labeled as sterile Always check the integrity of the packaging. Always verify the expiration date on the package. Whenever in doubt of the sterility of an object, consider it unsterile. 3. Always face the sterile field Rationale: objects that are out of the line of vision may be inadvertently contaminated. 4. Sterile articles may touch only sterile articles or surfaces if they are to maintain their sterility Rationale: Anything considered unsterile may transfer microorganisms to the sterile object it touches. An object used in cleaning the skin (e.g. swabs) must be used once and then discarded because the skin cannot be sterilized. 5. Sterile equipment or areas must be kept above the waist and on the top on the sterile field. Rationale: Waist level is the limit of good visual field. Maximum visibility of all sterile objects prevents inadvertent contamination. 6. Prevent unnecessary traffic and air currents around the sterile area. Close doors Unfold drapes or wrappers slowly. Do not sneeze, cough, or talk excessively over the sterile field. Do not reach across sterile fields. Move around a sterile field to reach for an object, if necessary 7. Open, unused sterile articles are no longer sterile after the procedure. Rationale: - Once protective wrapping have been removed, the article is being contaminated by air so, it must be discarded or resterilized before it is used. - Liquids opened during the procedure that remain in their original container are also considered contaminated. 8. A person is considered sterile who become contaminated must reestablish sterility. Rationale: If a scrubbed person punctures the gloves or is contaminated by touching an unsterile object, he or she must change the contaminated article. If a Scrubbed person leaves the area of the sterile field. He or she must go through the procedure of rescrubbing, gowning and gloving 9. Surgical technique is a team effort. A collective and individual sterile conscience is the best method of enhancing sterile technique.

Rationale: Staff members must Periodic review of procedures and infection control surveillance report enhance everyones sterile technique.

Related Nursing Skills: Performing Sterile Procedures] Surgical hand scrub Purpose: Remove as many microorganisms from the hands as possible before the sterile procedure. Equipment: Sink with knee or foot controls Antimicrobial Soap Surgical scrub brush Plastic nail stick sterile nail cleaner Sterile towel for drying Steps: 1. Be sure fingernails are short, clean, and healthy. Nail polish should be removed 2. Removed rings. Apply surgical shoe covers, cap, facemask, and protective eyewear. 3. Wash and rinse hands for initial wash. Rationale: To removed gross contamination and transient microorganism 4. Open disposable brush impregnated with antimicrobial soap, adjust water temperature to warm using knee or foot control lever 5. Wet hands and arms. Keep Hands Above Elbows 6. Wet scrub brush or apply antibacterial soap if not already impregnated in the brush 7. Rinsed hands thoroughly under warm running water, holding hands upward. This is to allow water to drain towards the flexed elbows. Applying and Removing Sterile Gloves Purpose: Prevent transfer of microorganisms from hands to sterile object or open wounds. Equipment: Packaged sterile gloves in correct size Flat working surface

Steps A. Applying Gloves 1. Wash hands 2. Peel off outside wrapper as directed by manufacturer 3. Lay inner package on clean, flat surface about waist level. Open rapper from the outside, keeping gloves on inside surface 4. Grasp first glove by inside edge cuff with thumb and first two fingers of the dominant hand. Hold hands above waist; insert non- dominant hand into glove. 5. Slip gloved hand (four fingers with thumb up) underneath second gloved cuff and pull over dominant hand. 6. Keeping hands above waist, adjust glove fit, touching only sterile areas. B. Removing Gloves 7. Wash gloved hands first 8. With Dominant hand, grasp outer surface of non-dominant glove just below thumb. Peel off glove inside out, without touching exposed wrist. 9. Place ungloved hand under thumb side of second cuff and peel off toward the fingers holding first glove inside second glove. Discard into appropriate receptacle. 10. Wash hands Donning a Sterile Gown and Closed Gloving Purpose: To apply attire necessary to safely carry out sterile procedures usually in the operating room and delivery room. Equipment: Sterile gown Sterile Gloves Mayo stand or flat surface area above waist level Steps: 1. Wear shoe covers, cap that covers all hair, facemask and protective eye wear and perform the surgical scrub. a. Donning a Sterile Gown 2. Grasp folded sterile gown at the neckline and step away from the sterile field. Allow gown to gently unfold, being careful that it does not touch the floor. The inside of the gown is toward the user. 3. Holding the arms at shoulder level, grasp the sterile gown just below the neckband near the shoulders and slide in the sleeves until the fingers are at the end of the cuffs but not through the cuffs. 4. Have someone tie the back of the gown, taking care that only the ties are touched and not the sides or front of the gown. b. Closed Gloving

5. With singers still within the cuff of the gown, open the inner sterile glove package and pick up the first glove by the cuff, using the nondominant hand. 6. Position the glove over the cuff of the gown so the fingers are in alignment, and stretch the entire glove over the cuff of the gown, being careful not to touch its edge. Fingers remain within the cuff of the gown. 7. Work the fingers into the glove and pull the glove up over wrist the non-dominant hand that still remains within the cuff of the gown. 8. Use the sterile gloved hand to pick up the second glove, placing it over the cuff of the gown of the other hand and repeat the glove application process. 9. Adjust Gloves for comfort and fit. Donning and Removing Gloves, Mask, Gowns and Eye Wear For sterile procedures on a general nursing division, the nurse may wear surgical mask and gloves without a cap. Eyes wear ideally worn if there is risk of fluid or blood splashing into the nurses eyes. For sterile surgical procedures, the nurse first applies a clean cap that covers all of the hair and then the surgical mask, eye wear, and shoe cover. A mask must fit snugly around the face and nose to prevent contamination by droplet nuclei. To remove protective devices: remove gloves first, then the mask, the gown, the eyewear or goggles, cap and shoe cover.

Preparing and Maintaining a Sterile Field Purpose: To create an environment that helps the sterility of supplies and equipment and prevents transfer of microorganisms during sterile procedure. Equipment: Flat work surface Sterile drape Sterile supplies, e.g. sterile gauze, sterile basin, etc. Packaged sterile gloves Steps: a. Special considerations 1. Wash hands 2. Inspect all sterile packages for package integrity, contamination, or moisture 3. During the procedure, never turn back on sterile field or lower hands below the level of the field b. Opening a sterile Drape

5. Remove the sterile drape from the outer wrapper and place the inner drape in the surface work of the surface, at or above waist level, with the outer flap facing from you. 6. Open the side flaps in the same manner, using the right hand for the right flap and the left hand for the left flap. 7. Open the innermost flap that faces you, being that it does not touch your clothing or any object. c. Adding Sterile Supplies to the Field 8. Open unsealed edge of prepackaged sterile supplies, taking care not to touch the supplies with the hands 9. Hold supplies 10 to 12 inches above the field and allow them to fall to the middle of the sterile field. 10. Holding the sterile object with one hand and wrapping the flaps with other hand add wrapped sterile supplies. Carefully drop the object onto sterile field. d. Pouring Solution to a Sterile Field 11. Check the label and expiration date of the solution. Note any signs of contamination. 12. Remove cap and place it with the inside facing up on flat surface. 13. Pour a small amount of solution into sink or waste container to rinse the rim of the container. 14. Add any additional supplies and don sterile gloves before starting the procedure. Care of the Sterile Pick up Forceps Purpose: To transfer sterile articles and maintain sterility of these articles and the sterile field. Equipment: Sterile forceps in a sterile bottle with germicidal/ disinfectant solution Steps: 1. The prongs of the sterile forceps should be fully immersed in disinfectant solution 2. Sterile forceps are always held above and in front of the waist, within the vision of the nurse. 3. The tips of the forceps are always considered sterile and need to be held down