Chest Tube Procedures PDF

MODULE 1 Chest Tube - also known as a thoracic catheter, is a sterile tube with a number of drainage holes that is inserted into the pleural space. Pleural space - is the space between the parietal and visceral pleura and is also known as the pleural ca...

MODULE 1 Chest Tube - also known as a thoracic catheter, is a sterile tube with a number of drainage holes that is inserted into the pleural space. Pleural space - is the space between the parietal and visceral pleura and is also known as the pleural cavity. A patient may require a chest drainage system any time the negative pressure in the pleural cavity is disrupted, resulting in respiratory distress. (Bauman & Handley, 2011; Perry et al., 2014). The chest tube is connected to a closed chest drainage system, which allows for air or fluid to be drained, and prevents air or fluid from entering the pleural space. The system is airtight to prevent the inflow of atmospheric pressure. Chest tube drainage system - is a sterile, disposable system that consists of a compartment system that has a one-way valve, with one or multiple chambers, to remove air or fluid and prevent return of the air or fluid back into the patient. The traditional chest drainage system typically has three chambers (Bauman & Handley, 2011; Rajan, 2013). 1. Collection chamber 2. Water-seal chamber 3. Wet or dry suction control chamber INDICATIONS: Collapsed lung (pneumothorax) Infection Cancer Comfort Chest Surgery Bleeding around your lung, especially after a trauma (such as a car accident) Water-seal system: Add sterile water or normal saline (NS) solution to cover the lower 2.5 cm (1 inch) of the water-seal U tube. Or pour sterile water or NS into the suction control chamber if suction is to be used (see manufacturer directions) Waterless system: Add vial of 30- to 45-mL sterile sodium chloride or water (for diagnostic air-leak indicator), 20-mL syringe, 21-gauge needle, and antiseptic swab Dry suction system ❏ Clean gloves ❏ Sterile gauze sponges ❏ Local anesthetic, if not an emergent procedure ❏ Chest tube tray (all items are sterile): Knife handle (1), chest tube clamp, small sponge forceps, needle holder, knife blade No. 10, 3-0 silk sutures, tray liner (sterile field), curved 8-inch Kelly clamps (2), 4 × 4–inch sponges (10), suture scissors, hand towels (3), sterile gloves ❏ Dressings: Petrolatum gauze, split chest-tube dressings, several 4 × 4–inch gauze dressings, large gauze dressings (2), and 4-inch tape or elastic bandage (Elastoplast) ❏ Head cover ❏ Facemask/face shield ❏ Sterile gloves ❏ Two rubber-tipped hemostats (shodded) for each chest tube ❏ 1-inch adhesive tape for taping connections or plastic zip ties ❏ Stethoscope, sphygmomanometer, and pulse oximeter Related Interventions Unexpected Outcomes 1 Patient develops respiratory distress. Notify health care provider Chest pain, a decrease in breath sounds immediately over affected and unaffected lungs, Collect a set of vital signs and marked cyanosis, asymmetric chest pulse oximetry. movements, presence of subcutaneous Prepare for chest x-ray. emphysema around tube insertion site or Provide oxygen as ordered. neck, hypotension, tachycardia, and/or mediastinal shift, are critical and indicate a severe change in patient status such as excessive blood loss or tension pneumothorax. 2 Air leak is unrelated to patient’s See Table 26-3 for determining respirations. source of an air leak and problem solving. Notify health care provider. 3 There is no chest tube drainage Observe for kink in chest drainage system. Observe for possible clot in chest drainage system. Observe for mediastinal shift or respiratory distress (medical emergency). Notify health care provider. 4 Chest tube is dislodged. Immediately apply pressure over chest tube insertion site. Have assistant obtain sterile petroleum gauze dressing. Apply as patient exhales. Secure dressing with tight seal. Notify health care provider. 5 Substantial increase in bright red Obtain vital signs. drainage is observed. Monitor drainage. Assess patient’s cardiopulmonary status. Notify health care provider. SPECIAL CONSIDERATIONS Teaching Instruct patient and family caregivers regarding proper functioning of chest tube and drainage system. Inform patient to remain in bed if chest tube is attached to suction (Maliakal, 2011). Instruct patient to not lie on the tubing or allow it to get kinked to promote drainage (Maliakal, 2011). Instruct patient to immediately report any changes in chest comfort. Pediatric If possible, using pictures and special dolls, familiarize child and family with equipment before inserting chest drainage system (Hockenberry and Wilson, 2011). Chest tube drainage greater than 3 mL/kg/hr for more than 3 consecutive hours is excessive and may indicate postoperative hemorrhage. Notify the health care provider immediately (Hockenberry and Wilson, 2011). Gerontologic Fragility of the older adult’s skin requires special care and planning for management of chest tube dressing. Frequently assess surrounding skin for signs of skin breakdown. Home Care Patients with chronic conditions (e.g., uncomplicated pneumothorax, effusions, empyema) that require long-term chest tube may be discharged with smaller mobile drains (Varela et al., 2010). Instruct patient how to ambulate and remain active with a mobile chest tube drainage system. Instruct patient and family caregivers about when to contact health care provider regarding changes in the drainage system (e.g., chest pain, breathlessness, change in color or amount of drainage, leakage on the dressing around the chest tube). Provide patient and family caregiver information specific to the type of drain; when possible have patient demonstrate proper maintenance of the mobile drainage system. Most of these systems do not have a suction control chamber and use a mechanical one-way valve instead of a water-seal chamber (Varela et al., 2010). TRACHEOSTOMY CARE TRACHEOSTOMY- is a surgical procedure done to provide long-term airway support or as an emergency procedure when an endotracheal tube cannot be passed successfully. An opening (stoma) is made in the trachea below the cricoid cartilage, and a semi rigid plastic tube (tracheostomy tube) is passed through the opening and into the trachea. A cuff, similar to that in an endotracheal tube, is inflated near the distal airway. A tracheostomy is a 51- to 76-mm (2- to 3-inch) curved metal or plastic tube inserted into a stoma through the neck and into the trachea to maintain a patent airway. It is placed in patients who require long-term airway management because of airway obstruction, airway clearance needs, and long-term intubation (Regan and Dallachiesa, 2009). PURPOSES: To maintain airway patency by removing mucus and encrusted secretions. To maintain cleanliness and prevent infection at the tracheostomy site To facilitate healing and prevent skin excoriation around the tracheostomy incision To promote comfort To prevent displacement. PARTS OF TRACHEOSTOMY TUBE A commonly used tracheostomy tube consists of three parts: outer cannula with flange (neck plate), inner cannula, and an obturator. The outer cannula is the outer tube that holds the tracheostomy open.  A neck plate extends from the sides of the outer tube and has holes to attach cloth ties or velcro strap around the neck. The inner cannula fits inside the outer cannula. It has a lock to keep it from being coughed out, and it is removed for cleaning. The obturator is used to insert a tracheostomy tube. It fits inside the tube to provide a smooth surface that guides the tracheostomy tube when it is being inserted. EQUIPMENTS Bedside table Towel Tracheostomy suction supplies (see Skill 25-2) Sterile tracheostomy care kit, if available (be sure to collect supplies listed that are not available in kit), or two sterile 4 × 4–inch gauze pads Sterile cotton-tipped applicators Sterile tracheostomy dressing (pre cut and sewn surgical dressing) Sterile basin Normal saline Small sterile brush (pipe cleaner) (or disposable inner cannula) Roll of twill tape, tracheostomy ties, or tracheostomy holder Scissors Pulse oximeter Clean gloves (two pair) Mask, goggles, or face shield Unexpected Outcomes Related Interventions 1 Excessively loose or tight tracheostomy Adjust ties or apply new ties/tracheostomy holder ties/tracheostomy holder. 2 Inflammation of tracheostomy stoma. Increase frequency of tracheostomy care. Apply topical antibacterial solution, allow it to dry, and apply bacterial barrier. Apply hydrocolloid or transparent dressing just under the stoma to protect skin from breakdown. Consult with a skin care specialist. 3 Patient has a pressure area around the Increase frequency of tracheostomy care and keep tracheostomy tube. dressing under faceplate at all times. Consider using double dressing or applying hydrocolloid or stoma adhesive dressing around the stoma. 4 Accidental decannulation. Call for assistance. Replace old tracheostomy tube with new tube. Some experienced nurses or respiratory therapists may be able to quickly reinsert tracheostomy tube. Keep spare tracheostomy tube of same size and kind at bedside in event of emergency replacement (Weber-Jones, 2010). Same-size ET tube can be inserted in stoma in an emergency. Insert suction catheter to confirm that new tube is in trachea. Be prepared to manually ventilate patients in whom respiratory distress develops with Ambu bag until tracheostomy is replaced. Notify health care provider. Remove inner cannula if applicable for cleaning or 5 Respiratory distress from mucus plug in cannula. suction cannula. Notify health care provider if tracheostomy tube requires replacement (Weber-Jones, 2010). SPECIAL CONSIDERATIONS Teaching Different types of tracheostomy tubes have different faceplates. Some are rigid; others are not. Instruct caregivers not to lift up rigid faceplates or they will dislodge the tube. Some commercial tracheostomy tube holders require removal of excess tie material to fit properly. If you anticipate long-term placement of tracheostomy, plan to teach patient and family tracheostomy care. Patients with new tracheostomy frequently have bloody secretions for 2 to 3 days after procedure and for 24 hours after each tracheostomy tube change (Frace, 2010). Pediatric Children generally have shorter necks, making the stoma more difficult to clean. Pediatric tracheostomy tubes (smaller than size 4) do not contain an inner cannula. Nurses perform routine tracheostomy tube changes weekly after a tract has formed, generally 5 days (Hockenberry and Wilson, 2011). Gerontologic Some older adults may have more fragile skin and are more prone to skin breakdown from secretions or pressure (Meiner and Lueckenotte, 2011). Some older adults with impaired nutrition do not heal well. CVP CENTRAL VENOUS PRESSURE (CVP) describes the pressure of blood in the thoracic vena cava, near the right atrium of the heart. CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood into the arterial system. Central venous pressure is considered a direct measurement of the blood pressure in the right atrium and vena cava. It is acquired by threading a central venous catheter (subclavian double lumen central line shown) into any of several large veins. It is threaded so that the tip of the catheter rests in the lower third of the superior vena cava. The pressure monitoring assembly is attached to the distal port of a multi lumen central vein catheter. INDICATIONS: Assess right ventricular function Systemic fluid status Rapid infusions Infusions of hypertonic solutions and medications that can damage veins Serial venous blood assessment INSERTION SITES: 1. Internal jugular veins This site is chosen frequently as there is a high rate of successful insertion and a low incidence of complications such as pneumothorax. Internal jugular veins are short, straight, and relatively large allowing easy access, however, catheter occlusion may occur as a result of head movement and may cause irritation in conscious patients. 2. Subclavian veins This site is often chosen as there are more recognizable anatomical landmarks, making insertion of the device easier. Because this site is positioned beneath the clavicle there is a risk of pneumothorax during insertion. A subclavian CVC is generally recommended as it is more comfortable for the patient. 3. Femoral veins This site provides rapid central access during an emergency such as a cardiac arrest. As the CVC is placed in a vein near the groin there is an increased risk of associated infection. In addition, femoral CVCs are reported to be uncomfortable and may discourage the conscious patient from moving. Assisting with CVP placement: Adhere to institutional Policy and Procedure. Obtain history and assess the patient. Explain the procedure to the patient, include: ○ local anesthetic ○ trendelenburg positioning ○ draping ○ limit movement ○ need to maintain a sterile field. ○ post procedure chest X-ray Obtain a sterile, flushed and pressurized transducer assembly Obtain the catheter size, style and length ordered. Obtain supplies: ○ Masks ○ Sterile gloves ○ Line insertion kit ○ Heparin flush per policy Position patient supine on bed capable of trendelenburg position Prepare for post procedure chest X-ray How to measure the CVP? The CVP can be measured either manually using a manometer and electronically using a transducer. In either case the CVP must be “zeroed” at the level of the right atrium. This is usually taken to be the level of the 4th intercoastal space in the mid-axillary line while the patient is lying supine. Each measurement of CVP should be taken at this same zero position. 1. Using the Manometer A 3-way tap is used to connect the manometer to an intravenous drip set on one side, and via extension tubing filled with intravenous fluid, to the patient on the other. It is important to ensure that there are no air bubbles in the tubing, to avoid administering an air embolism to the patient. You should also check that the CVP catheter tubing is not kinked or blocked, that intravenous fluid can easily be flushed in and that blood can easily be aspirated from the line. The 3-way tap is then turned so that it is open to the fluid bag and the manometer but closed to the patient, allowing the manometer column to fill with fluid. It is important not to overfill the manometer, so as to prevent the cotton wool bung at the manometer tip from getting wet. Once the manometer is filled adequately the 3-way tap is turned again-this time, so it is open to the patient and the manometer but closed to the fluid bag. The fluid level within the manometer column will fall to the level of the CVP, the value of which can be read on the manometer scale which is marked in centimeters, therefore giving a value for CVP in centimeters of water. The fluid level will continue to rise and fall slightly with respiration and the average reading should be recorded. 2. Using the Transducer The transducer is fixed at the level of the right atrium and connected to the patients CVP catheter via fluid filled extension tubing. Similar care should be taken to avoid bubbles and kinks as mentioned above. The transducer is then ‘zeroed’ to atmospheric pressure by turning its 3-way tap so that it is open to the transducer and to the room air but closed to the patient. The 3-way tap is then turned so that it is now closed to room air and open between the patient and the transducer. A continuous CVP reading measured in mmHg rather than cmH2O, can be obtained EQUIPMENTS: Venous pressure tray Cut-down tray Infusion solution and infusion set 3-way or 4-way stopcock (a pressure transducer may also be used) IV pole attached to bed Arms board Adhesive tape ECG monitor Carpenter’s level (for establishing zero point) INTERPRETING MEASUREMENTS: The normal range for CVP is 5-10cm H2O (2-6mmHg) when taken from the mid-axillary line at the fourth intercostal space. Many factors can affect CVP, including vessel tone, medications, heart disease and medical treatments. A CVP measurement should be viewed in conjunction with other observations such as pulse, blood pressure and respiratory rate and the patients response to treatment POTENTIAL COMPLICATIONS: Hemorrhage from the catheter site - if it becomes disconnected from the infusion. Patients who have coagulation problems such as those on warfarin or those will clotting disorders are at risk. Catheter occlusion, by a blood clot or kinked tube - regular flushing of the CVC line and a well secured dressing should help to avoid this.  Infection - redness, pain, swelling around the catheter insertion site may all indicate infection. Careful asepsis is needed when touching a CVC site. Swabs for MC&S should be taken if infection is suspected. Air embolism - if the infusion or monitoring lines become disconnected there is a risk that air can enter the venous system. All lines and connections should be checked at the start of every shift to minimize the risk of this occurring. Catheter displacement - if the CVC moves into the chambers of the heart then cardiac arrhythmias may be noted, and should be reported. If the CVC is no longer in the correct position, CVP readings and medication administration will be affected. SPECIAL CONSIDERATIONS: Teaching Instruct patient to report discomfort around the site; discomfort in arms, shoulders, or side of the neck; or any shortness of breath. Discuss and provide written emergency measures and telephone numbers of health care personnel to be used in case of catheter damage, displacement, swelling, redness, or leakage at insertion site; occlusion of port or catheter; temperature above 100.4° F (38° C) (see agency policy); and shaking chills. Provide written instruction for dressing changes, inspection of insertion site, flushing, and tubing changes. Arrange for instruction and return demonstration of skills by patient or family caregiver. Have patient or family caregiver maintain a list of caregivers and telephone numbers (e.g., physician, nurse, social worker, pharmacist, dietitian). MODULE 2 Water, a primary component of body fluids, is the most abundant substance in the body. Water plays a vital role in several physiologic processes such as digestion, absorption, and use of nutrients, distribution, waste excretion, and perfusion and maintenance of hemodynamics (Jain 2015; Schmidt 2010). Homeostasis of fluids and electrolytes occurs by complex systems that ensure proper functioning. Certain diseases or conditions require surgical intervention to create an opening into the abdominal wall for fecal or urinary elimination. A key nursing responsibility is to support patients as they respond to threats to their health. A basic human function is a urinary elimination, a function that can be compromised by a wide variety of illnesses and conditions. It is the role of a nurse to support bladder emptying as needed by helping a patient to a toilet or bedside commode, assist with a urinal, or perform catheterization.  Regular elimination of bowel waste products is essential for normal body functioning. Because bowel function depends on the balance of physical and psychological factors; elimination patterns and habits vary among individuals. When patients’ functional status changes or they become ill, they may not be able to maintain normal elimination habits. They require assistance such as the use of a bedpan or enema administration. To manage patients’ elimination problems, you need to understand normal elimination and factors that promote, impede, or alter elimination such as constipation, diarrhea, and fecal incontinence. BLADDER IRRIGATION Urinary catheter irrigations are performed on an intermittent or a a continuous basis to maintain catheter patency. TWO TYPES OF IRRIGATION Both open and closed irrigation can be used to irrigate the bladder with medication. OPEN CATHETER IRRIGATION used only when intermittent irrigation of the catheter and bladder is required. The skill involves breaking or opening the closed drainage system at the connection between the catheter and the drainage system. This procedure should be avoided unless irrigation is needed to relieve or prevent obstruction (Senese et al., 2005). Strict asepsis is required throughout the procedure to minimize contamination and subsequent development of a urinary tract infection (UTI). CLOSED CATHETER IRRIGATION Intermittent irrigation- involves the insertion of a sterile catheter into a catheter port to irrigate a bolus of fluid. Continuous bladder irrigation (CBI)- is a continuous infusion of a sterile solution into the bladder, usually using a three-way irrigation system with a triple-lumen catheter. EQUIPMENTS: Sterile irrigation solution at room temperature (as prescribed) Antiseptic swabs Clean gloves Closed Intermittent Irrigation Sterile container Sterile 30- to 60-mL irrigation syringe (piston type) Syringe to access system (Luer-Lok syringe without needle for needleless access port per manufacturer directions) Screw clamp or rubber band (used to temporarily occlude the catheter as irrigant is instilled)  Closed Continuous Irrigation Irrigation tubing with a clamp to regulate the irrigation flow rate Y-connector (optional) to connect irrigation tubing to double-lumen Catheter Intravenous (IV) pole (closed continuous or intermittent) Open Intermittent Irrigation Disposable sterile irrigation kit that contains solution container, collection basin Drape sterile gloves 30- to 60-mL irrigation syringe (piston type) Sterile catheter plug Sterile gloves (optional) Unexpected Outcomes Related Interventions Examine tubing for clots, sediment, and kinks. 1. Irrigating solution does not return (intermittent irrigation) or is not flowing Notify health care provider if irrigant does not flow freely at the prescribed rate (CBI). from the bladder, the patient complains of pain, or bladder distention occurs. Examine drainage tubing for clots, sediment, or 2. Drainage output is less than the amount of kinks. irrigation solution infused. Inspect urine for the presence of or increase in blood clots and sediment. Evaluate the patient for pain and distended bladder. Notify health care provider. Assess for hypovolemic shock (vital signs, skin color, and 3. Bright-red bleeding with the irrigation (CBI) moisture, infusion wide open. anxiety level). Leave irrigation infusion wide open and notify health care provider.  Examine drainage tubing for clots, sediment, or kinks. 4. Patient experiences pain with irrigation. Evaluate urine for the presence of or increase in blood clots and sediment. Evaluate for a distended bladder. Notify health care provider. 5. Fever; cloudy, foul-smelling urine; abdominal Notify health care provider. pain; change in mental Monitor vital signs and character of urine. status, indicating a possible infection. Recording and Reporting Record irrigation method, amount of and type of irrigation solution, amount returned as drainage, characteristics of output, urine output, and patient tolerance to procedure in nurses’ notes. Report catheter occlusion, sudden bleeding, infection, or increased pain to health care provider. Record I&O on appropriate flow sheet. Special Considerations Teaching Instruct patient and family caregiver to observe urine daily for changes in color, presence of mucus or blood, and odor. Inform patients that bleeding is common after many urologic procedures and to expect bright red-tinged urine during the first 48 hours after surgery, followed by a change in urine ranging from pink-tinged to clear. Instruct patient to maintain adequate oral intake of 2â ¯L/day (unless contraindicated). Home Care Patients and/or caregivers can be taught to perform catheter irrigations with adequate support, demonstration/return demonstration, and written instructions. Teach patients and/or caregivers to observe urine color, clarity, odor, and amount. Arrange for home delivery and storage of catheter/irrigation supplies.  Teach patients and/or caregivers signs of catheter obstruction or UTI. Peritoneal (per-ih-toe-NEE-ul die-AL-uh-sis) dialysis is another form of dialysis where the patient’s own peritoneal membrane (or lining of the abdominal organs and body surfaces within the abdominal cavity) acts as the artificial kidney. There is no blood removed or returned to the patient. Dialysis using the peritoneal membrane is also a means to remove toxins, poisons, and excess fluid that accumulates in the body when patients’ kidneys are no longer able to function adequately. INDICATIONS acute deterioration in kidney function, such as with severe blood loss or severe dehydration due to vomiting and diarrhea. used for gentle fluid removal in patients with non-primary kidney disease, such as patients with congestive heart failure or cirrhosis of the liver. used to permanently replace a patient’s kidney function in patients with longstanding kidney disease.* Diabetes *High blood pressure *Kidney inflammation (glomerulonephritis) *Multiple cysts in the kidneys (polycystic kidney disease) used in place of the kidneys for patients with primary kidney disease such as chronic glomerulonephritis when kidneys are no longer able to perform their function sufficiently well. TWO TYPES OF PERITONEAL DIALYSIS: 1. Automated peritoneal dialysis (APD) 2. Continuous ambulatory peritoneal dialysis (CAPD) PATIENT EDUCATION Peritoneal dialysis might not work Peritoneal dialysis may be the better if you have: option if you: Can't tolerate the rapid changes of fluid balance associated with Extensive surgical scars hemodialysis in your abdomen Want to minimize the disruption of your daily activities A large area of weakened abdominal muscle (hernia)  Want to work or travel more easily Limited ability to care for yourself, or a lack of caregiving support Have some residual kidney function Inflammatory bowel disease or frequent bouts of diverticulitis COMPLICATIONS Infections. An infection of the abdominal lining (peritonitis) is a common complication of peritoneal dialysis. An infection can also develop at the site where the catheter is inserted to carry the cleansing fluid (dialysate) into and out of your abdomen. The risk of infection is greater if the person doing the dialysis isn't adequately trained. Weight gain. The dialysate contains sugar (dextrose). Absorbing some of the dialysates might cause you to take in hundreds of extra calories daily, leading to weight gain. The extra calories can also cause high blood sugar, especially if you have diabetes. Hernia. Holding fluid in your abdomen for long periods may strain your muscles. Inadequate dialysis. Peritoneal dialysis can become ineffective after several years. You might need to switch to hemodialysis. CONTRAINDICATIONS Certain prescription and over-the-counter medications that can damage your kidneys, including nonsteroidal anti-inflammatory drugs. Soaking in a bath or hot tub, or swimming in a lake, pond, river, or non-chlorinated pool — which increases the risk of infection. Showers and swimming in a chlorinated pool are generally acceptable MODULE 3 Sterile procedures are required before and during specific patient care activities to maintain an area free from microorganisms and to prevent infection. Performing a surgical hand scrub, donning sterile gown, and preparing a sterile field are ways to prevent and minimize infection during surgeries or invasive procedures. SCRUBBING Surgical hand antisepsis is an extension of hand washing (AfPP 2011). It is also characterized as: the antiseptic surgical scrub or antiseptic hand rub performed before donning sterile attire preoperatively (AORN 2014).  Patients undergoing operative procedures are at an increased risk for infection. Nurses working in operating rooms perform surgical hand antisepsis to decrease and suppress the growth of skin microorganisms in glove tears. During surgical hand antisepsis the nurse scrubs from fingertips to elbows with an antiseptic soap before each operation. The optimum duration of the surgical hand scrub is unclear, although research indicates that it probably depends on the type of antimicrobial product (CDC, 2002). The traditional scrub time in the United States for both the initial and the subsequent scrub is 5 minutes. PURPOSE OF SURGICAL HAND SCRUB: The aim is to both reduce the number of resident and transient flora to a minimum but also to inhibit their re-growth for as long as possible, not just on the hands but also on the wrists and forearms (AfPP 2011). PREPARATION PRIOR TO SCRUB PROCESS All staff should be in the appropriate theater attire before commencing surgical hand antisepsis. Expert opinion asserts that headwear (AfPP 2011), masks (AORN 2014) and attire should be comfortable, safe and unlikely to need adjustment after the scrub procedure thus avoiding potential contamination. Scrub suit sleeves must be rolled up well past the elbows and nail varnish, false nails, rings, watches and bracelets should be removed. Expert opinion proposes that this type of accessory is likely to harbor pathogenic organisms which could contaminate surgically scrubbed hands and arms (NICE 2008). Any skin abrasions to digits, hands or arms must be occluded with a waterproof dressing. Wear appropriate mask and eye protection or a face shield as guided by local governance (AfPP 2011) to protect mucous membranes of the eyes, nose and mouth during procedures that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions. (AORN AND CDC GUIDELINES FOR HAND SCRUBS 2009) Ideally the surgical hand scrub product should have the following properties: Broad spectrum of action Fast acting Persistent Non-irritating to the skin SURGICAL HAND ANTISEPSIS SOLUTIONS: Solutions for hand antisepsis are either aqueous (water) based or alcohol based. 1. Aqueous scrubs Aqueous scrubs are water-based solutions containing active ingredients that are used during traditional hand scrubs. The most common solutions contain chlorhexidine gluconate or povidone iodine. 2. Alcohol rubs Alcohol-based solutions are used to perform an 'alcohol rub'. Health professionals apply the solution to dry hands and then rub them together systematically before allowing the solution to evaporate. Alcohol rubs do not require water for their application. Some alcohol rub solutions contain additional active antiseptic agents. ANTISEPTIC AGENTS 1. Alcohol - Alcohols have little or no residual effect, and the concentration rather than the type of alcohol is thought to be most important in determining its effectiveness (Larson 1995). Alcohol rubs are usually available in preparations of 60% to 90% strength. Compared with other common antiseptic products, alcohol is associated with the most rapid and greatest reduction in microbial counts (Lowbury 1974a), but it does not remove surface dirt as it does not contain surfactants or have a foaming action (Hobson 1998). 2. Iodine and iodophors - Iodine has mostly been replaced by iodophors, as iodine often causes irritation and discolouring of skin. Iodophors are composed of elemental iodine, iodide or triiodide, and a polymer carrier of high molecular weight (WHO 2009). Combining iodine with various polymers increases the solubility of iodine, promotes sustained release of iodine and reduces skin irritation. 3. Chlorhexidine - Chlorhexidine is a biguanide. It is not sporicidal. Although its immediate antimicrobial activity is slower than that of alcohols, it is more persistent because it binds to the outermost layer of skin, the stratum corneum (Larson 1990). Over time, repeated exposure can lead to a cumulative effect where both transient and resident organisms are reduced (Larson 1990). 4. Quaternary Ammonium Compounds - Quaternary ammonium compounds (QACs) are composed of a nitrogen atom linked to four alkyl groups. Alkyl benzalkonium chlorides are the most widely used as antiseptics, though other compounds include benzethonium chloride, cetrimide and cetylpyridium chloride. QACs are primarily bacteriostatic and fungistatic, although they are microbicidal against some organisms at high concentrations. 5. Triclosan - It inhibits staphylococci, coliforms, enterobacteria and a wide range of gram-negative intestinal and skin flora (Bartzokas 1983). Most strains of pseudomonas are resistant, and triclosan has only fair activity against mycobacterium tuberculosis and poor activity against fungi (Faoagali 1995). 6. Chloroxylenol - Chloroxylenol, is not as quick acting as chlorhexidine or iodophors, and its residual activity is less pronounced than that observed with chlorhexidine gluconate (McDonnell 1999). In 1994, the FDA TFM tentatively classified chloroxylenol as having insufficient data to classify as safe and effective (WHO 2009).  AORN and CDC Recommendations 1. AORN recommends for facilities to standardize scrub times and has presented studies to show that scrub times of three to four minutes are as effective as five minutes scrubs. 2. The CDC has stated that former traditional 10-minute scrubs are not necessary and frequently leads to skin damage, and sites studies that scrubbing for 2 or 3 minutes reduced bacterial counts to acceptable levels AORN- Surgical Scrub Brush 1. AORN outlines that the use of a brush for surgical hand scrubs is not necessary and scrubbing with a brush is associated with an increase in skin cell shedding. 2. AORN published an article that states that brushless scrubbing is believed to be less caustic and abrasive to the skin than traditional scrubbing and can aid in maintaining skin integrity, even after repeated use in the preoperative setting 3. AORN’s standards note that the use of a brush for surgical hand scrub isn’t necessary and that scrubbing with a brush can damage skin, creating microservices that encourage bacterial growth and increased bacterial load. 4. Use only Brush side for nails and cuticles or areas with visible soil. GOWNING Nurses wear sterile gowns when assisting at the sterile field in the operating room, delivery room, and special treatment areas. It allows the nurse to handle sterile objects and also be comfortable with less risk of contamination. The sterile gown acts as a barrier to decrease shedding of microorganisms from skin surfaces into the air and thus prevents wound contamination. Nurses caring for patients with large open wounds or assisting physicians during major invasive procedures (e.g., inserting an arterial catheter) also wear sterile gowns. The circulating nurse generally does not wear one. The nurse does not apply a sterile gown until after applying a mask and surgical cap and performing surgical handwashing. He or she picks up the gown from a sterile pack, or an assistant hands the gown to the nurse. Only a certain portion of the gown (i.e., the area from the anterior waist to, but not including, the collar and the anterior surface of the sleeves) is considered sterile. The back of the gown, the area under the arms, the collar, the area below the waist, and the underside of the sleeves are not sterile because the nurse cannot keep these areas in constant view and ensure their sterility. PURPOSE OF STERILE GOWN The aim is to exclude the skin as a contaminant and to create a barrier between the sterile and non-sterile field.it protects the wearer from cross contamination. GENERAL CONSIDERATIONS:  1. The scrub person gowns from a surface separate from the main sterile field. 2. Gown packages preferably are open in a separate table from other packages to avoid any chance of contamination from dripping water. When putting on the sterile gown, avoid touching the front surface of the gown and keep the gown from touching any object. Remove the gown from the autoclaved bundle, hold it at the neck, and allow it to unroll. With the back of the gown toward the wearer, carefully shake out and unfold it. While the assistant holds the collar at the left tie string with the right hand, the wearer inserts the left arm into the sleeve. Then while the assistant holds the collar at the right tie string with the left hand, the wearer inserts the right arm into the sleeve. While awaiting the assistant to tie and adjust the gown, the wearer keeps both arms extended upward. When tying the gown, the assistant stands directly behind the gown wearer, places his/her hands only on the shoulders and inside of the gown and does not touch the sides or front of the gown. The surgical gown is considered sterile in the front chest area and from the wrist to the elbow. Preparing Sterile Field INTRODUCTION When performing sterile procedures, you need a sterile work area that provides room for handling and placing of sterile items. A sterile field is an area free of microorganisms and prepared to receive sterile items. It also provides an area in which sterility is continually maintained. You prepare the field by using the inner surface of a sterile wrapper as the work surface or by using a sterile drape or dressing tray. After creating the surface for the sterile field, add sterile items by placing them directly on the field or transferring them with sterile forceps. Discard an object that comes in contact with the 1-inch (2.5-cm) border. Sometimes you will wear sterile gloves while preparing items on a sterile field. If you do this, you can touch the entire drape, but sterile items must be handed over by an assistant. The gloves cannot touch the wrappers of sterile items. PREPARING A STERILE FIELD: Perioperative personnel are key to creating, maintaining, and monitoring the sterile field. Before preparing a sterile field, they should perform a surgical hand scrub and don a sterile gown and gloves. This helps minimize contamination by microbes present on the skin and clothing. The sterile field should be prepared where it will be used. Moving the sterile field after it is created increases the risk of contamination, because air currents created by movement can lead to microbial and particle contamination. For the same reason, movement of personnel around the sterile field should be kept to a minimum. In addition, the sterile field should be prepared as near as possible to the start time of the surgical or other invasive procedure. This helps minimize the amount of dust and other airborne particles that settle on the field, which is important because these particles can increase contamination by bacteria and other microbes. AORN recommendations note that the potential for contamination is event-related, and that there is no specified time for preparing a sterile field relative to the time of the procedure.