STERILE TECHNIQUE

NURSING DIAGNOSES
Risk for Infection related to: interruption of skin integrity by presence of surgical incision Diminished immune response

Sterilization
To eliminate all microorganisms as well as vegetative states such as spores from objects that come into contact with the tissues of the body that are normally sterile.

 IDEAL METHOD must be: 1. Effective 2. Inexpensive 3. Simple 4. Safe (for the item and the personnel) Any item to be sterilized must first be completely clean.

Methods of Sterilization
1. Thermal
a. Moist Heat- Steam Under Pressure b. Hot Air- Dry Heat c. Microwaves

2. Chemical
a. b. c. d. Ethylene Oxide Gas Hydrogen Peroxide Plasma/Vapor Ozone Gas Liquid Chemical Sterilant- Peracetic Acid

3. Ionizing Radiation

a. Moist Heat- Steam Under pressure The high pressure system enables the steam to reach a much higher temperature than is otherwise possible, and it is the temperature-not the pressure-that destroys microorganisms. Items should be left in the steam sterilizer (a.r.a Autoclave) until they are cool and dry, so that the exterior of the package can be handled, maintaining the sterility of the contents.

 Can penetrate substances that cannot be sterilized using other methods. Used primarily to sterilize anhydrous oils, petroleum products, and bulk powders that steam under pressure and ethylene oxide cannot penetrate. When there is no moisture, higher temperatures are required to destroy microoganisms.

 Uses a low-pressure steam along with the non-ionizing radiation of microwaves to produce temperatures sufficiently high to destroy microorganisms. The temperature required is lower than that of steam, and the time necessary is less

a. Ethylene Oxide Gas (EO Gas) Used for items sensitive to heat or moisture (eg. Plastic and electronic components) Process must be carefully monitored because EO is flammable and explosive in air. OSHA Standard: 1. Length of exposure to EO: 1ppm-8hours-40hours/wk 2. All absorbent materials must be adequately aerated before use 3. Manufacturers recommendation must be followed: An item that can be safely steam sterilized should never be gas sterilized.

 Hydrogen peroxide plasma is created by activating hydrogen peroxide to produce a reactive plasma or vapor.
Sterilization is achieved at low temperatures, making it safe for some heat-sensitive items.

c. Ozone Gas
Ozone sterilization is appropriate for many heat- and moisture- sensitive items and has the added benefit of leaving no residue. Ozone can be corrosive, and so should not be used for items made of steel, brass, and aluminum. Also will destroy items made of natural gum rubber such as latex.

 Suitable for sterilizing heat-sensitive items that are not harmed by moisture. Provides an alternative to gas or plasma sterilization if the item to be sterilized can be immersed. No aeration period required just rinsing with distilled water Instruments can be used immediately in a sterile procedure but must be dried by a sterile towel before being placed on a sterile field.

Activated Glutaraldehyde Solution

3. Ionizing Radiation
Exposure to Irradiation Used to sterilize most heat- and moisturesensitive items and generates no residual radiation. Capable of penetrating large bulky items Cobalt 60- most commonly used source for irradiation sterilization

 Used when items cannot be sterilized or in situations where no method of sterilization is available. Done to eliminate as many microorganisms from an item or from the environment as possible but does not eliminate spores

 An agent that kills growing or vegetative forms of bacteria. (EPA- Environmental Protection Agency)
Agents are labeled: Virucidal Fungicidal Sporicidal- if effective against spores Tuberculocidal

1. Low-level
Used for housekeeping purposes and for non-critical items that comes in contact with the intact skin

2. Intermediate-level
Used for semi-critical items that come in contact with intact skin or mucous membranes but do not enter body tissues

3. High-level
Used for critical items that will come in contact with body tissues below the skin or mucous membranes but will not be introduced into the intravascular system

 Alcohol Chlorine Compounds (Household bleach in H2O) Iodophors (Betadine) It must be made clear that this agent merely disinfects and does not sterilize items that the solution contacts.

 Boiling Water To Use: 1. Completely cover the items so that all surface areas are exposed to the water. 2. Start timing only after a rolling boil has begun. Boil for a minimum of 30mins. 3. If sodium carbonate is added to the water to make a 2% solution, the recommended time is 15 min. - Used for items that need disinfection between uses (eg. Bedpans and emesis basins)

 Ultraviolet (UV) Rays Can kill vegetative bacteria, fungi, and lipoprotein viruses. UV Lights are used in the OR to decrease airborne microorganism levels but lights are turned on only when rooms are unoccupied. UV Lights are also used in Isolation rooms designed for patients with infectious TB.

 Special tapes- dark lines appear on the tape after it has been exposed to a temperature for sufficient time to sterilize the item Glass tubing indicators containing heat sensitive substance Vacuum seal for bottles of liquids Expiry date (dont use contents after the date) Factors affecting sterility of wrapped packages:
a. Type of wrapping material b. Storage conditions c. Integrity of the package

GENERAL PRINCIPLES OF STERILITY

1. Microorganisms move through space on air currents.

Thus, items that are exposed to the air for a prolonged period are considered contaminated. When a sterile field is open, keep the doors closed and do not shake drapes and gowns, even if they are sterile.

2. Microorganisms are transferred from one surface to another whenever a non-sterile object touches another object. Keep sterile objects at a distance from the non-sterile ones to prevent transfer of microorganisms. Any contact, no matter how brief, renders sterile items non-sterile. When in doubt of the sterility of an item, consider it unsterile.

3. Microorganisms move from one object to another as a result of gravity when a nonsterile item is held above another item. Keep nonsterile objects, among them your own arm from being over the sterile field.

4. Microorganisms travel rapidly along any moisture through a wicking action.

If moisture connects a nonsterile surface to a sterile one, the sterile surface is considered contaminated.

5. Microorganisms move slowly along a dry surface.

If one side of a dry object is touched, that side is contaminated, but the opposite side is still considered to be sterile. When someone picks up sterile forceps, the handle is immediately contaminated but the tips, which have not been touched are sterile. Maintain safety margin of at least 1inch around a contaminated portion.

6. Microorganisms are released into the air on droplet nuclei whenever a person breathes or speaks
In a situation where sterility is critical (ie. The OR), personnel wear masks to stop this source of contamination. In general setting, a mask may be omitted but avoid talking across a sterile field. Turn your head away when speaking, and speak only when necessary in a sterile environment.

7. Microorganisms are in constant motion in a variety of ways.

sterile areas must be protected by providing wide margins for safety.

8. You cannot guarantee what you cannot see.

Consider anything that is out of sight to be nonsterile A persons back is considered nonsterile , even when clothed in an originally sterile gown. Therefore, two persons in sterile gowns should always pass face to face back to back Keep gloved hands in front of you, in your line of vision. All items below your waist or below table level are considered nonsterile because they are out of full view

9. The edge of any sterile field is potentially contaminated by microorganisms moving in from the outside.

Keep sterile objects away from the edge of the field. Again, 1 inch is considered a minimum safety margin.

10. If you must set up a sterile field ahead of time, cover it with a sterile drape to prevent contamination.
Use a single thickness of paper drape or double thickness of cloth drapes.

STERILE PROCEDURES

1. Wash hands 2. Choose a flat, hard, dry surface on which to prepare a sterile field. A clear sufficient are, so you have plenty of room to work. Beginner: You will find you need at least 12-in square field. 3. Before sterilization, objects are wrapped so that they can be opened without contaminating the contents. The wrapper, when opened, provides a sterile field. 4. As you add additional sterile items, place them well within the edge of the sterile field.

1. Wash your hands 2. When you open a sterile package, do not reach over a sterile object or area 3. Grasp only the outside edge of the wrapper. To accomplish this, open the far flap first, then the side flaps, and finally the flap closest to you. The item can also be turned, or you can walk around it. In some instances you may reach around the object but it is difficult to do this without contaminating the item. 4. Do not allow anything nonsterile to touch the contents of the package.

1. Wash your hands. 2. Unwrap the item as for any sterile package. Pick it up by sliding your hand underneath the covering. Gather the ends of the covering back around you wrist , forming a sterile cover for you hand, and keep the ends from dragging. 3. Place items well within the sterile field, keeping your hands as far away from the field as possible. Small items, such as gauze dressings, may be dropped 6-8 inches above the sterile field. Large items should be put down carefully. You can use sterile forceps to remove an item from a package and place it in the sterile field. 4. Avoid reaching over the sterile field with your arm as much as possible.

1. Wash your hands 2. Pour a small amount of a nonsterile solution (e.g. Betadine) into a waste receptacle (to clean the lip of the container) before you pour the contents into the sterile receptacle. 3. To pour a liquid into a container in the sterile field, pour it from 6-8 inches above the receiving container, to avoid the possibility of the two containers touching.

4. Pour slowly to prevent splashing. If liquid is spilled onto the sterile field, the spot is considered contaminated if the moisture can soak through to the nonsterile surface beneath. If the drape is waterproof (many disposable drapes have a plastic layer) and the sterile liquid pools up on the surface, the area is still sterile. Usually however, this area is covered with a dry drape because moisture may attract microorganisms in the air. 5. Keep your arm as far as possible from the sterile field. Avoid reaching over the sterile field if possible.

1. Remove all rings and wash your hands before putting on sterile gloves. Put on sterile gloves without touching the outside of the gloves, so contamination does not occur. 2. Sterile gloves are sealed in a sterile package. Open thee package in the same way as you would for any other sterile package, unless it is a commercially prepared paper package. In that instance, instructions for opening are printed on the outside of the package. Inside the sterile package is a folder containing the gloves. A small, folded-back margin is provided over each glove, so you can open the folder without touching the gloves.

 The gloves in the package are arranged palm upward, with the left glove on the left side and the right glove on the right side. A cuff of 2-4 inches is folded down over each glove. 3. Open one side of the folder, either left or right, touching only the center lower corner. Pick up the exposed glove with your opposite hand (the left glove with the right hand or the right glove with the left hand). Be careful to touch only the folded cuff. 4. Insert your free hand into the glove without touching skin to the outside of the glove. Be sure you hold the glove well away from your body and from the table or package as you work.

5. Open the second side of the folder with your ungloved hand, exposing the second glove. Pick up the glove with your gloved hand from under the cuff, which is the outside surface. Be sure to keep the thumb of the gloved hand rigidly extended outward or folded against the palm, so you are not tempted to grasp the other glove. Hold the glove under its cuff by your four gloved fingers. The cuff on the second glove protects the gloved hand from contamination by touching and also from microorganisms moving by gravity.

6. Carefully maneuver the second hand into the glove. 7. When both gloves are on, turn the cuffs up by flipping them, taking care not to roll the outside of the gloves onto your skin. You may then make any necessary adjustments so the gloves fit smoothly.