Aseptic Procedures PDF

CHAPTER 11 Aseptic procedures Barbara Workman Aims and learning outcomes This chapter discusses the principles of asepsis, and the application of those principles when undertaking aseptic procedures. By the end of the chapter you will be able to: outline the principles of a...

CHAPTER 11 Aseptic procedures Barbara Workman Aims and learning outcomes This chapter discusses the principles of asepsis, and the application of those principles when undertaking aseptic procedures. By the end of the chapter you will be able to: outline the principles of aseptic precautions apply these principles to practical tasks of preparing a sterile field, using sterile gloves, and assisting other health care professionals during aseptic procedures change a dressing, and remove wound drains and skin closures follow guidelines to insert a urinary catheter. The last two procedures will require supervision in practice until you are competent to undertake them independently. Asepsis Asepsis can be defined as ‘the prevention of microbial contamination of living tissue or fluid or sterile materials by excluding, removing or killing micro-organisms’ (Xavier 1999), the aim being to prevent infection. Aseptic technique is the collective term for methods used to maintain asepsis, and is designed to interrupt the routes of transmission 275 Key Nursing Skills of infection between the patient, staff, equipment and environment. It is the first line of defence against infection and is commonly practised wherever invasive procedures take place. Asepsis is achieved by using sterilized equipment; a non-touch technique to avoid direct contact with the site; taking precautions to reduce airborne micro-organisms; thorough cleansing of the patient and his environment; and effective handwashing by health care per- sonnel (Xavier 1999). There have been some variable aseptic practices noted between practitioners and within Trusts, often relying on tradi- tion rather than logical application of aseptic principles, and not always supported by appropriate evidence (Rowley 2001). A frame- work to encourage a consistent approach to aseptic procedures has been suggested by Rowley (2001). When undertaking aseptic pro- cedures these principles can be remembered by using the framework ANTT: Aseptic Non-Touch Technique (Rowley 2001): Always wash hands effectively Never contaminate key parts Touch non-key parts with confidence Take appropriate infective precautions Sterilized equipment When a patient’s skin or mucous membrane is broken due to an inva- sive procedure, such as a surgical incision or an intramuscular injec- tion, infection is able to bypass the body’s natural defences. Therefore all equipment used to penetrate the body’s natural defences should be sterilized before use. If equipment cannot be sterilized, then disinfec- tion, which removes harmful micro-organisms, is used to prevent the transmission of infection. For example, a sterile catheter is used to empty the bladder, but hands cannot be sterilized and must be disin- fected before inserting the catheter. Trolleys are usually disinfected before commencing dressings or other aseptic procedures by daily cleaning with warm water and 276 Aseptic procedures detergent, followed by thorough drying (Ayliffe et al. 1999), but unless trolleys are visibly contaminated or there is a local outbreak of infection, such as MRSA, cleaning between patients is not essential (Briggs et al. 1996). All sterile packaging should be checked prior to use for: integrity evidence of sterility secure seals expiry date. Pre-packaged lotions should be sterile, as should any dressings that are to come into contact with a wound. Multi-dose vials of lotions should only be used for one patient to prevent cross-contamination. Non-touch technique A non-touch technique has been developed to prevent contamination of the area from micro-organisms on the hands. Historically, forceps have been used in dressing procedures, but Bree-Williams and Waterman (1996) found that their use was often incorrect and con- fused. Evidence suggests that forceps can damage delicate tissues and be less effective when cleaning an area than a sterile gloved hand (Tomlinson 1987) or irrigation, and therefore the use of forceps in aseptic dressing procedures is declining, although for some delicate manipulative tasks, such as removing sutures, forceps are useful. Non-touch technique also means that any equipment that is used in an aseptic procedure will remain sterile only when touched by another sterile object. For example, while a needle and syringe are assembled, the barrel of the syringe and the hub of the needle are non- key parts and can be touched by hand, but key parts of the equipment such as the needle remain sterile until used during the procedure. When preparing and using a sterile field, there should be careful place- ment of the sterile equipment so contamination is kept to the min- imum (Figure 11.1). Implements such as forceps and syringes should be placed so that the area to be handled is at the edge of the sterile field and near the nurse so that stretching over the equipment is not necessary. The tips of equipment expected to touch the swabs should not touch each other. 277  Key Nursing Skills Figure 11.1 Sterile field layout. The sterile field is laid out so that the risk of contamination is reduced. The gallipots or receivers are placed nearest the patient so that fluid is less likely to be dripped across the sterile field. Micro- organisms travel from unsterile environments through wet material; the aim, therefore, is to keep the sterile field dry (Perry and Potter 1998). Clean swabs and dressings can be placed in an area of the sterile field so that they are well away from the other equipment, but are ready for use. Reduction of airborne organisms It is estimated that approximately 10 per cent of hospital infections result from airborne micro-organisms (Rowley 2001). Contamination of wounds or equipment by airborne bacteria has not been consist- ently proven, but micro-organisms may be stirred up from movement of personnel, bedmaking and drawing curtains (Briggs et al. 1996). The greatest source of infection may be the general cleanliness of the en- vironment. Ideally, a designated area that has pressure-controlled air exchanges, such as a ward treatment room, should be used. Accepted practice aims to reduce the amount of air movement in the area during an aseptic procedure (AORN 1996). Sensible precautions therefore usually take the following forms: closure of curtains and arrangement of bedclothes before sterile equipment is taken into the bed area windows and doors are shut, and movement in and out of the cur- tains is kept to the minimum ward cleaning is completed 30 minutes before and avoided during the procedure. 278 Aseptic procedures Clean environment and patient The standards of cleanliness in hospitals have been much criticized recently, and the government response has been to publish standard principles for hospital environmental hygiene (Department of Health 2001a). These encompass a wide range of routine activities that con- tribute to the prevention of hospital-acquired infection, and include guidelines on cleanliness of the environment and standards of clinical practice. The areas that are used for aseptic procedures should be physically clean, with appropriate disposal of all clinical waste. Plan procedures to attend to clean wounds before infected ones (AORN 1996). The degree of cleanliness is more difficult to control in a patient’s home, but the nurse should ensure that the risks of contamination from the environment are kept to a minimum. For example, a patient’s pet may need to be excluded from the room during the aseptic procedure to reduce contamination. Hands should be decontaminated immediately before and after each and every episode of direct patient care (see Chapter 3). The use of protective clothing such as gloves and aprons should also follow infection control guidelines. For aseptic procedures, sterile gloves are worn. Additional precautions include the following: When using an examination couch for procedures, a protective dis- posable paper sheet should be changed between patients, and the couch should be disinfected daily or when visibly contaminated. The bedclothes should be protected with a waterproof sheet or absorbent pad to prevent irrigation fluid seeping through bed- clothes and contaminating the mattress (Perry and Potter 1998). Self-contamination A patient’s own flora from the gastro-intestinal tract, skin or respirat- ory tract may infect a wound or an intravenous or urinary catheter (Ayliffe et al. 1999). Helping a patient maintain personal cleanliness, such as using an antiseptic skin preparation before a procedure, offer- ing handwashing facilities after toileting, and using separate wash cloths for face and perineal areas will reduce this risk. 279 Key Nursing Skills Handwashing Effective handwashing, following infection control guidelines (see Chapter 3), will reduce contamination risks between patients, and is the single most important activity to prevent transmission of infection. There is confusion as to how often and at what junctures handwashing should occur during an aseptic procedure, which results in ritualistic and/or contradictory practices (Bree-Williams and Waterman 1996). If considering the principles of asepsis, the following can be used as a guide to handwashing during an aseptic procedure: Prior to preparing equipment and patient, a social handwash (see Chapter 3) can be used to remove all transient micro-organisms and physical dirt. A full disinfection handwash is not necessary until everything is ready to begin the sterile procedure, as the hands will be touching a number of objects ranging from equip- ment to patient bedclothes during preparation. Opening additional packs and fluids to add to the sterile field will bring the hands into contact with dry, dust-free equipment that carries a low level of pathogenic activity (Hollingworth and Kingston 1998), and therefore has a low risk of contamination. Provided the sterile products are not touched, physically clean hands may open the packs. Whether using the sterile bag technique or forceps to lay out the sterile field and remove a soiled dressing, hand cleansing, either by washing or alcohol disinfection, may be undertaken after removal of the dressing, as that is the most likely time of contamination prior to commencing the procedure. Using a sterile bag to lay out the sterile field has not brought the hands into contact with any- thing unsterile that will then contact the patient directly until the wound is exposed. A disinfection handwash should be undertaken before application of sterile gloves, which may then be worn to proceed. If the hands have become contaminated at any stage during the procedure, they can be disinfected using an alcohol hand rub, using two applications and rubbing as for handwashing, provided they are physically clean. This will not be appropriate if there is physical dirt as the alcohol will not be effective (Department of Health 2001a). 280  Aseptic procedures NURSING PROBLEM 11.1 Patient history: Mrs Cameron is a 64-year-old lady who has had an emergency laparotomy for abdominal pain. Problem: Mrs Cameron requires a post-operative wound dressing. Goal: Mrs Cameron’s wound will heal successfully with no infection. Intervention: aseptic dressing technique Equipment A dressing pack containing a dressing towel, gauze swabs, and gal- lipot for irrigation fluid; possibly also including waste disposal bag, forceps, or sterile gloves. Cleaning lotion, such as sterile saline, or prepacked irrigation device. 10 ml syringe. Receiver/jug containing hand-hot water for warming the irriga- tion solution. Sterile disposable gloves. Alcohol hand rub. Tape. Additional dressings and wound care products as prescribed. Clean scissors for cutting tape. Scissors that have been washed in detergent and dried, or cleaned with an alcohol swab, may be used to cut tape. If scissors are required to cut dressings, for example, to make a keyhole shape, then they should be sterile. Receiver to collect irrigation fluid if required. Waterproof protection for the bed if irrigation is required. Procedure Clarify the procedure required from the nursing notes. Check for special instructions, such as the type of dressing to be used, to enable appropriate equipment to be selected. Some wounds may require a regular photographic record to monitor progress, or a wound map may be required. 281 Key Nursing Skills Identify the Mrs Cameron by name and gain her verbal consent for the procedure. This ensures her cooperation. Ensure you main- tain her privacy and dignity by drawing the curtains while check- ing the current dressing to find out whether additional equipment, such as extra gauze, will be required. Check the type of tape secur- ing the dressing and observe for any discomfort or inflammation in the area so that an appropriate hypoallergenic fixture is used. Assess Mrs Cameron’s pain score. If necessary, administer analge- sia prior to the dressing. This will allow the analgesia to begin to work by the time the dressing is ready to commence. Offer toilet facilities to ensure comfort during the procedure. Position Mrs Cameron comfortably, maintaining her dignity, pri- vacy and warmth at all times. If there is likely to be only a short interval before you return to commence the procedure, close the curtains and position the bedcovers for easy access to the site. If the wait is likely to be more than 5–10 minutes, don’t close the curtains until the equipment is ready: a long wait behind curtains can be worrying for some patients, and may increase anxiety. Ensure that all your jewellery is removed other than a wedding ring. This ensures that hands can be washed effectively. Nails should be short and clean. Ensure hair is tidy and clipped out of the face. Hair can harbour micro-organisms, and touching it during an aseptic procedure will contaminate the hands. Wash hands with a socially clean wash. A clean, disposable apron should be worn for each procedure. Ensure the trolley is physically clean and has been washed with detergent that day. Gather required equipment (see above), and check for sterile seals, integrity of packaging and expiry dates. Place on the bottom of the trolley and transport to the patient. The curtains should be closed and Mrs Cameron positioned com- fortably. If the bed height or couch can be raised, position it at about waist level, which should be a comfortable height for work- ing at in order to reduce back strain. Ensure a good light source so that you can see the area to be worked on clearly. 282  Aseptic procedures TIP! Ifa designated, undertaking an aseptic procedure in the patient’s home, use hard, flat surface on which to place your equip- ment. It can be wiped clean of dust and positioned adjacent to the patient. Preparation of a sterile field This procedure can be followed for all aseptic procedures. Position the trolley beside Mrs Cameron, and on the side nearest to the area that is to be worked on, preferably so that her face and expression can be observed during the procedure. You can see whether she is suffering any undue distress during the procedure that could be relieved by explanation and reassurance. Open the dressing pack and slide the inner pack onto the top of the trolley. If there are forceps, an instrument bag, or a waste bag tucked into the packaging, take out and put on one side of the trolley. Wash hands with a disinfection wash and dry thoroughly. Consider the outer inch of the sterile towel as unsterile; hold about an inch of the corners of the pack. Start with the corner fur- thest from you, open outwards and straighten out, then the sides, and then the corner nearest you, until the sheet is stretched out flat (Figure 11.2.1). This prevents contamination of the sterile field. Adjust the sterile field so that it is square. Figure 11.2.1 Straighten out sterile towel. 283 Key Nursing Skills Lay out the area as in Figure 11.1 (page 278) by placing your hand inside the disposal bag (Figure 11.2.2), and positioning the sterile equipment. Forceps may be used to arrange the sterile field instead of the waste bag, and then placed carefully to one side on the ster- ile field so that the rest of the equipment is not contaminated. Figure 11.2.2 Using disposal bag to position equipment. Additional equipment is added by peeling the outer packaging apart, removing by sterile forceps, and positioning on the sterile field. If forceps are not used, the contents can be allowed to slip out of the packaging, taking care not to touch the sterile field with the outer pack, and not to allow equipment to roll off the edge (Figure 11.2.3). Figure 11.2.3 Opening additional equipment. 284  Aseptic procedures Lotions should be poured carefully from the side. If using a multi- dose bottle the label should turn away from the pouring side to prevent drips (Figure 11.2.4). If forceps are being used, a gallipot may be picked up and held to one side, away from the sterile field, while the lotion is poured in. Figure 11.2.4 Pouring lotions from a sachet. TIP! Ifshould assisting at an aseptic procedure, the label of the lotion be checked with the other health care professional so that you are both satisfied that the correct substance is being used. Open sterile gloves and place on top of the sterile field (see Figure 11.4 below). Loosen tape on the dressing. Place your hand inside the sterile bag, and remove the old dress- ing, discreetly observing the discharge on the wound dressing on removal. Gather all dressing material up into the bag (Figure 11.3), turn inside out and secure on the trolley below the level of the sterile field, but on the same side as the dressing to allow easy disposal of waste during the procedure. If forceps are used to remove the old dressing, they are then returned for resterilizing if metal, or discarded. Clean hands either by a disinfection wash or alcohol rub. Dry thoroughly. Put on sterile gloves. 285 Key Nursing Skills Figure 11.3 Removing old dressing. Assess the wound: observe the wound and surrounding area for inflammation, swelling, or discharge. Do not allow the wound to remain uncovered for too long as the temperature will drop and interrupt healing. If the skin around the wound needs cleaning, it can be swabbed by gauze swabs slightly moistened with sterile saline. The wound should not be swabbed with gauze or cotton wool as fibres may enter the wound bed, and cause a foreign body reaction (Briggs et al. 1996). To clean around a wound, wipe from top to bottom, or from clean area to dirty if that is more obvious, using one wipe for each swab. If the wound needs cleaning, fill a 10 ml syringe with sterile saline, or use a prepacked irrigation device. Placing the sterile receiver below the wound to catch the flow, irrigate the wound with the syringe, ensuring that it does not touch the wound. The pressure at which to irrigate has not been confirmed (Oliver 1997) but should be sufficient to flush away surface debris without causing trauma. If a small irrigation only is required, fluid may be collected by holding a gauze swab below the wound. Dry the surrounding skin with dry gauze, working from top to bot- tom or clean to dirty as before. Position the prescribed dressing and secure. Tape pieces should be cut individually and applied, but the tape should not be carried to the wound as it may become contaminated. 286  Aseptic procedures On completion, fold up sterile field, remove apron and gloves, and deposit all in waste bag. All waste should be wrapped before leav- ing the area (to reduce transmission of infection outside the treat- ment area) and disposed of as clinical waste (Xavier 1999). Before leaving Mrs Cameron, position her comfortably, ensuring all that she requires is within reach. Equipment for resterilizing should be placed on the top of the trolley and returned to the dirty utility room; if it contains body secretions, it should be rinsed before being returned to CSSD. TIP! Where sharps have been used as part of an aseptic proced- ure, it is the responsibility of the practitioner using the sharp (e.g. needle or stitch-cutter) to ensure its safe disposal in an appropriate container (see Chapter 3). After waste disposal, wash hands. Document activity and observa- tions. Evaluation Mrs Cameron’s wound heals by first intention (i.e. without evidence of infection). Putting on sterile gloves TIP! Choose the correct size to ensure a comfortable fit and ease of manipulation, and to reduce potential breaks in the gloves. Open outer packaging and allow contents to slip onto flat surface (Figure 11.4.1). Following disinfection handwash and thorough drying, open inner packaging Using your non-dominant hand, pick up the opposite glove (Figure 11.4.2) by grasping the exposed inside of the cuff (i.e. left hand picks up right glove, or right hand picks up left glove). Pull the glove onto your dominant hand, keeping your thumb folded across your palm to avoid touching the sterile outside of the glove (Figure 11.4.3). Hold the cuff on the inside until your fin- gers have entered the appropriate glove fingers and wriggled into place, then allow the cuff to unroll a little (Figure 11.4.4). 287  Key Nursing Skills (1) (2) (3) (4) (5) (6) Figure 11.4.1–6 Donning sterile gloves. 288  Aseptic procedures Using your gloved hand, slip your finger under the cuff of the other glove to pick it up (Figure 11.4.5). Slide your non-dominant hand into the glove, keeping the thumb tucked in until it is fully covered. The dominant hand can release the glove when placed correctly. Be careful not to contaminate the fingers when straight- ening the cuffs of either hand (Figure 11.4.6). The gloves can be adjusted to fit comfortably by interlacing the fingers of both hands and smoothing the material. The gloves will remain sterile so long as they only touch sterile materials. TIP! Wearing sterile gloves can give you a false sense of security that may lead to contamination of key parts when handling equipment, so be vigilant and maintain ANTT. NURSING PROBLEM 11.2 Problem: Mrs Cameron has a wound drain in situ that requires shortening after 24 hours, and removal after 48 hours. Goal: Mrs Cameron’s wound drain is shortened and removed safely and without discomfort. Wound drains Wound drains are designed to aid drainage of fluids such as pus, blood, or exudate from a body cavity. Accumulation of such fluids increases the risk of infection and may delay wound healing, but the presence of a drain may act as a conduit for micro-organisms (Briggs 1997). Manley and Bellman (2000) suggest that drains should be removed in the fol- lowing circumstances: when the drain no longer fulfils its function, and drainage is min- imal or nil suction drains should be removed when there is less than 50 ml drainage in 24 hours when an abscess cavity is confirmed by radiology as being closed when there is a risk of complications occurring due to the location and length of time in situ. 289  Key Nursing Skills The decision to remove a drain should be confirmed by a qualified nurse or medical practitioner. The many different types of drains are well documented else- where, but the principles of shortening and removal are outlined in the following procedure. TIP! When shortening or removing a wound drain, ensure that the patient has had some effective pain relief. This will help them relax and cooperate, and relieve discomfort following removal. Intervention: shortening a wound drain Equipment As for aseptic dressing technique (see page 281) but also: Sterile stitch cutter. Sterile forceps. Sterile safety pin. Procedure Prepare for procedure following the steps described for the aseptic dressing technique (page 281) up to the stage of wound assess- ment. Expose the wound drain site, and clean the surrounding skin if necessary. A drain may be repositioned by removing the suture that is secur- ing it in position. Identify the suture holding it in situ and, lifting it with the sterile forceps, cut the suture under the knot, next to the skin, and gently remove the suture. Withdraw the drain the prescribed distance (usually 2–3 cm), warning the patient that she may experience a pulling sensation. Take a gauze pad and with the non-dominant hand hold it at the drain site, applying slight counter-pressure to the skin around the wound. With the other hand, gently pull the drain. If resistance is felt or the patient complains of discomfort, pause and slow down. Encourage the patient to take deep breaths to help her relax whilst you shorten the drain. 290  Aseptic procedures Insert the sterile safety pin through the drain at the new length to prevent it slipping back into the wound. Dry the skin around the wound with gauze swab. A keyhole dressing (Figure 11.5) is applied around the drain, and additional gauze placed over the drain and secured. Figure 11.5 Keyhole dressing. TIP! Ifbethere are copious amounts of drainage, a stoma bag may used rather than a dressing to collect discharge. Aseptic precautions should be adhered to when placing the bag in situ. Complete the aseptic procedure as described on page 286. Record type and amount of drainage, and the condition of the wound. Intervention: removing a wound drain Equipment As for aseptic dressing technique (see page 281) but also: Sterile stitch cutter. Sterile forceps. Specimen jar if signs of local infection are present. 291 Key Nursing Skills Procedure Prepare for procedure and position the patient following the steps described for the aseptic dressing technique (page 281) up to the stage of wound assessment. If the drain is by vacuum, discontinue the vacuum by clamping the drain. Expose the wound drain site, and clean the surrounding skin if necessary. If a suture is still in situ, identify the suture and, lifting it with the sterile forceps, cut the suture under the knot, next to the skin, and gently remove the suture. Warn the patient that she may experience a pulling sensation as you remove the drain. Take a gauze pad and with the non-dominant hand hold it at the drain site, applying slight counter-pressure to the skin around the wound. With the other hand gently pull the drain out. If resist- ance is felt or the patient complains of discomfort, pause and slow down. Encourage the patient to take deep breaths while you remove the drain. Discard the drain into the waste bag, taking note of the colour or odour of any discharge. If there are signs of infection, place the drain in a specimen jar to send for microscopy and culture. Apply gentle pressure with a gauze swab until any bleeding or drainage from the site has stopped, and then apply a sterile dressing. Complete the aseptic procedure as described on page 286. Record the type and amount of drainage, and the condition of the wound. Evaluation Has Mrs Cameron’s wound drain been effective? Are there any signs of fluid collecting internally – i.e. evidence of haematoma (bruising), swelling, heat or pain? Is the wound healing as expected? 292